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OF THE 


MEDICAL SCIENCES 


EMBRACING THE ENTIRE RANGE OF 


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AND 


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LIST OF CONTRIBUTORS TO VOLUME VI. 


CHARLES W. ALLEN, M.D....New York, N. Y. 
Visiting Physician, Charity Hospital. 

BUDO LISSA OEM) een oe le: Sr. Lovurs, Mo. 

EDMUND ANDREWS, M.D.......... CuicaGo, Int. 


Professor of Clinical Surgery, Chicago Medical Col- 
lege ; Visiting Surgeon, Mercy Hospital. 


bi te aA RCHINARD, Merb). oo. New ORLEANS, LA. 
Visiting Physician, Nervous Diseases Service, Charity 
Hospital; Assistant Pathologist to the same ‘hospital. 


I. EDMONSON ATKINSON, M.D..Bautrworsg, Mp. 
Professor of Pathology and Clinical Professor of Der- 
matology, University of Maryland. 


OA Neo Bw DALRD OND. 258.0625 hece'e ATLANTA, GA. 


PRANK, BAKER: SM. Diice.. 0. WasuHineton, D. C. 
Professor of Anatomy, Medical Department of George- 
town University. 


HENRY BY BAKER cM. Dooce. oes Lansine, Micu. 
Secretary of the Michigan State Board of Health. 
WILLIAM BARNES, M.D.........., DEcaATuR, Iu. 
MOPAS HH BARTUERY ~ M.D: 3.4. Brookuyn, N. Y. 


Lecturer on Chemistry, Long Island College Hospital : 
Chemist to the Brooklyn Board of Health. 


MeN LGA ETN eM Dye a cigs sly oss St. Lovuts, Mo. 
Professor of Special Pathology and Therapeutics, St. 
Louis Medical College. 


ALBERT N. BLODGETT, M.D........ Boston, Mass. 
- Professor of Pathology and Therapeutics, Boston Den- 
tal College. 


Wet oh OL Minpe isd )s rte es heck ae tees Boston, Mass. 

Professor of Materia Medica and Botany, Emeritus, at 

the Massachusetts College of Pharmacy ; Visiting 
Surgeon, Boston City Hospital. 


MHADE BOLTON, MD... c.cckl be. BALTIMORE, Mp. 

Assistant in Bacteriology, Johns Hopkins University. 
PaPORS ROME Hult NC Ls cor, te anes wletae eee a. Sr. Lours, Mo. 
BOR SAINSDRLDGE. OE Dace cate as Cuitcaeo, Inu. 


Professor of Pathology and Adjunct Professor of the 
Principles and Practice of Medicine, Rush Medical 
College. 


EDWARD BENNET BRONSON; M.D..NEw York, 


ewy 
Professor of Dermatology, New York ATEN ca 
Visiting Surgeon, Charity Hospital. 


BOLD sCINGES TCH VWI ESL), et gate os New York, N. Y. 
Assistant Surgeon, New York Orthopedic Dispensary 
and Hospital. 


Pet erect CeO DoS eer « TORONTO, CANADA. 
Professor of Chemistry, Ontario Agricultural College ; 
Secretary of the Provincial Board of Health. 


L. DUNCAN BULKLEY, A PY Blan at New York, N. Y. 
Physician to the New York Skin and Cancer Hospital ; 
Consulting Physician, Manhattan Eye and Ear 
Hospital. 


T&S CS 


WILLIAM N. BULLARD, M.D....... Boston, Mass. 
Physician to the Nervous ‘Department, Boston Dispen- 
sary ; Visiting Physician, Carney Hospital. 


FRANK BULLER, M.D........Monrrean, Canapa. 
Professor of Ophthalmology and Otology, McGill Uni- 
versity. 


J. WELLINGTON BYERS, M.D..CHartorts, N. C. 


Aly OO ey Gabby MCD) T ade dees Boston, Mass. 
Attending Surgeon, Massachusetts General Hospital, 
Boston. 


DONALD M. CAMMANN, M.D...NEew Yorg, N. Y. 

Instructor in Diseases of the Chest, New York Poly. © 

clinic; Visiting Physician, Orphans’ Home and 
Asylum. 


WILLIAM H. CARMALT, M.D..NEw Haven, Conn. 
Professor of Surgery, Yale University ; Visiting Sur- 
geon, New Haven Hospital. 


Weare COUNCEUMAN, WDi eure BALTIMORE, Mp. 
Associate Professor of Pathological pnatomy, Johns 
Hopkins University. 


EDWARD CURTIS, MD yes New York, N. Y. 

Professor Emeritus of Materia Medica and Thera- 

peutics, College of Physicians and Surgeons, New 
York. 


EES TR RIGCU RR LIS ON Aes cre ees Cuicaao, Inu. 
Professor of Histology, Chicago Medical College ; Vis- 
iting Physician, Mercy Hospital. 


CHARLES LOOMIS DANA, M.D..New York, N. Y. 
Professor of Diseases of the Mind and Nervous Sys- 
tem, and of Medical Electricity, New York Post- 
graduate Medical School and Hospital; Visiting 
Physician, Bellevue Hospital. 


NP DANDRIDGE IAL Deve cons oe: CINCINNATI, O. 
Professor of Genito-urinary and Venereal Diseases, 
Miami Medical College. 


INNS ean LD Sache s sin eaion ils cate ee CuicaGo, IL. 

Professor of the Principles and Practice of Medicine 

and of Clinical Medicine, Chicago Medical College; 
Visiting Physician, Mercy Hospital. 


ROBERT H. M. DAWBARN, M.D..NEw Yorks, N. Y. 

Examiner in Surgery, College of Physicians and Sur- 

geons, New York; Visiting Physician, Northwestern 
Dispensary, Department of Diseases of Children. 


D. BRYSON DELAVAN, M.D....New Yorks, N. Y. 

Professor of Laryngology and Rhinology, New York 

Polyclinic; Chief of Clinic, Department of Diseases 

of the Throat, College of Physicians and Surgeons, 
New York. 


W5. DENNETT, A 8d Dee Cee New York, N. Y. 
Assistant Surgeon, Ophthalmic Department, New York 
Eye and Ear Infirmary. 


JAMES H. ETHERIDGE, M.D....... Cuicaao, Inu. 
Professor of Materia Medica and Medical Jurispru- 
dence, Rush Medical College. 


lil 


LIST OF CONTRIBUTORS TO VOLUME VI. 


WaltA Here N Tee Dk irs New York, N. Y. 

Attending Physician, Presbyterian Hospital; Assistant 

to the Chair of Principles and Practice of Medicine, 
Bellevue Hospital Medical College. 


WiGGLAMeHs FORD, “MD... PHILADELPHIA, PA. 
President of the Philadelphia Board of Health. 
HU GEN EE OS THR Ma ora. oct. cigeacs AvausTA, GA. 


President of the Board of Health of Augusta. 


GEORGE B. FOWLER, M.D....NeEw York, N. Y. 
Professor of Physiological Chemistry, New York 
Polyclinic; Visiting Physician, New, York Infant 
Asylum. 
SLOLO NeH eA GE: Bist oe ye eer conte Irmaca, N. Y. 
Assistant Professor of Physiology, and Lecturer on 
Microscopical Technology, Cornell University. 


WILLIAM GARDNER, M.D....MonrTREAL, CANADA. 
Professor of Gynecology, McGill University ; Gyne- 
cologist to the Montreal General Hospital. 


GHORGE: Wi GAY, ovaD oe: -oeee Boston, Mass. 
Visiting Surgeon, Boston City Hospital. 
BeGRAD GLE MID: See er iret eee, eae CHICAGO, ILL. 
Professor of Physiology, Chicago Medical College. 


JAMES BE. GRAHAM, M.D....... TORONTO, CANADA. 
Lecturer on Diseases of the Integumentary System, 
Toronto School of Medicine. 
J OO NAGREEN SMD ors oe caer St. Louis, Mo. 
Professor of Ophthalmology, St. Louis Medical Col- 
lege. 
CHARLES E. HACKLEY, M.D...NeEw York, N. Y. 
Visiting Physician, New York Hospital. 


ALLAN McLANE HAMILTON, M.D...NEw York, 


Visiting Physician, Department of Nervous Diseases, 
mae a for the Relief of the Ruptured and Crip- 
pled. 

ROBERT P. HARRIS, M.D...... PHILADELPHIA, Pa. 

Member of the American Philosophical Society and of 
the Philadelphia Obstetrical Society ; Fellow of the 
College of Physicians of Philadelphia; Correspond- 
ing Member, Royal Academy of Surgery of Naples. 


SS HERRICK?) Maye (eee San FRANCISCO, CAL. 


WIGLVAM SBS DES SMD ees Boston, Mass. 
Assistant Professor of Chemistry, Harvard Medical 
School. 7 
WH HOW EEL. MDs Sete bee BALTIMORE, Mp. 
Johns Hopkins University. 


JAMES NEVINS HYDE, M.D........ CuicaGo, Inu. 
Professor of Skin and Venereal Diseases, Rush Medi- 
cal College. 


EDWARD JACKSON, M.D...... PHILADELPHIA, PA. 
Professor of Diseases of the Eye, Philadelphia Poly- 
clinic and College for Graduates in Medicine. 


LAURENCE JOHNSON, M.D..... New York, N. Y. 
Professor of Medical Botany, Medical Department of 
the University of the City of New York. 


HENRY LEFFMANN, M.D..... PHILADELPHIA, PA. 

Professor of Clinical Chemistry and Hygiene, Phila- 

delphia Polyclinic ; Assistant to the Chair of Chemis- 
try, Jefferson Medical College. 


ROBERT WEeCOv he ty eh Loe ee Boston, Mass. 

Assistant in Surgical Out-Patient Department, Boston 

Children’s Hospital; Late House Surgeon, Boston 
City Hospital. 


iv 


CHARLES SEDGWICK MINOT, M.D..Bostron, Mass. 
Assistant Professor of Histology and Embryology, 
Harvard Medical School. 


ROBERT B. MORRISON, SD as BALTIMORE, Mp. 
Professor of Dermatology and Syphilis, Baltimore 
Polyclinic and Post-Graduate Medical School. 


HH: 7 MUDD; MaDe 4 es eae St. Louis, Mo. 
Professor of Anatomy and Clinical Surgery, St. Louis 
Medical College. 


SAMUEL NICKLES, M.D...v.....0- Crncrnnatr, 0. 
Professor of Materia Medica, Medical College of 
Ohio. 


WILLIAM OLDRIGHT, M.D..... Toronto, CANADA. 
Lecturer on Sanitary Science, Toronto School of Med- 
icine ; Chairman Provincial Board of Health. 


FREDERICK N. OWEN, E.M...New York, N. Y. 
Civil and Sanitary Engineer. 


ROSWELL PARKA M.D esos BuFrFrato, N. Y. 
Professor of the Principles and Practice of Surgery 
University of Buffalo, N. Y. . 


THEOPHILUS PARVIN, M.D...PHILADELPHIA, PA. 
Professor of Obstetrics and Diseases of Women and 
Children, Jefferson Medical College. 


ABNER POST, (MA eee eee Boston, Mass. 
Surgeon to Out-Patients, Boston City Hospital. 


WILLIAM HENRY POTTER, A.B., D.M.D....Bos- 
TON, Mass. 
Demonstrator of Operative Dentistry, Harvard Dental 
School. 


T. MITCHELL PRUDDEN, M.D..NEew York, N. Y. 

’ Lecturer on Normal Histology, Yale College; Director 
of the Physiological and Pathological Laboratory. of 
the Alumni Association, College of Physicians and 
Surgeons, New York. 


LEOPOLD: BUTZER, M.D ee... New Yors, N. Y. 
Visiting Physician, Randall’s Island Hospital. 


HUNTINGTON RICHARDS, M.Dila..: NEw York, 
NAY: 


Aural Surgeon, New York Eye and Ear Infirmary ; 
Chief of Clinic, Department of the Ear, College of 
Physicians and Surgeons, New York. 


THOMAS G. RODDICK, M.D..MontTrea, CANADA. 
Professor of Clinical Surgery, McGill University ; Vis- 
iting Surgeon, Montreal General Hospital. 


J. WEST ROOSEVELT, M.D..... New Yorks, N. Y. 

Professor of the Principles and Practice of Medicine, 

in the Medical College of the Woman’s Infirmary, 

of New York; Visiting Physician to Bellevue and 
Roosevelt Hospitals. 


IRVING G.OROSSELO MD: os. o. WASHINGTON, D. C. 
EDWARD W. SCHAUFFLER, M.D...Kansas Crry, 
Mo 


Professor of the Principles and Practice of Medicine, 
Kansas City Medical College. 


WILLIAM T. SEDGWICK, Pu.D..... Boston, Mass. 
Assistant Professor of Biology, Massachusetts Insti- 
tute of Technology. 


NS BIC NN NDS DD deer orien MILWAUKEE, WIS. 

Attending Surgeon, Milwaukee Hospital ; Professor of 

the Principles and Practice of Surgery and of Clini- 

cal Surgery in the College of Physicians and Sur- 
geons, Chicago, II. 


CHARLES SMART, M.D........ WASHINGTON, D. C. 
Surgeon, United States Army. 
STEPHENGS MITA IM Dar cecum. New York, N. Y. 


Professor of Clinical Surgery, Medical Department of 
the University of the City of New York; Visiting 
Surgeon, Bellevue and St. Vincent’s Hospitals. 


LIST OF CONTRIBUTORS..TO VOLUME VI. 


M. ALLEN STARR, M.D., Ph.D..New Yorks, N. Y. 


Clinical Lecturer upon Diseases of the Mind and Ner- 


vous System, ‘College of Physicians and Surgeons, 
New York; Attending Physician, Nervous Class, 
Demilt Dispensary. 


THOMAS L. STEDMAN, M.D..... New York, N. Y. 


Late Attending Surgeon, New York Orthopedic Dis- 
pensary and Hospital. 


JAMES STEWART, M.D....... MONTREAL, CANADA, 
Professor of Materia Medica and Therapeutics, McGill 
University. 
THOMAS. DAS WIP? MDs... .. 35 New York, N. Y. 
Visiting Physician, Demilt Dispensary. 
SAMUEL THEOBALD, M.D........ BALTIMORE, Mp. 


Attending Surgeon, Baltimore Eye, Ear, and Throat 
Charity Hospital; Ophthalmic and Aural Surgeon, 
Saint Joseph’s General Hospital, Baltimore. 


PITGNYe  UPSON COLD Con. «cnet ee CLEVELAND, O. 


ARTHUR VAN HARLINGEN, M.D..... PHILADEL- 
PHIA, Pa. 
Professor of Diseases of the Skin, Philadelphia Poly- 
clinic and College for Graduates in Medicine: Con- 
sulting Physician, Dispensary for Skin Diseases. 


GEORGE L. WALTON, M.D......... Boston, Mass. 
Assistant in Out Patient Department for Diseases of 
the Nervous System, Massachusetts General Hospital. 


RUDOLPH AY WITTHAUS, M.D. New Yorn, N.Y. 
Professor of Chemistry, Medical Department of the 
University of New York. 


LEROY MILTON YALE, M.D..... New York, N. Y. 
Visiting Surgeon, Presbyterian Hospital. 
HENRY CRECY YARROW, M.D.....WAsHrINGTON, 

GEMS, ‘ 


A. A. Surgeon, United States Army ; Honorary Cura- 
tor, Department of Reptiles, United States National 
Museum ; Professor of Dermatology, National Medi- 
cal College, Columbian University. 


PHIDCPFARNNER GA Denis oainee cen CINCINNATI, O. 
Clinical Lecturer upon Diseases of the Nervous System, 
Medical College of Ohio. 


iis 


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ane 


A REFERENCE HANDBO 


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PR mera 


THE 


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PRAIRIE ITCH. This is an affection, or rather a 
group of affections, met with frequently in the northern 
and western portions of this country, but seldom seen in 
the Southern States, which has long been, and still is, a 
subject of much dispute among practitioners in the re- 
gions first mentioned, as to its nature, cause, and treat- 
ment. The literature of the disease is very meagre, and 
the views of those who have written concerning the 
affection are so at variance, that it is impossible to avoid 
the conclusion that they have seen and described differ- 
ent disorders, which have no other relation to each other 
than that they are all characterized by the one symptom 
of itching. 

The names by which these different forms of pruri- 
tus have been designated, are almost as numerous as the 
localities in which they have been observed. Among 
others may be mentioned, prairie digs, Michigan itch, 
Texas mange, lumberman’s itch, swamp itch, Ohio 
scratches, whore’s itch, army itch, winter itch, etc. 

A general description of the symptoms observed in the 
majority of these cases, as gathered from the articles on 
the subject published in various journals, chiefly of the 
West, is as follows: The affection begins usually rather 
suddenly, and is not preceded by any premonitory symp- 
toms. The patient is, apparently without any cause, at- 
tacked by an intense pruritus, confined usually to the 
parts covered by the clothing. The itching is worse at 
night after the sufferer has retired, though he is not en- 
tirely free during the day. The sensations are described 
as itching, burning, or tingling. There is said to be, 
at times, a papular eruption, followed by the appearance 
of vesicles, pustules, and sometimes urticarial wheals. 
After a time the evidences of scratching become visible, 
and most writers, indeed, regard all the lesions as the 
direct result of this form of irritation, believing that the 
affection is a pure pruritus, unaccompanied by any pri- 
mary lesions. Sometimes there are evidences of consid- 
erable dermatitis, the integument surrounding the lesions 
being of a bright scarlet hue, while a feeling of tension 
in the skin is complained of. The disease is said by 
some to be contagious, and many instances have been 
reported in which it seems difficult to exclude or explain 
away this element. On the other hand, others assert 
with equal confidence that no evidences of contagion are 
present, but that the pruritus occurs frequently in mem- 
bers of one family or community, simply because all are 
exposed to the same climatic conditions. It is said by 
some to occur only in those regions where the inhabi- 
tants are exposed to sudden and extensive variations of 
temperature. Others assert that it is as troublesome in 
milder climates and during the warmer seasons of the 
year, as it is in winter and in places where the tempera- 
ture of the atmosphere is subject to great changes. 

The affection is, by some, regarded as an eczema papu- 
losum ; others believe that the great majority of the 
cases are nothing more than pruritus hiemalis; some, 
again, look upon it as scabies pure and simple, while 
still others incline to the opinion that it is a disease sw 
generis, and due to the presence of a micro-organism in 


Vou. VI.—1 


Prairie Itch. 
Pregnancy. 


the layers of the skin. It is very probable that all of 
these different observers are right, and that there are sev- 
eral diseases grouped under the one name of prairie itch. 
Dr. J. N. Hyde, of Chicago, who has made a very care- 
ful study of pruritus hiemalis, believes that most cases 
of prairie itch are instances of the first-named disease, 
though he thinks that some cases of scabies, and pos- 
sibly of other forms of disease, are included by various 
observers under this common designation. Dr. J. E. 
Engsted, of Dakota, has described a parasite which he 
has found in cases of prairie itch. The organisms ap- 
pear as flattened cells, of varying lengths, arranged usu- 
ally in chatas of from five to twenty links, or as oval cells« 
with from four to twenty hooklets projecting from their 
sides. 

The treatment which has been recommended for prai- 
rie itch naturally varies according to the views that dif- 
ferent observers hold concerning the nature and cause of 
the disease. Those who believe that the affection is con- 
tagious and due to the presence of a parasite, whether 
animal or vegetable, advise the employment of one or 
other of the various parasiticides, such as mercurial or 
sulphur ointments, naphthol, carbolic acid, hyposulphite 
of soda, etc. The secret of success, they say, is in the 
persistent and thorough application of these remedies ; 
internal medication is without avail. Others, who re- 
ject the parasitic theory, also advise external applications, 
but of antipruritic rather than of antiparasitic remedies. 
Alkaline lotions, bismuth or starch powders, various 
preparations of carbolic acid, one part each of chloral 
and camphor in eight parts of unguentum aque rose, 
lead lotions, diachylon ointment, etc., are among the rem- 
edies of this sort which have been found more or less 
efficacious in different cases. Hyde insists upon regula- 
tion of the diet, and the avoidance of all articles of food 
or medicaments which are capable of exciting cutaneous 
rashes or of aggravating pruritic symptoms. Of course, 
strict cleanliness and the avoidance of underclothing 
made of rough and irritating material are very essen- 
tial points in the treatment, whatever the cause or the 
nature of the pruritus may be. 

During the fall of 1886, many short communications 
on prairie itch appeared in the medical journals of this 
country. The reader may find information of value in 
the issues at that time of the Detroit Medical Age, the 
Journal of Cutaneous and Venereal Diseases, the New 
York Medical Record, and other journals, chiefly those 
of the West. 

Much assistance in the preparation of this brief sketch 
has been derived from the several articles in these jour-. 
nals, and also from a pamphlet on ‘‘ The Affections of 
the Skin Induced by Temperature Variations in Cold 
Weather,” by Dr. James Nevins Hyde, of eee . 


PREGNANCY. Pregnancy is the condition of a 
woman who has within her the product of conception. 
It begins with fecundation, and ends with the expulsion 
or removal of the fecundated ovule, no matter how far 


1 


¥ 


Pregnancy. 
Pregnancy. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the process of development has been carried, nor how 
long after development has ceased the ovum has been 
retained. 

The word pregnancy, going back to its Latin etymology 
in the verb gigno, thence to the Greek yevvaw, and finally 
to the Sanscrit zan, or gan, carries with it as the essen- 
tial idea reproduction. But, on the other hand, the 
usual synonyms merely express one or another phe- 
nomenon of the pregnant condition. Thus, the English 
gestation, from the Latin gestatio, the German Schwan- 
gerschaft, and the Greek xveois, are each derived from a 
verb signifying in these different languages to carry ; 
the Latin graviditas, and the Italian gravidanza, indicate 
the increased weight caused by pregnancy, and the 
French grossesse the greater size. 

In normal pregnancy, the only variety which will be 
considered in this article, the fecundated ovule is 
developed in the cavity of the uterus—that is, the preg- 
nancy is uterine, not extra-uterine. The pregnancy is 
simple, or single, when only one ovum occupies the 
uterus; but if two or more, it is called multiple, or 
pluriparous. 

DURATION OF PREGNANCY.—AS has been indicated, a 
woman becomes pregnant when conception occurs, that 
is, if there is an actual union between the ovule and 
the spermatozoid, but when this occurs is one of nature’s 
secrets which probably she will never reveal, and hence 
the actual beginning of pregnancy we cannottell. Preg- 
nancy, an internal incubation corresponding with the 
external which occurs in fowls, continues until the foetus 
is best prepared to live external to the mother, and is 
usually regarded as lasting from about two hundred and 
seventy to two hundred and eighty days, or in other 
words, nine solar or tenlunar months. It is true that a 
foetus born some weeks earlier than the shorter period 
stated may live, and therefore is said to be viable, 
though the chances of living lessen as the normal period 
of pregnancy is receded from. Obstetricians have, until 
recently, fixed upon seven months of intra-uterine life as 
the period when viability begins. But occasional excep- 
tions have been observed, that is, children born at between 
six and seven months live; and as recently, by means of 
the cowveuse and gavage, the number of exceptions is in- 
creasing, Tarnier suggests that this period should be 
six months, thus corresponding with the civil law of 
France, which makes a child legitimate if born at the ex- 
piration of one hundred and eighty days after the time 
when impregnation by the husband was possible. 

CHANGES CAUSED BY PREGNANCY.—Two important 
series of changes result from pregnancy—the one belong- 
ing to the impregnated ovule, and the other to the 
maternal organism. The former changes have been 


_ presented elsewhere in this work, and therefore there 


will be considered in this article only those concerning 
the mother. 

The maternal alterations consequent upon pregnancy 
are conveniently divided into local and general. The 
former belong chiefly to the sexual organs, and will be 
first presented. 

Ohanges in the Sexual Organs.—These organs in the 
female include those of reproduction, and those of lacta- 
tion, and the alterations in each are to be considered in 
tracing the history of pregnancy. The most remarkable 
modifications occur in the organ of gestation, the uterus. 
It is the home for nine months of the new being, which 
in its rapid and marvellous development requires ample 
supply of nutritive material and constantly increasing 
room. But the uterus, in the earlier months or weeks of 
pregnancy, increases in size and capacity quite indepen- 
dently of any mechanical action of the ovum, for the 
latter is at first too small to produce such effects ; and 
also, the changes just mentioned are observed when the 
uterus is quite empty, that is, when the pregnancy is ex- 
tra-uterine. 

The first modifications occur in the mucous membrane, 
which undergoes hypertrophy and hyperplasia, and fur- 
nishes the external covering of the ovum, the deciduous 
membrane. This deciduous membrane admits of a three- 
fold division. First, that upon which the ovule rests, and 


2 


which contributes to the formation of the placenta; this 
has been known from the time of John Hunter as the de- 
cidua serotina, because it was believed to be formed after 
the other decidue ; second, that arising from the hyper- 
trophied folds of this tissue between which the ovule is 
placed, and which uniting over it, make a complete cov- 
ering, and which was called the decidua reflexa, because 
it was thought that the impregnated ovule entering. the 
uterus, pushed away an exudate which was supposed to 
be formed as a consequence of impregnation, and which 
completely lined its cavity ; and third, the decidua which 
occupies the rest of the internal surface of the uterus, 
but which in the latter part of the third, or early in the 
fourth, month of pregnancy unites with the decidua im- 
mediately covering the ovule, and is known as the 
decidua vera. 

The peritoneal investment of the uterus undergoes re- 
markable increase, for without being thinned it still 
covers the organ enormously increased in size at the 
end of pregnancy. 

The muscular tissue of the organ is greatly developed. 
Not only is there hypertrophy of already existing mus- 
cular fibres—these fibres becoming ten times longer and. 
five times broader—but there is an actual hyperplasia, 
new contractile tissue being formed. Blood-vessels and 
nerves also increase in size; the veins indeed, in certain 
parts of the uterine wall, become so enlarged that they 
are called sinuses ; hypertrophy of the lymphatics is well 
marked. The increased size of the uterus may, toward 
the end of pregnancy, result in part from passive stretch- 
ing of the tissues composing its walls; but early in the 
pregnant state these walls are thicker than in the unim- 
pregnated condition, and while the neck becomes greatly 
stretched and thinned, the fundus at the end of preg- 
nancy remains thick ; indeed, the entire wall of the body 
of the uterus may undergo even then no thinning in 
some cases. The weight of the uterus at the end of 
pregnancy is thirty-three times that of the nulliparous 
organ, eighteen times that of the parous. At this time 
its length is twelve inches and three-fourths, its breadth 
nine inches and a half, and its antero-posterior measure- 
ment nine inches, According to the late Sir James Simp- 
son, the surface of the unimpregnated uterus is five or six 
Square inches, and its capacity one cubic inch; but at 
the end of the pregnancy the former is three hundred 
and fifty square inches, and the latter four hundred cubic 
inches. 

Changes in the form and the position of the uterus 
result from pregnancy. In the virgin the organ is at 
first pear-shaped, but flattened antero-posteriorly ; the 
body of the uterus next becomes somewhat spheroidal 
in form, and finally the ovoidal shape is well marked, 
especially as the cavity of the neck contributes to the 
general uterine cavity, or in other words, effacement of 
the neck takes place ; the larger end of the ovoid is above. 
At first the impregnated uterus sinks somewhat in the 
true pelvis, though this generally received statement is 
disputed by Tarnier ; in the course of the fourth month, 
however, the increase in size of the organ is so great 
that there is not sufficient room in the pelvic cavity, and 
hence the uterus ascends; the process of ascension con- 
tinues until, at the middle of the ninth month, the fundus 
reaches as high as the lower portion of the ensiform car- 
tilage; and then, more especially if the subject be a 
primigravida, descent occurs, the presenting part of the 
foetus, still, of course, enclosed in the uterus, enters the 


‘pelvic cavity, and the upper part of the womb, while 


lower than it was, projects more in front, causing a nota- 
ble change in the form of the abdomen. In a multi- 
gravida the ascension is never so great, because the re- 
laxed abdominal walls do not compel so decided a change, 
nor does the descent toward the end of pregnancy occur 
so soon—indeed it may not be manifested until labor 
actually begins. Of course, in case of a mal-presentation, 
this phenomenon fails. The gravid uterus is seldom found 
in the median line, but is usually inclined toward one or 
the other, in the great majority of cases the right, side. 
So, too, in the development of the uterus there is a tor- 
sion of the organ, a movement upon its longitudinal axis 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Pregnancy. 
Pregnancy. 


by which the left side is thrown more anteriorly, while, 
ot course, the right recedes; this fact is of importance 
when auscultating for the purpose of hearing the uterine 
soufile, for this sound, being most distinct at the sides of 
the uterus, will be best heard at that side to which the 
stethoscope can be most readily applied. Uterine torsion 
is readily explained by reference to the embryological 
development of the organ. Lateroversion of the uterus, 
the inclination being usually, as has been stated, toward 
the right side, should be remembered in performing the 
Ceesarean section, for after opening the abdominal cavity 
it is important, in order that incision of the uterus shall 
be made in the median line, to press the organ from the 
side to which it is inclined so that it will occupy a cen- 
tral position. 

Changes in the properties of the uterus are to be con- 
sidered. While the walls of the unimpregnated uterus 
are firm and resisting, with the progress of pregnancy 
they become yielding and elastic, thus permitting 
momentary changes in form resulting from foetal move- 
ments, or from changes of position or other movements 
of the woman herself, or from external pressure. Fol- 
lowing these various modifications in shape, as for ex- 
ample, those caused by foetal movements, the uterus re- 
covers its normal form, partly as a consequence of its 
elasticity, and in part from its retractility. 

The sensibility of the uterus is only apparently, not 
really, increased ; the size of the organ being so much 
greater, the latter is more exposed, and then, too, it is 
liable to certain pathological conditions which are char- 
acterized by more or less suffering referred to it. The 
irritability of the uterus is greater in pregnancy ; the or- 
gan responds more readily to causes which excite the 
action of its muscular fibres, and in some subjects this 
reflex excitability is so decided that miscarriage is liable 
to result from comparatively trivial causes. But, on the 
other hand, this irritability in others is so slight that the 
greatest violences may be inflicted upon the subject with- 
out the pregnancy being interrupted. In consequence of 
the vast increase in the muscular tissue of the uterus, its 
contractile power is greatly augmented. This power is 
manifested first by what are known as the painless con- 
tractions of pregnancy, these contractions beginning as 
early as the fifth month, occurring at irregular intervals, 
and observed throughout the succeeding portion of preg- 
naney, and finally and chiefly by the contractions of 
labor, these contractions causing more or less suffering. 
The painless contractions of pregnancy are of importance 
in promoting the uterine venous circulation ; they pos- 
-sibly contribute in slight degree in maintaining the atti- 
tude of the foetus, as they are a factor in causing its po- 
sition. 

In addition to the changes already described, and 
which relate chiefly or exclusively to the body of the 
uterus, those occurring in the neck are to be mentioned. 
The neck of the womb undergoes only slight hypertrophy 
in pregnancy ; it is less abundantly: supplied with blood 
than the body is, and is not subjected to a stimulus from 
the growing ovum. The position of the neck depends 
upon the position of the body ; thus, if the latter be in- 
clined to the right side and anteriorly, the former will 
point to the left and backward. It should be remem- 
bered, however, especially if the subject be a multi- 
gravida, and the abdominal wall be greatly relaxed, 
there is in most cases more or less uterine anteflexion ; 
this comparatively frequent condition should be borne in 
mind in those instances in which a bougie is introduced 
into the uterus for the purpose of bringing on premature 
labor, or the same object sought by introducing dilators 
into the cervical canal; for harm may result, or simply 
difficulty, from the effort to force any of these bodies in 
that which is the usual direction of the canal in the non- 
pregnant. Apparent shortening of the neck results from 
the ascension of the body of the uterus in the abdominal 
cavity, but actual shortening, it is generally held, does 
not occur in the majority of cases until the latter part of 
pregnancy—in many instances, indeed, not until just be- 
fore the beginning of labor. 

Early in pregnancy a change in consistence of that 


part of the intravaginal cervix immediately adjacent to 
the external os occurs, the superficial tissues becoming 
softer. This softening advances regularly and slowly in 
the primigravida, until it involves the entire vaginal por- 
tion, so that, approximately, one-fourth is affected at four 
months, one-half at six, three-fourths at seven, and the 
remaining fourth is also softened at eight months. In 
the multigravida the process is more rapid, because the 
vaginal portion is shorter, and because it has once or 
oftener previously undergone the change. 

The form of the neck of the womb in the primigravida 
is at first more distinctly conical, but it soon becomes 
spindle-shaped from the accumulation of glandular secre- 
tions in the cervical canal; in the multigravida it is 
cylindrical, or somewhat expanded at its lower portion, 
so that it becomes club-shaped. The external orifice of 
the uterus in the former remains closed until the end of 
pregnancy ; in only very rare instances it may be more 
or less permeable by the finger in the latter weeks of 
pregnancy. In multigravide the external os is not sur- 
rounded by a uniformly smooth surface, but the border 
is irregular and fissured, the most distinct of the fissures 
being found in the majority of cases upon the left side ; 
the cervical canal is permeable by the finger to a distance 
directly related to the duration of the pregnancy, the 
finger readily passing to the middle of it at seven months ; 
the cavity which the canal presents is funnel-shaped, or 
we may regard the neck of the womb as a hollow cone 
with its base below. The vagina is elongated by the as- 
cension of the uterus; it is swollen, moister, its papille 
more distinct, and acquires a peculiar violet or purplish 
hue, arising from the increase of venous blood—this be- 
ing one of the signs of pregnancy first pointed out by 
Jacquemin, and the value of which has recently been 
urged by Chadwick ; greater arterial supply gives origin 
to the vaginal pulse, a sign of pregnancy which was 
pointed out by Osiander. The external genital organs 
are swollen, and have an increased secretion ; the inner 
surfaces of the vulva may show a similar, though less 
marked, change of color to that observed in the walls of 
the vagina ; varicose veins are found in some cases. 

The ovaries, in consequence of changes in the broad 
ligaments, ascend in the abdominal cavity, come nearer 
the uterus, and have an almost vertical direction ; they in- 
crease, according to Jacquemier, to about twice their: 
usual size ; ovulation, as a rule, is suspended, but the last 
corpus luteum undergoes remarkable hypertrophy, and 
disappears much later than that which follows menstru- 
ation without impregnation ; indeed, it has been found 
well marked in women dying during the lying-in period. 
The broad ligaments open up their peritoneal folds to 
receive between them the enlarged uterus, and become 
almost vertical; they increase in length and thickness. 
The round ligaments become greatly hypertrophied, so 
that they can be readily felt in thin subjects then, and 
also during labor. In consequence of the greater increase 
of the posterior than of the anterior wall of the uterus, 
their uterine insertion, instead of being median as to the 
sides of the uterus, is now at the junction of the posterior 
four-fifths with the anterior fifth of the lateral face of 
the uterus; their hypertrophy and change of position 
prepare them for their office during labor, drawing the 
superior part of the uterus forward and downward, thus 
causing the uterine axis to be brought in correspondence, 
during a ‘‘ pain,” with the axis of the pelvic inlet. The 
development of the round ligaments in pregnancy, one 
of them being usually larger than the other, may furnish 
a probable prognosis as to the vigor of uterine contrac- 
tions, for the greater that development, the greater like- 
wise is that of the uterine muscular tissue. 

The oviducts participate in the general hypertrophy, 
and, like the ovaries, occupy a vertical position. 

The changes in the mammary glands are very impor- 
tant and characteristic. In some instances the breasts 
become larger at the beginning of pregnancy, but in the 
majority of cases no increase in size occurs until at the 
time of the first menstrual suppression ; according to 
Zweifel, this enlargement probably depends upon accu- 
mulation of fat between the lobules, The breasts may 


3 


Pregnancy. 
Pregnancy. 


be the seat of occasional shooting pains, and there may 
be increased sensibility of the axillary glands. The super- 
ficial veins are larger and more distinct, their blue color 
strikingly contrasting with the whiteness of the skin; 
if the breasts are greatly enlarged, it is not unusual to ob- 
serve striz upon them similar to those found upon the 
abdominal wall. The latter part of the second, or in the 
third, month the nipple is found more prominent and 
sensitive, firmer and harder ; then, too, possibly a milk- 
like fluid may spontaneously escape or be pressed from 
it, though this phenomenon does not usually occur un- 
til in the last three months, and, on the other hand, in 
some instances, has been observed independently of preg- 
nancy. ‘The changes in the areola surrounding the nip- 
ple are very characteristic. First an apparently emphy- 


sematous swelling is observed, then an alteration in color 
corresponding to that of the hair and of the skin, and 
hence in blondes simply a deep rose color, and in bru- 
nettes a brown which grows darker with the progress of 
pregnancy : change in color is least in those having red 


rm ! 
Fi hy f 


i } 
‘. ‘ 
\ 


Yo 


Fre. 3083.—Changes in the Breast caused by Pregnancy. . 


hair, and in them may even be not apparent. Montgom- 
ery’s glands, the glandule@ lactifere aberrantes of Henle, 
notably increase in size, projecting from the sixteenth to 
the eighteenth of an inch. In addition to the primary 
areola, which has a radius of about one inch, a secon- 
dary areola surrounding it appears in the fifth or in the 
sixth month ; this is lighter in color and flecked with 
whitish spots, presenting an appearance similar toa piece 
of dusty-white blotting-paper upon which drops of 
water have fallen. The illustration given above shows 
very well the changes that have been described in the 
nipple, the development of the glands of Montgomery, 
the appearance of the primary areola, and the formation 
of the secondary areola. 

Disorders of urination are commonly observed during 
pregnancy. In the early weeks, in consequence of the 
pressure and sinking of the uterus, there usually is vesi- 
cal irritability, while in the last weeks the descent of the 
presenting part of the foetus into the pelvic cavity may, 
by pressure upon the urethra, cause ischuria. Pressure 
upon the rectum may produce constipation, though this 
is in many cases quite as frequently the result of the 


4 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


more sedentary habits of the woman when pregnant ; 
partly as the consequence of the hyperzemia of the pel- 
vic viscera generally, and partly from interruption by the 
enlarged uterus to venous return, hemorrhoids are not 
uncommon in the pregnant woman. 

The chief changes in the abdominal wall, in addition to 
its great stretching, are pigmentation over the linea alba, 
so that there is found a linea nigra, the formation of 
strie, and the ‘alterations in form of the umbilicus. The 
pigmentation referred to extends from the pubes to the 
navel, and, in some cases, above the latter, the discolora- 
tion then either forming a semicircle upon one side, or 
completely encircling it, before passing up toward the 
ensiform cartilage ; the distinctness and the depth of the 
color are in relation to the color of the subject, and 
hence much more pronounced in the brunette. Abdomi- 
nal strie, the so-called cicatrices of pregnancy, occupy 
each side of the abdominal wall below the umbilicus, 
and are arranged in a series ; they are in almost all cases 
present in first pregnancies, and it is not uncommon 
to find new ones in the multigravide. When recent 
they are a deep rose color, sometimes they are purplish, 
but after labor they become white or pearl-col- - 
ored; generally the surface is depressed, but in 
some cases, as the result of serous effusion from 
compression of the epigastric vein, it is promi- 
nent. These strive are the consequences of par- 
tial or complete atrophy of the lymph-spaces, 
partial atrophy of the skin, and longitudinal 
arrangement of the fibres of connective tissue. 
They may be absent in women who have borne 
many children, and they may be present in 
women who have never been pregnant; such 
instances, however, are exceptional. 

During the first three months of pregnancy 
the umbilical depression is slightly increased, 
or remains unchanged; in the fifth month it 
is found notably lessened, and at seven months 
|. has disappeared ; in the last two months there 

| is more or less protrusion. 

General Changes caused by Pregnancy.— 
Among the most important and earliest of the 
changes in the organism are those affecting the 
digestive organs. Gastric disturbance occurs in 
the first months of pregnancy in almost all 
cases. In some it may be so slight as scarcely 
to be an indisposition, only a transient discom- 
fort ; but in others so severe as to be a grave 
disease. From the fact that the nausea and vomiting are 
more frequent in the early part of the day—in some cases 
limited to this time—the condition is commonly called 
morning-sickness. Generally this disorder disappears 
after the first four months, but later in pregnancy there 
may be gastric irritability, caused by pressure of the 
uterus upon the stomach. 

Both quantitative and qualitative changes in the blood 
occur in pregnancy. That there is an actual increase in 
the quantity of blood is proved by the larger area of the. 
circulation and by the fulness of the vessels, a fulness 
which may contribute to the development of varicose 
veins, or to serous effusion. There is an increase in the 
watery portion of the blood and of the white cells, but a 
decrease in the albumen, the red corpuscles, and iron ; the 
fibrin, normally 3 parts to 1,000, lessens until the sixth 
month, when it begins to become greater, and at the end 
of pregnancy is 4.38. Increased work is thrown upon the | 
heart to send a larger quantity of blood through a 
larger area, and a consequent hypertrophy, involving 
especially the left ventricle, occurs.* The ascent of the 


* Larcher, in 1857, first made known the fact of cardiac hypertrophy 
in pregnancy. He stated that this hypertrophy occurred chiefly in the 
left ventricle, its walls becoming one-fourth thicker at least, one-third 
at most. Ducrest confirmed the inyestigations of Larcher, and Blot 
further proved that the heart increased more than one-fifth in weight. 
Lohlein, among others, on the other hand, maintained that the cardiac 
hypertrophy of pregnancy does not exist. Zweifel states that the thor- 
ough investigations of Miiller, of Jena, led him to conclude that this 
hypertrophy does occur, though not to the extent asserted by Larcher 
and others; and that the cardiac increase corresponds to the general 
increase of the body, for in every such increase the heart’s muscular 
mass has a proportional increment, 


4 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


diaphragm lessens the pulmonary capacity, so too the 
antero-posterior measurement of the chest decreases ; but 
there is a compensating increase in the transverse measure- 
ment ; nevertheless, it seems doubtful if there be complete 
compensation, for the pregnant woman, when the uterus 
interferes most with the descent of the diaphragm, is liable 
to suffer from hurried breathing, as in rapid walking or 
in ascending steps. Resulting from the greater quantity 
of the blood and the greater arterial tension, the quantity 
of urine secreted increases ; this increase is almost ex- 
clusively of its watery portion ; all the solid constituents, 
with the exception of the chlorides, progressively lessen 
with the advance of the pregnancy. Nauche, in 1881, 
described what was at first thought to be an organic sub- 
stance found upon the urine of pregnant women about 
thirty-six hours after it was passed, and which received 
the name of kyesteine, since it was regarded as charac- 
teristic of the pregnant condition; this is a soft, gru- 
mous, white pellicle, which about the fifth day breaks 
up and falls to the bottom of the-vessel. So far from 
being an organic substance, it is chiefly composed of am- 
monio-magnesian phosphates, vibrions, and monads; it 
may be found upon the urine of the non-pregnant, as 
well as upon that of the male. Itis not uncommon for 
the urine to be albuminous, especially in the latter part 
of pregnancy ; but if this be slight, and caused by vesi- 
cal catarrh,-the condition need give no anxiety. Still 
more rarely, sugar is found in the urine toward the end 
of pregnancy, and is simply significant of the elimination 
of milk-sugar ; true diabetes mellitus is rarely seen in 
pregnant women. According to the observations of Ro- 
kitansky, 1888, in more than one-half of pregnant women 
there are bone-like deposits upon the internal table of 
the cranial bones, and external to the dura mater, which 
he called osseous neoplasms or osteophytes. Similar de- 
posits have also been found upon the internal surface of 
the pelvic bones of women dying in childbed. While 
these deposits are not exclusively found in connection 
with pregnancy, for they have also been observed in the 
tuberculous, yet they are more frequent in the former 
than in any other condition. 

The spleen and also the thyroid gland increase in‘size ; 
it is probable, too, that the kidneys become somewhat 
larger in pregnancy. 

Pregnancy causes greater nervous sensibility, and 
hence various reflex nervous disturbances may occur. 
Neuralgic affections, especially involving one or more 
teeth, are not uncommon; often the severe toothache 
may require, or be thought to require, extraction of the 
’ painful organ, and women who have borne many chil- 


dren will sometimes say that every child has cost them a’ 


tooth. Many women are despondent and a prey to 
gloomy thoughts or grave apprehensions of danger, and 
in some actual insanity occurs; but in the majority of 
instances of mental derangement hereditary influence is 
the important factor, pregnancy being merely the exciting 
cause. 

A woman’s weight increases about one-thirteenth dur- 
ing pregnancy, this increase being greatest in the last 
three months—being from one kilogram anda half totwo 
kilograms (from 4 to 54 pounds) each month. 

MuutTipLE PrReGNANCY.—When two or more fecun- 
dated ovules occupy the uterus, the pregnancy is called 
multiple, or pluriparous. 

Twin pregnancy occurs once in 90; triple, once in 
7,900 ; and quadruple, once in 870,000—though Neefe, 
quoted by Zweifel, makes the latter proportion 1 to 
560,000 ; quintuple pregnancy is of course exceedingly 
rare. The frequency of pluriparous births varies in dif- 
ferent countries, and, contrary to the opinion of Pliny, 
such births are not more frequent in warm climates ; 
thus they occur oftener in Denmark and Sweden than 
-in France and Belgium. 

The sex of the children is the same in sixty-four per 
cent., different in thirty-six per cent. ; 

Multiparity and heredity seem to be the most important 
factors in the production of multiple pregnancy ; but in 
addition to these, other causes apparently are great stat- 
ure, race, and the size of the ovaries. 


Pregnancy. 
Pregnancy. 


_ In pluriparous inferior animals fecundation of ovules 
is simultaneous, and probably this is the fact in multiple 
pregnancy in the human female in the majority of cases; 
nevertheless there are a few instances recorded where 
the fecundation was successive, so that it may be admit- 
ted that a woman who has already conceived may, while 
that product of conception remains, conceive again—in 
other words super-impregnation may occur. But super- 
impregnation includes super-fecundation, and super- 
foetation. By the former is meant the fructification of 
ovules liberated about the same time, and by the latter 
the -fructification of ovules escaping at an interval of 
weeks or even of months, an hypothesis that is generally 
rejected ; this rejection rests upon physiological and ana- 
tomical grounds. First, we have reason to believe that 
ovulation is suspended during pregnancy. Just asthe hen 
does not lay eggs after she has begun setting, so the 
human female does not, while the process of internal in- 
cubation is going on, furnish any new ovules for impreg- 
nation. Then, too, between the third and fourth months 
the decidua covering the ovum and that lining the 
uterus are fused into a single membrane, so that ascen- 
sion of the spermatozoids to the usual seat of impregna- 
tion is impossible, and also, entrance of the ovule, im- 
pregnated or not, into the uterus is for a like reason 
impossible. Therefore, while that variety of super-im- 
pregnation known as super-fecundation is admitted, the 
other, super-foetation, is in the highest degree improbable, 
and after the fusion of the deciduous membranes, impos- 
sible. There is not space in the present article to con- 
sider and to answer the facts adduced in favor of the 
latter hypothesis. 

In order that twin conception may occur, there may 
be, first, two ovules furnished by two ovisacs, both of 
the latter belonging to one ovary, or one from each ovary ; 
then there will be two corpora lutea. Second, one ovisac 
may contain two ovules; this is not a mere hypothesis, 
for some observers have found an ovisac with even three 
ovules. Third, there may be two germinal vesicles in a 
single ovule, or the blastodermic membrane may divide 
into two. If the twins come from a single ovule, they 
are of the same sex. 

In the first variety the twins are enclosed in separate 
sacs, the walls of which are made each of an amnion and 
of a chorion; originally each sac had its separate decid- 
ual investment, but pressure caused absorption of the in- 
tervening decidual walls, so that then a single decidua 
covers them. The placentez are completely separate, or 
united only by a membranous band, but in either case 
there is no vascular anastomosis. Yet it may also happen 
that, though the twin conception results from two ovules 
coming from different ovisacs, there is a common cho- 
rion, but separate amnions, and the explanation proposed 
is that originally each had its own chorion, but, as stated 
in regard to the two decidusze becoming one, the interven- 
ing double chorion wall has undergone absorption. In 
these cases the placentze make a single mass, but ordinar- 
ily the vessels do not anastomose. If the twins originate 
from a single ovule they are enclosed in a common sac, 
but of course originally each twin had its own amnion ; 
for that is a production from the embryo, and the fact of 
there being a common sac has the same explanation as 
that which has been given for the presence of a common 
decidua and acommon chorion. The placentse form a 
single mass, and the blood-vessels anastomose. Accord- 
ing to Schatz (Archiv fiir Gyndcol., Band xxxii.), usually 
there remains but one anastomosis, and that arterial ; 
sometimes there is also a venous anastomosis, and rarely 
two of each. 

The weight and size of twins is usually under the aver- 
age; very frequently one is larger than the other ; in 
some cases a twin dies in the course of the pregnancy, 
while the other reaches complete development ; premature 
labor is frequently observed in twin pregnancies, still 
more is it the rule in other varieties of multiple pregnancy. 

The diagnosis of pluriparous will be considered in 
connection with that of single pregnancy. 

DIAGNOSIS OF PREGNANCY.—This is a subject of very 
great importance with reference to the reputation of the 


5 


Pregnancy. 
Pregnancy. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


physician, and hence the honor of medicine, because the 
two are indissolubly united ; but especially with reference 
to the reputation of the woman, supposing her to be 
falsely accused, and it may be with reference to her 
health, and in some cases her life even is at stake. The 
physician is liable to be deceived by false statements 
made by the woman herself ; in some cases she herself is 
deceived, but in others she means to mislead, either for 
the purpose of concealing a true pregnancy, or else with 
the design of extorting money from the alleged father 
of her unborn offspring, or to secure an interest in an 
estate. 

In the study of the signs of pregnancy, attention is 
first given to those of which the woman may inform us, 
then to those which we obtain by actual examination, the 
latter being such as we learn by the eye, by the ear, and 
by the sense of touch. ‘The former are called subjective 
and the latter objective ; probability only is given by sub- 
jective, but certainty by objective, signs. 

The absence of menstruation, morning-sickness, in- 
crease in the size of the breasts, occasional pains in them, 
and their secretion taking place, the abdomen growing 
larger, and the sensation of quickening—that is, the moth- 
er’s consciousness of the first foetal movements—and the 
repetition from time to time of these movements, consti- 
tute the chief evidences of pregnancy which can be given 
by the woman herself. But there may be an amenorrhea 
independently of pregnancy, or a girl may become preg- 
nant before she has menstruated, or a woman during the 
temporary and normal absence of the periodic flow, as 
when she is nursing. On the other hand, there may be, 
especially in the early months of pregnancy, a bloody 
discharge from the uterus occurring periodically, which, 
though not menstruation, but a threatening of miscar- 
riage, may be mistaken for the former. It should also be 
borne in mind that under the intense desire to be preg- 
nant, or, on the other hand, the great fear of such condi- 
tion, there may be what, from its etiology, has been ap- 
propriately termed psychical amenorrhcea. Nausea and 
vomiting, simulating the morning-sickness, may result 
from other causes, such as gastric disease, or reflex dis- 
order. Enlargement of the abdomen may occur from 
neoplasms, or hypertrophies of normal tissues, or from 
ascitic disease. Some at least of the changes in the 
breasts that have been mentioned as occurring in preg- 
nancy, may be the consequences of disease in the pelvis 
or abdomen, ¢é.g., they may occur in connection with the 
development of ovarian tumors. So faras the perception 
of foetal movements by the subject herself is concerned, 
a womdn may believe she recognizes them and be utterly 
mistaken, even though she has had the experience of such 
movements in several pregnancies. It is thus seen that 
none of these signs are positive proofs of pregnancy ; the 
combination of two or more will make the event very 
probable, but even should they all be asserted to be pres- 
ent, the physician must not rest his diagnosis upon them, 
especially as certain signs are available. 

In studying the objective signs of pregnancy we may 
conveniently divide them into those addressed to the 
sense of sight, of touch, and of hearing. 

1. Inspection.—This includes observing the carriage, 
countenance, the breasts, the abdomen, and the vagina. 
The pregnant uterus, especially in multigravide in whom, 
from the relaxation of the abdominal walls, the enlarged 
organ falls forward, compels the woman to throw the 
shoulders farther back to compensate for the increased 
weight in front, and hence a change in the spinal curve. 
The face may show pigment deposit upon the forehead 
and the cheeks, constituting, when great, what has been 
called the mask of pregnancy. The face may be haggard 
and anxious, and the fulness of the features lessened, 
more especially in a pregnant woman who has suffered 
greatly from nausea and vomiting; but it has not the 
emaciation, the lines descending from the angles of the 
mouth, and other manifestations characteristic of the ova- 
rian face. The breasts may be examined with reference 
to increased size, the presence of milk and of strive, and 
the prominence of the nipple; and as to the changes in 
the areola, its swollen condition, development of Mont- 


6 


gomery’s glands, and darkened hue; if the fifth month 
of supposed pregnancy has passed, the secondary areola 
will be in process of formation. The abdomen may be 
observed as to increase in size, as to the changes in the 
umbilicus, the presence of the linea nigra, and of striz, 
and in regard to the latter as to whether they are old or 
recent. The chief object in examining the vagina is to 
ascertain whether it shows the peculiar coloration to 
which Jacquemin, and more recently Chadwick, have at- 
tached such importance as an evidence of pregnancy. 
The latter, who has given much study to the subject, 
makes the following statement in the ‘‘ Transactions of 
the American Gynecological Society,” vol. xi.: ‘‘ The 
color begins as a pale violet in the early months, becomes 
more bluish as pregnancy advances, until it often assumes 
finally a dusky, almost black, tint.” He further states in 
reference to the cases examined by him, ‘‘ that, while 
in the majority of cases the bluish tinge appeared over 
the whole vaginal entrance, there was a fair proportion 
in which the violet tint was confined to the anterior wall 
of the vagina, just below the urinary meatus, whence it 
shaded off into the normal pink color laterally. This, 
when distinctly perceptible, I soon found to be, in my 
practice, an absolutely sure sign of pregnancy. ‘There 
were, furthermore, a very few in whom the blue tint 
was universal, but more accentuated on the posterior wall 
of the vaginal entrance, which I found was valueless as 
a sign of pregnancy unless the color was quite deep. 
The recognition of this peculiar localization of the blue 
tint on the anterior wall as a sure sign of pregnancy, I 
feel is the most important new point in this communica- 
tion.” 

2. Touch.—Obstetric touch is usually applied to an ex- 
amination made with one or more fingers, introduced into 
the vagina for the purpose of diagnosis. But the term 
should be given a far wider signification ; we touch, 
whether the entire hand or only a single finger be em- 
ployed, and so it is an appeal to the same sense, whether 
the application be made to the abdominal wall or through 
one of the canals opening from the lower part of the 
body—chiefly the vagina, more rarely the rectum, and 
still more rarely the urethra. To the application of the 
hand or hands to the abdomen the term external exami- 
nation, or abdominal palpation, is given; internal and ex- 
ternal examination may be made at the same time, the 
one assisting the other, and then the method is sometimes 
called the combined examination. By abdominal palpa- 
tion we may recognize the uterus enlarged by pregnancy 
from its form, from its being the seat of intermittent con- 
tractions, from its containing within it a mobile body, 
the mobility being either spontaneous or communicated ; 
we may distinguish different parts of that body—the feet, 
the back, the head, and the pelvis.. Palpation is usually 
done with the woman lying upon her back, the head and 
shoulders slightly elevated, and the lower limbs moder- 
ately flexed, so that the abdominal wall is somewhat re- 
laxed; it is important that the bladder and rectum shall 
have been recently emptied ; the abdomen should be ex- 
posed as far down as the mons veneris. The examiner, 
his hands having been carefully washed and warmed, 
standing with his back toward the woman’s face, and 
supposing him to be on the right side of the bed,* applies 
the left hand upon the hypogastrium, first gently, then 
presses with some firmness, this pressure being most 
marked at the ulnar side and made just as he is about to 
raise the hand to place it a little higher upon the ab- 
domen. The ascending movement is made, similar press- 
ure follows, and thus the manipulation is continued un- 
til the ulnar side suddenly meets with a marked lessening 
of resistance, so that it sinks, readily depressing the ab- 
dominal wall at that point, and the hand circumscribes 
the fundus. 

Another method of beginning palpation, and by which 
the lateral boundaries of the uterus are first defined, is to 


* By some it is advised to begin abdominal palpation by pressure with 
two hands upon various parts of the abdomen, so as to accustom it to such 
contact, and prevent contractions of its muscles; but this preliminary 
manipulation may be omitted in most cases, and direct exploration at 
ounce made, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


place the palms of the hands in contact directly in the 
* median line upon the lower part of the abdomen, as 
represented in the subjoined cut (Fig. 3085). Then the 
hands are gradually separated, the ulnar margin pressing 
downward upon the abdominal wall, until, having reached 
the sides of the uterus, they readily sink, and include be- 


tween them this organ. It is not then difficult to have 
them pass farther and farther upward upon the side of 
the uterus, until the fundus is reached and can be cir- 
cumscribed. 

Dr. Braxton Hicks claims that if the uterus be exam- 


| 
\ ok oa i 


Fie. 8085.—Application of the Hands in the Median Line. 


if it be firm at first ; each contraction lasts from two to 
five minutes, and they are seldom separated by so long 
an interval as thirty minutes: he has found this sign as 
early as the last of the third month. 


Pregnancy. 
Pregnancy. 


At five months the walls of the uterus have become so 
elastic and depressible, and the foetus is so developed, that 
it can be recognized by palpation if the abdominal walls 
are not too thick. In this examination some parts of the 
uterine tumor readily yield, while others are resistant, 
and the latter may in some cases be recognized by con- 
tinuing the manipulation on one part of the foetus ata 
time; most probably in the lower part of the abdomen 
the head may be felt. 

Passive movements may be given the fcetus, or part of 
it, and to such movements the term abdominal ballotte- 
ment is given. Usually, in performing ballottement the 
woman lies upon her back, and the operator’s hands are 
placed upon each side of the uterus; one hand is used to 
press away the foetus toward the opposite side, or motion 
may be given to a part of the fcetus, as the head, and 
then the manceuvre is called cephalic ballottement (Fig. 
3088). The late Dr. Albert H. Smith gave the following 
description of his method of performing external biman- 
ual ballottement : The woman is placed upon the edge 
of the bed with her clothing removed from the abdomen, 
and then rolled upon her side so that the anterior abdom- 
inal wall projects over the edge of the bed; then the 
rotation of her body is carried still farther, 
until the enlarged uterus becomes so dependent 
that it may be supported by the hand placed 
beneath it, while the other hand makes counter- 
pressure upon the opposite side of the uterine 
mass. Thus let the woman be upon her left 
side, the right side, therefore, being above; the 
examiner takes his seat with his face toward 
her head, his left side being toward the pendent 
abdominal mass, but about opposite the hips. 
The right hand is then passed far under the 
uterus as it projects over the bed, the palmar 
surface being in contact with the abdominal 
integument and the ulnar edge toward the iliac bone. 
The left hand is then placed similarly upon the right side 
of the abdomen, making counter-pressure upon the oppo- 
site side of the uterine body so as to grasp it between the 
two palms. This gives a full command of the tumor, 
and enables the examiner to apprehend the shape and 
density of the mass, its fluctuating character, the move- 
ment of a separate body in it, which can be operated 
upon by manipulation and repercussion. 


| 


! 


ll 


Fie. 3086.—Application of the Hands to the Sides of the Uterus. 


Spontaneous movements of the foetus, which can be 
readily recognized, are almost certain to occur during 
abdominal palpation, if the pregnancy has advanced to 
five months ; these movements may be of the entire body 
or of a member, and in the latter case they are short, 


7 


Pregnancy. 
Pregnancy. 


quick taps, for the moment causing a projection at that 
part of the uterine wall against which the blow is given, 
and hence may be seen as well as felt ; if the entire body - 


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Fic. 8087—The Fceetal Head included between the Examiner’s Hands. 


moves the motion is slow and gliding, and there is no 
sudden localized change in the form of the uterus. 

By palpation it is possible in most cases, when the 
pregnancy has advanced to seven months, to recognize 
different parts of the foetus, as, for example, the head 
and the breech with the intermediate back, and also 
parts of the lower limbs. 

By the vaginal examination we chiefly seek to learn 
the form, position, size, and consistence of the vaginal 
neck, and condition of the external os and cervical canal. 
It isin almost all cases made with the woman lying upon 
her back and the lower limbs moderately flexed. The 
index-finger of the right or of the left hand is generally 
employed; by using the medius also a gain of a little 
more than a third of an inch is secured, but the intro- 
duction of two fingers may in some cases be very pain- 
ful, and a single finger has a greater facility of move- 
ment, and also more clearly defined sensation. Softening 
and some enlargement of the neck of the uterus will be 
ascertained in case the woman be pregnant, and suppos- 
ing an antero-lateral inclination of the body of the uterus, 
the neck is found pointing in an opposite direction. The 
os in the primigravida is round, instead of being a trans- 
verse depression ; but in almost all cases the tip of the 
finger cannot enter it, or if it does, is arrested soon after 
entrance. On the other hand, the os in the multigravida 
presents an irregular border, marked by fissures and in- 
tervening prominences, the fissures being most distinct 
upon the sides, and the cervical canal is open to a degree 
in direct relation with the period of pregnancy—the fin- 
ger, for example, readily passing to the middle of the 
canal at seven months; the cavity thus entered is funnel- 
shaped. 

Vaginal ballottement is performed with the subject ly- 
ing, or standing. If in the former position, it is well to 
press upon the hypogastrium with the free hand, so as 
to force the lower portion nearer the index-finger of the 
other hand ; or in this case the index and medius may 
be introduced into the vagina, placed either in front of 
the cervix or behind it, the latter position being usually 
preferred ; the finger or fingers are made to press firmly 
against the uterus and upon the fcetal part resting on 


8 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the latter, and quick pushing upward is made, the move- 
ment being thus communicated to the foetal part, which 
is for the moment displaced, but afterward returns to its 
former position ; the movement of return is less dis- 
tinct than that of displacement, and possibly may fail 
to be recognized. If the woman’s shoulders and head 
be well elevated, the finger may be placed in front of 
the cervix, the position also selected should she be 
standing. The latter part of the fifth month is as 
early as vaginal ballottement can, as a rule, be success- 
fully made, but this sign becomes most distinct at six 
or seven months. By combining vaginal touch with 
abdominal palpation the continuity of a doubtful tu- 
mor felt in the abdomen with the cervix is proved ; 
so, too, this pressure upon the uterus through the ab- 
dominal wall facilitates vaginal examination of the 
part of the organ accessible to the finger or fingers. 

Abdominal pressure is also combined with digital 
examination through the rectum for the recognition of 
Hegar’s sign, an early softening and relaxation of that 
portion of the uterus immediately above the attach- 
ment of the utero-sacral ligaments, or the posterior 
portion of the lower uterine segment. 

3. Obstetric Auscultation.—This is a discovery 
of the present century. In 1818, Mayor, of 
Geneva, examining the abdomen of a pregnant 
woman, first heard the sounds of the feetal heart, 
and three years later Kergaradec, of Lausanne, 
ignorant of the prior success of Mayor, made 
the same discovery. In addition to this sound 
Kergaradec also heard a bruit to which, having 

\ ‘> an erroneous hypothesis of its cause, he gave the 
\ name of placental souffle, a name which some 
writers still use, in spite of the error long ago 
disproved, instead of calling it the uterine souffle. In 
addition to these sounds, others may be heard, such as 
the funic souffle, and those caused by the movements of 
the feetus ; but the first two are the most important, and 
they only will be here considered. 
The room in which auscultation is made should be 


\ 
s 
\ 
é 
, 
as 
1 


F1a. 8088.—Cephalic Ballottement. 


quiet, the woman lying upon her back, a pillow under 
her head, the lower limbs only slightly flexed, if not ex- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Pregnancy. 
Pregnancy. 


tended, the abdomen naked—though a thin, unstarched 
muslin or linen covering will in most cases not interfere 
materially with the examination ; as a rule, a stethoscope 
should be employed, not only from motives of delicacy, 
but also for the more certain limitation of the part where 
certain sounds are heard, and because the ear cannot be 
readily applied to certain portions of the abdomen where 
it may be necessary to listen ; nevertheless, the pressure 
of a stethoscope may in some cases be painful, while the 
direct application of the ear is readily tolerated, or, again, 
some may be able to hear more readily without than with 

-aninstrument. This examination may be made as early 
as the last of the fourth month, but for the majority of 
practitioners, probably, the proofs thence derived of preg- 
nancy will not be distinctly obtained until some time in 
the fifth month. 

The part to which the stethoscope should be applied 
will be determined by the period of pregnancy, and by 
whether the sounds of the foetal heart or the uterine souffle 
is sought. Should he seek the former, the pregnancy 
being only four or five months advanced, he will generally 

best succeed by placing the instru- 
A2~, ment, in or near the median line, 
“8 upon the fundus of the uterus, and 
Y in a position approximating the 
Ses GY axis of the pelvic inlet; but if the 
jg examination be made in the last 


three months, the uterus having 
now its ovoidal form, and the long 
axis of the foetus corre- 
sponding with that of 
the organ which it oc- 
cupies, then he should 
listen at one of the four 
points, in order, D, C, 
A, and B (see Fig. 3089). 

Obviously, the fcetal 
heart-sounds will be 
heard most distinctly 
through the back of the 
fetus, for the dorsal 
plane of the fcetus by 
its convexity is better 
adapted to the concavity 
of the internal uterine 
wall, and besides, with 
the superior members 
folded over the anterior 
chest, the heart is con- 
sequently made more 
remote; and, finally, the 
lungs being not expand- 
ed, the heart-sounds are 
heard posteriorly better 
than after pulmonary 
respiration has begun. 
As in the great majority of cases the head is in the 
lower part of the uterus, the foetal heart-sounds will be 
heard most distinctly at some point below a transverse 
line upon the abdomen passing through the umbilicus. 
But still more, as in by far the greater number of in- 
stances the occiput of the foetus is.in the left side of the 
pelvis, usually directed toward the left ilio-pectineal emi- 
nence, these sounds are most frequently heard with the 
greatest distinctness upon the left lower of the four spaces 
into which the abdomen of the mother is supposed to be 


Fra. 3089. 


divided (see Fig. 3089), and usually at a point correspond- . 


ing to the middle of a line drawn from the umbilicus to 
the left ilio-pectineal eminence. But if not heard satis- 
factorily at this place, or in its vicinity, corresponding 
positions upon the opposite side should be tried. All 
these failing, the two upper divisions should be examined, 
for the head, instead of being below, may be above—in 
other words, there is a pelvic presentation. So much of 
an explanation seemed necessary, though in consequence 
of it there is suggested a part of the diagnosis of presen- 
tation by this means, in regard to the parts of the abdom- 
inal wall to which the stethoscope should be applied in 
listening for the fetal heart. The mean frequency of 


the pulsations of the fetal heart is, according to some, 
140, but according to others, 135 ; temporary variations, not 
only in the frequency, but also in the force, of these pul- 
sations are common. The sound is double and rhythmic ; 
the first bruit is the clearer and more distinct ; a brief 
pause ensues, and the second is heard, which is followed 
by a longer interval before the double bruit is repeated. 
The uterine souffle is usually heard best at the lower 
part of the uterus and at its sides, especially the left, 
which, for reasons previously given, is brought nearer 
the anterior abdominal wall. This sound is synchronous 
with the mother’s pulse, but without shock ; it is some- 
what similar to the sound heard when the stethoscope is 
applied to a varicose aneurism, but it varies with the 
pressure made by the instrument, with uterine contrac- 
tions, and from one time to another, and with the dif- 
ferent parts examined, and it is usually not harsh. It 
may be heard earlier than the sounds of the fcetal heart, 
in some cases at the beginning of the third month. But 
it is not a conclusive, only a probable, proof of preg- 
nancy. This, as well as the fact that the placenta is 
foreign to its production, is proved by the following 


Fre. 3090. 


facts: It may be heard in many cases in which the uterus 
is greatly increased in size from fibroid disease ; it is also 
heard, in nine cases out of ten, two to three days after 
labor. 

The conclusive proofs of pregnancy are hearing the 
sounds of the foetal heart, feeling—possibly, also, seeing 
—fcoetal movements, and recognizing the fetus by pal- 
pation. 

Diagnosis of Multiple Pregnancy.—Practically, this dis- 
cussion may be limited to the diagnosis of twins in the 
uterus, for the other varieties of pluriparous pregnancy 
are comparatively very rare. Among the probable signs 
are greater development of the uterus than in single 
pregnancy; this development is unsymmetrical, a verti- 
cal furrow dividing the organ apparently in two parts ; 
the abdomen appears to be especially distended at the 
sides ; foetal movements are observed at different parts 
of the uterus, and, finally, the accidents of pregnancy are 
more frequently observed. The subjoined illustrations 
from Budin show how fallacious some of the proofs of 
twin pregnancy may be. In the first the positions usu- 
ally occupied by the foetuses are given ; both may pre- 
sent by the head, or both by the pelvis, or one by the 
head and the other by the pelvis ; but whatever the pres- 
entations, the foetuses are usually side by side. But in 


9 


PLCEEANSY: REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Pregnancy. 


the second drawing one fetus is in front, and in the | by auscultation will be presented in those cases in which 


third, one is above the other. the twins occupy the unusual positions as given in 
The only certain proofs of twin pregnancy are given | Figs. 3091 and 3092. 
by abdominal palpation and auscultation. Thus, by the Differential Diagnosis of Pregnancy.—It is important to 


Fra. 3091. 


former two heads may be felt in different parts of the 
uterus, and by the latter two fcetal hearts are heard, with Fie. 3093. 

maxima of intensity in different parts, also, of the organ. 

These sounds differ in frequency ; the difference may be | refer to some pathological conditions which may be con- 
founded with pregnancy, and briefly state the means 
by which error may be avoided. Hamatometra : The en- 
largement of the uterus is slower, and occurs by sud. 


Fie. 3092. Fig. 3094, 


only six or eight, or it may be ten or fifteen, but it is | den, not by gradual, increase, and this sudden increase 
always present. is at more or less regular intervals. Neither vaginal nor 

It should be remembered, however, that very great | abdominal ballottement is possible, and obstetric palpa- 
difficulty in making the diagnosis of twin pregnancy | tion and auscultation give negative results. Uterine 


10 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Fibroids : These are slower in development, and the 
uterus is hard instead of elastic, and generally irregular 
in form ; menstruation, instead of being absent, is usually 
abnormal, there being menorrhagia, and there may be 
likewise metrorrhagia ; by vaginal touch, absence of the 
changes in the cervix and os characteristic of pregnancy, 
often, too, some portion of the hard, irregular fibroid, may 
be felt ; abdominal palpation and auscultation give nega- 
tive results, except that by the latter the uterine soufHle 
may in many cases be recognized. Ovarian Tumor: 
Usually slower in development, and if of considerable 
size, marked impairment of general health with con- 
siderable emaciation ; the history of the growth, if it can 
be obtained, shows that the enlargement, instead of being 
at first median, was upon one or the other side; men- 
struation usually not absent unless the health has been 
greatly deteriorated ; marked fluctuation in most cases 
when the tumor has attained considerable size ; absence 
of proofs of pregnancy upon palpation and auscultation ; 
and vaginal examination will in most cases be able to 
prove displacement, but no material enlargement of the 
uterus. 

Uterus Enlarged by Ohronie Parenchymatous Metritis.— 
Menstruation may be irregular, but there is not absolute 
amenorrhea; the uterine wall, though somewhat soft- 
ened, is not elastic and yielding as in pregnancy, and 
moreover it is sensitive, pain being caused upon pressure, 
which is not observed when pressing the gravid organ. 

Accumulation of fat in the abdominal walls, ascites, 
tumors of the spleen, need only be mentioned in order 
that the practitioner may be put upon his guard against 
error from any of these sources. 

It should be remembered that in all doubtful cases 
time is one of the most important elements of diagnosis ; 
if a woman be pregnant, the fact will become clearer 
from day to day, for unequivocal signs of the condition 
will surely come. Therefore he is wisest who waits in 
such cases until he knows, either by the presence or the 
absence of these certain proofs, before he gives an opin- 
ion, and not he who risks a happy guess, or draws a 
conclusion from an average of probabilities. 

THE HYGIENE oF PREGNANCY.—This includes atten- 
tion to diet and the condition of the digestive organs, ex- 
ercise, rest, clothing, sleep, the care of the breasts, and 
the condition of the mind. In the early months of preg- 
nancy, it is not unusual for the irritability of the stom- 
ach to cause lessened desire for food, or possibly the 
appetite may crave some unusual article of diet; each 
condition must be considered and respected in the choice 
of aliments, and in directing the quantity. In some cases 
the morning-sickness is lessened by having the patient 
take her breakfast in bed, and not rise until an hour or 
two after. Generally, in the fourth month gastric disor- 
der disappears, and the appetite is good; digestible and 
nutritious food, both animal and vegetable, may be 
taken, and, so far as possible, dietetic means used for the 
prevention of constipation. As in the ascension of the 
uterus in the latter months it comes to press upon the 
stomach, the meals should not be so abundant, but more 
frequent, and especial care should be taken not to eat 
heartily in the evening. If the constipation is not re- 
lieved by diet, an evacuation should be secured each day 
by a Seidlitz powder, Hunyadi, compound licorice pow- 
der, calcined magnesia, or some similar means. 

Care must be taken that the clothing does not com- 
press the abdomen or chest, and it ought to be suitable 
for the season ; especially ought the pregnant woman to 
avoid being chilled, lest an annoying bronchitis, for ex- 
ample, or a serious nephritis with albuminuria, result 
from sudden suppression of perspiration. Moderate exer- 
cise will be useful, but that which fatigues or is violent, 
such as dancing, riding on horseback, or over rough roads, 
must be avoided. Long journeys by sea or land ought, 
if possible, to be postponed ; the fatigue, the excitement, 
the constant jarring for several days consecutively on a 
railway train, for example, and the possible dangers and 
accidents belonging to travel in general, present strong 
arguments in favor of the advice just given. So, too, 
fresh air is especially necessary for the pregnant woman 


fere with labor at the normal time, 


Pregnancy. 
Pregnancy, 


—she is breathing for two, and therefore must not be in 
crowded or badly ventilated rooms. The pregnant wo- 
man should observe regular hours of sleep, and it is also 


‘ well for her to have a brief rest during a part of each 


day, lying down even if she does not sleep. A warm 
bath may be taken as usual, but hot baths, especially if 
frequent and prolonged, may cause abortion ; sea-bathing, 
unless the water is quite warm, is not advisable, and 
when such baths are taken they must be without great 
exercise, as in swimming, and they ought to be brief. 

The belief held by many philosophers as far back as 
Plato, and also by many eminent physicians as well as 
by the public, is becoming stronger, that the condition of 
the mother’s mind has an important influence upon her 
unborn child ; not only is it held that certain deformities 
may result from maternal impressions, but modifications 
of the intellectual and moral character, as manifested in 
after years, may have their origin in the mental state of 
the pregnant woman. Hence the importance of the pro- 
spective mother preserving an equable condition of mind, 
and as cheerful a disposition as possible ; she should be 
carefully guarded against all injurious influences, and 
exposure to perils and to painful sights, and there ought 
to be thrown around her all protecting care and thought- 
ful kindness. 

Sexual intercourse during pregnancy is utterly unnat- 
ural; it is a frequent cause of abortions ; it is probably 
regarded with indifference or abhorrence by most wo- 
men, and is without any moral justification. Many pagan 
nations have not only condemned this violation of nat- 
ural law, but coupled severe punishment with the con- 
demnation. 

All compression of the mammary glands must be avoid- 
ed; the nipples especially should be given ample room for 
their development, and if retracted they ought to be drawn 
out by means of the thumb and finger for a few minutes 
each day, and in the intervals a nipple-shield may be 
worn over them for atime. It is customary to endeavor 
to harden the skin, so as to prevent the formation of fis- 
sures and abrasions from nursing, by washing the nipple 
each day with alcohol holding in suspension or solution 
an active astringent. I have for some time protested 
against this practice, on the ground that the alcohol dis- 
solves the sebaceous secretion with which nature has so 
abundantly supplied these organs, and which is their 
best protection from the injurious contact of fluids ; even 
if the skin may be hardened by alcohol or an astringent, 
nature intended it to be soft and pliable, and not harsh 
and resistant, and consequently much more liable to be tis- 
sured. Therefore, let me advise, instead of the time-hon- 
ored applications, scrupulous cleanliness of the nipples, 
the daily washing to be followed by bathing them gently 
with cologne or tincture of arnica and water, and at 
night the application of a little cocoa-butter. Delore 
suggests daily exposure of the nipple to the air as a 
means of rendering it less liable to become diseased dur- 
ing lactation. Certainly, if the exhibition of as much of 
the mammary glands as is made by some fashionable 
women at balls or parties has any justification, it would 
be in the fact that these women are pregnant, and are pre- 
paring for one of the most important duties of mother- 
hood. 

PROFESSIONAL CARE DURING PREGNANCY.—The ob- 
stetrician should see a woman from time to time during 
her pregnancy, giving her such instruction and advice as 
her condition may require. During the last three months, 
earlier if certain symptoms to be presented hereafter 
arise, it is important that the state of the renal functions 
should be learned, more especially as to the presence of 
albumen in the urine ; once in one or at most in two 
weeks, the condition of the urine should be ascertained 
by chemical, and if necessary by microscopical, examina- 
tion. é‘ 

It would be better too, if at least an external examina- 
tion were made when the foetus has become viable, so as 
to ascertain the position which it occupies in the uterus, 
and the presence or absence of any neoplasms of the or- 
gan of gestation, or of organs adjacent, which may inter- 
Some cases, too, may 


tl 


Pregnancy. 
Pregnancy. 


require measurements of the pelvis to be made, especially 
in a primigravida, or in a woman whose previous labors 
have been difficult, requiring artificial means for the re- 
moval of the child, or in whom possibly the delivery was 
spontaneous, the child, however, dying in the labor, from 
the delay and difficulty of the process. 

THE PATHOLOGY oF PreGNANCY.—The pathology of 
pregnancy includes, first, those diseases which are exag- 
gerations of physiological conditions belonging to the 
pregnant condition, or caused by it; second, diseases be- 
ginning before pregnancy, or accidentally occurring dur- 
ing it, that is intercurrent, and which may be modified 
by the pregnant state or may affect it, and traumatisms, 
including injuries and surgical operations ; third, affec- 
tions of the sexual organs ; and, fourth, maladies of the 
ovum. These classes will be now briefly considered in 
their order, omitting, however, from this presentation 
any of the diseases embraced in this class that are dis- 
cussed elsewhere in this work. 

Hyperemesis.—The morning-sickness of pregnancy, in 
its ordinary form, has been previously mentioned, and 
Wwe are now concerned with that exaggeration of the dis- 
order known as hyperemesis, or as the uncontrollable, in- 
coercible, or pernicious vomiting of pregnancy. In about 
two-thirds of the cases this disease is first manifested 
before the end of the third month. Usually there is a 
gradual transition, from the ordinary nausea and vomit- 
ing to the grave form of the disorder, when the patient 
rejects the simplest food or drink, very soon after taking 
it, and then a part only of the food is vomited; in some 
cases, however, there is immediate vomiting—for exam- 
ple, simply a little cold water is thrown up immediately 
after it is swallowed, but more frequently it is retained 
until it becomes warm. Apparently the most trivial 
causes will excite vomiting, such as an attempt to sit up, 
or changing from one position to another, for example, 
from the back to the side, or when a reverse movement is 
made. The patient rapidly emaciates, the urine becomes 
scanty, may contain albumen, and is high-colored ; there 
is in some cases an abundant secretion of saliva, and 
usually anorexia is present—in part probably from the 
patient’s knowing that taking food will be followed by 
vomiting. 

With the continuance of the disorder the symptoms 
become graver, and that which has been described as the 
second stage occurs. ‘The emaciation makes rapid prog- 
ress, and the patient becomes more exhausted, fainting, 
it may be, upon so slight exertion as sitting up in bed; 
the gums may be swollen, the teeth covered with sordes, 
and the breath offensive; the pulse is 120 or more a 
minute, and the thirst excessive. Older observers, without 
the proof of thermometric facts, described this stage as 
febrile, the conclusion being derived from the frequency 
of the pulse; but some recent observations do not prove a 
marked increase in the temperature. The third period 
soon follows. Now the vomiting ceases, but there are 
disordered vision and hearing, and often intense neuralgic 
pains ; the pulse may be 140 a minute; mental disorder 
is shown in hallucination and delirium, and coma closes 
the scene. 

The disease is not always steadily progressive, but 
presents, it may be, from time to time remissions, conse- 
quent, for example, upon a change of scene, or upon 
some new article of food or of drink. JI have known one 
instance in which the vomiting ceased for some days from 
drinking lager-beer. Cazeaux quotes from Dubois an in- 
stance of grave vomiting in pregnancy, in which the dis- 
ease disappeared after a violent attack of diarrhoea, and 
another in which a powerful mental impression, the hus- 
band of the patient gravely suffering from strangulated 
hernia, had a similar effect. 

Among causes of obstinate vomiting in pregnancy are 
displacements of the uterus, inflammation of the cervix, 
adhesions of the membranes at the internal os, rigidity 
of the muscular fibres of the uterus not permitting ready 
dilatation, circumscribed inflammation of the organ, and 
inflammation of structures adjacent to it; Lebert and 
Rosenthal refer the disorder in some cases to partial man- 
ifestations of a general nerve inanition. 


12 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Post-mortem examinations have shown disease of dif- 
ferent organs, more especially of the stomach—ulceration 
and cancer, for example—but, as Tarnier observes, it is 
impossible to describe the pathological anatomy of the 
disease, and while actual alterations in certain organs 
have been found, there is no constancy in these facts, 
and in some instances no lesion can be discovered. 

Guéniot found that in 118 cases the recovery took place 
in 72, and 46 died; of the 72 who recovered, 42 either 
spontaneously aborted, or else premature labor or abor- 
tion was induced. Of the 46 who died, 28 did not abort, 
and 18 had abortion or premature labor induced, or mis- 
carriage Was spontaneous. 

The treatment is hygienic, medical, or obstetrical. A 
change of residence, as from the city to the country, an 
entirely new diet, especially choosing an article of nour- 
ishment for which there may be a particular desire. 
Possibly iced lime-water and milk, or ice-cream may be 
tolerated and prepare the way for taking other food ; 
effervescent drinks may be employed. Finally, abso- 
lute rest may be given the stomach for a time, rectal ali- 
mentation being employed. ‘The medicines advised are 
very many, and by their number testify to the fact that 
results accomplished are quite uncertain. Among these 
are tincture of nux vomica, oxalate of cerium, dilute hy- 
drocyanic acid, subnitrate of bismuth, chloroform, or sul- 
phuric ether, each of the two latter given in doses of a 
few drops with water, or in perles, the various prepara- 
tions of pepsine, chloral, bromide of potassium, and opium 
or one of its liquid forms, or morphia. Inhalations of 
oxygen have occasionally succeeded, and also the use of 
electricity ; recently, too, cocaine has been strongly rec- 
ommended. The application of ether spray to the epi- 
gastrium has been employed; so, too, have Chapman’s ice- 
bags to the spine; a small blister to the epigastrium, in 
some cases followed by the use of morphia endermically, 
has relieved some. 

Of course a uterine displacement should be corrected ; 
cauterization of the cervix, and the application of bel- 
ladonna to the vaginal portion has been employed with 
occasional success; Copeman used digital dilatation of 
the cervical canal, while others have leeched the cervix. 

The obstetric treatment consists in the induction of 
abortion, or, if the pregnancy has continued until the 
child is viable, of premature labor. But this grave step 
is rarely required, and ought not to be undertaken until 
the usual means for the arrest of the disease have been 
vainly tried, and until the condition of the patient is such 
that her life is in imminent peril from the disease ; it 
should also be borne in mind, that while in the majority 
of cases the vomiting ceases when the uterus is emptied, 
or soon after, there are some in which no such happy re- 
sult follows; and, on the other hand, that cases now and 
then are seen in which the disorder is most grave and has 
persisted notwithstanding well-directed remedies, so that 
the practitioner despairs of a favorable ending, and yet, 
with some slight dietetic or medicinal change sudden im- 
provement takes place and the disease ceases. The re- 
sponsibility of ending the pregnancy ought to be shared 
with a reliable confrére. 

Finally, the induction of abortion is not to be thought 
of if the patient has passed into the third stage of the 
disease, for then death is inevitable, and may be hastened 
by this treatment, bringing reproach alike upon the meth- 
od and the art. 

Serous Cacheria or Hydremia.—Among the exaggera- 
tions of the physiological changes of pregnancy is that 
condition which Stoltz, and before him, according to 
Tarnier, Baudelocque, the nephew, and Lasserre, called a 
serous cachexia ; Kiwisch gave the name of serous ple- 
thora to those blood changes consisting of increase of the 
quantity of blood and of its water. Stoltz speaks of the 
serous cachexia as an exaggerated hydreemia. 

Patients suffering from this condition may have cedema 
of the lower limbs only, but frequently the serous effu- 
sion involves the connective tissue of the external gen- 
erative organs, the upper limbs, the trunk, and the face ; 
there may also be effusion of serum in the great serous 
cavities. If there should be disease of the heart the 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


symptoms are more serious. Nevertheless, notwith- 
standing this general or localized dropsy, the urine is en- 
tirely free from, or contains only a trace of, albumen. 

The treatment should consist in rest, nutritious diet, the 
administration of tonics, especially of iron, the hot bath, 
diuretics, and occasional mild derivation to the intestinal 
canal. Tarnier attaches great importance to milk diet. 
In some cases punctures of the swollen external genitals 
or of the cedematous lower limbs may be advisable, but 
should not be made unless the necessity be urgent, lest 
gangrene ensue. If there is great accumulation of serum 
in either the thoracic or the abdominal cavity, thoracen- 
tesis or abdominal paracentesis may be employed with- 
out hesitation. Charles has recently recorded in the 
Journal d@ Accouchements a fatal result in a woman near 
the close of her pregnancy, in whom the most prominent 
symptom was this hydremia. 

Anemia.—Those who suffer from hydremia are ane- 
mic, but there may be an anemia not marked by serous 
effusions, or, at least, there is only a moderate oedema, 
more especially of the lower limbs. Such a condition 
creates a liability to post-partum hemorrhage, and should 
be corrected by attention to nutrition, and by the use of 
tonics, especially of iron preparations. 

Pernicious Anemia.—In addition to the simple form 
of anzemia just mentioned, there is a grave manifestation 
of the disease, occurring comparatively rarely, and known 
as pernicious or progressive anemia. Twenty-six years 
ago this disorder was described by Gusserow, but some 
time before this cases of the disease were reported and 
many others observed, but not published ; in this coun- 
try, for example, practitioners, more than thirty years 
since, met with instances of the disease presenting the 
grave symptoms which Gusserow and others afterward 
described, and which, by a sort of general consent, was 
given the title of puerperal ansemia. 

The etiology of the affection is obscure ; in some cases 
those affected have suffered from malaria, or were ex- 
hausted by rapidly recurring pregnancies, by obstinate 
vomiting, or by insufficient food ; hemorrhage, profound 
mental shock, and diarrhea were also considered causes. 
Nevertheless, cases of the disease have occurred in which 
none of these factors were present. 

Generally the disease begins gradually. The skin of the 
face grows paler and paler, and has a waxy appearance ; 
in some cases the skin has a yellowish hue, but there is 
no emaciation, the weight, for a time at least, being re- 
tained ; but after a time fever occurs, and then there is 
loss of flesh. Often there is anorexia. The more promi- 
nent general symptoms are palpitation of the heart, faint- 
ing, syncope, and headache ; frequently sleeplessness is 
observed, but in some cases drowsiness. Hmorrhages 
are not unusual, and the gums may be spongy and swol- 
len, as in scorbutus. 

Abortion or premature labor is a common occurrence, 
and in the latter case the foetus is usually found to be 
dead. A fatal issue occurred in the majority of cases ob- 
served, though in some it was delayed for months. 

In regard to the treatment, remedies addressed to the 
anemic condition are, of course, indicated, but it is not 
necessary to enumerate them. A more important ques- 
tion arises in reference to the induction of abortion or of 
premature labor. Interruption of pregnancy was advo- 
cated by Gusserow, has received the indorsement of 
Charpentier, and more recently of Zweifel, but, on the 
other hand, is rejected by Kleinwachter, because of its 
hastening the commonly fatal termination of the disease. 
Chiara advocates an early induction of premature labor, 
or even of abortion, as in the obstinate vomiting of preg- 
nancy. ‘Tarnier observes that the epoch of intervention 
presents a grave question which is difficult to decide. 

Varicose Veins.—Varicose veins of the lower limbs, or 
of the external genitals, or of the vagina, of the rectum 
and anus, are not very uncommon in pregnancy, though 
authors widely differ in their statements as to the fre- 
quency of this accident. For example, Budin asserts that 
twenty to thirty per cent. of pregnant women suffer from 
varicose veins, while Cazin makes the number one in 
twenty-one ; and my own observations, made in the Phil- 


Pregnancy. 
Pregnancy, 


adelphia Hospital, are much more nearly in accord with 
the latter than with the former statement. 

Among the alleged causes of varicose veins are in- 
creased quantity and changed character of the blood, 
gravitation, greater vascular tension, and pressure upon 
intra-abdominal veins by the enlarged uterus. Tarnier 
states that some authors have added to modifications in 
the circulatory apparatus, in explaining the occurrence 
of varices, those which take place in the nervous system 
under the influence of pregnancy. It must be confessed, 
however, that this etiology is not very obvious. Rupt- 
ure of a varix in pregnancy may cause a rapidly mortal 
hemorrhage, while such rupture in a varix of the vulva 
or vagina, taking place in labor, may result in the for- 
mation of a thrombus or hematoma, seriously interfer- 
ing with the delivery of the child. 

If the varicosities be large, all straining, or lifting heavy 
weights, taking long walks, and even being for a consid- 
erable time in the erect position, should be avoided ; the 
subject must lie down a part of each day; moderate 
compression with a properly applied flannel bandage to 
an affected limb, especially if there be much oedema, as 
there frequently is, will be useful. The patient ought 
to be taught, in case there is threatened rupture of a 
varix, how to arrest hemorrhage from it by direct com- 
pression. 

Albuminuria.—Albuminuria is probably present in 
five to ten per cent. of pregnant women, although Du- 
mas, uniting the statistics of Hippolyte, Abeille, Moricke, 
and Petit, finds that one in five or six thus suffers ; Tar- 
nier refers to the results recently published by Negri, 
Doléris, and Pouey, showing that the proportion of albu- 
minurics is about five per cent. 

A woman suffering with albuminuria may become preg- 
nant, or another, being pregnant, may be attacked with ne- 
phritis ; but in either case the albuminuria is an accident 
independent of the pregnancy. On the other hand, how- 
ever, there may be a nephritis which results from the 
pregnant state, the urine showing the presence of albu- 
men, hyaline casts, and renal epithelium ; but the disease 
disappears after the pregnancy. Various explanations 
have been given of the nephritis of pregnancy. Among 
these are the renal disorder which results from the in- 
creased work thrown upon the kidneys by the pregnant 
state, the greater vascular tension, pressure upon the renal 
veins by the enlarged uterus, similar pressure upon the 
ureters, and finally from reflex irritation, this irritation 
arising from the uterus and affecting the renal circulation 
and secretion. Leyden (Zeitschrift fir klin. Med., 1886) 
maintains that the lesions of the kidneys found in preg- 
nancy nephritis do not correspond either to venous stasis 
or to acute nephritis, and attributes great importance in 
their production to arterial anemia. According to him, 
this anemia results from hindrance to circulation in the 
abdomen caused by the enlarged uterus, this hindrance 
increasing with the greater size of the organ of gesta- 
tion. The cause acts mechanically by diminishing the 
quantity of urine, and hence albuminuria, and dynami- 
cally from lessening the supply of oxygen, and hence fatty 
degeneration of the kidney. Zweifel (Lehrbuch der Ge- 
burtshitife, 1887) holds that of the many theories ad- 
vanced in explanation of the disorder, only two deserve 
special mention, and yet neither has been proved. ‘The 
first was proposed by Frerichs, and accepted by Bam- 
berger, Leitzmann, Rosenstein, Lange, Hohl, Moéricke, 
and others. According to this theory the renal changes 
are the result of increased intra-abdominal pressure, pre- 
venting the escape of the venous blood from the kidney, 
and thus causing engorgement of the organ. The other 
theory, that of Halbertsma, explains all the facts as re- 
sulting from pressure of the enlarged uterus upon the 
ureters. The former is accepted by Zweifel. : 

It is unnecessary to state the usual manifestations of 
albuminuria in pregnancy, nor the means by which a 
diagnosis is made. The most serious possible result is 
eclampsia; for while the majority of albuminurics are 
not eclamptic, it is very rare for eclampsia to occur In 
pregnancy unless the patient has albuminuria. Winter 
has recently called attention to premature detachment of 


13 


Pregnancy. 
Pregnancy. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the placenta as a not uncommon accident in nephritic 
patients. 

The treatment of albuminuria in pregnancy is gov- 
erned by the same rules that apply to the management 
of the disease in the non-pregnant, except, probably, as 
advised by Tarnier, an absolute milk-diet, if the quantity 
of albumen in the urine be great, should be strictly en- 
forced, and in some cases it gives remarkably good re- 
sults ; in some patients, the induction of premature labor 
or even of abortion may be clearly indicated. 

Cardiac Disease.—It has been claimed that disease of 
the heart may result from pregnancy. Thus, admitting 
a normal hypertrophy of the organ caused by the preg- 
nant condition, it is asserted that, as a consequence of 
rapidly recurring pregnancies, an ordinarily transitory 
hypertrophy becomes permanent. But this is only hypo- 
thetical. Further, as stated by Tarnier, Ollivier claims 
that subacute and chronic endocarditis may originate 
solely under the influence of pregnancy. However these 
questions may be decided, the obstetrician is concerned 
almost exclusively with cardiac disease which was pres- 
ent when the pregnancy occurred. Undoubtedly the 
pregnant woman, from the fact of her condition, is more 
liable to suffering, and even to danger, if she has valvu- 
lar disease ; the pregnancy becomes a complication in 
many cases, though not necessarily in all. Budin and 
others have shown that cardiopathics are peculiarly lia- 
ble to abortion ; Porak found that in 214 women who had 
disease of the heart, the pregnancy continued until term 
in only 126, while 88 aborted, or had premature labor. 
Whether premature or mature labor, or miscarriage oc- 
cur, there is an increased liability to post-partum heemor- 
rhage. The treatment during pregnancy does not ordi- 
narily differ from that required by cardiac disease in 
the non-pregnant condition. In some cases the induc- 
tion of abortion or of premature labor may be indicated 
by the danger to the life of the mother. ; 

Relaxation of the Pelvie Joints—Some swelling and 
softening of the pelvic joints is one of the normal phe- 
nomena of pregnancy, but should these be excessive the 
mobility of the pelvic bones may become so great that 
it is impossible for the patient to walk, and, indeed, any 
movement of these bones may be attended with great 
suffering. The joint most liable to be affected by this 
abnormal relaxation is the pubic. The relaxation usu- 
ally occurs in the latter half of pregnancy, but Moreau 
mentioned a case in which it appeared in the second 
month, and in this ‘patient it continued for more than 
two years after delivery. Having begun, it usually in- 
creases until the end of pregnancy, when it gradually 
lessens and disappears in most cases. The most impor- 
tant treatment is rest; the more exercise is urged upon 
the patient, the more miserable she becomes through 
suffering and aggravation of the disorder. A prolonged 
rest, too, is required after labor, and when the patient 
gets up the immobility of the bones should be secured 
by a suitable apparatus. Barker states that in all cases 
he has seen this immobility has been effected by a little 
ingenuity in making and adapting a hip-binder of very 
strong, coarse cloth. 

Neuroses.—Different nervous affections may occur in 
pregnancy, some of them indeed depending upon the 
pregnant condition, Among the latter may be men- 
tioned neuralgic disorders, especially of the teeth. 

HHysteria.—In most cases of hysteria the disease ante- 
dates the pregnancy, but in a few it seems to originate 
from it. While in a few cases hysteria has disappeared 
during pregnancy, in the majority it continues, some- 
times becomes aggravated, and even insanity may follow 
labor. An interesting fact, observed by many, is that in 
some instances there is an almost, or quite, total absence 
of suffering during childbirth. . 

The treatment of hysteria in a pregnant woman is the 
same as if she were not pregnant. 

Epilepsy.—If an epileptic become pregnant the disease 
may be mitigated by the pregnancy, but the attacks re- 
turn with their original severity and frequency of oc- 
currence subsequently ; probably, however, a temporary 
favorable modification occurs in the majority of cases. 


14 


In the rare instances in which the disease begins in preg- 
nancy, it ceases after labor. 

Chorea.—This is not a frequent disorder observed in 
gestation, for Barnes could find but fifty-six cases 
which had been published, and Fehling, in 1874, was 
able to add only twelve to this number. The liability to 
the disease is greater in primigravide than in multi- 
gravide ; previous attacks of the disease create a predis- 
position to it; it may recur in several successive preg- 
nancies, or be present in the first only. It usually begins 
in the first half of gestation, continues during the en- 
tire subsequent time, and in rare instances during the 
puerperal state. Wenzel’s statistics show the mortality of 
the disease to be 27.3 per cent., and Spiegelberg found 
23 deaths in eighty-four cases. The medical treatment 
need not be stated, for it is the same as when the disease 
occurs in the non-pregnant condition. The obstetric 
treatment, if the child be viable and the usual means for 
relief have been tried without benefit, and if the choreic 
movements are, violent while the patient’s strength is 
failing, is the induction of labor. Whether cases occur 
in which abortion is necessary is an undecided question. 

Diseases of the Skin.—Duhring calls attention to the 
fact that in a few cases eczema, herpes, or pruritus 
may result from the pregnant condition, but they cease 
as soon as the pregnancy is over, and that chloasma is 
common ; while, on the other hand, chronic affections, as 
eczema and, psoriasis, are often observed to be much 
better during this period. Inrare cases the pruritus is so 
severe that abortion has occurred. In three patients 
suffering with the disease who were seen by Cazeaux, 
the pruritus readily yielded to alkaline baths; Tarnier 
commends a solution of cocaine. Slocum has reported a 
case of hirsuties gestationis. The woman had been preg- 
nant three times, giving birth to three children at term, 
‘‘and with each gestation a growth of hair on the sides 
of the face, and under the chin, started at the begin- 
ning of the pregnancy and continued until childbirth, 
growing to the length of oneand a half inch. As the ca- 
tamenial function returned, the hair fell out, the face as- 
suming its normal smoothness.”’ 

Acute Infectious Diseases.—Several observations have 
been made showing that when the mother suffers from a 
high temperature, the pulsations of the foetal heart are 
increased in frequency and lessened in force, and inter- 
ruption of pregnancy not unseldom occurs. ‘The experi- 
ments of German observers seemed to prove that this 
interruption was due to the continued elevation of tem- 
perature ; but the experiments of Charpentier, Doléris, 
and F. Doré, proved that if the increase was gradual, 
pregnant animals did not abort, nor was the life of the 
foetus in the least compromised. Accepting these results, 
the conclusion must be, as Charpentier has stated 
(‘‘ Archives de Toxicologie,” 1887), that hyperthermia 
does not exercise an important, only a secondary, influ- 
ence in the production of abortion and the death of the 
foetus, when the mother suffers with grave pyrexia, 
variola, scarlatina, rubeola, erysipelas, typhoid fever, 
etc. 

The interruption to pregnancy occurring in infectious 
diseases has also been regarded as resulting from heemor- 
rhagic endometritis. The investigations of Slavjansky, 
for example, showed such condition in the cases of 
pregnant women attacked with cholera. But, on the 
other hand, Queirel, in his recent studies of the epidemic 
of cholera at Marseilles, took pains to seek for this 
endometritis, and he has not found it; he states that 
hemorrhages have not occurred either in abortions or 
in labors, though he has frequently met with uterine 
inertia. Klotz, of the University of Innsbriick, studying 
the course of measles in pregnant women, in eleven cases 
of which there was interruption of pregnancy, endeavored 
to ascertain the causes of foetal death not only in measles 
but in other infectious diseases, and concluded that hee- 
morrhagic endometritis was not proved anatomically in 
this disease, in scarlatina, in variola, in erysipelas, or in 
typhus. 

Zweifel gives importance to the action of the ‘‘ fever- 


' blood” upon the nerve-centres causing uterine action, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


great increase of temperature producing, as a rule, 
uterine contractions. 

Probably, however, the most important factor in inter- 
rupting the pregnancy is, as asserted by Charpentier, 
toxemia, the death of the foetus resulting from this, and 
then its discharge from the uterus follows. 

Typhoid fever may occur in pregnancy ; this condition, 
according to the statement of Murchison, and contrary to 
the opinion of Rokitansky and Niemeyer, furnished no 
exemption from the disease. In the great majority of 
cases, though the pregnancy is interrupted, recovery 
takes place. 

Yellow fever is quite as likely to occur, according to 
Bemiss, in the pregnant as in the non-pregnant, but the 
liability to the disease is increased by childbed. Still 
referring to the statements of Bemiss, the liability to death 
is twice as great in pregnancy and in childbed. 
pregnant woman recovers from yellow fever, and gesta- 
tion continues, the child is protected from the disease. 
The last statement certainly points to and strengthens the 
assertion previously made, that the usual cause of death 
in acute infectious diseases is toxeemia, that is to say, 
the specific poison of the disease passes from the mater- 
nal to the feetal blood. It is not admitted that there is 
even a partial exemption from intermittent fever given 
by pregnancy ; where facts seem to sustain this view, 
their probable explanation is found in pregnant women 
not being so much exposed to the malarial poison. It 
seems to be tolerably well established that the foetus may 
suffer from malarial poisoning, this condition being man- 
ifested by regularly recurring paroxysms of convulsive 
movements; and in some of these cases the child at 
birth was found to be suffering from enlarged spleen. 
The administration of quinine is not forbidden by preg- 
nancy, and if abortion or premature labor occur, the 
event is not to be attributed to the drug, but to the ma- 
larial intoxication ; nevertheless, it is possible that in some 
women there may be such idiosyncrasy that some other 
antiperiodic should be employed. 

About sixty per cent. of pregnant women abort or 
have premature labor if attacked by cholera, though the 
recent statistics of Queirel, including 67 cases, show that 
in only 29 the pregnancy was arrested. The statistics 
just referred to also show that when the ‘pregnancy was 
interrupted, the mortality was about sixty-six per cent., 
but if it continued, only fifty per cent. The death of 
the foetus, probably, is usually due to toxeemia, as pre- 
vicusly stated, or it may result from asphyxia. 

Curschman claims that pregnancy causes a certain pre- 
disposition to variola. In varioloid there is little danger 
to the mother or to the fcetus, but in variola abortion or 
premature labor usually occurs, and is followed by the 
death of the mother. If a pregnant woman has variola, 
the rule is that the foetus is also affected, and it may pass 
through all the stages of the disease in the uterus, but in 
some cases is born with the disease, and in others may be 
attacked soon after birth ; very rarely an apparently 
healthy mother gives birth to a child having variola, and 
the explanation proposed is that the mother had the dis- 
ease without the eruption, and thus infected the child. 

In some cases successful vaccination of a pregnant 
woman has rendered the new-born insusceptible to vac- 
cination. Hence there is a stronger argument for vacci- 
nating the pregnant woman if she is liable to be exposed 
to small-pox. 

Scarlatina has been rarely observed in pregnancy. It 
is very liable to interrupt the pregnancy, and is peculiarly 
fatal. A similar statement may be made as to rubeola. 

Pneumonia is a more frequent disease of the male than 
of the female, but in the female it has a one-third greater 
mortality, and is far more dangerous in pregnancy. The 
pregnant woman, if attacked with the disease, is liable to 
abort or to have premature labor; this liability to inter- 
ruption of the pregnancy is greatest the farther the latter 
has advanced ; after interruption the patient in most cases 
dies within two or three days, if recovery does not take 
place. Some have urged ending the pregnancy by artificial 
means, but the practice is not generally accepted, most 
authorities preferring the expectant plan of treatment. 


If the. 


Pregnancy. 
Pregnancy. 


Pleurisy usually terminates favorably, and does not 
disturb the pregnancy, but if the disease be double, or if 
bronchitis be associated with it, abortion or premature 
labor may result. Thoracentesis has been performed upon 
the pregnant woman without disturbing the gestation. 

Jaundice ; Icterus Gravidarum.—This disease may oc- 
cur in pregnancy in one of two forms—simple or malig- 
nant. The first, when it appears in the later months, is 
attributed by Frerichs to pressure of the enlarged uterus 
or of the colon distended with feces, upon the bile-duct : 
while Tarnier suggests that there is an icterus peculiar to 
pregnant women, and Peter regards it as arising from 
congestion of the liver; Bedford has suggested that the 
disease may sometimes be in part due to mental emotions. 
The prognosis is favorable; nevertheless, in rare in- 
stances that which was apparently the benign form of the 
affection becomes malignant. The malignant form of 
the disease, which is seldom seen, is dependent upon 
acute yellow atrophy of the liver, and usually causes 
abortion or premature labor, and has a fatal result. 
There have been occasionally epidemics of jaundice in 
pregnant women, gestation in many instances being ar- 
rested, the majority of those affected dying. 

It has been been advised in malignant jaundice that the 
uterus should be emptied, but this rule has not been 
adopted ; certainly, if in a case of benign jaundice its fu- 
ture malignant character could be foreseen, the practice 
would be justifiable. So, too, it has been advised that 
in case of an outbreak of epidemic jaundice, security 
for pregnant women not yet attacked might be found in 
a change of residence. 

Traumattsm.—This includes injuries, and surgical op- 
erations in pregnancy. Very grave injuries have been 
received by pregnant women, and important surgical op- 
erations, such as removal of ovarian tumors, performed, 
and gestation has continued, while, on the other hand, 
comparatively trivial injuries have arrested it. Accord- 
ing to Cohnstein, penetrating wounds of the abdomen 
usually arrest the pregnancy, though the uterus may not 
be injured., Operations upon the genital zone are very 
liable to disturb the pregnancy. A question of some im- 
portance is as to the repair of fractures in the pregnant 
woman, and a difference of opinion exists, some contend- 
ing that this repair takes place as promptly as it would 
if she were not pregnant, while others, among whom 
Cazeaux and Tarnier may be mentioned, hold that there 
may be very great delay—the former narrating an in- 
stance in which a woman in the second month of preg- 
nancy fractured the tibia, and consolidation failed to oc- 
cur until after labor at term. 

In three cases of gun-shot wounds—one case being re- 
ported by each of the following, Richard, Staples, and 
Hays—involving the uterus, the pregnancy was arrested ; 
in one a living child was born ; all the mothers recovered. 

The simple rule in regard to operations in pregnancy 
may be founded upon the statement of Sir James Paget, 
that it would be mere recklessness to operate on a preg- 
nant woman without good cause; yet, if good cause for 


operation exists, she may be treated very successfully. 


Chronic Infectious Diseases.—The statistics of the late 
Austin Flint and those of Gaulard show that a large per- 
centage of women become phthisical during pregnancy 
or lactation. James, however, claims that pregnancy has 
a favorable effect, but that labor and lactation are un- 
doubtedly injurious ; it would seem impossible to isolate 
the effects of labor from those of its preceding and fol- 
lowing state, and really the conclusion is without prac- 
tical value, save that the woman who has tuberculosis 
ought not to nurse her child, and this rule has been 
clearly shown by previous observations. 

Pregnancy in the phthisical is rarely interrupted, even 
though the woman may be greatly exhausted by the dis- 
ease ; the disease, when labor is over, usually pursues a 
more rapid course; as might be expected, the children 
born of such mothers are in most cases feeble, and gen- 
erally die early. 

If the physician is consulted, it is his duty to earnestly 
advise against the marriage of a phthisical subject, 
whether maiden or woman. 


15 


Pregnancy. 
Pregnancy. 


Fournier holds that pregnancy is a complication of 
syphilis, complicating it by adding to it its own peculiar 
anzemia, its disposition to neuroses, its disorders of nutri- 
tion, etc. Abortion or premature labor is a very com- 
mon consequence of the disease ; thus, out of 414 pregnant 
women at Lourcine, in only 260 did the pregnancy con- 
tinue until term. The secondary stage of the disease is 
‘that which furnishes the greatest liability to interruption 
of pregnancy, and from the fourth month to the end of 
the second year is the period during which a pregnancy 
is most liable to be arrested. 

It is claimed by some, denied by others, that a syphi- 
litic father may beget a syphilitic child, the mother re- 
maining free from disease ; yet, according to Fournier, 
who admits the possibility of direct paternal infection, 
the probabilities are that the child will not be infected. 
The most frequent source of infection is the mother. 
She may be syphilitic before conception, or she may 
acquire the disease just before, the fecundating being 
the infecting coition, or, finally, she may acquire syphilis 
during the pregnancy. Now, in the two first cases the 
child may be syphilitic ; but in the third case, the infec- 
tion taking place during pregnancy, it has been held that 
if this occurs after the middle of pregnancy the danger 
is very slight, and almost none if the mother becomes 
affected toward the end of normal gestation. Yet Tar- 
nier refers to one instance in which the child was born 
syphilitic, though the mother did not become infected 
until the eighth month. The probabilities of the off- 
spring being syphilitic are greatest in those cases in 
which both the parents are syphilitic. Should a syphi- 
litic woman become pregnant, an antisyphilitic treatment 
must be employed, and so, too, if she becomes syphilitic 
during her pregnancy. If she is free from the disease, 
but is impregnated by a syphilitic man, ought this treat- 
ment to be pursued? The answer generally made is, not 
unless she has previously had pregnancies arrested pre- 
sumably from syphilis. 

Diseases of the Sexual Organs.—Pruritus of the vulva is 
sometimes met with in pregnant women. The applica- 
tion of a solution of borax in water, or in rose water to 
which morphia is added, as recommended by Meigs, or 
of cloths wrung out of hot water, generally gives relief. 
Other means are brushing the parts with a solution of 
muriate of cocaine, or of carbolic acid, or of chloral. 
Tarnier states that he has, in almost all cases, succeeded 
in relieving the pruritus by the employment of a solution 
of corrosive sublimate in the following formula: Corro- 
sive sublimate, one part; alcohol, five parts; rose water, 
twenty, and water, two hundred and twenty-five. 

Vegetations of the vulva may appear during pregnancy, 
and usually spontaneously disappear when the pregnancy 
is over. While, probably, in the majority of cases these 
growths are specific in origin, yet in some they may not 
be. Unless they are large and occupy so much space that 
they will interfere with the expulsion of the foetus, active 
treatment during pregnancy is not advisable, for excision 
would be attended with considerable hemorrhage, and 
besides the growths would soon be reproduced. ‘The af- 
fected surfaces should be, so far as practicable, separated 
and kept clean ; disinfectant and astringent solutions are 
to be applied. Tarnier speaks favorably of the applica- 
tion of a strong mixture of tannin and water, and Char- 
pentier has seen the growths disappear by isolating the 
affected parts, and applying compresses dipped in Labar- 
raque’s solution. 

Prolapse of the vagina, especially if cystocele be asso- 
ciated with it, may require the use of astringent injec- 
tions and wearing an elastic ring pessary ; for the latter, 
should it cause pain, a tampon of prepared wool to which 
a String is attached, dipped in a mixture of glycerine and 
tannin, may be worn during the day and removed when 
the woman retires. 

Different forms of vaginitis may affect the pregnant 
woman, the chief of these being simple, granular, and 
specific; the two latter may be associated. In simple 
vaginitis, the most marked symptom of which is a leu- 
corrheal discharge, bathing, cleanliness, antiseptic and 
mild astringent injections twice a day, will be useful; 


16 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


vaginal injections in pregnancy should be warm or tepid, 
and the fluid is to be used as a wash, not asa douche. 
Granular vaginitis, first described by Deville, in 1844, is 
characterized by the presence upon the surface of the 
vagina, especially at its upper part, of elevations about 
the size of a hemp-seed, so that the examining finger 
touches a rough, grater-like tissue, and by rather a pro- 
fuse yellowish discharge which irritates the parts with 
which it comes in contact in passing out of the vagina. 
In addition to the means applicable to simple vaginitis, 
every other day a cotton or wool tampon, containing half 
a teaspoonful of powdered alum and the same quantity 
of subnitrate of bismuth, may be placed in the vagina ; 
instead of this dry tampon one made of cotton first 
dipped in glycerine, and its surface freely covered with 
boric acid, may be employed ; in either case the tampon 
is removed after twelve hours. Nitrate of silver injec- 
tions also prove useful, or the diseased surface being ex- 
posed by a speculum, and then cleansed, is brushed over 
with the solution. Gonorrhceal inflammation of the va- 
gina demands treatment in the interest of the child and 
of the mother, for the former, during its passage through 
the vagina may, by the contact of the infectious matter 
with the conjunctive, subsequently have a specific con- 
junctivitis, or the latter, from extension of the vaginitis 
after labor, have a salpingitis. Nitrate of silver injections 
here, too, are useful, but probably the most valuable 
remedy is corrosive sublimate, an injection of one part 
to three thousand of water being used at least twice a 
day. 

In 1871 Winckel first described a form of vaginitis 
characterized by the presence upon the vaginal surface 
of a large number of transparent cysts, fifteen or twenty 
often being found upon a part the size of a dollar; most 
of these cysts contained gas, and when punctured col- 
lapsed with a sound quite audible; there was usually 
hypersecretion ; he gave the disease the name of colpohy- 
perplasia cystica. 

Painless contractions of the uterus as one of the nor- 
mal phenomena of pregnancy have been described ; but 
under certain circumstances these contractions cause 
more or less severe suffering. If we admit with Wigand 
the existence of uterine rheumatism, the explanation of 
such suffering is in many cases quite simple, for it is the 
same in contractions of the uterine muscle as it is in the 
exercise of voluntary muscles affected by rheumatism. 
But most authorities do not regard the existence of uter- 
ine rheumatism as proved. The hypothesis of uterine 
neuralgia, or that of a metritis, has been suggested, or 
else we may say that in some women the gravid uterus 
is peculiarly sensitive to pressure, whether that be made 
from within or from without, as caused by foetal move- 
ments, or by placing the hand upon the abdomen. There 
is, however, a form of intermittent pain in the gravid 
uterus resulting from injury, which apparently threat- 
ens premature labor or abortion, though neither occurs ; 
and which has not been the subject of special considera- 
tion ; two cases of this kind I have recently met with, one 
in hospital, the other in private practice. In the former 
a multigravida, at the beginning of the seventh month 
of pregnancy, fell, striking the front part of the abdo- 
men upon a stove. As painful contractions of the uterus 
succeeded it was at first supposed labor was at hand, but 
there was no increased vaginal discharge, no effacement 
of the uterine neck, and no dilatation of the os. Though 
the uterine soreness and the painful contractions con- 
tinued for two or three weeks, the pregnancy went to 
term, and the labor was normal. In the second case a 
multigravida, at the beginning of the seventh month, was 
lying in bed upon her back ; one of her children, aged two 
years, was in the bed, and in his romping fell so that his 
head struck one side of the uterus. For several days she 
suffered severe intermittent pain in the uterus, but this 
pain, though the entire organ contracted during it, was 
referred exclusively to the side which had been struck. 
In each case the explanation of the suffering was that the 
normal and ordinarily painless contractions of pregnancy 
became painful because of injury to the organ. The 
treatment of such cases will be rest, opium, and the ap- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Pregnancy. 
Pregnancy. 


plication of warm compresses to the abdomen ; occasion- 
ally a mild counter-irritant may be required. 

Various positional disorders of the gravid uterus may 
“occur—prolapse, anteversion, anteflexion, retroversion, 
and retroflexion—the gravest of these being complete 


Fre. 3095. 


prolapse and the posterior displacements ; in addition to 
these there may be hernie of the organ. 

In prolapse of the uterus the organ may descend to the 
pelvic floor, and may partially or entirely protrude from 
the vulvar orifice ; should the latter occur the prolapse is 
called complete. In most cases the patients are multigra- 
vide ; in some the accident occurs gradually, in others 
suddenly, in consequence of a violent effort, as lifting a 
heavy weight ; and in rare cases impregnation of a pro- 
lapsed uterus has taken place ; there have been 
instances where prolapse of the uterus has oc- 
curred during labor ; in some of these the labor 
was spontaneous, in others it was artificial, the 
accident taking place, for example, during ex- 
traction with the forceps. 

Visual, digital, and bimanual examination 
will readily recognize this positional disorder 
of the uterus and its degree, care being taken 
to avoid mistaking hypertrophic elongation of 
the cervix for this displacement. XS 

The consequences of prolapse of the gravid S 
uterus may be very serious. There is great liability 7 
to interruption of the pregnancy, and in rare in- 
stances incarceration of the organ occurs, having 
similar grave results to those which will be referred 
to in connection with this accident in posterior dis- 
placements. 

The question as to whether the pregnancy in a 
completely prolapsed uterus can continue until term, 
has received different answers, eminent German authori- 
ties, such as Schroeder, Gusserow, and Zweifel, asserting 
that no authentic case of this kind has ever been reported ; 
while some French authorities, among whom may be 
mentioned Charpentier and Tarnier, hold the opposite ; 
the statement of the former seems the more probable. 

If prolapse occur in pregnancy an effort should be made 
to restore the uterus to its normal position and to keep it 
there ; after its restoration the patient ought to remain in 
the horizontal position until danger of the recurrence of 
the accident is improbable. If the organ be irreducible, 
and serious difficulties are present, especially incarcera- 
tion, there must be no hesitation in producing abortion, 


Vou. VI.—2 


and after this has occurred the restoration of the organ 
is to be made. ; 

Anteversion, or anteflexion, of the pregnant uterus is 
a less frequent, and usually a less grave, accident than 
the corresponding posterior positional disorders. Should 
either of the first two accidents occur in the early 
months of pregnancy, the progress of gestation gradually 
rectifies it in almost all cases. In the late months of 
pregnancy there may be in the multigravida, in conse- 
quence of great relaxation of the abdominal wall, marked 
projection of the uterus in front, causing the woman 
more or less inconvenience and discomfort; the relaxa- 
tion may be so great that the anterior wall rests upon 
the thighs when the subject is standing. Lying upon 
the back as much as possible, and, when the woman is 
up, wearing a suitably applied bandage, constitute the 
proper treatment of this accident in the latter part of 
pregnancy. 

Should incarceration of the gravid anteverted or ante- 
flexed uterus happen, an accident possible only in the early 
months, and which has a predisposing cause in increase 
of the antero-posterior diameters of the pelvis, the fun- 
dus of the uterus is fixed behind the pubic joint ; but 
manual reduction can usually be readily effected. For 
this reduction the patient is placed in a horizontal posi- 
tion, the hips somewhat higher than the head; then an 
effort is made, by drawing upon the cervix and pressing 
upon the anterior wall of the uterus, near the fundus, to 
restore the organ to its normal position; or pressure may 
be made with the index and medius introduced into the 
vagina upon the body of the uterus. ‘‘ Godefroy placed 
the index of one hand in the vagina, the other in the rec- 
tum, and effected reduction by pressure in opposite di- 
rections ; while Moreau drew the neck down by a finger 
in the vagina, and pushed up the fundus by means of a 
sound in the bladder.” 

Posterior version or flexion of the gravid uterus is a 
more frequent and grave disorder, if it should not be 
rectified by nature or by art. These names are frequently 
used synonymously, and indeed it is asserted that a pure 
retroversion of the gravid uterus is rarely met with, some 
flexion usually being combined with it. Nevertheless, it 


Fria. 3096. 


is probable that a woman whose uterus is retroverted 
rarely becomes pregnant, and hence, if the gravid uterus 
is found retroverted the accident almost certainly _oc- 
curred after impregnation; and on the other hand, a 


17 


Pregnancy. 
Pregnancy. 


woman with retroflexed uterus may become pregnant 
more frequently than one whose uterus is in normal 
position, because the deviation is frequently the cause 
of abortion. In retroversion the axis of the cervix cor- 
responds with that of the body of the organ, while in 
retroflexion it forms an angle—acute, right, or obtuse— 
with the uterine axis. The preceding illustrations, the 
first of flexion, and the second of version, show the es- 
sential difference between the two. In regard to retro- 
version of the gravid uterus, there has been much dis- 
pute as to whether the deviation is sudden or gradual, 
and as to whether distention of the bladder is cause or 
consequence. It may be admitted that each form of de- 
viation can occur, that is, it may be sudden or gradual, 
and that distention of the bladder is occasionally a cause, 
while in all cases it is one of the gravest consequences of 
the change of position. 

In the majority of cases of these positional disorders 
of the gravid uterus, spontaneous rectification occurs in 
the progress of pregnancy. In very rare instances, how- 
ever, of retroflexed uterus, as first suggested by Merri- 
man, and as confirmed by the observations of Oldham 
and Stillé, pregnancy may go to term or near it, though 
the uterus remains retroflexed. 

In some cases, again, spontaneous abortion is not an 
infrequent result. But should neither spontaneous nor 
artificial restoration be made, nor abortion occur, incar- 
ceration follows, for the unusual development of the 
uterus observed by Oldham and by Stillé is so rare an 
event that it may be omitted from consideration. When- 
the uterus remains imprisoned, there will result reten- 
tion of urine and obstruction of the rectum; uremia 
and local or general peritonitis may occur; the bladder 
may rupture, or there may be a simple or a diphtheritic 
cystitis, and, as a consequence, detachment of the whole 
or of parts of the vesical mucous membrane. Valenta 
has reported a case in which retroflexion caused in the 
fifth month gangrene of the bladder, perforation into the 
small intestine, and death. 

In making the diagnosis the bladder should be first 
emptied by the catheter if possible, but, if this be impos- 
sible, especially in case there be great accumulation of 
urine, by the aspirator; if the patient is very sensitive 
an anesthetic must be employed. Given the probable 
fact of pregnancy, its certain proof may usually be had 
from auscultation in case the pregnancy has advanced to 
four months or more. Then by examination with the 
finger, both vaginal and rectal, by abdominal palpation, 
and finally by combining the latter with vaginal touch, 
the fact of retroversion or retroflexion of the uterus will 
in most cases be clearly established. 

The diagnosis of the deviation having been made, the 
next step is to correct it, and prevent its return. Sup- 
posing the simplest form of the disorder, a displacement 
at two or three months being present, and the uterus be 
mobile, its correction can generally be readily made by 
the bimanual method, and the return of the disorder 
be prevented by the application of a suitable pessary, 
which in most cases ought to be worn until the end of 
the fourth month. Even if the uterus be almost, or quite 
immobile, and no grave consequences of the displacement 
be yet present, its gradual restoration may be possible. 
In attempting such restoration the patient takes the knee- 
chest position and then the operator introduces the large 
blade of a Sims’s speculum, pressing the point of the 
blade as. far up as possible in the posterior cul-de-sac. 
By this pressure upon the posterior wall of the uterus, we 
endeavor to lift up the organ while retracting the peri- 
neum; the movement of the uterus may be assisted by 
hooking a tenaculum into the vaginal cervix, which is 
thus drawn backward and downward. The operation 
may be repeated for a brief time each day, should no un- 
favorable symptoms arise; there may be very slight gain 
each time, but patient perseverance will, in many cases, 
be rewarded with complete success. If, however, symp- 
toms of incarceration are manifested, immediate restora- 
tion must be attempted. In such cases an anesthetic will 
usually be required, and therefore the knee-chest position 
cannot be taken while efforts at restoration are made, 


18 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Indeed, such position would hinder rather than assist re- 
turn of the organ to its normal place in some degrees of 
this displacement ; for example, in case the fundus of the 
uterus has descended, so as to be near the vaginal outlet, 
and the cervix is directed above the pubic joint, the or- 
gan occupying a position corresponding nearly with the 
axis of the pelvic inlet, the cervix being highest, it is 
manifest that there would be, so far as the action of grav- 
ity and atmospheric pressure are concerned, force exerted 
which would increase rather than lessen the displace- 
ment. Under such circumstances it is better for the pa- 
tient to be lying upon her side, or- upon her back. The 
four fingers of one hand may be introduced into the va- 
gina to press the organ up, or two fingers applied to the 
anterior surface of the neck, now its superior, to draw 
this part downward and backward, while two of the 
other hand are placed in the rectum and the body of the 
uterus is by them pushed upward and forward. It is 
doubtful if the colpeurynter, whether introduced into the 
vagina or into the rectum, is of much value. 

If the organ cannot be restored to its normal position, 
and serious symptoms are present, the only resource is to 
empty it, that is, produce abortion ; and in those cases in 
which it was impossible to reach the os, for the introduc- 
tion of a sound, puncture of the uterus, thus evacuating 
the amniotic liquor, has been successfully employed. 

Hernie of the Uterus.—Hernie of the gravid uterus 
are rare. In some instances protrusion of a part of the 
organ may take place in an umbilical hernia, or again 
there may be a ventral hernia, the integrity of the abdom- 
inal wall having been lost from the distention of a pre- 
vious pregnancy, or from an injury, the separation usu- 
ally being between the recti muscles. The conditions 
which have been mentioned rarely give rise to serious 
difficulty during pregnancy, or in labor; nevertheless in 
the latter, if a considerable eventration is present, the 
uterus thus being withdrawn from the assisting action of 
the abdominal muscles during the second stage, that stage 
will be tedious, and an instance of this kind I have 
known. The comfort of the patient during pregnancy 
will usually be promoted by a suitable bandage. 

The only other forms of hernie known are inguinal 
and crural. Eisenhart states that hernia of the gravid 
uterus is nearly as rare as that of the non-gravid, and 
the slight preponderance in number of the former is 
probably due to the fact that pregnancy directs attention 
to a condition that would be otherwise unnoticed. In 
some historical references this writer states that Nicolaus 
Pol (1581) reported the first case ; Ceesarean section was 
performed, the mother surviving three days, but the 
child lived until it was a year and a half old. In 1610 
Sennert operated on a case, the mother living twenty 
days, and the child until it was nine years and a half 
old. Saxtorph’s and Ledesma’s cases are next given, 
that of the latter occurring in 1840. Rektorisk reported 
a case in 1860; the Cesarean operation was done, the 

-mother died, but the child lived. 

Inguinal hernia has been frequently observed with 
uterus bicornis or didelphys. In Winckel’s case, reported. 
by Eisenhart, the uterus was bicornis ; the hernia, which 
involved the right horn, occurred suddenly in the fourth 
month of pregnancy. Scanzoni has reported a case of 
inguinal hernia in a patient who had two pregnancies in 
one year, one of these being ended by spontaneous and 
the other by artificial abortion. 

In either crural or inguinal hernia, Winckel advises 
abortion ; but if the foetus be viable, the Czesarean sec- 
tion should be done at the end of pregnancy, and after 
the operation the uterus is, if possible, to be restored to 
the abdominal cavity ; but if this cannot be done it should 
be extirpated. 

Structural Diseases of the Uterus.—Two only of these 
will be considered, benign and malignant growths. Fi- 
broids, or myomatous tumors of the uterus are compara- 
tively rarely observed in pregnancy, for such tumors cause 
a relative sterility ; thus, while the average sterility of wo- 
men is one in eight, that of those suffering from such neo- 
plasms is one in three. These tumors usually increase in 
size and become softer in pregnancy, and after this a par- 


—— 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Pregnancy. 
Pregnancy. 


tial atrophy is frequently observed, more especially in 
those which have a predominance of muscular tissue in 
their structure: 

Stratz (Zectschrift fir Geburtshilfe) has recently report- 
ed the results of 11 cases of uterine myomata observed in 
pregnancy. In 4 spontaneous abortion occurred, and in 
3 it was induced ; twice the tumor and the uterus were 
removed, and twice also the tumor only was taken away, 
once by laparotomy, and once through the vagina, and 
in the two latter cases only were living children born at 
term ; all the mothers recovered. On the other hand, of 
13 women in whom the tumors were discovered during 
labor, 7 died, and 8 of the children were saved. Hence 
he draws the conclusion that intervention during preg- 
nancy is much more favorable for the mother, while de- 
lay until labor occurs is more favorable for the child. Rec- 
ognizing the fact that the mother’s is more valuable than 
the child’s life, Stratz holds that intervention during preg- 
nancy ought to be the general rule; that in very many 
cases abortion should be produced, as the sole rational 
measure, since myomotomy is yet too recent an operation 
for its true value to be known. But it should be remem- 
bered that whether a fibroid is a serious complication of 
pregnancy depends upon its size and position ; growths 
of moderate size, unless so situated that they notably 
lessen the size of the birth-canal or seriously interfere 
with the expansion of the lower segment of the uterus, 
may not prevent normal labor ; and such growths, as the 
experience of most practitioners will testify, are those 
which are most frequently observed. If the fibroid is 
situated at the uterine fundus, abortion is very liable to 
occur. In many instances where the growth was in the 
lower part of the uterus or in the cervix, and submu- 
cous, it was successfully extirpated during labor. If the 
tumor be subserous, and not so large that it prevents the 
development of the uterus, there is no indication for in- 
terference; on the other hand, its removal is indicated if 
it be large, and then, in case it be pedunculated and with- 
out extensive adhesions, that removal is not difficult, nor 
likely to-be followed by interruption of the pregnancy. 

If the fundus of the uterus be affected by cancer or by 
sarcoma, pregnancy is not at all probable, and should it 
happen, abortion is inevitable. Malignant disease of the 
cervix, however, is not so invariable an obstacle to im- 
pregnation. Nevertheless, it is a comparatively rare oc- 
currence that a woman who has cancer of the womb 
becomes pregnant ; the statistics presented by Stratz, 
op. cit., show that in 1,034 cases conception was observed 
in only 12. 

Pregnancy causes the more rapid growth of malignant 
tumors of the uterus, and extirpation of the diseased 
structure, although the operation may cause abortion, is 
plainly indicated. 

If an ovarian tumor is small it rarely interferes with 
pregnancy, and, therefore, the statement made by Stratz 
is too absolute, that the occurrence of pregnancy in a 
woman having such a growth is a sufficient indication for 
at once performing ovariotomy. But should the tumor, 
either by size or position, interfere with the progress of 
the pregnancy, ovariotomy is indicated, and the earlier in 
gestation the operation is done the more favorable the 
prognosis. In fourteen cases of ovarian tumors compli- 
cating pregnancy, reported by Stratz, ovariotomy was 
done; all the mothers recovered, and thirteen out of 
fifteen children were saved, abortion occurring in two 
cases, and there being one twin pregnancy. These re- 
sults are very much better than those following the ex- 
pectant plan, the induction of abortion, or puncturing 
the cyst. 

Mastitis, ending in resolution or in suppuration, has 
occasionally been observed during pregnancy, but the 
treatment of this affection does not require special con- 
sideration. There is a normal hypertrophy of the 
mamime in pregnancy ; but in rare instances this hy- 
pertrophy becomes very great, transgressing all physio- 
logical bounds, and in such cases abortion is liable to 
occur ; usually the hypertrophy is followed by atrophy 
when the pregnancy is over. Treatment—including the 
application of support to the enlarged breasts, of iodine, 


or of cold, and of compression, and the internal admin- 
istration of the potassic iodide—has rarely proved of not- 
able value. 

Tumors of the breast, whether benign or malignant, 
usually increase rapidly in size during pregnancy ; in a 
few instances malignant growths begin at this time. If 
mammary cancer is complicated by pregnancy, or origi- 
nates during it, extirpation of the growth is indicated. 

Diseases of the Ovoum.—There will be included in this 
class anomalies of the amnion, the chorion, the decidue, 
and of the placenta and cord, diseases of the foetus hav- 
ing been elsewhere considered in this work. 

Amniotic Adhesions and Bands.—Adhesions between 
the amnion and the fcetus and amniotic bands are in 
some instances met with. These were supposed by some 
observers to result from inflammation of the amnion, 
amniotitis ; but the hypothesis now most generally ac- 
cepted is that adhesions are caused by an arrest of devel- 
opment, and that bands uniting the skin of the fcetus, 
or, in some instances, floating in the amniotic liquor, 
either unattached or attached only at one end, result 
from stretching the adhesions through an increase of 


Fre. 3097.,—Amniotic Adhesions and Bands. (Charpentier,) 

the amniotic liquor. Deformities of the foetus may be 
caused by these anomalies, and, in some instances, am- 
putation of a limb, or part of it, may be effected by an 
amniotic band. 

Polyhydramnios ; Oligohydramnios.—By the former— 
commonly called hydramnios—is meant excess, and by 
the latter deficiency, of the amniotic liquor. Whenever 
the amniotic liquor is in marked excess of two quarts, 
there is said to be polyhydramnios ; in some instances this 
excess is between twenty and thirty quarts. The affec- 
tion is more frequent in multigravide than in primigra- 
vide—according to McClintock, 23 to 5; more frequent 
in twin than in single pregnancies, and generally in 
the former the twins are of the same sex ; and in some 
cases there is polyhydramnios in one fetal sac, oligo- 
hydramnios in the other ; in afew instances polyhydram- 
nios has been found in extra-uterine pregnancy. 

The disease has been attributed to amniotis, to persist- 
ence of the vasa propria of Jungbluth, which usually 
become obliterated in the last months of pregnancy, to 
great activity of therenal function of the foetus, to trans- 
udation of serum of the maternal blood through the feetal 
membranes, and to transudation from the feetal circula- 
tion. 

Two forms of polyhydramnios are met with, the one 
chronic, the other acute ; the former is much the more 
frequent. In the chronic affection the dropsical accu- 
mulation takes place slowly, and is, therefore, better tol- 
erated ; but in the acute disease the accumulation 1s very 
rapid, and fever is present. Tarnier distinguishes the 
last form of the affection as primary or secondary ; by 


19 


Pregnancy. 
Pregnancy. 


the latter is meant an acute form grafted upon the 
chronic. 

The most striking characteristics of polyhydramnios 
are the rapid increase in size of the uterus—the organ at 
five months, for example, being as large as it should be 
at the end of pregnancy—and the very distinct fluctua- 
tion. Besides these we have pressure-accidents relating 
to respiration and circulation, the former becoming diffi- 
cult, so that the patient must be erect or sitting; and 
from interference with the latter there may be general 
cedema, but there always is cedematous swelling of the 
lower limbs; the uterine walls, both by abdominal and 
by vaginal examination, are found tense and resisting, 
and obstetric palpation and auscultation are difficult, or 
may even yield negative results so far as clearly estab- 
lishing the diagnosis of pregnancy ; vaginal examination 
shows the os high up, and a tense, elastic mass, in some 
cases giving distinct fluctuation, is found blocking up 
the pelvic inlet ; the neck may be partially or completely 
effaced. 

The induction of labor is clearly indicated if the uter- 
ine distention be so great that the life of the mother is 
in peril. The obstetrician must remember that there is 
great liability to post-partum hemorrhage from uterine 
atony, and must guard against this accident. 

Oligohydramnios may, according tosome, cause adhe- 
sions between the fcetus and the amnion, and the subse- 
quent formation of amniotic bands by stretching these 
adhesions when the amniotic liquor becomes abundant: 
a more probable explanation of these conditions has 
been given. But it seems not doubtful that in those 
cases in which this fluid is scanty, the foetus cannot have 
its normal attitude, and undergoes injurious compression 
from which deformities may result. 

Diseases of the Chorion.—Cystie Mole, or Hydatidiform 
Degeneration of the Chorial Vili. 'This is an affection of 


Fre@. 3098.-—Cystic Mole. 


(Charpentier. ) 


the chorial villi, but whether these are primarily or sec- 
ondarily involved has been a matter of dispute. Hecker 
asserted that it arose from failure in the development of 
the allantois, but this view, though strengthened by the 
absence of blood-vessels in the walls of the vesicles, is 
not generally accepted. Lesions of the decidua are pres- 


20 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


ent, and these in most cases follow the change in the villi; 
but sometimes, according to Virchow, endometritis pre- 
cedes the chorial disease, and may contribute to it. The 
arguments in favor of the maternal origin of the disease 
are its frequent recurrence in the same woman—thus De- 
paul reported the case of one patient who thus suffered 
in three, and Mayer, one who had the disease in eleven 
pregnancies—and its occurrence in women advanced in 
years—for example, Schroeder saw it in one woman fifty 
years of age, and in another fifty-three years of age. On 
the other hand, instances of twin pregnancy, in which 
one ovum was diseased and the other healthy, have been 
observed, and such facts strongly indicate the fetal ori- 
gin of the malady. 

The generally accepted view of the nature of this af- 
fection is that proposed by Virchow, who believes that it 
arises from a myxomatous degeneration of the chorial villi. 
The part affected by this change is converted into a vast 
number of cyst-like formations—there may be five or six 
thousand ; these vary in size, some being as large as an 
almond, others as small as, or smaller than, a currant, and 
still others scarcely visible to the unaided eye. Depaul 
states that they vary in size from a pin’s head to a pul- 
let’s egg ; they have pedicles, but these are not attached 
to a common stem, as is seen in a bunch of white cur- 
rants, or of grapes, to which their appearance has been 
compared, but to other vesicles. The semi-fluid substance 
in the vesicles is similar to that found in Wharton’s jelly ; 
it is composed of water, albumen, mucine, salts, chloride 
of sodium, and phosphoric acid (Fig. 3098). 

If the disease begins before the formation of the pla- 
centa, the entire chorial tissue will be involved, but if 
after, the disease is limited to the placenta chiefly, and in 
some instances to a part of it. 

The affection is rare, Madame Boivin having met with 
but one case in 20,375 deliveries. 

Depaul has presented three important signs of a cystic 
mole: 1. A more rapid enlargement of the abdomen 
than is seen in normal pregnancy. In one of his patients 
the uterus was four fingers’ breadth above the umbilicus 
at four months. 2. Attacks of uterine hemorrhage. This 
symptom has occurred as early as the forty-fifth day, and, 
on the other hand, has been delayed as late as the four- 
teenth month. Discharges of blood in some cases alternate 
with discharges of a watery fluid. 3. The expulsion of 
separate vesicles, or of clusters ; of course this sign is con- 
clusive. The danger to the woman is exhaustion from 
repeated hemorrhages, or a single hemorrhage may be 
so great as to be fatal. The foetus in almost all cases dies. 
Nevertheless, there are instances in which an ‘‘ hydatid” 
mass has been expelled, and the pregnancy continued 
until term, when a healthy child was born. Such cases 
were probably examples of a twin pregnancy in which 
myxomatous degeneration affected one ovum, which was 
discharged, while the other remained healthy. 

No active treatment is required until hemorrhage oc- 
curs. If this be slight, rest, cold acid drinks, and an 
opiate may be sufficient. Even if the disease be proved 
by the expulsion of the so-called hydatids, it does not 
follow that the uterus is to be at once emptied. The 
dominant fact guiding the treatment is hemorrhage. If 
this persists, if it is grave, and only temporarily restrained 
by the tampon, the os uteri should be dilated, the uterine 
cavity emptied, and hemostasis secured by proper means. 

Destructive Cystic Mole.—Zweifel describes, under the 
designation Die destruirende Blasenmole, rare cases, of 
which only three have been observed—one each by Volk- 
mann, Waldeyer, and Kriger—in which the chorial villi 
grow so rapidly into the uterine wall that they reach the 
peritoneal covering, and hence this wall becomes greatly 
weakened. The difficulty in removing such a growth, 
the impossibility of making the removal complete, and 
the liability of causing rupture of the uterus, are obvi- 
ous ; but without such removal the hemorrhage cannot 
be arrested. Two of the three cases that have been re- 
ported died from hemorrhage, and the third from peri- 
tonitis. Where interference is necessary, Zweifel advises 
dilatation of the os by a compressed sponge that has 
been thoroughly disinfected by hot air ; expression of the 


REFERENCE HANDBOOK OF THE.MEDICAL SCIENCES. 


uterine contents may be tried, and if this fails, the hand 
must be introduced into the uterus and the curette then 
employed, this operation being followed by washing out 
with antiseptic injections the parts detached. 

Myxoma of the Membranes of the Ovum. In addition to 
the ‘‘ partial hyperplasia of the foetal connective tissue 
in the chorial villi, the cystic mole, Breslau and 
Eberth have found a similar hyperplasia in the 
parts of the chorion without villi. This appears 
in the form of a soft gelatinous thickening of the 
membranes, and during labor it feels like the 
scalp distended by serous infiltration” (Zweifel). 

Fibrous Myxoma of the Placenta. This degen- 
~ eration was first described by Virchow, who gave 
to it the name of fibrous myxoma of the placenta. 
The growth is composed of mucous and fibrous 
tissue ; it is vascular, but there are no vesi- 
cles as in cystic degeneration of the chorial 
villi. In some cases there is a single large 
tumor, as in one reported by Storch, in 
which the mass was five inches and a half 
long, and three inches and a half broad ; 
but in other instances there is a large num- 
ber of small tumors. 

Decidual Endometritis.—Four varieties of 
this affection have been described. 

1. Diffuse Decidual Endomeiritis. This Wage 
usually affects only the uterine decidua, de- 0 
cidua vera; there is thickening of the mem- 
brane from proliferation of the decidual 
cells, and development of the connective tis- 
sue; it is also as- 
serted that the sub- 
jacent muscular 
fibres may undergo 
hyperplasia. 

2. Polypoid Decid- 
ual Hndometritis. 
This is character- 
ized by thickening 
of the decidua 
vera, and polypoid 
growths, irregular 
in form, broad- 
ae and about three-fourths of an inch in height (Fig. 
3100). . 

Breus states that if polypoid endometritis occurs early, 
the inflammatory process readily extends to the chorial 
villi, with consequent atrophy of the ovum and _ abor- 
tion; upon the aborted ovum there will be found the 
proofs of diffuse and polypoid decidual endometritis. 

3. Cystic Decidual Hndometritis. In this form of the 
disease not only the decidua vera is involved, but also 
the glands; obstruction of the gland-ducts results from 
inflammatory swelling, and cysts are formed—in other 
words, they are retention-cysts. 

4. Catarrhal Decidual Endometritis. The characteris- 
tic evidence of this disease is the discharge from time to 
time of a watery fluid, known as hydrorrheea gravidarum. 
This discharge, which may occur as early as the third 
month, but usually not until the late months, of preg- 
nancy, is more frequently observed in multigravide than 
in primigravide ; it is albuminous, generally yellowish, 
and may contain blood. Many of the cases of supposed 
rupture of the membranes and discharge of the amniotic 
liquor days and even weeks before labor, are really in- 
stances of hydrorrhcea, a discharge of so-called false 
waters occurring. Slight pains commonly accompany the 
discharge ; in most cases it is repeated several times. Pre- 
mature labor rarely follows hydrorrhcea, but its possible 
occurrence suggests that the patient, especially if there 
are uterine contractions, should lie down, and decided 
pain indicates the use of opium either by rectal injection 
or by the mouth. The causes of decidual endometritis 
are not well known. In some cases it is apparently the 
result of syphilis, and in others of violent bodily effort, 
or of excessive work ; in others it existed prior to the 
pregnancy, and in still others follows the death of the 

cetus., 


Fie. 3099.—Destructive Cystic Mole. 


Pregnancy, 
Pregnancy. 


_ Decidual Hamorrhage.—Extravasation of blood may 
take place involving all the deciduous membranes; ‘if 
the extravasate is situated in the serotine membrane it 
may extend between the reflexa and the chorion, invagi- 
nating the latter and the amnion into the cavity of the 
ovum, and the embryo, if not previously dead, dies from 
compression ;” sometimes even the cavity of the ovum 
is ruptured and the effusion penetrates into it. If the 
ovum is not ruptured the amniotic liquor is absorbed 
after the death of the embryo, and the latter disappears, 
the ovum containing only the remains of the cord. If 
expulsion of the ovum occurs soon after the hemorrhage, 
the mass is composed chiefly of a large clot of blood, 
and has been called a blood mole. If, however, the ex- 
pulsion be delayed, the embryo having prematurely es- 
caped, or having undergone absorption, the effused blood 
has become more firm, and regressive metamorphoses hav- 
ing taken place, the mass is known as the fleshy mole. 
In either case the pregnancy has been called a false or 
molar pregnancy, and the mass expelled a blighted ovum 
(Fig. 3101). 

Placental Apoplexy.—Jacquemin has described three 
forms of placental hemorrhage. In the first the blood 
is infiltrated in one or several lobes of the placenta ; in 
the second it occupies an irregular cavity which presents 
projections in different directions ; but in the third there 
are regular and circumscribed cavities, varying in size 
from a hemp-seed to a ;pigeon’s egg; these effusions are 
usually multiple, and at first appear as blood-red extrava- 
sates, but afterward lose their deep hue and become gray- 
ish-red, or yellowish-white, fibrin-like masses. Accord- 
ing to Kleinwachter placentitis is the usual cause of these 
heemorrhages. 

When the effusions are multiple or large, they may so 
seriously interfere with the nutrition of the foetus that its 
death results. 

Placentitis.—According to Hegar and Maier, inflamma- 
tion of the placenta may originate as a cell proliferation 
of the decidual tissue, or from the larger foetal arteries ; 
it soon terminates in induration ; in some cases it results 
in strong adhesions between the placenta and the uterus, 
requiring at labor manual detachment of the former. The 


Fia. 3100.—Polypoid Decidual Endometritis. 


(Charpentier. ) 


formation of pus is, according to Zweifel, exceedingly 
rare, and can only be ascertained by the help of the 
microscope. 

Caleareous and Fatty Degeneration of the Placenta.— 
The presence of sand-like grains either upon or in the ma- 
ternal or the foetal portion of the placenta is not uncom- 
mon; in some cases the calcareous products may present 


21 


Pregnancy. 
Presbyopia. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the form of needles or of scales. The presence of these for- 
mations is without importance. 

Fatty degeneration has been described by Barnes ‘‘ as 
generally partial, invading one or more cotyledons, or 
part of them, forming in many cases diseased masses im- 
bedded in comparatively healthy tissue, thus giving evi- 
dence that it originated during the life of the foetus. In 
some instances we find, indeed, a living foetus with a 
placenta in part affected; in others we find the disease 
more advanced and the foetus dead, but with some healthy 
placenta, the vessels still containing blood. To the naked 
eye the fatty placenta may exhibit masses of a yellowish 
pale color, more solid than the spongy, healthy tissues 
surrounding them, and easily friable.” Among the con- 
sequences of fatty degeneration is abortion. Barnes holds 
that this change may explain some cases of hemorrhage 
during gestation which are attributed to placenta previa. 

Tumors of the Placenta.—Cystic and solid tumors of 
the placenta are sometimes met with; one variety of the 
latter has been previously mentioned. Klotz has recently 
(Archiv fur Gyndk., Band xxviii.) described adenoma of 
the placenta. This tumor originates in the spongy por- 
tion of the placenta or in the glandular cavities of the 
serotine decidua. Adenoma of the placenta causes the 


Fie, 3101.—Hemorrhagic Mole. CS, blood-clots; HK, hemorrhagic 
cysts. (Charpentier. ) 


death and the expulsion of the fetus, and this is followed 
by retention of the placenta, the retention lasting for 
weeks, and even months. 

Syphilis of the Placenta.—The following are the micro- 
scopical appearances of placentz from syphilitic mothers, 
as given by Zilles in his valuable monograph, Studien 
aber Hrkrankungen der Placenta und der Nabelschnur be- 
dingt durch Syphilis (1885): The placenta is of massive 
development and of great weight, in comparison with 
the imperfect development of the fetus. The general 
color of the organ is pale red, but in the diseased portions 
yellowish-white. Here and there the tissue is firmer, 
more resistant, compact, and friable than the normal pla- 
centa. At various points gummatous nodules are found ; 
they are wedge-shaped, nodulated, fibrous formations, 
with their bases in the decidua, but they generally grow 
smaller as they penetrate more deeply into the fcetal pla- 
centa ; they vary in size, some being as small as a pin’s 
head, others as large as a walnut; in some instances they 
occupy circumscribed portions of the entire thickness of 
the placenta. The gummata upon section show a struct- 
ure of concentric lamelle ; the external layers are firmer, 
more like fibrous tissue, and have a grayish-yellow color, 
while in the centre there is a yellowish-red, or orange-yel- 
low, cheese-like, soft or fluid material. Scattered through 
the peripheral zone are nodules of a cloudy orange-yellow 
color and cheesy in character, about the size of miliary 
tubercles. If complete degeneration of the central por- 
tion has occurred, an irregular cavity is present, its walls 


22 


being formed of fatty, granular débris, and covered with 
pus-corpuscles. The decidua at the uterine surface is 
greatly thickened, cloudy, and presents yellowish-white 
spots. If the fcetus is affected, nodules, similar to those 
previously described, are found under the amnion. The 
umbilical cord is firmer than normal, and upon section a 
remarkable crescent-shaped thickening of the vessels can 
be seen with the naked eye. There are also seen the 
characteristic nodules in the tissue of the cord at some 
distance from the vessels. 

Anomalies of the Cord.—Cotls of the Cord about the Fatus 
or its Members. One or more loops or “‘ circulars” may be 
around the foetus, or one of its members ; the part most 
frequently thus encircled is the neck, and in one case 
that has been reported the cord was wound around the 
neck eight times. This accident occurs more frequently 
in multigravide than in primigravide, and is oftener 
found with the male than with the female fetus. In 
general no injurious result follows such position of the 
cord, but in some cases the calibre of the umbilical vessels 
is materially lessened, and death of the foetus ensues. 

Knots.,—Accumulation of Wharton’s jelly at particular 
parts of the cord, causing there a notable projection, is 
known as a false knot. Buta true knot is formed if the 
foetus passes through a loop in the cord ; such a knot is 
met with once in two hundred cases ; the knot is in some 
cases double, and in others, instead of either one single 
knot or a double knot being present, there are several sin- 
gle knots. Depaul, for example, saw a case in which there 
were five. The knots are recent, or old; in the former, 
which occur during delivery, the diameter of the cord is 
normal, there is no lessening of Wharton’s jelly ; but in 
the latter the knot is smaller, Wharton’s jelly being nota- 
bly lessened. If the knots are contiguous, and are formed 
during pregnancy, it is possible, according to some au- 
thorities, that they may be drawn so tightly that the cir- 
culation is seriously interfered with and the foetus dies ; 
but ordinarily the circulation is not interrupted from this 
cause. 

Torsions.—The umbilical cord normally presents tor- 
sions, this twisting being, in by far the larger number of 
cases, from left to right. But there may be an excessive 
number of these torsions ; Dohrn saw a case in which there 
were 85, Meckel 95. They have been more frequently ob- 
served in the case of the male than in that of the female 
foetus, the proportion being 8 to 5. Spiegelberg de- 
scribed them as preemortal, and postmortal; the first are 
usually caused by the movements of the foetus, but the 
second by those of the mother. Dancing is mentioned 
by Kormann as a cause of twists in the cord. ‘Torsions 
are most numerous near the umbilicus, and next in the 
vicinity of its placental attachment. In some instances 
division of the cord has followed torsions, the foetus thus 
being left free in the uterine cavity ; in rare cases occlu- 
sion of the vessels or great stenosis has been thus caused, 
and of course in either condition the foetus dies. 

Stenoses of the Umbilical Vessels.—Narrowing of the 
vessels of the cord may occur independently of knots or 
torsions. ‘These stenoses, first observed by Oedmanson 
and Winckel, and described by Birch-Hirschfeld, are usu- 
ally found in the vein near the placenta. The latter also 
found circumscribed stenoses of the arteries in the vicin- 
ity of the umbilicus, and also near the placenta; he re- 
gards them as resulting from syphilis. -Spaeth states that 
atheromatous changes may occur in the arteries. Hyrtl 
found stenosis of the umbilical vein consequent upon 
periphlebitis. Theophilus Parvin. 


PRESBYOPIA (Pr), from mpéoBus, old, and &y, eye, is 
‘‘the condition in which, as the result of the increase of 
years, the range of accommodation is diminished, and 
the vision of near objects interfered with.”! The range 
of accommodation diminishes year by year, from about 
15 dioptrics (1/23), at the earliest age (ten years) at which 
accurate observations have been made, to about 1 diop- 
tric (7s), at the age of sixty-five or seventy ; at forty it 
amounts to something less than 5 dioptrics (4), and at 
forty-five to about 3.3 dioptrics (qs).’ 

Of the 15 dioptrics of accommodation which the child 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


of ten years can bring into exercise, from two-thirds to © 


three-fourths (10 to 11 dioptrics) may be lost without 
greatly incommoding an emmetrope in ordinary near 
vision. In emmetropia the distance (P2) of the binocular 
near-point ( 2) is the reciprocal of the number of dioptrics 
of accommodation ; hence, with a binocular range of ac- 
commodation of 5 dioptrics, Pz = 4 metre (20 centimetres 
= 8 inches), at which distance the smallest print in ordi- 
nary use is easily deciphered by eyes of average visual 
acuteness ; when the range of accommodation is reduced 
to 4 dioptrics P. = + metre (25 centimetres = 10 inches), 
at which distance ordinary newspaper print is still easily 
read ; with the loss of another dioptric of accommoda- 
tion (leaving but 3 dioptrics available), Pz = 4 metre (83.3 
centimetres = 13.12 inches), and the reading of fine print 
becomes difficult, except under the favorable conditions 
of good illumination and normal acuteness of vision. 
These several values of P2 correspond, in emmetropia, to 
ages ranging from about thirty-eight to about forty-seven 
years, and few emmetropes attain the latter age without 
seeking aid from convex glasses in reading or other fine 
work ; the adoption of convex glasses by an emmetrope 
under forty, is generally determined either by the exact- 
ing nature of the work in which he habitually employs 
his eyes, or by the fact that his acuteness of vision is 
somewhat below the normal standard. When at the age 
of from fifty to fifty-five years the range of accommoda- 
tion-is reduced to 2 dioptrics, P2 = 4 metre (50 centi- 
metres = 19.68 inches), and the book must be held at 
arm’s length, at which distance only exceptionally large 
print can be read; but, even with this range of accom- 
modation, a public speaker may be able to read fluently 
from a plainly written manuscript lying before him upon 
a reading-desk or table. 

The diminution of the range of accommodation with 
advancing years is a strictly physiological change, and 
is directly related to the progressive increase in the 
hardness of the crystalline lens, in consequence of which 
it becomes less and less capable of undergoing the change 
in curvature required for the adjustment of the eye for 
near vision. As this hardening of the crystalline occurs 
in all eyes alike, irrespective of their refractive condi- 
tion, as determined by the relation of the curvature of 
the refractive surfaces to the length of the axis of the 
eyeball, it would be scientifically correct to define pres- 
byopia as the loss of accommodative power incident to 
advancing years. Immemorial usage has, however, as- 
sociated the name with the special condition in which, as 
a result of increasing age, near vision becomes indistinct 
while distant vision remains either absolutely or rela- 
tively unimpaired. As thus defined, presbyopia is an 
incident in the life-history of all emmetropes and. hyper- 
metropes, and also of myopes whenever the myopia is of 
low grade—say, 3 dioptrics or less. In myopia of higher 
grades, say, of 4 dioptrics or more, the distance of the 
far-point remains within + metre (25 centimetres = 10 
inches) of the eyes, which is somewhat less than the 
usual reading distance for fine print ; so that the charac- 
teristic disability of presbyopia, namely, the failure of 
vision for small near objects, is either never developed or 
only very late in life.* The apparent antagonism be- 
tween myopia, in which only near objects are seen dis- 
tinctly, and presbyopia, in which distant objects are seen 
clearly, while near objects appear confused, was very 
early recognized,* and, in the absence of any clear con- 
ception of the nature of the function of accommodation, 
presbyopia was, for more than two thousand years, re- 
garded as the opposite condition to myopia. Hyperme- 
tropia, the true opposite of myopia, remained confounded 
with presbyopia until the middle of the present century, 
when the demonstration of the change in the form of 
the crystalline lens in accommodation by Cramer* and 
by Helmholtz,° and the masterly analysis of the phenom- 
ena of accommodation in its relation to the several 
anomalies of refraction, by Donders,® dispelled the cloud 
of obscurity in which the whole subject had been so 


* That is, in connection with the moderate falling off of the refraction 
which occurs late in life, see p. 24. 


Pregnancy. 
Presbyopia. 


long enveloped, and through which only momentary 
glimpses of the truth had been previously enjoyed by a 
few exceptionally acute observers.’ 

Premonitory signs of presbyopia may ordinarily be 
detected in emmetropes before the thirty-fifth year; ex- 
ceptionally fine print, such as No. 1 of Jaeger’s scale, is 
no longer read with the same perfect fluency as in youth, 
especially if the illumination is defective. Within the 
next five years the finer newspaper print loses something 
in sharpness of definition, and the finest needle-work be- 
comes difficult, and perhaps deteriorates somewhat in 
quality. If the acuteness of vision (V—see Optometry) 
is normal, and the print is not too fine, relief from the 
consciously increasing effort inaccommodation may be ob- 
tained by holding the book or work a little farther from 
the eyes; but if vision is subnormal, or if the print is bad 
or very fine, a stronger illumination may be demanded 
without increasing the reading distance. By the age of 
forty-five the disability has- generally increased to the 
point that only fairly large print can be read with ease 
by ordinary artificial light, and a more powerful lamp is 
procured, or the book is held nearer to the light ; about 
this time the probable need of help from glasses com- 
monly suggests itself, and they are, perhaps, tried and 
adopted. 

A hypermetrope habitually wearing neutralizing (con- 
vex) glasses, or a myope wearing neutralizing (concave) 
glasses, experiences the disabilities of presbyopic vision at 
about the same age, and in about the same degree, as the 
emmetrope ; thus, between the ages of forty and forty- 
five, the hypermetrope discovers that his convex glasses 
are no longer quite sufficient in reading, and similarly, the 
myope discovers that his concave glasses have become 
something of a hinderance in near vision, although, in 
both cases, the neutralizing (convex. or concave) glasses 
continue to serve perfectly for distant vision. A change 
to stronger convex glasses by the hypermetrope, or to 
weaker concave glasses (or, perhaps, the temporary re- 
moval of his glasses) by the myope is the remedy which 
now suggests itself, and which is, sooner or later, adopted. 
With the change of glasses reading again becomes easy, 
but with a corresponding falling off in the distinctness 
of distant vision; for this reason, an elderly ametrope 
ordinarily requires two pairs of glasses, the one pair (neu- 
tralizing) for distance, the other pair (stronger convex 
or weaker concave) for reading and other near work. 

A hypermetrope, not wearing convex glasses, experi- 
ences the disabilities of presbyopia at an earlier age than 
the emmetrope, after having, perhaps, passed through a 
more or less protracted stage of suffering from asthen- 
opia (see Asthenopia). In myopia, on the other hand, if 
of low grade, the reading-power with the unaided eyes 
is retained to a more advanced age than in emmetropia ; 
in the higher grades of myopia the reading-power is re- 
tained indefinitely. 

As a result of the very gradual increase in the resist- 
ance which must be overcome in order to effect such de- 
gree of accommodative adjustment as is still possible in 
presbyopia, the relation of the accommodation to the 
convergence undergoes an important change, the binocu- 
lar accommodation (A.) associated with convergence for 
the habitual reading distance of from thirty to thirty-five 
centimetres (12 to 14 inches) becoming at length nearly 
equal to the absolute accommodation (A) ; in other words, 
the binocular near-point (p2) comes to coincide very nearly 
with the absolute near-point (p). With the use of convex 
glasses in near work, the distance (P2) of the binocular 
near-point (2) undergoes a rapid increase, so that such 
reading-power as may have been retained up to the time 
of the adoption of the glasses is speedily lost, and reading 
without glasses becomes inpossible. Hence the common 
experience of presbyopes, that having once formed the 
habit of using convex glasses, their continued use has 
become imperative, and this whether the glasses have 
been adopted somewhat prematurely, or only after the 
need of them has become urgent. The too early use of 
convex glasses is, therefore, to be deprecated, as entailing 
upon the wearer all the disabilities of presbyopia several 
years, perhaps, before the normal age ; on the other hand, 


23 


Presbyopia. 
Prescription. 


as there is a definite limit to the absolute range of accom- 
modation at any given age, the use of convex glasses 
cannot, as a rule, be deferred by an emmetrope much be- 
yond forty-five, unless he be content to forego the use 
of the eyes in reading ordinary print, or in other fine 
work. 

The total disuse of the accommodation for a consider- 
able period, especially if occasioned by protracted and 
exhausting illness, may lead to the premature develop- 
ment of presbyopic symptoms, which may then be inter- 
preted as an indication for the immediate adoption of 
convex glasses. If glasses are used in such a case, they 
should be of the least power compatible with the use of 
the eyes under favorable conditions of illumination, and 
the patient should be encouraged in the hope that, as the 
accommodative power increases with use, the glasses 
may be laid aside. In cases of this kind it is often pos- 
sible to bring the accommodation again into effective use 
by the instiliation, once or twice daily for a few weeks, 
of a weak solution of pilocarpine, and thus to put off the 
use of glasses for perhaps several years. 

In addition to the impairment of the accommodation, 
which is the essential characteristic of presbyopia, the 
refraction undergoes, in the course of time, a slight but 
positive diminution, so that ultimately an emmetrope be- 
comes slightly hypermetropic (H acquisita—see Hyper- 
metropia), a hypermetrope somewhat more hyperme- 
tropic, and a myope somewhat less myopic; a very low 
grade of myopia may thus give place to emmetropia, or 
may even pass through emmetropia to hypermetropia. 
A low grade of hypermetropia which, sooner or later, 
necessarily becomes absolute (H adsoluta), is, in fact, the 
ultimate normal condition of all emmetropes, so that 
weak convex glasses come to be required for perfect vi- 
sion at a distance ; hypermetropes similarly require a 
moderate increase in the power of their convex glasses 
and myopes require a corresponding diminution in the 
power of their concave glasses. This falling off in the 
refraction is ordinarily scarcely to be detected at the age 
of forty-five ; at sixty it may amount to perhaps 0.5 diop- 
tric, at seventy or seventy-five to 1 dioptric, and at eighty 
to 2 dioptrics or more.® 

The treatment of presbyopia is necessarily confined to 
the palliation of the actual disability, by the use of such 
convex glasses aS may suffice to supplement the failing 
accommodation and also to correct any existing hyper- 
metropia, whether original or acquired. A person origi- 
nally emmetropic may, at the age of seventy, require con- 
vex glasses of as much as 5 dioptrics power (4), in order 
to read fairly good print at a distance of from ten to twelve 
inches; and if the acuteness of vision is somewhat below 
the normal, it may be necessary to use glasses of 6 or 7, or 
even 8 dioptrics (4 to 4), in order to admit of reading at 
the shorter distance of from nine to seven inches. In the 
case of a person originally hypermetropic, the measure 
of the required glasses will be increased by a quantity 
equal to the grade of the hypermetropia ; in myopia the 
measure of the glasses will be similarly diminished. 

The glasses first given to a presbyopic emmetrope of 
from forty to forty-five years of age, should ordinarily 
not much exceed 1 dioptric (say zy or 3), and, in many 
cases still weaker glasses (say ¢#y or -#s) are quite suffi- 
cient, and may be more acceptable to the patient than 
stronger glasses. These glasses should be used for only 
such work as is performed with difficulty without glasses 
(reading fine print by artificial light, etc.), in order that 
the habit of using the accommodation may not be need- 
lessly or prematurely abandoned,* and they should not 
be exchanged for stronger glasses so long as they con- 
tinue to afford the needed assistance. Subsequent changes 
should always be made with reference to the glasses ac- 
tually in use, adding perhaps 0.25 or at most 0.5 dioptric 
at each change, and it is generally advisable to retain the 


* The proposal to make use of weak convex glasses somewhat before 
the appearance of marked presbyopic symptoms, for the alleged purpose 
of preserving and strengthening the sight, is so irrational as to justify 
the suspicion that it may have originated in the interest of trade; the 
only apparent foundation for such a practice is the fact that in hyperme- 
tropia convex glasses are needed at an earlier age than in emmetropia. 


24 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


old glasses for a time, for reading in bright daylight, re- 
serving the stronger glasses for more exacting work. It 
follows that a presbyope should always know the power 
of the glasses which he is using, in order that, in replac- 
ing a lost pair, he may not be reduced to the necessity of 
selecting new glasses at random, or after a hasty and in- 
adequate trial, conducted, perhaps, by an ‘‘ optician” 
whose knowledge is limited to the trick of selling his 
wares, 

A presbyope using glasses suited to his condition, is 
able to use his eyes in near work freely and without fa- 
tigue; glasses of insufficient strength fall short of afford- 
ing the full measure of relief, and glasses of excessive 
strength compel the hoiding of the book too near the 
face, thus imposing needless work upon the recti-interni 
muscles, and so possibly giving rise to muscular asthen- 
opia * (see Asthenopia). 

The clinical investigation of any case of presbyopia in- 
volves, first of all, the careful testing of the eyes for 
ametropia (hypermetropia, myopia, or astigmatism ; see 
these titles; see also Optometry). As has been already 
explained, the measure of any hypermetropia that may 
be detected must be added to, and the measure of any 
myopia subtracted from, the value of the glasses ordinar- 
ily required by an emmetrope of corresponding age, in 
order to arrive at an approximation to the glasses to be 
given for reading. These tests are best conducted at a 
range of at least five metres (about sixteen feet), and only 
after the satisfactory determination of the state of the 
refraction, should a trial of reading-glasses, based upon 
this determination, be made. (The final tests are made in 
reading fine print (such as Nos. 1 to 5 of Jaeger’s test- 
types). If astigmatism is present, it should, as a rule, be 
accurately corrected by having one surface of each glass 
ground to the appropriate cylindrical curvature (see Astig- 
matism). 

A rapid increase in the grade of presbyopia, necessitat- 
ing frequent and considerable additions to the strength 
of the reading-glasses, should always be regarded as a 
suspicious symptom, indicating the possible development 
of glaucoma. 

Repeated changes from weaker to stronger glasses, but 
with a shortening of the reading distance after each 
change, point to a falling off in the acuteness of vision, 
oftenest from failure in the perceptive power of the ret- 
ina, or of the conductive power of the optic nerve. 

A marked diminution in the apparent grade of presby- 
opia is occasionally observed rather late in life, and is 
due to the development of a myopic state of the refrac- 
tion ; this change, which is popularly known as ‘‘ second 
sight,” is ordinarily a symptom of incipient cataract. 

John Green. 


1 Donders: On the Anomalies of Accommodation and Refraction of 
the Eye, p. 210. The New Sydenham Society. London, 1864. 

2 Donders: Op. cit., p. 20%. 

3 Aristotelian Treatise, tpoBAjpmara, xxxi., 25; cf. Paulus Aegineta. 

4 Cramer: Tydschrift der Maatsch. vor Geneeskunde, 1851. 

5 Helmholtz : Monatsberichte der Akademie der Wissenschaften, Ber- 
lin, February, 1853. 

6 Donders: Archiv fiir Ophthalmologie, vi., 1860. On the Anomalies 
of Accommodation and Refraction, 1864. 

7 Vide Donders: Op. cit., p. 825, note. 8 Tbid., p. 208. 

® Scheffler: Die Theorie der Augenfehler und der Brille. Wien, 1868. 


PRESCRIPTION-WRITING. <A. medical prescription 
is a written order to the pharmacist to take certain quan- 
tities of certain medicines, deal with them in certain 
pharmaceutical ways, ‘‘put up” the product in certain 
form for dispensing, and label the package with certain 
directions for use. Correctness in prescribing, therefore, 
relates to the three several matters of the selection of the 
ingredients or composition of the prescription, the fixing of 
quantities or computation of the prescription, and the 


* Inasmuch as presbyopia is essentially an affection of the accommoda- 
tion, the proposal to give convex glasses in which the spherical surfaces 
are ground upon prisms, with bases turned toward the nose (Scheffler °) 
is irrational, Such glasses, by lessening the tension on the convergence, 
tend also to lessen the concomitant exercise of the accommodation, and 
so may help to make stronger glasses acceptable than would otherwise be 
the case ; this implies, however, the needless disuse of the remaining 
accommodation, and the promotion of an abnormally rapid development 
of the presbyopia. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


actual writing of the order in technical style, or expression 
of the prescription, These several topics will be con- 
sidered seriatim, in the order named. 

I. THE Composine oF A PRESCRIPTION.—Assuming 
that a prescription is intended, as should always be the 
case, to fulfil a single therapeutic purpose only, then the 
first point that presents is whether, under the circum- 
stances of the case, a séngle medicine of the appropriate 
kind should be prescribed, or a team of such medicines. 
As regards this point, no general rule can be laid down 
—the matter will depend partly upon the nature of the 
therapeutic indication, and partly upon the respective 
peculiarities of the individual drug and the individual 
case. Thus to provoke emesis, a single drug is commonly 
prescribed ; to excite diwresis, a team ; while for purging 
the medicine will be single, if it be castor- or croton-oil, 
but multiple, if the selection be from among the resinous 
cathartics. The advantage of a team of similar.medicines 
in prescription may be, on the one hand, a more effective, 
or, on the other, a more kindly accomplishment of the 
specific purpose in view, or it may be both possibilities 
combined. Thus, by a wise association in prescription of 
allied drugs, a maximum of therapeutic effect is attain- 
able with a minimum of by-derangement. Having fixed 
upon the active member, or team of members, of the 
prescription, the next point is whether the medicinal 
working of the same may not be made even more effective 
or more kindly than would otherwise be the case by the 

further addition to the prescription of some special sub- 
stance. Such increase in both lines—effectiveness and 
kindliness—may result by a chemical action upon the 
drug, on the one hand, or by a medicinal impression 
upon the system of the subject, on the other. Thus, as 
an instance of the working of a chemical action, stands 
the fact that the efficacy and kindliness of operation of a 
dose of salicylic acid are both enhanced by the addition to 
the acid of a solution of a sodic carbonate, whereby the 
salicylic acid, which under its own form is both insoluble 
and irritant, becomes the more soluble, and at the same 
time far less harsh, body, sodic salicylate. As instances 
of an associated medicinal impression by an unrelated 
drug affecting the operation of the active member of a 
prescription, may be cited the rather mysterious enhance- 
ment of the diuretic action of digitalis by the associate 
action of calomel, and the neutralizing of the griping of 
the rougher cathartics by the associated antispasmodic 
action of the pungent volatile oils, or of neurotics, such 
as belladonna or hyoscyamus. In the category of ad- 
ditions to a prescription for the purpose of enhancing 
kindliness of operation, belong flavoring substances. For 
an agreeable, or, at least, a not offensive potion, is not 
merely pleasanter than an ill-tasting one to swallow, but 
is also, by the very reason of non-offensiveness, far less 
likely than a nauseous dose to destroy appetite or derange 
digestion. The art of prescribing pleasant mixtures is 
therefore one of genuine advantage to the patient, as well 
as to the prescriber! Agreeability of taste is, of course, 
far more important in the case of fluid than of solid 
mixtures, and is attained, in the case of fluids, in part by 
wisdom in the selection of the active member of the 
prescription, and in part by the addition to the prescrip- 
tion of sugar, or of syrup, or of preparations of the more 
pleasantly flavored aromatics. Lastly, in composing a 
prescription, comes the thought of a possibly necessary 
substance to give volume, or, in the case of a powder or 
pill, to give form, or, in the case of a fluid mixture, to 
serve as a diluent, or as a solvent. The character and 
relative proportion of such a member of a prescription 
will vary so greatly in different cases, that no general 
rule affecting the selection of vehicles can be formulated. 
Members of a prescription for the several purposes 
named, are commonly referred to as, respectively, the 
basis, the adjuvant, the corrigent,.and the excipient, or 
vehicle, of the prescription. In the association of different 
substances in a prescription, no matter what the purpose 
of the several ingredients, regard must always be had for 
the mutual chemical relations of the things so brought 
into mutual contact, lest undesirable reactions take place 
in the compounding (see Incompatibility, Medicinal). 


Presbyopia. 
Prescription, 


II. THe ComMPputine OF AMOUNTS IN PRESCRIPTIONS. 
—The first point in the matter of amounts in prescrip- 
tions is, in general, not to order more of the medicine than 
present prognosis seems to call for. Not unnaturally, the 
laity instinctively argue that the remedy should fit the 
case in measure as well as in mode, and hence, that an ex- 
cess of medicine in the prescription is prima facie 
evidence of a deficiency of skill on the part of the pre- 
scriber. They, furthermore, naturally object to the pay- 
ing for the superfluous. Apart from these considerations, 
there are also many and obvious objections to a course 
that leaves half-used parcels of medicine to accumulate 
in a house, at the risk of inappropriate application on 
subsequent occasions, at ignorant hands. Hence, in cases 
where an exact forecast of the amount of a medicine likely 
to be required is impossible, it is wiser to order no more 
than will surely be within bounds, letting the prescrip- 
tion be renewed if the amount prove too little. Assum- 
ing due regard to be paid to this principle, then the 
determination of amounts in a given prescription pro- 
ceeds, by theory, thus: the amount of dasis will be the 
product of the two factors, quantity of dose and number 
of doses required, and the several amounts of the other 
ingredients will be deduced from the amount of the 
basis, in accordance with the respective requirements of 
relative proportion. In putting this theory into practice, 
however, the important consideration has to be regarded, 
that quantities must be such as can be conveniently 
expressed in terms of the system of weight or of measure 
employed in the prescribing. This consideration deter- 
mines, in general, the use of round numbers, and, in 
particular, of swch round numbers as best conform to the 
relation between denominations in the particular system 
of weight or of measure followed in the prescription. 
For example, in general, no prescriber would fix a dose 
to be expressed by such a number as one and one-tenth, 
whether referring to grains or grammes, nor would he 
ever estimate upon an aggregate of such an awkward 
number of doses as seven, or eleven, or nineteen, or twenty- 
three. And, for example again, in particular, the pre- 
scriber by the apothecaries’ system of weight or of meas- 
ure, recognizing the generally duodecimal ratio of the 
denominations of these scales, instinctively proportions 
the numbers of his prescription on a duwodecimal basis. 
His ratios, that is, are as one to some one of the numbers 
2, 4, 6, 8, 12, 18, 24, 60, 120, 180, 240, 480. On the other 
hand, if the metric system be the system followed, the 
decimal basis of this system almost of necessity entails 
the use of decimal ratios in proportioning amounts in 
prescription. Quantities are in this case fixed upon that 
are to each other as one to some number of this series of 
numbers: 2, 5, 10, 20, 25, 50, 75, 100, 200, 250, 500, 
1,000. This fundamental difference in the figures to be 
used in working by the metric, as compared with the 
apothecaries’, system, is a point very commonly over- 
looked by novices, in this country, in the art of prescrib- 
ing by metric denominations. Because already fixed in 
the duodecimal habit through previous practice with the 
apothecaries’ system, such novices are apt to compute in 
duodecimai ratios quantities which they then set down in 
terms of decimaily related denominations—a proceeding 
wherein theoretical stupidity begets, as it should, prac- 
tical disaster. For, by this proceeding, as it is hardly 
necessary to point out, there is wholly missed the one 
point of advantage which the metric system has to offer, 
namely, ease of computation by decimal ratios. A 
medicine, then, whose dose in prescription by apothe- 
caries’ weight is taken at one grain, is—or should be—in 
prescribing by metric weight, taken at five centigrammes, 
and not at the sz centigramme amount which the Amer- 
ican metric prescriber, translating from terms of apothe- 
caries’ weight, so commonly figures by. As well might 
an original metrician—to coin a convenient word—who 
essays a prescription by the apothecaries’ system, first 
fix his dose, by his old metric habit, at five centigrammes, 
and then, blindly insisting on exactly that quantum, 
despite its unsuitableness to the foreign system of 
weights, prescribe in grains on the absurd basis of a 
seven-cighths grain dose ! 


25 


Prescription- 
Writing. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Such are the essential points of the theory of comput- 


ing prescription-amounts, and having due regard to these 
points, the prescription of solid mixtures for make-up into 
pills, powders, troches, suppositories, etc., is easy enough, 
but in the prescription of fluéd mixtures many additional 
considerations enter into relation, as follows: In the 
first place, although it is not essential, it is yet elegant, 
and hence customary, to have a prescribed mixture 
aggregate just a bottleful of someone of the sizes of the 
medicine-phials of the shops. Regard must therefore 
be had to the several sizes of such bottles. In the United 
States medicine-phials are made of capacities conforming 
to apothecaries’ measure, which capacities are severally 
as follows : one, two, and four fluidrachms, and one, two, 
four, six, eight, and twelve fluidounces. This fact of the 
conformity of medicine-bottles to apothecaries’ measure, 
makes, in this country, the prescribing of fluid mixtures 
readier by the apothecaries’ than by the metric system. 
Phials for metric prescription should be of the natural 
metric capacities, severally, of twenty-five, fifty, oné hun- 
dred, two hundred, etc., cubic centimetres ; but in this 
country phials of such capacities are, at least, not com- 
mon. A few years ago an order, by this writer, upon a 
dealer for a set of such bottles, if they were procurable 
in the city of New York, was returned with the report 
that there was nothing of the kind in the market. 

The second special point affecting amounts in the case 
of fluid mixtures relates to the case of solids in solution, 
the point being the physical fact that, in dissolving, a 
solid of a given measure in its condition of dry powder 
does not augment the volume of the solvent by the full amount 
of such measure, but, on the contrary, increases such vol- 
ume so little that, in the ordinarily comparatively weak 
solutions used as medicines, the increment can safely be 
disregarded in the estimation of amounts for prescrip- 
tion. 

The third point relates to the system by which, in a 
given case of a fluid mixture for internal giving, the in- 
dividual doses are to be measured out. 'This consideration 
does not obtain in the case of solids, since, in such case, 
doses are defined by a stated number of pills, powders, 
or troches—are, that is, already apportioned by the apoth- 
ecary. But in the case of a fluid mixture, the medicine 
is necessarily dispensed in bulk (except when put up in 
capsules), and doses must be measured out by the admin- 
istrator at the bedside. The point then presents itself of 
practical bearing, whether, in a given case, the dose is to 
be measured by a method of precision—by use of a 
graduated pipette, if the dose be quite small, or of a 
graduated vessel if of ordinary or large dimension—or 
whether the determination is to be by the conventional 
drop on the one hand, or spoonful on the other. If a 
graduate is to be used, then the point now in question 
does not present itself ; but if the drop or the spoonful is 
to measure the dose, then the consideration arises, in the 
apportioning of amounts in prescription, of the respec- 
tive actual dimensions of these variable measures, under 
the conditions obtaining in the individual case. As re- 
gards the drop, it must be remembered that this measure 
varies in dimension, not only according to the viscosity 
and specific gravity of the fluid dropped, but also accord- 
ing to the shape, extent, and character of the surface from 
which the drop delivers itself, and even, furthermore, in 
the case of drops delivered from a phial, according to the 
degree of fulness of the bottle on the occasion of the drop- 
ping. <A bottle with a flanged mouth, such as the ordi- 
nary medicine-phial, yields, with the same fluid, a com- 
paratively large drop when full or nearly so at the drop- 
ping, anda comparatively small one when at least half 
empty, the difference in the respective drop-dimensions 
in the two instances being even as considerable as that 
between the numbers five and three. The reason for this 
difference in size of drops is that, from a full bottle, the 
contents begin to run out when the bottle is but slightly 
tipped, and so, because of the position of the free edge 
of the lip, the nascent drop creeps into the re-entrant an- 
gle formed by the under surface of the lip and the side 
of the neck, and there has a chance to grow to a compar- 
atively goodly size before gravity determines the fall. 


26 


On the other hand, a phial half empty must be tipped to 
the horizontal before the contents can run out, in which 
position the narrow rim of the lip points directly down- 
ward, and so presents but a small surface-area for the 
fluid to cling to. Under these circumstances the fall will 
necessarily be in comparatively small drops. As regards 
the spoonful, it must be remembered that this measure, 
like the drop, is subject to variation, so that, in the case 
of prescriptions containing powerful medicines, amounts 
should be calculated on the basis of the maximum capac- 
ity of the measure. Whatever, then, may be the variation 
from the calculated dose in actual mensuration, will be on 
the safe side of a shortage instead of a possible excess of 
amount. Nowa given spoon will naturally hold more of 
a viscid than of a thin fluid, and, in practical mensura- 
tion, will more readily hold its full complement when 
the fluid is poured énio it, as from a bottle, than when 
the spoon is made to dip up the fluid from an open vessel. 
Hence, in the case of a syrwpy mixture, with the dose to 
be taken direct from the phial, the conditions obtain where 
the spoonful will be at its maximum ; while, on the other 
hand, in the instance of a thin watery dilution standing 
in a tumbler, with the dose to be dipped up by means of 
the spoon, the measure, although the same in name, may 
be very different indeed in fact. Another point, which 
should be thoroughly understood, relates to the size of 
the average spoon of to-day as compared with the spoon 
of the same denomination of two generations ago. Com- 
ing down from our ancestors is the estimate of the tadle- 
spoonful as the measure of half a fluidounce, or sixteen 
cubic centimetres, and of the teaspoonful as that of a flui- 
drachm, or four cubic centimetres. These alleged equiv- 
alences, true of the average of spoonfuls of former days, 
are still handed down as present truth from teacher to 
student, and so come to be almost universally applied in 
prescription calculations. If, however, the reader will 
take from any chance pantry a sample of the average 
commoner kind of teaspoon, such as is generally rele- 
gated for service in the nursery, and will provide for him- 
self an accurate graduate and a phial of water, he can 
learn for himself, in two minutes, the fact that the tea- 
spoonful will run much nearer s7z to the fluidounce than 
the traditional e7git—will equal the quantity of five rather 
than of four cubic centimetres. And, by the same token, 
the average tablespoonful of our own present spoons is 
of the dimension of three rather than of four to the two- 
fluidounce measure—of twenty rather than of sixteen cu- 
bic centimetres. And, indeed, in the case of thick fluids, 
such as strongly syrupy mixtures, or a fixed oil like cas- 
tor-oil, where also the fluid is poured into the spoon, the 
spoonful will considerably exceed even these larger esti- 
mates. In view of these facts, this writer, in his teaching, 
has always advised for prescription-purposes the estimate 
of the equivalence of the teaspoonful as at five cubic cen- 
timetres, or at the rate of six to the fluidounce ; and of 
the tablespoonful at twenty cubic centimetres, or at the 
rate of three to two fluidounces—six to four fluidounces. 

By basing calculations on such assumed equivalences, 
any error in actual mensuration will be, as it should be, 
in the direction of a measure smaller rather than greater 
than intended. Furthermore, it is a happy fact that these 
equivalences give numerical relations far handier for pur- 
poses of calculation than the older estimates. In the 
case of the metric values, it goes without saying that for 
computation in decimal denominations, the numbers five 
and twenty are much more convenient for expressions of 
respective unit-quantities than the numbers rowr and s¢z- 
teen, And in the apothecaries’ system the proportion of 
six to the fluidounce permits of a greaternumber of easily 
calculated combinations than the time-honored eight to 
the same measure, as is shown in the tables below. 

A fourth consideration affecting the estimation of 
amounts in the prescription of fluid mixtures, obtains in 
the prescribing of a solid to be borne in solution in an 
inert fluid menstruum, the point being the matter of the 
proper proportion between solid and solvent. Of course, 
in the first place, the proportion must be compatible with 
the solubility, in the selected menstruum, of the given 
solid; and, also of course, in the second place, if the 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Prescription- 
Writing. 


dose is to be extemporaneously diluted for the taking, 
the concentration of the prescribed solution may be to 
any degree so compatible with solubility. If, however, 
as so often is the case, the prescription proposes a solu- 
tion fit for direct administration without further dilu- 
tion, then the consideration of taste enters into relation. 
An over-strong solution will be rough to the taste, and 
may also be irritant or even corrosive to the alimentary 
mucous membranes ; while, on the other hand, if the 
solution be inordinately weak, the volume required for 
the carrying of a proper dose of the dissolved basis may 
be inconveniently large. Of course, in this matter the 
individual peculiarities of the constituents of a given 
prescription will require individual consideration ; but, 


in a general way, the truth obtains that the teaspoonful - 


is best made the carrier of not more than—in convenient 
round numbers of the respective systems of weight— 
twenty-five centigrammes, or five grains; and, similarly, 
the tablespoonful of not more than, respectively, one 
gramme, or twenty grains, of a solid in solution. In the 
case of fairly bland substances, whose solubilities will 
at the same time permit, twice these quantities may be 
permissible ; but such proportion should not be ex- 
ceeded. 

From this presentation of points affecting the prescrip- 
tion of fluid mixtures, it appears that, in cases where it 
is expected that the whole bottleful is to be used, the 
estimate of amounts must harmonize a trio of conditions 
as follows: 1, The total must be just a bottleful ; 2, it 
must aggregate about the number of doses therapeutically 
indicated ; and, 3, at the same time the amount of the 
active basis, while being such as to yield the proper 
strength of solution, must also be such as to admit of 
ready expression in terms of the system of weight or 
measure employed in the writing. In the use of the 
metric system this triple harmonization presents no diffi- 
culties, for the simple reason that since any amount is 
equally easy of expression by this system, it is only ne- 
cessary to harmonize the first two considerations, letting 
the amount of active basis required foot up to what it 
will. Thus, for instance, let it be supposed that an in- 
dication seems to call for a medication three times a day 
for a few days; then all it is necessary to remember is 
that, if the active basis be one of small dose such that a 
teaspoonful is the more convenient carrier, a fifty cubic 
centimetre aggregate will fulfil the conditions of: an even 
bottleful on the one hand, and about the requisite num- 
ber of doses upon the other (ten teaspoonfuls, reckoning 
the teaspoonful at five cubic centimetres). Then the in- 
dividual dose of basis may be taken unconditionally by 
the therapeutic indication—it may be fixed at one, two, 
three, four, five, six, seven, eight, nine, ten, or any odd 
number of centigrammes, and the expression of the ag- 
gregate will be equally easy, such aggregate being sim- 
ply ten times the quantity for the individual dose, re- 
spectively as follows: 0.10, 0.20, 0.30, 0.40, 0.50, 0.60, 
0.70, 0.80, 0.90, 1.00 Gm., etc. Similarly, if the case be 
one where a tablespoonful will be the more convenient 
measure for the dose, then a two hundred cubic centime- 
tre volume will again yield ten doses (about the number 
indicated) of the selected dimension, and once more 
the ,individual dose of basis may be what it please, 
and the aggregate will be equally easy of expression. 
When, however, the apothecaries’ system is followed in 
the prescription, at once a complication arises, for the 
reason that in apothecaries’ weight all amounts are not 
equally easy of expression—some, indeed, being so awk- 
ward to express as to be practically unavailable. Thus, 
for instance, although by this system, as already pointed 
out, ratios are naturally taken in duodecimals, yet such 
a natural duodecimal multiple as seventy-two, represent- 
ing grains, is a monstrosity for expression. In comput- 
ing, therefore, by apothecaries’ weight and measure, the 
prescriber is bound by the clumsiness of the denomina- 
tion-ratios of the system, and so, for cases where the 
total basis exceeds a drachm, finds available for the ful- 
filment of the tripartite conditioning set forth above, a 
certain set of combinations only. These combinations 
the young prescriber must learn by rote. They are 


easily enough figured out for one’s self; but for con- 
venience of reference there are set forth, in tabular form 
below, the combinations convenient when the individual 
dose of basis is to be one or other of the several amounts, 
Jive, ten, fifteen, or twenty grains. If the individual dose 
of basis be Jess than a grain or two, then the total amount 
of basis required, being but a moderate number of grains, 
is easy enough of expression, and the difficulty now un- 
der consideration does not obtain. 


TABLE OF CONVENIENT COMBINATIONS FOR THE PRESCRIPTION OF 
FLUID MIxTURES BY APOTHECARIES’ MEASURE AND WEIGHT. 


1. Dose to be borne in an average teaspoonful, reckoning six teaspoon- 
Juls to the fluidounce. 


Gi it 1m 
om |8y 
p's |82,3/Amount of basis to be prescribed in order to yield to the 
- s Soa teaspoonful the several doses of 
Orn Bl O's 
Cos} ‘s 2 ° = J 
ae, 2/5 ae Five Ten Fifteen Twenty 
ro) 7, grains. grains. grains. grains. 
ly 3 er. XY. 3 Ss. Bef: ae 
1 6 see 3). Zz iss. Belts 
2 12 ENE Zoaliy. 3 ily. Z ss. 
4 24 3 ij. % 8s. a Vie Sah 
6 36 3 ij. 3 VJ. Bixee % iss, 
8 48 Z ss. Ele Z iss. Z ij. 
12 72 3 vj. % iss. z iij. 


2. Dose to be borne in an average tablespoonful, reckoning one and a 
half tablespoonful to the fluidounce. 


Ln G4 mM 
es ae Amount of basis to be prescribed in order to yield to the 
ho et tablespoonful the several doses of 
ok ga a 
saga ss 
aa SiS 4 Five Ten Fifteen Twenty 
fo} “1488 grains. grains, grains. grains. 
2 3 gr. Xv. 3,88. api Zi 
4 6 3 88. ate 3 iss, B Aye 
6 9 ey ot Risse wh 3 iij. 
8 12 zeae 3 ij. Ewe Z ss. 
12 18 Z iss. ZAipe ea 3 vj. 
3. Dose to be borne in a@ measured fluidrachm. 
Su (SE 
is a Amount of basis to be prescribed in order to yield to the 
+a eS fluidrachm the several doses of 
ond) o5's 
eS s\aze 
ae. Elogs Five Ten Fifteen , Twenty 
sierra pe grains. grains, grains, grains. 
i 4 Dj. Dij. 3J Div 
1 8 dij. Div. Zi D viij 
2 16 Div. D viij. % ss, Dxv] 
4 32 D Viij. Dxvj. % J. Aoie 
6 48 Z ss. =I. 3 iss. z ij 
8 64 Dxyj. i e 3 ij. ae 
12 96 arp EVs % ij. Ziv. 
4, Dose to be borne in a measured half fiuidounce. 
oa |SS , 2 : 
»>'s |. &.q|/Amountof basis to be prescribed in order to yield to the 
ye jw so half fluidounce the several doses of 
on ot rey =| 
of glace 
Se O}a'n =| 
re: I gé 8 Five Ten Fifteen Twenty 
o) ee a grains grains, grains. grains, 
al D. Sin ke Dj. 3 ss. dij. 
2 4 dj. dij. 3]: Dv. | 
4 8 dij Div. 3 ij. Dvilj. 
6 | 12 3}. Bij. | 3 iij. Z ss, 
8 16 Div D viij. Z 8s. DXvj 
135 15.24 3 ij. Z 88. avi. 3). 


III. Toe ExpReEssING OF A PRESCRIPTION.—A pre- 
scription is an order, dated and signed, to the pharmacist 
to take certain quantities of certain several substances ; to 
perform upon them certain pharmaceutical operations ; to 
label the package with certain directions concerning use, 
and to address it with the name of the patient. Upon 
this order the author may also have occasion to set down 
certain injunctions, such as ‘‘not to be renewed,” or, 
‘“not to be shown to the patient,” etc. In form, pre- 


27 


Prescription- 
Writing. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


scriptions are commonly written after the following para- 
digm : 
[Not renewable without authority. ] 
For Mr, A. B. 
Take 
Of substance A, i 
Of substance B, quantity /. 
Of substance C, quantity 2, [ete.] 
Doso-and-so [with them] -.0 4 ses emer stele coe se 
duabel- [the package]| 7... >. aides cota bids as eee sie 
[Signed] C. D.. M.D., 
No. 1 Blank Street. 


quantity x. 


[Dated] November 22, 1886. 


Instead of a written signature, a very common anda 
very good plan, followed by many practitioners, is to have 
prescription-blanks printed for their personal use, bear- 
ing the imprint of name, address, and office-hours. In 
such case the imprint is commonly at the head of the pa- 
per. In language, a prescription is commonly written in 
part in Latin, and in part in the vernacular. In the 
United States the use of the Latin is commonly confined 
to such portion of the prescription as has to do with 
directions to the pharmacist for the compounding and 
‘putting up ” of the medicine ; but in many other coun- 
tries the directions for use are also written in Latin. This 
latter foreign custom has nothing to commend itself, but, 
on the contrary, is intrinsically objectionable on the score 
of opening an unnecessary doorway for the entry of mis- 
takes. For such directions must, of necessity, finally ap- 
pear in the vernacular in the label upon the package 
which is to serve for the patient’s guidance; so that, to 
write them in the prescription in Latin is to entail their 
translation back into the vernacular at the hands of the 
pharmacist for the purpose of transcription, all at the risk 
of mistakes. Far better is the American custom, whereby 
the prescriber can—and always ought—set down, in the 
vernacular, in fullest necessary detatl, the directions for 
administration, which directions are then simply to be 
copied, exactly as written, in the labelling of the package. 
Another, and quite universal, custom is to express by ab- 
breviation or by symbol, in the pharmaceutical portion of 
the prescription, what might be called staple words. 
Thus, in the foregoing paradigm, take is expressed by the 
symbol ‘‘ BR,” which, originally the astronomical sign 
‘* or,” of the planet Jupiter (symbolical of the prayer to 
the deity Jove which in ancient times headed prescrip- 
tions), now bears its present peculiar form in order to do 
duty also as the initial letter of the Latin word 7eczpe, 
signifying take thou. Next, titles of denominations of 
weight or measure are expressed by the commonly em- 
ployed symbols for such denominations, and numeral 
adjectives by the so-called Roman numerals in the use of 
the apothecaries’ system of weight or measure ; but by the 
ordinary Arabic numerals when the prescription is by 
metric weight or measure, as is practically a necessity for 
the expression of the related integral and decimal frac- 
tions by which metric quantities are signified. Next, the 
word misce, signifying mix thou—the most commonly oc- 
curring word expressing requirement of pharmaceutical 
manipulation, is expressed by its initial letter J7, and 
similarly, and lastly, the word signa, signifying label thou, 
by its initial letter S. Other commonly employed abbre- 
viations are ‘‘ aa” for ana, latinized Greek for the phrase 
of each ; “no.” for numero, signifying to the number of ; 
““q. s.” for quantum sufficiat, signifying as much as may 
be necessary, and ‘‘p. r. nu.” for pro re natd, signifying ac- 
cording to need. 

It thus appears that all of the prescription requiring 
full dress in Latin is comprised in the titles of substances 
prescribed, and in the directions for the compounding. 
And for the correct latinizing of such items a critical 
knowledge of the Latin language, though, of course, of 
great advantage, is yet not indispensable. For, so far as 
relates to the expression of medicine-titles, all that is ne- 
cessary is to know how to set these titles in proper case ; 
and, as concerns the expression of pharmaceutical direc- 
tions, it is to be remembered that, in the great majority 


of instances, the directions for compounding requiring | 


specification in prescription-writing, are simple and set, 
so that their Latin phrasing is easily compassed by the 


28 


knowledge of a few arbitrary words and phrases. Indeed, 
for all but seldom occurring exceptional directions, the 
latinizing can be effected by the words and phrases in the 
following list, properly coupled with the Latin words sig- 
nifying forms of medicines, presumably already learned. 
List oF OpD WoRDS AND PHRASES OF COMMON Oc- 
CURRENCE IN THE EXPRESSION OF PHARMACEUTICAL 
DIRECTIONS, IN PRESCRIPTIONS.—1. Verbs, in imperative 
mood ; ‘‘object” to be in the accusative case (analogue of 
the English objective) : 
Adde, add. 
Cola, strain. 
Divide, divide. 
Heténde, spread. Solve, dissolve. 
Fac, make. Tére, rub. 
2. Verbs, in subjunctive mood, taking a subject or a predt- 
cate, nominative : 
Billiat, \et [it] boil. 
Firat, let [tt] be made [into]. 
Fiant, let [them] be made [into]. 
3. Verbal adjective (participle) to agree with its noun in 
gender, number, and case : 
Dividéndus (masculine) ; —a (feminine) ; —wm (neuter), 
to be divided. 
4. Prepositions: noun following to be in the accusative 
case : 


Filtra, filter. 
Mécera, macerate. 
Misce, mix. 


Ad, to; up to. In, into. Supra, upon. 
5. Prepositions : noun following to be in the ablative 
case : 
Cum, with. Pro, for. 
6. Miscellaneous Words and Phrases: 
Ana, of each. Guttdtim, by drops. 
Béne, well, Non, not. 


Bis, twice. Sémel, once. 
Déin or deinde, thereupon. Simul, together. 
Et, and. Stdtem, at once. 


Gradatim, gradually. Ter, thrice. 


In the instance of a pharmaceutical operation which 
cannot be expressed in Latin by the application of the 
foregoing vocabulary, the wise course, even for the Latin 
scholar, is to forego elegance and write the direction in 
the vernacular. Otherwise it might chance that the pre- 
scription overstep the pharmacist’s capacity for transla- 
tion, to the obvious defeat of the compounding. 

As regards the rendering, in proper Latin case, of the 
titles of the ingredient substances of a prescription, the 
points are as follows: There are, in Latin, six cases in 
the declension of nouns and adjectives, but of these cases 
four only are concerned in the latinizing of medicine- 
titles. These four are, respectively, as follows: The 
nominative case, corresponding to the English nominative, 
is the case in which titular words stand in simple state- 
ment—by which, in short, names are learned. Thus we 
recognize prepared chalk by the Latin title Creta prepa- 
rata, Wherein the two words of the title are in the nomi- 
native case. Next, the genitive case corresponds to the 
English objective case after the preposition of, and is the 
case in which titular words most commonly stand in pre- 
scription-writing. For, in the first place, compound titles, 
even in simple statement, commonly afford an instance 
of the genitive, as in the case of the title tincture of opium. 
Here the phrase of opiwm is rendered in Latin by the 
word opium set in the genitive case. Then, in the second 
place, in prescribing, the order for the ‘‘taking” of a 
given ingredient is, in the enormous majority of instances, 
a direction for the taking of a specified quantity of the 
substance in question. A prescription for a phial of 
laudanum, that is, will read: ‘‘ Take of tincture of opium 
one-half fluidounce.” In such case the titular word of 
the preparation itself—in this instance the word tincture 
—will have to stand in the genitive, since now it, also, 
follows the preposition of. With the exception, there- 
fore, of a few conditions when titular words stand, in 
prescription-expression, in the accusative, the rule is that 
all titular nouns and adjectives which, in simple state- 
ment of the title, stand in the noménative, require, in pre- 
cription-orders, to be set in the genitive. 

The third Latin case that concerns the prescriber is 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Prescription- 
Writing. 


the accusative, the Latin analogue of the English objective 
following a transitive verb. Titular nouns and adjectives 
take the accusative under the two following circum- 
stances: First, when the order is not the common one to 
take a certain specified measure or weight of the thing, 
but to take the thing itself in a conditioned entirety. A 
common instance of this circumstance is where yolk or 
white of egg is an ingredient of a prescription. Here by 
the condition of things it is easiest to measure quantity 
by the natural measure of the egg-substance itself. Hence, 
in prescribing yolk the order is commonly to take the 
yolk of one egg, or of two, or of three eggs, as the case 
may be; in which case the title-word yolk, standing as the 
direct object of the transitive verb take, requires to be put 
in the accusative. Another commonly occurring instance 
where the accusative must appear, is where the prescriber 


writes for a certain number of a ready-made medicinal © 


entity, such as pills or troches, of standard composition, 
and hence of independent title. Thus, to prescribe the 
pharmacopeeial compound cathartic pill, the simplest wa 
is to order directly the desired number of the already 
made pills, which the pharmacist keeps in stock. Such 
prescription, therefore, reads: ‘‘ Take compound cathar- 
tic pills to the number of” so many, and so the word for 
pills, with its dependent adjectives, appearing as the im- 
mediate object of the verb take, stands in the accusative. 
The second circumstance determining the setting in the 
accusative of titular nouns and adjectives occurs, in one 
form of writing, in cases where the prescription orders 
that a given substance be taken wp to the attainment of a 
certain total bulk or weight. This form of order most com- 
monly obtains in the prescription of fluid mixtures, where 
it is often convenient to order in specified quantities the 
necessary amounts, respectively, of basis or adjuvant ; but, 
as regards the inert vehicle, to simply direct the compounder 
to ‘‘ take” the vehicle substance until the whole mixture 
shall attain the measure of the desired bottleful. In such 
case the order for the vehicle may be phrased in either 
of two styles—in the one of which the titular words will 
appear as usual in the genitive, but, in the other, in the 
accusative. The phrase in the latter style is according 
to the model, take so-and-so up to |the measure of | so much. 
Here the title of the substance ‘‘ taken” is the immediate 
object of the verb take, and therefore stands in the accu- 
sative ; the phrase up to the measure of being expressed by 
the preposition ad. The other style of phrasing the order 
is after this model: Take of so-and-so as much as may be 
necessary to attain the measure of so much. Here the title 
of the medicine once more follows the preposition of, and 
hence appears in the genitive. In the rendering of the 
order in this style, the Latin phrase quantum sufficiat ad 
(commonly abbreviated to g. s. ad) is the translation of 
the English ‘‘as much as may be necessary to attain the 
measure of.” 

The fourth and last Latin case that concerns the pre- 
scriber is the ablative, a case corresponding to the English 
objective after certain prepositions. The prepositions 
governing the ablative that occur in prescription-writing 
are cum, ‘“‘ with,” and pro, ‘‘for.” The former of these 
occurs in a few titles, as for instance, Hydrargyrum 
cum Oretdé, mercury with chalk; Hmplastrum Picis cum 
Cantharide, pitch plaster with cantharides ; and the lat- 
ter in the much-used phrase pro re natd, ‘‘ according to 
need.” But as regards the ablative, the special point ob- 
tains that the circumstances of prescription-phrasing 
never require the rendering in the ablative of a title-word 
which in the title appears in a different case. The few 
instances of the ablative in medicine-titles are therefore 
fixed, and the ablatives so occurring are easily learned by 
rote. 

The expression of case is, in Latin, effected by modifi- 
cation of the ending of the word itself which is to be de- 
clined, and in such modification, adjectives share as well 
as nouns. Different modifications are employed to sig- 
nify case in the singular and plural number, respectively, 
and of such modifications there are, in ordinary, five dis- 
tinct systems, constituting the five several declensions of 
nouns and adjectives, besides cases of irregular declension 
presented by certain pronouns and cardinal numerals, 


Of the five systematic declensions, one, the fifth, affords 
but a single example in prescription-Latin, namely, the 
ablative re of the noun ves in the oft-quoted phrase pro 
re natdé. Of the other four declensions, examples occur 
in prescription-writing, of the nominative, genitive, accu- 
sative and ablative cases, respectively, in the singular 
number, and of the nominative, genitive, and accusative in 
the plural. The following table shows the endings for 
the several cases so enumerated, so far as concerns nouns 
and adjectives embraced in the prescriber’s vocabulary. 
Endings for nouns not in such vocabulary are purposely 
omitted, as are also the irregular declensions of pronouns, 
In the table the italicised letters m., f., and 7., signify re- 
spectively, that the case-endings in the columns beneath 
are those of nouns or adjectives of the masculine, femi- 
nine, or neuter gender ; for, as appears in the table, case- 
endings often differ, even in the same declension, accord- 
ing to the gender of the word. The endings of the first 
and second declensions, severally, which appear in pa- 
renthesis, are the endings of certain Greek nouns, adopted 
into Latin with something of the Greek form retained. 
The table also gives a list of words of foreign origin ap- 
plied as drug-titles, which, following the Latin idiom in 
such case, make no change of ending to signify case—are, 
in short, éndeclinable. 


TABLE OF PARTS OF LATIN DECLENSIONS SO FAR AS HXEMPLIFIED BY 
WorRDS USED IN PRESCRIPTION-WRITING. 


1. Regular Declensions of Nouns and Adjectives. 


8 of d g 
23 ae ee £3 
AG 8 § 5 33 
ag 29 Hs = 9 
® No ) Fs 
A = A a 
Us m.* nN, m. and f. nN. m.t 
SINGULAR : 
Nominative .. |-a _(-e) | -us (-os) -um (-on) |(various) (various)} -us 
Genitive ...... -2e  (-eS) -i -is -fis 
Accusative....| -am (-en) -um (-on) -em (like nom.) | -um 
Ablative 2)... -a | -O -e 
PLURAL : 
Nominative ...| -2 -i -a | -es -a | -us 
Genitive ...... -arum | -orum -um, -ium -uum 
Accusative ....| -as -O8 -a | -es -a | -us 


(Fifth Declension exemplified only in ablative singular re in phrase pro 
re nati.) 

* Except juniperus, prunus, sambucus, and ulmus, feminine. 

+ Except cornus and quercus, feminine. 


2. Declension of Cardinal Numerals. 


| Unus, One. Duo, Two. Tres, Three. 
m. JS. n. | M. if m.|m.andf. n. 
Nominative. . | un-us -a -um | du-o -22 -o | tr -es ia 
Genitive .... -ius -orum -arum -orum -ium 
Accusative...) -um -am -um|— -0os -as -O -eS -ia 
| 
All other cardinal numerals are indeclinable. 
INDECLINABLE DRUG-TITLES—@il neuter. 
Amyl, Coca, Kino, 
Azederach, Curare, Matico, 
Buchu, Elixir, Sago, 
Cajuputi, Jaborandi, Sassafras, 
Catechu, Kamala, Sumbul. 


As appears at a glance from the foregoing table, in the 
case of any noun or adjective belonging to either of the 
three declensions numbered as first, second, and fourth, 
respectively, if the nominative be given, any other case 
can be at once formed by substituting the proper case- 
ending for that of the nominative. In words of the third 
declension, however, this possibility in very many cases 
does not obtain. For in this declension the nominative 
often stands apart from the other cases in the way of 
having the very root, or ‘‘stem,” of the word curtailed 
or modified in its construction. Thus, the stem anthemid-, 
giving genitive anthemidis, accusative anthemidem, and 
ablative anthemide, gives nominative anthemis—a word 
in which the full stem does not appear. Similarly, the 
root flor-, giving genitive floris, etc., gives nominative 
flos ; and root rho-, giving genitive rhois, offers the much 
modified nominative form rhus. Hence, for the proper 


29 


Prescription. 
Pro-Amnion. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


rendering in oblique case of nouns or adjectives of the 
third declension, it becomes necessary to learn arbitrarily 
the form of some one of the oblique cases—most. con- 
veniently the genitive—as well as that of the nominative. 

A special point concerned in the expression of case ob- 
tains in the case of adjectives, to the effect that very many 
of these words form their case-endings after different 
ones of the declension-models, according to the gender 
of the noun to which the adjective is attached. In 
compound drug-titles, therefore, which include an ad- 
jective, the gender of the noun modified by the adjective 
becomes necessary to know for the ¢éntelligent, proper 
rendering of the adjective’s case-ending. Of course, such 
knowledge is not essential, since the title, adjective and 
all, can be learned by rote, and then, remembering the 
nominative form of the adjective, the necessary change 
to genitive or accusative, to suit the requirement of the 
prescription-phrase, can be done by rule. But it saves a 
vast amount of unnecessary memorizing to understand 
the system, so far as system goes, by which genders of 
Latin nouns are determined. Reverting, then, to the 
above declension-table, it appears that all prescription- 
occurring nouns of the first declension are feminine in 
gender ; all those of the second declension ending in -wm, 
or -on, are neuter, and, with a few exceptions, all of the 
second declension ending in -us, or -os, and all of the fourth 
declension ending in -ws, are masculine. The exceptions 
in the two latter instances are nouns in -ws, representing 
ancient Latin tree-names, which, because of the ancient 
Latin conception of an inherent feminity in trees as 
things, take the feminine gender in spite of their etymo- 
logically masculine nominative ending. In the third 
declension all genders appear, and, although in nouns of 
certain nominative-endings the ending carries with it the 
gender, yet in the case of many other nouns this is not 
so, and genders must be learned arbitrarily. Happily, 
however, the number of nouns of the third declension, 
among drug-titles, which bear an associated adjective, 
are quite few. 

From the above analysis it is evident that, in the case of 
a given nown in the nominative, the rendering of the same 
in an oblique case can proceed by rule according to the 
foregoing declension-table, if only the declension of the 
noun be known ; with the further item, in the instance of 
a noun of the third declension, that some one oblique 
case, aS well as the nominative, be known, for the afford- 
ing of the full stem of the word. Similarly, the proper 
case-dress of any given adjective can be fixed if the scheme 
of declension of the adjective itself be known, on the one 
hand, and, on the other, the gender of the noun to which 
the adjective is to be affixed—adjectives requiring to 
agree with their respective nouns in gender, number, and 
case. This requisite information concerning nouns and 
adjectives of prescription-use is afforded in the two 
following tables—the one giving a key to the declensions 
of nouns, with genders, and also, in the case of nouns of 
the third declension, genitive endings—and the other 
showing the schemes of declension of adjectives. 


TABLE SHOWING DECLENSION AND GENDER OF NOUNS OCCURRING IN 
TITLES OF U. S. PHARMACOPGIAL MEDICINES AND IN COMMON PRE- 
SCRIPTION-TERMS, 

Nominaiive singular ending in -a: 

All First Declension and Feminine, except (of Greek origin) the fol- 

lowing in —ma-: : 

Physosti/gma (physostig’/matis), 8d, | E’nema (ene’matis), 3d, 7. 

n, Catapla/sma (catapla/smatis), 3d, n. 

[Aspidospe/rma (aspidospe/rmatis), | Gargari/sma (gargari/smatis), 3d, 
3d, n.] nN. 

Nominative Singular ending in =e: 

All First Declension, Feminine (Greek nouns). 
[N.B.—Nouns in-e of Third Declension do not occur in prescription- 
writing. | 
Nominative Singular ending in -us: 

All Second Declension, Masculine, except— 

Juniperus, 2d, Fru/ctus, 4th, m. 

. 


Pru/nus, ‘ Spiritus, ‘ 
Sambu/cus, ‘‘ Co/rnus, 4th, f. 
U’Imus, = Que’rcus, ‘* 
Rhus (rho/is), 3d, f. (‘‘ rhus gla- 

bra”). 


30 


Nominative Singular ending in -os: 
Comprise only the following — 


Prinos, 2d, m. Bos (bo/vis), 3d, m. or f. 


Flos (flo/ris), 3d, m. 
Nominative Singular ending in -um: 
All Second Declension, Neuter. 


Nominative Singular ending in -on: 
Comprise only the following— 


Eri/geron (erigero/ntis), 3d, 7. 
Li/mon (limo/nis), 3d, m. 


Erythro/xylon, 2d, 7. 
Heemato/xylon, ‘‘ 
Toxicode’ndron, ‘ 


Nouns of ali other endings are of Third Declension, and are as follows: 
Ending in -c: 
Lac (la/ctis), 2. 


Ending in -1: 


(-al) (-ol) 
Chlo/ral (chlora/lis), Alcohol (alcoho/lis), 7. 
(-él) Thy’mol (thymo/lis), 72. 


Fel (fe/llis), 7. 
Mel (me’llis), 2. 


[V.B.—Some authorities regara 
these nouns in -ol as indeclinable. | 


Ending in -en: 


Alu/men (alu/minis), 7. | Se’men (se/minis), 7. 


Ending in -0o: 

Noy Male) ey (-ago) 
Confe/ctio (confectio/nis), f. Mucila’go (mucila/ginis), f. 
Emu/Isio (emulsio/nis), /. Ustila’go (ustila/ginis), 
Lo/tio (lotio‘nis), 7. (-bo and —po) 
Po/rtio (portio/nis), /. Ca/rbo (carbo/nis), 772. 
Tritura/tio (trituratio’nis), f. Pe’po (pepo/nis), 7. 

Sa/po (sapo/nis), 2. 
Einding in -Y: 
-er) (-or) 
fii/ther (e/theris), m. Li/quor (li’quoris), m. 
Pi’per (pi’peris), 7. (-ur) 
Zi/ngiber (zingi/beris), 7. | Su/Iphur (su/lphuris), 22. 
Ending in -s: 
(-és, genitive —eris) 
Pu/lvis (pu/lveris), m. 
(-és, genitive —is) 
Ca/nnabis (ca/nnabis), f. 
Digita/lis (digita/lis), /. 
Hydra/stis (hydra/stis), / 
Sina/pis (sina/pis), f. 


(-as, genitive -atis) 
Ace/tas (aceta/tis), m. 
[and all salt-names in —as.] 


(-as, genitive —adis) 
Ascle/pias (asclepi/adis), /. 

(-is, genitive -ztis) 
A/rsenis (arseni‘tis), 7. 


[and all salt-names in -is.] (-08, see ante.) 


: a ees. (-us, see ante.) 
(-is, genitive —idis) 
A/nthemis (anthe’midis), 7. 
Ca/ntharis (cantha/ridis), /. 
Colocy/nthis (colocy/nthidis), /. —ps 
Hamame’lis (hamame‘lidis), /. A/deps (a/dipis), m. 
l’ris (i/ridis), /. (-7rs) 
Ma/cis (ma/cidis), f. Pars (pa/rtis), f. 
Ending in -X: 

(-ax) (-ée) 
Bo/rax (bora/cis), ™. Pix (pi/cis), 7. 
Sty’/rax (styra/cis), m, Ra/dix (radi/cis), f. 

(-ex) Sa/lix (sa/licis), f. 
Co/rtex (co’rticis), m. and /. (-uz) 
Ru/mex (ru/micis), /. Nux (nu‘cis), /. 

—lax 
Calx (ca/Icis), f. 


(ns) 
Ju’glans (jugla/ndis), f. 


TABLE SHOWING SCHEMES OF DECLENSION AND GENDER OF ADJEC- 
TIVES OCCURRING IN U. S. PHARMACOPG@IAL MEDICINAL TITLES AND 
IN PRESCRIPTION-PHRASES. 

ScHEME, I.—Second and First Declensions Combined. 
Feminine. Neuter. 
-a@ [1st dec.] —wm (-o7) [2d dec.} 

ScHEME II.—Tzrird Decilension, 

Masculine and Feminine. 

-is (genitive —is). 
ScHEME III.—Third Declension, 


Masculine and Feminine. 
-ior (genitive -ioris). 


Masculine. 
—us [2d dec.] 


Neuter, 
-é (genitive —is), 


Neuter. 
-ius (genitive —ioris), 
ScHEME I1V.—Third Decilension. 
All Genders. 
-ens (genitive singular —e7tis) ; (genitive plural -entizm). 
-or (genitive -oris). 


In commentary upon the declension-schemes of adjec- 
tives set forth in the foregoing table, it may be stated that 
Scheme I. embraces by far the greater number of adjec- 
tives. In this scheme the neuter ending -on, borrowed 
from the Greek like the same ending among nouns of the 
second declension, finds among drug-titles but a single 
example, diachylon. Scheme II. embraces a few adjec- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


tives only among those occurring in medicine-titles, and 
affords an example of the nominative-ending -e of the 
third declension, which does not occur among nouns of 
pharmacopeeial titles. Scheme III. is a special scheme 
for the declension of the comparative of adjectives, and 
affords but a single example from among the adjectives 
of medicine-titles, namely, the adjective fortior, fortius, 
“stronger.” Of Scheme IV. pharmacopceial adjectives 
give but two examples in -ens, namely, effervescens and 
recens, and but one in -or, namely, tricolor. A survey of 
the genders marked on the table shows that in every case 
a distinctive gender, where there is such, can be told from 
the adjective nominative ending, with the exception that, 
among adjective nominatives in -uws, one, fortius, is of 
the third declension neuter, and belonging to the third 
scheme, whereas all other adjectives of this nominative 
are of the second declension masculine, and belong to 
the first scheme. 

A final point, concerning the expression of a prescrip- 
tion, is that, having regard to the fact that a slip of the pen 
on the part of the writer, or a slip of the understanding on 
the part of the pharmacist-reader of a prescription, may 
convert what was meant as a missive of mercy into a 
death-warrant, it most solemnly behooves the prescriber 
to execute his task deliberately, thoughtfully, and, in chir- 
ography, legibly, abjuring all dangerous cloak-of-ignorance 
abbreviation: of medicine-titles ; and, finally, to fail not of 
that trusty safeguard against error, a review of the paper 
after the writing. Hdward Curtis. 


- PRIAPISM. The term priapism is usually understood 
to signify an unnaturally prolonged erection. The erec- 
tion may be imperfect, or may even exceed the normal 
state, and is usually unaccompanied by sexual desire. It 
can hardly be considered as a distinct disease, but is prob- 
ably always symptomatic of some abnormal local condi- 
tion, or of some nervous derangement. A few cases have 
been reported in which it has followed violent or exces- 
sive coitus. A case was reported by Mr. Callaway! in 
1824. The man was forty-four years of age, and while 
intoxicated had connection. Priapism continued for six- 
teen days, when Mr. Callaway ‘‘ made an incision into the 
left crus penis below the scrotum, and a large quantity of 
dark grumous blood with small coagula escaped,” and in 
a few days the man returned to work. Mr. Luke? re- 
ported a case in which priapism came on after repeated 
connection, and lasted for about four months. It occurs 
in connection with inflammations, new-growths, and trau- 
matisms of the genito-urinary apparatus. Neumann? re- 
ports a case of carcinoma of the posterior and inferior 
wall of the bladder, with perforation of the bladder-wall 
and peritonitis, in which priapism was present for thirty- 
one days. The disease had invaded the vesicule semi- 
nales, the vas deferens, and the left ureter. It had com- 
pressed the vessels and caused inflammation of the corpora 
cavernosa. 

In gonorrheeal inflammation of the vesicule erections 
are frequent and may amount to priapism. 

In a case at the Boston City Hospital, rupture of the 
urethra and corpora cavernosa followed a fall upon the 
perineum. External urethrotomy was done, and an un- 
successful attempt made to unite the corpora by suture 
of the fibrous sheath. Partial priapism was present dur- 
ing the latter portion of the case, but finally disappeared. 

Priapism occurs in a certain proportion of cases of 
acute poisoning from cantharides. 

Priapism is a not uncommon symptom in acute mye- 
litis. Generally the erection is incomplete, but it often 
persists for days with slight variations in degree. In- 
juries of the spine and cord are liable to be followed by 
continued or recurrent priapism, or by turgescence with- 
out rigidity. In eighty-two cases of fracture of the spine 
tabulated from the records of the Boston City Hospital, 
priapism occurred in eighteen. It is most common in 
connection with crushing of the cervical portion, rarer 
with that of the dorsal, and, according to Erb,® never oc- 
curs with fracture from the third lumbar vertebra down- 
ward. 

Priapism has been noted in some cases of tumor or 


Preseription. 
Pro-Amnion, 


other disease of the cerebellum and pons varolii, and is 
said to occur frequently in hydrophobia and tetanus. 

The treatment must be directed mainly toward the 
condition of which priapism is but a symptom, but the 
patient’s comfort may often be greatly increased by local 
applications of cold water or evaporating lotions, or by 
the local use of opium. Suppositories or cold rectal in- 
jections may give some relief. Internally the bromides 
are most likely to be of service. Abner Post. 

1 London Medical Repository, 1824, p. 286. 2 Lancet, July, 1845. 

3 Wien. Med. Jahrb., Heft ii., S. 148, 1883. 


4 Burrell: Transactions of the Mass. Medical Society, 1887. 
5 Ziemssen’s Cyclopeedia, xiii., p. 313, 


PRO-AMNION. ‘This convenient term was introduced 
by Ed. van Beneden to designate that part of the area 
embryonalis at the sides and in front of the head of the 
developing embryo, which remains without mesoderm for 
a considerable period, so that the ectoderm and ento- 
derm are brought in the region of the pro-amnion into 
immediate contact. As found in one stage of the rabbit, 
it has already been figured in this work, vol. ii., p. 308. 
A later stage in the rabbit, as seen in longitudinal section, 
is figured by Kélliker in his ‘‘Grundriss d. Entwickelungs- 
ges.,” 2 Aufl., p. 107. Wefind that it had been observed 
in the chick by Remak, His, and Kolliker. Strahl -was 
the first to direct special attention to it. It has since 
been observed by various writers; van Beneden and 
Julin have described it in the rabbit, Heape in the mole, 
and recently its exact history has been admirably worked 
out in the chick by Ravn. The pro-amnion, then, has 
been observed in representatives of the classes Reptilia, 
Aves, and Mammalia; hence, we may conclude that it 
is common to all Amniota. It will be remembered 
that the mesoderm grows out in all directions from the 
blastopore, or hinder end of the primitive streak. In a 
chick of twenty-seven hours, the front edge of the me- 
soderm is a somewhat irregular transverse line, which 
crosses the germinal area about at the front border of the 
head. This line is well shown in His’s drawings, loc. cit., 
Pl., xii., Fig. 14. As the mesoderm expands, it does not 
grow forward in the median line, but does grow for- 
ward at the sides of the area pellucida in front of the head 
of the embryo. A space is thus enclosed between the 
mesoderm on each side ; this space later becomes the pro- 
amnion ; it contains no mesoderm. Later on, the lateral 
portions of the mesoderm approach the median line again, 
some distance in front of the head, so that now the pro- 
amniotic area is completely surrounded by mesoderm. 
We see, as the next phase of development, the head amni- 
otic fold arising in such a position that the pro-amnion 
is embraced between the arc of this fold and the head of 
the embryo; the pro-amnion, therefore, constitutes the 
floor of the pit formed by the upgrowth of the head am- 
nion. In the chick the pro-amnion never acquires any 
considerable development, but gradually disappears by 
encroachments of the mesoderm upon all sides, as has 
been well described by Ravn, whose Fig. 3, loc. cit., Pl. 
xxi., will serve to give a clear general notion of the rela- 
tion of the pro-amnion to the head, and to the true amnion 
in the chick. The disappearance of the pro-amnion in 
the chick involves some curious appearances in sections 
of embryos, which have not been understood hitherto, 
but which Ravn has correctly and fully elucidated, so 
far as I can judge. 

In the rabbit, according to van Beneden and Julin, 
whose observations have been confirmed to a certain ex- 
tent by Kélliker and Heape, the réle of the pro-amnion 
is more considerable. The history of the pro-amnion, as 
given by van Beneden, may be followed easily by the 
aid of the accompanying diagrams (Fig. 3102), copied from 
van Beneden. In A, the pro-amnion, pro.A, is very 
small, and the allantois, Al, is just growing out. In B, 
the embryo, which for greater clearness has been shaded 
with stippling, has grown very much, and the anterior 
half of its body is bent down at a sharp angle into the 
yolk-sac. The embryo, however, remains separated 
from the cavity Y, of the yolk-sac, by the pro-amnion, 
which forms as it were a hood, pro,A, over the anterior 


31 


Pro-Amnion. [ses. 
Professional Neuro- 


extremity of the embryo. The amnion proper is as yet 
developed only over the posterior end of theembryo. For 
the further history of the amnion see Amnion, vol. i. of 


Reilly i) 


Neesassayu a THTOTTTHMSHNHHETINEY 2 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the rabbit—a point just mentioned. It is unlikely that 
man forms an exception to a rule of such wide applica- 
tion, in regard to an organ phylogenetically so ancient. 


y ; Ec, 


Fie. 3102.—Diagram of the Development of the Foetal Adnexa in the Rabbit. (After van Beneden and Julin.) A, B, C, D, successive stages ; pro.A, 
pro-amnion ; Av, area vasculosa ; Coe, ceelom; Coe’, Coe’, extra-embryonic portion of the celom ; Hn, entodermic cavity of the embryo; Hnt, ex- 
tra-embryonic entoderm; Hc, ectoderm; Mes, mesoderm; Api, area placentalis; Al, allantois; 7, terminal sinus of the area vasculosa; Y, yolk- 
sac; am, amnion; am’, portion of the amnion united with the wall of the allantois; Ch, chorion. 


this HANDBOOK. The pro-amnion, as can be seen in C 
and D, retains its importance as a foetal covering for a 
considerable period, during which the amnion am, and 
allantois Ad, are rapidly pursuing their development. 
After the stage shown in Fig. 3102, D, by the expansion 
of the cavity marked Coe’, the amnion proper, am, en- 
croaches more and more upon the pro-amnion, pro. A, 
until at last the embryo is entirely covered by the true 
amnion, and the pro-amnion is altogether lost. It is to 
be noted especially that the amnion develops principally 
over the posterior end of the embryo, and grows forward. 
To this fact reference will be made again directly. 

We possess no observations at present, as to the exist- 
ence of a pro-amnion in man, but from what we know of 
the early stages, we may conclude that it disappears quite 
soon after its origin ; for we may assume that it occurs in 
man, since it has been demonstrated in all classes of am- 
niota. This deduction renders it improbable to my 
mind that His’s hypothesis of the formation of the human 
amnion is quite correct. We see, in fact, that in the 
amniota generally the principal growth of the amnion is 
from the allantois or allantois stock, when the allantois 
is rudimentary. This growth extends far forward, as in 


32 


It is a well-known rule that the older an organ in the 
evolutionary series, the less does its mode of development 
vary in any essential respect from species to species. 


LITERATURE. 


Beneden, E. v.: Recherches sur la formation des annexes foetales 
chez les mammiféres (Lapin et Cheiroptéres), Arch. biol., v., 869-434, 5 
Pls., 1884. 

Heape, Walter: Quart, Journ. Micr, Sci., xxvii., 123-163. 

His, Wilhelm: Untersuchungen ber die erste Anlage des Wirbel- 
thieres. Die erste Entwickelung des Hiilmchens im Hi. 4to, pp. 237, 
Tafn. 12. Leipzig, 1868. 

K6lliker, Albert: Grundriss der Entwickelungsgeschichte des Men- 
schen und der hdheren Tiere. Zweite Auflage, S8Svo, pp. viii., 454. 
Leipzig, 1884. For pro-amnion, see p. 107. 

Strah], H.: Ueber Entwickelungsvorginge am Vorderende des Em- 
bryo von Lacerta agilis, Arch, f, Anat. Physiol., Anat. Abth., pp. 41-88, 
Tafn. iii.—iv., 1884. 

Ravn, Edward: Ueber die mesodermfreie Stelle in der Keimscheibe 
des Huhnerembryo, Arch. f, Anat. Physiol., Anat. Abth., 1886; 412-421, 


Charles Sedgwick Minot. 


PROFESSIONAL NEUROSES. Synonyms.—Beschaf- 
tigungsneurosen, Professional Dyskinesize, Nevrose co- 
ordinatrice professionnelle, Anapeiratic Paralysis, Neural 
Disorders of Writers and Artisans. 

DEFINITION.—Under the term professional neuroses is 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. bropmnion. 


included a class of spasmodic and co-ordinative disturb- 
ances mainly of functional origin, affecting the groups 
of muscles used in special kinds of muscular work. 

While spasm and co-ordinative disturbance are the 
main and typical features, paresis, sensory disturbances, 
vaso-motor phenomena, and general nervous symptoms 
are also present. 

Forms.—Every class of work, or form of occupation, 
which calls for continual use of the same groups of mus- 
cles, furnishes examples of professional neuroses. The 
upper extremities are, however, naturally the parts chiefly 
affected. Those professions in which the smaller and 
more delicately adjusted muscular groups are brought into 
play, furnish the largest contingent. The list of names 
for the various forms of professional neuroses increases 
almost every year, and now includes: Writers’ cramp ; 
telegraphers’ cramp; milkers’ cramp ; musicians’ cramp, 
including pianists’, violinists’, flutists’, and elocutionists’ 
cramp ; tailors’ and seamstresses’ cramp ; blacksmiths’ and 
carpenters’ cramp, or hammer-cramp; dancers’ cramp ; 
photographers’ cramp; watchmakers’ cramp ; cigarmak- 
ers’ cramp ; auctioneers’ cramp ; Swimmers’ cramp ; saw- 
yers’ cramp. 

History.—We hear nothing of any of these now nu- 
merous neuroses until about fifty years ago. Dr. Bern. 
Ramazini, who in 1746 wrote a work on the diseases of 
tradesmen, does not describe writers’ cramp, although 
he speaks of the diseases which come from the sedentary 
life of the clerk. Ramazini says, that the causes of the 
““morbt scriborum” are ‘‘continua sessio, manus perpetua 
et eodem semper tenore motio, mentis attentio ne libros 
erroribus conspurcent.”” He cites only one case, that of 
paresis of the arm, which at all suggests writers’ cramp. 
‘The disease, therefore, is undoubtedly a product of the 
present century. The idea that the Emperor Augustus 
had writers’ cramp is based merely on a single sentence 
in Suetonius. The first to refer to the disease was Sir 
Charles Bell, who gives a brief account of a case of 
writers’ cramp in his work on the nerves, published in 
1830. A year later, a case was reported in Germany by 
Brick, and at about the same time one by Gierl. In the 
next four years, a number of German writers reported 
their observations of the disease. Cazenave, in 1835, was 
the first French writer upon the subject. In this country 
Weir Mitchell, Beard, Hammond, and Lewis have writ- 
ten specially upon it. In the past fifteen years the liter- 
ature of professional neuroses has been continually en- 
riched by the contributions of writers from various 
countries. 

WRITERS’ Cramp (Syn.: Scriveners’ palsy, mogo- 
graphia, graphospasm, steel-pen palsy, chorea scrip- 
torum). 

Etiology.—As the disease is one of this century, it is 
most probable that the influences of our present civil- 
ization, by increasing the neuropathic constitution, furnish 
a larger material for writers’ cramp. Fora neuropathic 
history is present in many cases, and all writers, except 
Beard, agree that it is this class which is peculiarly 
liable to the disorder. A history of some family nervous 
affection, such as chorea, epilepsy, or insanity, is obtained 
in a minor proportion of cases. On the other hand, it is 
strikingly true that some victims of writers’ cramp are 
strong and robust in every way. The explanation here 
is that such persons overwork themselves to a degree ex- 
ceeding that which nervous and delicate persons can do. 
Those who write a beautiful hand are more liable to the 
affection than poor writers, for the reason, chiefly, that 
poor writers get no position in which they can overuse 
their writing-muscles. The introduction of steel pens 
(1820 to 1830) corresponds with the appearance of writers’ 
cramp, and there is no doubt that the use of steel pens 
tends to favor this disease, owing doubtless to the rough- 
ness of the end. Besides this, steel pen-holders continu- 
ally carry away heat from the fingers, thus tending to 
lower vitality, and are difficult to grasp firmly. Writers 
soon learn that wooden, rubber, or cork holders are 
safer. The introduction of stylographic pens, and espe- 
cially of type-writers, may lessen the relative amount of 
writers’ cramp, just as steel pens at one time increased it. 


Vou. VI.—3 


(ses. 
Professional Neuro=«= 


Americans ought, theoretically, to be very subject to 
writers’ cramp. So far as I can learn, however, this is 
not the case, and, in my opinion, in New York City the 
disease is a somewhat rare one. 

Men are much more subject to the disease than wom- 
en, though the difference is not so great now as formerly, 
owing to the greater number of women employed in writ- 
ing. 

Among thirty-one cases of typical writers’ cramp ob- 
served by Poore, all were men. Women are more liable 
to have impairment of the writing-arm from pains and 
paresis, without having the true professional dyskinesis. 

The average age in cases collected and observed by 
Lewis was twenty-seven (26.96) years. Among 64 cases 
of Berger’s, 24, or nearly one-half, occurred between the 
ages of twenty and thirty, 12 between thirty and forty, 
16 between forty and fifty, 7 between fifty and sixty, 5 
between sixty and seventy. On the other hand, Dr. J. 
Russell Reynolds’s cases were all over thirty, and Dr. 
Hammond’s cases all over forty. The cases which I 
have seen have all been a little over thirty. The disease 
occurs, therefore, very rarely before twenty, and most 
often at about the age of thirty. 

The use of alcohol or tobacco in excess, onanism, and 
other sexual excesses, emotional disturbances, and wor- 
ry, all predispose to the disease. ; 

The exciting cause is the abuse of writing. In ordi- 
nary writing about four motions of flexure, extension, and 
lateral movement are made for each word. Calculating 
at the rate of five letters for a word, and twenty words 
per minute as the rate of writing, this would be two 
hundred and forty-five thousand muscular contractions 
in a working day of eight hours. When the speed is 
increased, and the hours of work lengthened, under the 
pressure of a desire to earn more or to complete a task, 
it is easy to understand how the nerve-cells may become 
exhausted, or refuse to work together. Persons who do 
copying or routine work are much more liable to the af- 
fection, but it is largely because they abuse their writing- 
powers. Persons who write as they compose—authors, 
literary men, clergymen—are not so subject to the 
trouble, because they necessarily rest more in their 
work. Brain-workers are, therefore, as a rule, exempt 
from writers’ cramp. 

Berger and Erlenmeyer seem to think that the ‘‘ Amer- 
ican method” of writing specially tends to produce 
cramp. Thecontrary is, [ think, true. In the American, 
or free-hand, mode of writing, as taught in most of our 
schools, the wrist does not touch the paper, and the 
hand is just supported by the little finger, the motion 
being made largely by the whole arm. 

Debilitating disease may lead to a development of 
writers’ cramp. Weir Mitchell reports two cases occur- 
ring in patients who had albuminuria. The symptoms 
were relieved when the albuminuria was treated. Lead 
poisoning (Berger), exposure to cold and rheumatic influ- 
ences, injuries of the arm, tight sleeves, ingrowing nails, 
the pressure of a sleeve-button on the ulnar nerve, have 
all been mentioned as exciting causes of the affection. 

Pathological Anatomy.—Neuritis is undoubtedly present 
in some forms of writers’ cramp, so-called. It is not 
present, however, so far as external tests go, in the 
typical neurosis. Nor are there any post-mortem obser- 
vations throwing light on the anatomy of the disease. 

Pathology.— We must believe, therefore, that it is a 
neurosis, having no appreciable anatomical basis. 

The act of writing ‘is a very complicated one, calling 
into play numerous sets of delicately innervated muscles. 

These muscles are employed: 1, in pen-prehension ; 
2, in pen-movement ; 3, in holding the arm and wrist 
tense. 

1. The muscles employed in pen-prehension are the 
two outer lumbricales, two outer interossei, the adductor 
muscles of the thumb, the flexor longus pollicis ; to some 
extent the deep and superficial, short and long flexors, 
and the extensors of the thumb. These are supplied 
mostly by the ulnar (interossei, adductor pollicis, inner 
heads of deep flexor of fingers, and inner head of short 
flexor of thumb). The rest of the muscles are supplied 


33 


Professional 
Neuroses, 


by the median. (I cannot understand Poore’s  state- 
ment, that the muscles of pen-prehension are innervated 
by the median and musculo-spiral.) The spinal centre 
for these muscles, 7.¢., for the intrinsic muscles of the 
hand, and for the extensors of the thumb and flexors of 
the fingers, is situated at the level of the eighth cervical 
and first dorsal nerves, and the cell-groups are probably 
the anterior and median. 

2. In moving the pen, if the writing is done mainly 
by finger, and not by arm, movements, the muscles 
brought into play, according to Poore, are the flexor 
longus pollicis, extensor secundi internodii pollicis, flexor 
profundus digitorum, extensor communis digitorum, 
and to some extent the interossei. The musculo-spiral 
and. ulnar nerves innervate these groups about equally. 
In moving the pen by the ‘‘ American” or free-hand 
method, there is a very slight play of the above muscles, 
while most of the pen movement is done by the muscles 
of the upper arm and shoulder, viz., the teres major, 
pectorales, latissimus dorsi, biceps, and triceps. 

The spinal centres for these muscles are distributed 
along the fifth, sixth, and seventh cervical segments of 
the cord. The cells are larger, and situated more super- 
ficially, in the anterior gray horns. 

3. Besides these movements involved in pen-prehen- 
sion, and in the letter-making, a certain amount of 
muscular tension is exercised in ‘‘ poising”’ the forearm 
and hand and steadying the wrist. The biceps and tri- 
ceps, the supinators and the flexors, and extensors of the 
hand are here brought into play. 

From the foregoing it will be seen that the muscles of 
pen-prehension are most used in all but the free-hand 
style of writing, since the same groups have a double 
duty, that of clasping and of moving the instrument. 
That this prehension group is oftenest affected is shown 
by the following table, compiled by Poore from a study 
of thirty-two cases of undoubted writers’ cramp. He 
found the muscles affected in the following proportions : 
Interossei (supplied by the ulnar), 18 times; extensors 
of thumb (supplied by musculo-spiral), 10 times; flexor 
brevis pollicis (Supplied by median and ulnar), 7 times ; 
abductor pollicis (supplied by median), 7 times; flexor 
longus pollicis (supplied by median), 4 times ; adductor 
pollicis (supplied by ulnar), 3 times; opponens pollicis 
(supplied by median), 2 times ; all the muscles of fore- 
arm, more or less, 2 times. 

While writers’ cramp is often complicated with some 
neurotic disturbance leading to associated symptoms of 
pain, paralysis, tenderness over nerves, vaso-motor dis- 
turbances, etc., there can be no doubt that the lesion in 
typicai cases is central. Writing is an acquired auto- 
matic movement, and it must have as its anatomical basis 
a certain established arrangement of nerve-cell groups in 
the cervical part of the spinal cord. ‘The nerve impulses 
generated in the cerebral cortex pass along the pyramidal 
tracts and set at work those ganglion groups which, in 
turn, innervate the muscles used in writing with motor 
impulses. These groups are themselves innervated also 
sensorially by the nerves of muscle-sense in movement. 
In writers’ cramp the spinal groups of cells are more or 
less used up or exhausted, and the motor impulse which 
naturally would innervate them strikes cells which re- 
spond unequally, or it overflows to other cell-groups, and 
hence the spasmodic, irregular movements of the arm. 

The cerebral centres in the cortex are closely connected 
with those in the cord, and may be said to form part of 
the writing-mechanism. It happens in some cases that 
this centre too is exhausted and discharges its impulses 
irregularly. In some cases, therefore, the cerebral, and 
in some the spinal, cell-groups are the more affected, and 
a diagnosis of the exact condition in each is approxi- 
mately possible, and may be not without practical impor- 
tance. 

Writers’ cramp is a disorder of efferent paths and sta- 
tions. The muscular sense does not seem to be involved. 

The pathology of writers’ cramp is that of all the other 
forms of professional neuroses, and nothing need be said 
upon this point regarding them when they come to be 
considered. 


34 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Symplomatology.— Writers’ cramp very rarely attacks 
a person suddenly. The patient first notices a certain 
amount of stiffness occurring at times in the fingers, or 
the pen is carried with some uncertainty, and jerky 
movements are made. He feels a sensation of fatigue in 
the hand and arm, and this may amount to an actual 
tired pain. The first symptoms may last for months or 
even years. The hand is rested as much as possible, 
new pens or pen-holders, and new modes of holding it, 
are tried. Often the patient, fearing the onset of the 
cramp, and as its result loss of employment, becomes 
anxious, worried, and mentally depressed. Sometimes 
the trouble is worse when beginning a daily task, and it 
gradually wears off in afew hours. At other times ex- 
actly the reverse is the case. When the disease has 
reached its highest stage, writing becomes almost or 
entirely impossible. The moment the pen is taken in 
the hand and an attempt at using it made, spasmodic 
contractions of some of the fingers, or even of the arm, oc- 
cur, the pen fiies in any direction, and it is impossible to 
control or co-ordinate the movements. In a well-marked 
case, with the history of which I am acquainted, the 
patient, when called upon to sign a check, was obliged . 
to make an unintelligible scrawl, which was attested to 
by witnesses. The rule is that, although writing cannot 
be done, all other complex movements are performed as 
wellasever. . Thus the sufferer from writers’ cramp may 
be able to play the piano, or paint, or thread a needle, or 
use the hand in any complex movements. Telegraphers, 
however, who use to some extent the same muscles as in 
writing, and who also often have to do a great deal of 
writing, are liable to suffer from both writers’ and tele- 
graphers’ cramp at the same time. No evidences of actual 
paralysis are present in the affected muscles, and there is 
rarely anesthesia, but the arm aches and is sometimes 
tender. Sensations of numbness and prickling are pres- 
ent ; in rare cases vaso-motor disturbances are observed ; 
associated muscular movements of the other arm, or of 
the neck or face, sometimes occur. The hand may 
tremble on attempting to write, or fall almost paralyzed 
when the pen is taken. 

The various symptoms occur with different degrees of 
prominence, so that the disease has been classed under 
the heads of, 1, the spastic; 2, the paralytic, and 3, the 
tremulous type. To this Dr. Lewis adds, types with 4, 
sensory, and with 5, vaso-motor symptoms. 

Such a classification is convenient, but it is to be re- 
membered that in the majority of cases the forms are 
mixed. 

1. The spastic form is undoubtedly the most common, 
and it has given to the disease its name. Cramp of some 
muscle or muscles was present in over half of Berger’s 
cases of writers’ cramp, and in thirty-one of Lewis’ forty- 
three cases of telegraphers’ cramp. The muscles of the 
thumb and first three fingers are oftenest affected, and in 
some cases the flexors, in some the extensors are chiefly 
involved. Canstett bases a classification upon this fact. 
In telegraphers’ cramp it is the extensors, but in writers’ 
cramp the flexors, that are mainly affected. The thumb, 
or fore-finger, or the little finger alone may suffer from 
the spasms. The pronators and supinators are quite 
often involved, and Berger notes a case in which there was 
spasm only in the pronator radii teres. Duchenne and 
Weir Mitchell report cases of ‘‘ lock-cramp,” in which, on 
attempting to write, the hand closes tightly in strong con- 
traction, and remains so for a considerable time. This 
symptom suggests the hypertonia of Thomsen’s disease. 
As stated, associated spasmodic movements sometimes 
occur in the neck muscles, or in the other arm. 

With the spasm, there is also inco-ordination so far as 
writing movements are concerned, and this fact is quite 
as important in producing the bad writing as the spasm. 
The inco-ordination is apparently of the motor, or at 
least: central, type, and is not due to anesthesia of the 
muscle-sense, as in locomotor ataxia. 

2. The paralytic form, or that type in which muscular 
feebleness is the dominant symptom, ranks next in fre- 
quency. In Berger’s 64 cases, 24 were purely spastic, 10 
paralytic, 8 tremulous, and 22 mixed. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


In the typical paralytic form the patient, as soon as he 
begins to write, feels an overpowering sense of weakness 
and fatigue in the fingers and arm. The fingers them- 
selves loosen their grip, and the pen may drop from the 
hand. Powerful impulses of the will and change in the 
mode of holding the pen, enable the sufferer to continue, 
but the arm aches, and finally is absolutely painful, and 
weakness and fatigue compel the writer to desist. Some- 
times the paretic condition is succeeded by the spastic. 

Many of the cases of paralytic writers’ cramp are not 
true examples of the neurosis, but are rather cases of 
neuritis of a rheumatic or other type. Poore’s tables 
show that nearly a third of the cases of impaired writing 
power are really forms of neuritic paresis. In this para- 
lytic form the muscles of the thumb and the interossei 
are oftenest affected. The first dorsal interosseus and 
the abductor pollicis may be independently attacked. 
The writing, while writing is still possible, is fainter, and 
the characters larger as well as less perfectly formed. 
In the true cramp, the hand or arm muscles show no pa- 
resis, except in the act of writing ; but in the neuritic im- 
pairment of writing, the paresis is absolute. 

Duchenne records a case in which the lateral move- 
ments of the hand and arm along the paper were impos- 
sible. After writing a few words the patient had to 
draw the paper from right to left. In this instance the 
deltoid and infraspinatus were paralyzed. 

3. The Tremulous Type. This, though rare, is very 
characteristic when present. The patient, when attempt- 
ing to write, observes a tremulous movement of his hand 
and arm. ‘This ceases when his attempts to write cease. 
The tremor usually affects most the fingers used in pen- 
prehension, but it generally spreads to the forearm, and 
may even involve the entire extremity. An oscillatory 
or lateral tremor, due to involvement of the pronators 
and supinators, has been observed by Cazenave. 

The tremor, as may be seen, is of the character known 
as ‘‘intention-tremor,” such as is observed in dissem- 
inated sclerosis. It is much shorter in range and more 
rapid than the tremor of that disease, and corresponds 
practically more with the ordinary fatigue tremor often 
seen after great muscular exertion. 

General Symptoms.—Writers’ cramp is essentially a 
motor neurosis, and its leading symptom is the impair- 
ment of a motor function. Other symptoms, however, 
both general and local, are always associated with it. 
These are mainly (1) psychical and (2) sensory, more 
rarely (8) vaso-motor, and (4) trophic. 

1. PsychicalSymptoms. The patient is often nervous, 
emotional, and mentally depressed at times. He suffers 
from insomnia and vertigo. Patients are generally 
unwilling to admit that there is any other trouble than 
the local one, and only careful examination may bring 
evidence of constitutional trouble. There are cases of 
purely mental ‘‘ writers’ cramp.” Thus, Shever gives 
the history of a man forty-two years of age, who was 
suddenly attacked with vertigo. Next day he found 
that he could not write, because an inexplicable feeling 
of fright seized him when he began to form letters. His 
condition became ameliorated, so that he could write for 
a time, when again the fear would seize him. He could 
write with his eyes closed. ‘There were no other symp- 
toms. Dr. Morris J. Lewis, who has investigated the 
subject of telegraphers’ cramp more thoroughly than any- 
one else in this country (‘‘Pepper’s System of Medi- 
cine,” vol. v., p. 520), states that telegraph operators 
who suffer from cramp, are sometimes unable mentally to 
grasp the proper number of dots and dashes composing 
certain Morse characters. They also have special diffi- 
culty in making these characters and of recognizing them 
by sound. ‘The dot-characters give the most trouble. 

2. Sensory Troubles. These consist of pain, sense of 
fatigue, feelings of numbness, prickling, pressure, 
weight, tension, constriction, etc. Hyperesthesia, and 
more rarely anesthesia, are also observed. 

The most common sensory symptom is that of aching 
and fatigue, and this is usually confined to thearm. The 
pain is especially noticed in connection with the para- 
lytic form (Zuber), and it generally follows the course of 


Professional 
Neuroses, 


the nerves. The radial and median are those chiefly in- 
volved, while very little pain is ever felt along the ulnar. 
The arm is tender along the course of the nerves, and 
there may be tenderness over the cervical vertebrae. Erb 
had a patient who suffered from a steady pain over the 
left frontal region, almost exactly, it seems, over the 
probable writing-centre. M. Meyer calls attention to 
the presence of pain and tenderness, at times, in the 
apophyses. Disturbance of the common sensibility of 
the muscles of the arm has been obServed by Poore. In 
fine, the involved extremity may be affected with a great 
variety of subjective sensory disturbances. 

8. Vaso-motor, Trophic, and Secretory Disturbances. 
The condition known as digit? mortut has been observed, 
coming on paroxysmally. It is a symptom which the 
general neurasthenic state helps to produce. When the 
nerves are involved, decided vascular changes may occur, 
such as passive congestion of the hand and arm, with 
swelling and turgescence of the fingers, and a sensation 
of throbbing. In bad cases the fingers will look as if 
they had chilblains. Local sweating, dryness of the 
skin, and cracking of the nails, all are conditions which 
may follow impairment of writing-power from neuritic 
causes. P 

Hlectrical Reattions.—The results of observations upon 
the electrical reactions of the affected parts are somewhat 
contradictory. Ordinary tests will, as arule, reveal very 
little change. Sometimes there is a quantitative increase, 
sometimes a decrease, of irritability to both forms of 
current. The increase occurs in the earlier stages, the 
decrease in the later. The contraction formula, Ka C C 
>An C C, is not changed, unless a decided neuritis com- 
plicates or causes the trouble. An increase, or modifica- 
tion, of electro-muscular sensibility has been noted. The 
electrical examinations, therefore, are only of value in 
excluding a neuritis, or possibly in determining the stage 
of the disease. 

Course and Duration.—Writers’ cramp is a chronic 
disease. It begins insidiously, and attacks one group 
of muscles after another, as each is brought into play 
by new methods of writing. If the left hand is used, 
that, too, is liable to become affected. The course va- 
ries, however; for a time progress may be arrested, or 
improvement set in. When the disease becomes well 
established, it will most often last a lifetime. For ‘ex- 
ample, a pianist, while yet a young man, was attacked 
with pianists’ cramp. He changed his profession, and 
gave up piano-playing ; yet, at the end of five years, if he 
attempted to use the piano, the cramp still attacked him. 

Prognosis.—The prognosis is unfavorable, yet not so 
much so as has once been thought. Undoubted cases 
of complete recovery have been reported, and Berger’s 
statistics place the per cent. as high as eight. I have 
observed a case of complete cure of telegraphers’ cramp, 
and one of writers’ cramp. 

The prognosis is much more favorable if the patient 
begins treatment early, and before marked spastic symp- 
toms are present. It is believed that certain modern 
therapeutical methods, to be referred to later, will also 
modify the prognosis. Some patients who suffer from 
a mild form of the trouble manage, by the help of in- 
struments or special pens, to do their work for years. 

The more acute the disease, and the more evidently 
peripheral and neuritic its origin, the better the prog- 
nosis. Severe sensory disturbances are of more favora- 
ble omen than severe motor trouble. Perhaps in about 
one-fourth of the cases, patients who use their sound 
arm will not be affected in it. 

The facts stated regarding the cause, physiology, and 
general symptomatology of writers’ cramp apply to the 
other forms of functional neuroses. A few special de- 
tails, however, will be given regarding these. The most 
common and important are musicians’ cramp and tele- 
graphers’ cramp. 

Musicians’ Cramp.—Under this head we include pian- 
ists’ cramp, violinists’ cramp, flutists’ cramp, and the 
cramp of clarionet players. 

Pianists’ cramp occurs usually in young women who 
are studying to become professionals, or who are espe- 


35 


Professional 
Neuroses. 


cially hard-working and ambitious. The absurd “ Stutt- 
gart method ” of teaching the piano, in which the mo- 
tions are confined as much as possible to the fingers, 
predisposes especially to this disease. The symptoms 
are those of fatigue, pain, and weakness. The pains are 
of an aching character. They are felt in the forearm 
especially, but extend up to the arm and between the 
shoulders. Spasmodic symptoms are rare. The right 
hand is oftener affected, but both hands eventually be- 

come involved. ? 
Violinist’ cramp may attack the right hand which 
holds the bow, or the left hand which fingers the strings, 
but more often the left 


ferer feels at first a sense 
of fatigue and uncertainty 
in the fingers and arm, 
then pain, and finally some 
spasmodic movements oc- 
WCUr, 

Clarionet players some- 
times suffer from cramp 
of the tongue (Striimpell), 
and of the laryngeal mus- 
cles (Eichhorst). 

Flute players, according 
to observations related to 
me by Dr. T. H. Kellogg, 
suffer not very infrequent- 
ly from slight laryngeal 


Ve 


GLEN. co. 
AS 


Li 


Fie. 3103. — Mathieu’s Apparatus. 
The pen is moved by the thumb 
and index-finger. 


spasms. ‘The same observer has noted similar spasms in 
elocutionists. The term mogophonia is applied to this 
trouble. 


Telegraphers’ cramp was first described by Simon, in 
1878 (Comptes rendus Soc. de Biol., 6, 92-96). It has been 
noticed by English and Scotch physicians, and has been 
exhaustively studied by Dr. Lewis, of Philadelphia (loc. 
cit.). Dr. Beard also made some studies of it. It affects 
especially those operators using the Morse system, an in- 
strument which is still the one most widely in vogue. 
Contrary to the opinions of,previous writers, Dr. Lewis 
believes that this neurosis is not a rare one, and is des- 
tined to become more frequent. Considering that there 
are perhaps less than thirty thousand telegraph operators 
in the country, aS against the vast army of clerks, copy- 
ists, writers, etc., the fact that Dr. Lewis was able to 
collect forty-three cases of telegraphers’ cramp is signifi- 
cant. 

Dr. W. H. McEnroe, of New York City, who has had a 
largely personal experience with telegraph operators and 
their diseases, informs me that the cramp is rare, the pro- 
portion being about one in every two hundred. 

The technical name, among operators, for the cramp is 
‘‘loss of the grip.” In telegraphing, the extensors of the 
wrist and fingers are called most 
into play, and hence are most and 
earliest affected. The symptoms 
come on very slowly, the thumb 
and index-finger being first affect- 
ed. The victim finds that he can- 
not depress the key on account of 
spasm in these muscles, and he 
finds most difficulty in making the 
dot-characters, such as h (....), 
OL Dee iy ) Oren Ga ms stay ren 
the flexors are most affected, the 
key is depressed with undue force, 
and a dash is made instead of a 
dot. Sufferers from the ‘‘loss of Frye. 3104.—Mathieu’s Ap- 
grip” generally suffer from writ-  paratus. The pen is held 
ers’ crampalso. Most cases occur Hy the index- and middle- 
between the ages of twenty and sag 
thirty. Males and females are almost equally affected— 
perhaps there is a preponderance in favor of females ; 
and, according to Lewis, the disease attacks them earlier 
than it does males. While spasm is usually present, the 
disease may show itself simply in pain, paresis, and in- 
capacity to co-ordinate the muscles. 


lo, TIEMANN 8&0. 


In sewing spasm, which affects tailors, seamstresses, 


36 


hand isaffected. Thesuf- . 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


and shoemakers, clonic and tonic spasms attack the 
muscles of the hands on attempting to use them in the 
regular work. ‘Tailors who sit cross-legged sometimes 
suffer from a peculiar spasm on assuming this position. 
It is possible, however, that these are cases of tetany, and 
not of the functional neurosis under consideration. 
Smiths’ spasm, crampe des forgerons, hephestic hemi- 
plegia, appears to have been observed only by Duchenne 
and Dr. Frank Smith (Dictionnaire encyclop. des Sciences 
médicales, t. x., p. 775). It occurs in persons engaged in 


pen-blade manufacturing, saw-straightening, razor-blade 
striking, scissors-making, file-forging, etc. 


il) . Y 


| Wy 
Yj, 


In doing this 
work they have to 
use a light or heavy 
hammer, with which 
strokes are delivered 
very rapidly and 
carefully. After a 
time spasmodic 
movements occur in 
the arm used, and the 
arm falls powerless. 
As in the cases re- | 
ported there are gen- 

erally hemiplegic symptoms, and 
also neuralgias, vertigo, and other 
cerebral troubles, the disease can- 
not be a pure ‘‘ professional” 
neurosis, 

Drivers’ spasm has been ob- 
served in a veterinary surgeon 
by Dr. Samuel Wilkes (‘‘ Diseases 
Fig. Baer eee Ar of the Nervous System”). The 

viofimgor, and thumb are Patient had to drive hard-bitted 

immobilized. horses for many hours daily. 
Finally his arms were attacked 
with cramps whenever he took the reins. 

Milkers’ spasm is an extremely rare affection, which 
was first described by Basedow and seems to occur in 
milkmaids, never in milkmen (Casper’s Wochenschr., 
1851). Berger is the only other author who reports a 
case. 

Cigarmakers’ cramp must be an exceedingly rare affec- 
tion. I can find reports upon it by only two observers, 
O. Berger (Berlin. klin. Woch., 1873, No. 21), and Koster 
(ibid., 1884). 

Watchmakers’ cramp (O. Berger, 8. Weir Mitchell) and 
Photographers’ cramp (H. Napias: Revue d@ Hygiene, i., 
927, 1879), are also to be regarded merely as pathological 
curiosities. 

Ballet-dancers’ Cramp.—Under this name certain pain- 
ful and paralytic troubles occurring in ballet-dancers, 
especially premiéres danseuses, have been described by 
Schultz, Onimus, and Kraussold. It does not appear that 


G.TIEMANN & 60. 


< 
SG. T/EMANN & C0. 


Ss 


Fra. 3106.—Duchenne’s Apparatus. 


the trouble is really a co-ordinative functional one, but is 
rather neuralgic, or the result of local strain upon the 
parts. 

The list of professional neuroses is made to include, 


‘besides those above given, cramps and co-ordinative 


troubles affecting artificial flower-makers, billiard-play- 
ers, dentists, hide-dressers, electrical instrument-makers, 
stampers, turners, Sewing-machine girls, money-counters, 
weavers, painters, and pedestrians. | 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


In most of these cases there is probably some inflam- 
matory affection of the nerves, or ligaments, and not a 
true central neurosis. 

The Diagnosis of well-marked cases of writers’ cramp 
presents no difficulty. In the earlier stages, however, it 
may be confounded with a large number of disorders, 
viz., post-hemiplegic chorea, hemiataxia, progressive 
muscular atrophy, progressive locomotor ataxia, various 
forms of tremor, lead paralysis, rheumatoid arthritis, 
neuritis, cerebral and nerve tumors, and tenosynovitis. 

In many of these cases it is only necessary to bear in 
mind the history of the disease in order at once to reach 


Fie. 3107.—Cazenave’s Apparatus, Modifieé by Duchenne. 


a diagnosis, for in writers’, or telegraphers’, or musicians’ 
cramp the symptoms are localized in asingle, or at most 
two, extremities. : 

Dr. Weir Mitchell has called attention to the fact that 
a person may have avery slight and transient cerebral 
hemiplegia, followed later by post-hemiplegic disorders 
of movement, which may be mistaken for writers’ cramp. 
Such troubles occur either much earlier, or somewhat 
later, in life than the writers’ cramp, and the motor dis- 
turbances affect the leg and possibly the face as well as 
the arm. Dr. Lewis (loc. cit.) cites from Dr. Weir 
Mitchell’s note-books two cases, illustrating the fact that 
some cases of slight arm paralysis, due to small lesions 
affecting the arm-centre of the cortex, may be mistaken 
for functional paralysis. 

Some occupations which call into play repeatedly and 
continuously the same group of muscles, produce in 
them a gradual atrophy. This has been called ‘‘ pro- 
fessional muscular atrophy” by Onimus. I have seen it 
occur in the thenar muscles and deltoid of a butcher, 
whose work obliged him to handle a cleaver 
for many hours daily. I have also observed 
atrophy of the thenar muscles in a lapidary. 
The act of writing may induce a progres- 
sive paresis and atrophy of the muscles of 
pen-prehension. These occupation muscu- 
lar atrophies are, I believe, myo- 
pathic in origin; they are not ac- \ aes 
companied with the central vaso- Rey ox ; 
motor or secretory disturbances of SYK Ks." 
true spinal progressive muscular / Z - 
atrophy, and they are char- 
acterized by a rapid im- * 5 
provement or arrest in pro- Vf ee 
gress under rest and treat- 4 
ment. Dr. Lewis cites some 
cases to show that in the . 
earlier stages, or in mild Fie. 3108.—The Pen is Attached to 
types of multiple sclerosis, 2 Block, which is Grasped by the 
euivregoler diffuea sclerosis G7. 
of the brain and cord, mo- , 
tor disturbances occur which may be mistaken for writ- 
ers’ cramp. 

As already stated, the diagnosis of the various ‘‘ cramps” 
is practically easy when any ordinary care is exercised 
in examination ; and, after all, the most important point 
for the physician to determine is the form of impaired 
writing-power from which the patient suffers. 


ty 


. 
. 
plese. ee a. 
Semen” 


Professional 
Neuroses, 


If there is a great deal of pain in the arm, with tender- 
ness along the course of the nerves; if there is decided 
change in the electrical reactions; if there are sensations 
of tingling, numbness, etc.; and if the patient shows an 
absolute loss of power in the various groups of muscles, 
with some incapacity for doing other acts besides the one 
with which he is specially concerned ; then the trouble is 
undoubtedly peripheral and due largely to an underlying 
neuritis. The prognosis in these cases is much more 
favorable. If, on the other hand, the disorder comes on 
in persons who have not done an excessive amount of 
writing; if it is associated with nerve-strain; if the 
electrical reactions are but slightly changed, the sensory 
symptoms slight, and the motor inco-ordination marked, 
limited to the special class of work, and not accompanied 
with absolute paresis, the disorder is central, and needs 
both a different treatment and prognosis. It is these 
cases that form writers’ cramp proper, although no doubt 
neuritic and central forms are associated, or the former 
may run into the latter. 

For convenience I append a diagnostic table showing 
the differential points between central and peripheral 
writers’ cramp: 


IMPAIRED WRITING-POWER, ETC., 


IMPAIRED WRITING-POWER, ETC., 
MAINLY OF NEURITIC ORIGIN. 


MAINLY CENTRAL 1N ORIGIN. 


1, Caused by excessive writing. 1. May be no marked excess of writ- 
ing; but a neurotic history is 
obtained. 

2. Marked sensory symptoms of | 2. Sensory symptoms subordinate, 
tenderness over nerves, General nervousness and men- 

tal depression are noted. 

8. Electrical reactions show in-/| 38, Electrical changes slight. 
creased irritability, possibly 
qualitative changes, 

4. Paresis of certain groups of | 4. Paresis but little marked or ab- 
muscles. This may be shown sent. Patient can do all other 
in inability to do other co- kinds of muscular work easily, 
ordinate acts. 


Prophylaxis and Treatment.—Although the amount of 
writing done at the present day is enormously increased, 
there is not acorresponding increase in writers’ cramp. 
This is due to the introduction of gold and stylographic 
pens, type-writers, and better pen-holders. , 
Persons who do a great deal of writing, if 
they find any signs of impending cramp, 
should use some of these instru- 
ments as much as possible. Stylo- 
graphic pens are less liable to lead 
to trouble in writing, because not 
so much prehensive power is needed 
in their use. The same is 4 
true to a less extent of gold (Gee 
pens. The pen- holders |, 
should have a_ slightly |= 
roughened surface, of cork 
or soft rubber. 
Large-handled pen- 
holders are held 
moreeasily. Small, 
smooth, metal or 
hard-rubber holders 
are to beavoided. Pencils are not so good as pens, because 
they require more prehensive force. ‘The paper written 
upon should be smooth. The best style of writing is 
that already referred to as the American, the movements 
being made both.with the arm and the fingers. Many 
nervous persons have a bad habit of gripping the pen 
very tightly, and pressing down on the paper with exces: 
sive force. Fatigue soon results, and painful sensations 
develop in the arm. Proper attention should be paid to 
the position of the paper written upon, the height of the 
desk, the light, and the sleeves of the coat or dress. 
The paper should be laid at an oblique angle to the edge 
of the desk, and not at a right angle as many writing 
teachers are accustomed to direct. As some cases of 
“cramp” are undoubtedly cerebral, it is very unwise 
to attempt any extraordinary exploits in writing, or to 
work with the ambition to put the writing capacity to 
the utmost test. Cramp is often dated from days when 
such extra work is done. Sensations of weariness and 


37 


Fia. 3109.—Velpeau’s Apparatus. 
Same principle as the preced- 
ing, but the block is held ina 
different grip. 


Professional Neuro- prrERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Prostate, [ses. 


slight premonitions of cramp should be watched and 
promptly treated. It seems to be agreed that no modifi- 
cation of the telegraphers’ key is of much value in pre- 
venting ‘‘loss of grip.” Telegraphing with : 
the finger-movement alone, the wrist and fore- 
‘arm resting on 
the table, is a 
bad method that 
should be avoided. 

When thecramp 
is fully developed, 
by far the most 


The hand is fast- 
The board slides along upon the 


Fria. 3110.—Apparatus of MM. Charcot and Cazenave. 
ened to a board, as is also the pen. 
paper. 


essential thing is prolonged rest, and the physician 
should always consider the question whether the patient 
should not abandon his occupation altogether. If com- 
plete rest is not attainable, the various methods of getting 
partial rest are as follows: 

1. Getting a new form of pen and pen-holder. 


Fria. 3111.—Nussbaum’s Apparatus. It consists of a bracelet of hard 
rubber, upon which the pen can be fastened at any length. In order 
to hold it firmly, the fingers have to be spread out. A piece of flannel 
is placed between the hand and the paper. 


2. Holding the pen in a different way. 

3. Using the unaffected arm. 

4, Using some form of mechanical appliance. 

With regard to 1 and 2, enough has already been said. 

3. Asarule, if the unaffected arm is used, it soon be- 
comes involved also. This is not always the case, how- 
ever. 

4, The mechanicalappliances are splints, rubber bands 
around the wrist, and various instruments contrived to 
prevent spasm and throw the work of writing on 
new and larger groups of muscles. 

Instruments for writers’ cramp are very numer- 
ous. The first one was invented by M. Caze- 
nave, in 1846, and simply fastened together and 0) <<a 
immobilized the thumb, forefinger, and middle- Ts 
finger. M. Mathieu constructed several in- iA z 
struments which relieved the hand of the nec- 
essity of pen-prehension and immobilized the fingers—a 
matter of especial importance when there is paralysis. 
MM. Vulpian and Charriére devised a series of instru- 
ments in which the pen is fastened at various angles to a 
ball or bar, which latter is grasped by the hand. Pre- 
hension and the writing-movements are thus performed 
by a different and larger number of muscles. 

As will be seen, the French have been particularly pro- 
lific in originating these instruments. 

Mr. Charles Thurber, of Philadelphia, himself a suf- 
ferer from writers’ cramp, invented an instrument which 


38 


he called the ‘‘ Kaligraph.’”’ It consists essentially of a 
pantograph so arranged that, by making the letters very 
large at one angle, they are reduced to a natural size 
at the other. Besides this, the writing is done entirely 
without any effort of pen-prehension, and may even be 

accomplished by attaching the directing pin 
to the wrist. The principles involved, there- 
fore, are good, and practically it has been 
successful. It is, however, cumbersome and 
expensive. Professor Nussbaum has devised 
an apparatus involving a new principle. In 
order to write with it the fingers must be 
separated, and some effort must be made with 
the extensors, while none at all is made by 
the flexors of the fingers and the wrist. Hence, 
new sets of muscles are actively innervated 
while those ordinarily used are rested. Prac- 
tically this instrument is often very helpful. 
All the various instruments have been of ser- 
vice, or have even been curative in some spe- 
cial cases, but not too much must be ex- 
pected of them. As arule, they are only palliative. A 
cheap instrument that may prove satisfactory is that of 
Mathieu. 

Illustrations of the different instruments are given 
on this and the two preceding pages. 

In the medical treatment of writers’ cramp, the two 
most important agents are massage and electricity. 

By massage only very mediocre results were obtained 
until greater attention was drawn to it by Mr. J. Wolff, 
a writing-master of Frankfort-on-the-Main. This gentle- 
man has cured many cases, though not all that he has 
tried (Berger), and he has secured many testimonials for 
his method.. It has only been fully described, however, 
by Drs. Schott and Stein, the former of whom disputes 
with Mr. Wolff the honor of devising the method. The 
treatment, as described by Schott (G. W. Jacoby : ‘‘ Mas- 
sage in Nervous Diseases,” Journal of Nervous and Mental 
Diseases, June, 1886), consists of a system of gymnastics 
and massage. 

The gymnastics consist of movements performed by 
the patient alone, and movements executed with the co- 
operation of the operator. 

The first are performed by the patient during from 
twenty to thirty minutes, rarely for forty-five minutes. 
These movements consist of gymnastics of the fingers, 
extension, flexion, abduction, and adduction being per- 
formed, and the thumb being exercised separately. After 
this the same four motions are executed at the wrist- 
joint, then extension and flexion of the forearm, and 
ultimately the arms themselves are exercised in the same 
manner and are to be lifted over the head. Each single 
exercise is to be performed from six to twelve times. 
After each motion a pause is to be observed. 

The opposed movements are to be carried out in the 
same manner, except that the operator must carefully 


i 


A\ 
7 SMBS 
il iN 


Fra. 3112.—Thurber’s Kaligraph. 


resist their execution as though he were endeavoring to 
force the patient to perform a motion just the reverse of 
his intentions. Regularity of pressure is to be observed 
in this, so that the same amount of force is always used, 
and so that the pressure does not vary in intensity from 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. p7oressional Neuro- 


moment to moment. The time to be devoted to these 

opposed movements should be the same as that for the un- 

opposed ones. According to the intensity of the affec- 

te the exercises must be repeated two to three times 
aily. 

The massage itself consists of two parts—nerve and 
muscle massage. The nerve-massage is effleurage along 
the course of the nerve-trunks, the median, ulnar, and 
radial, going upward to the axillary and cervical plexuses. 
This efileurage lasts about ten minutes. Following this 
is the muscle-massage. This consists of pétrissage, be- 
ginning with the hand and ending at the shoulder. The 
duration is the same as that of the last movement. One 
sitting a day has always proved sufficient. 

Wolff, in addition, uses ‘‘a peculiar method of writing 
instruction,’’ and employs rubber bands and rings in his 
manipulations, Wolff is by no means alone in getting 
good results from massage. 

Electricity ranks second to massage in the treatment of 
professional neuroses. The faradic current may be used 
when the affection is paralytic, but the galvanic current 
is usually more efficacious. The polar method is to be 
employed, the anode or sedative pole being placed over 
the cervical spine, and the kathode over the various 
muscular groups affected. A stable current of five to ten 
milliampéres for from ten to fifteen minutes is indicated. 
Galvanization of the sympathetic is recommended by 
some. Galvanic belts applied about the arm seem ir- 
rational enough, but have been known apparently to 
effect cures. Vigouroux claims to have cured a case by 
static electricity. 

Lotions containing muriate of ammonia, liniments, hot 
and cold douches, the cautery, all have been recommended 
in professional neuroses. 'Tenotomy was once employed, 
but has been abandoned. Very little can be expected of 
drugs. The most trustworthy are: atropine, strychnine, 
the iodides and bromides, and cod-liver oil. It should 
be remembered that sometimes the disease is almost 
purely cerebral, and then an anti-neurasthenic treatment 
is called for. But in other cases, when the disorder is 
largely peripheral, the usual treatment for a low grade 
of myo-neuritis must be employed. 

Charles Loomis Dana. 


PROPYLAMINE. A. body isomeric with trimethyla- 
mine, with which it is often confounded. See Trimethy- 
lamine. 


PROSTATE, THE. The prostate gland (Gr. xpoordrns, 
from apo and iordyva, to set, or fornu, I stand) derives its 
name from its position at the entrance to the bladder. 

ANnatoMy.—The prostate is a body largely glandular 
in character, and in shape much like a Spanish chestnut. 
In the upright position of the body it lies just below the 
bladder and behind the symphysis pubis. The base of 
this heart-shaped gland is in contact with the bladder and 
vesiculze seminales, while the apex rests upon the poste- 
rior layer of the deep perineal fascia; the anterior sur- 
face looks toward the pubes, and the posterior surface 
rests upon the anterior rectal wall. 

The urethra, as it leaves the bladder (pars prostatica 
urethra), traverses the prostate from near the middle of 
its base to its apex, and rather more than one half of the 
gland lies behind the canal. 

The prostate weighs from five to six drachms, and 
measures approximately one inch and a half in length, one 
and a half to two inches in breadth, and one inch in thick- 
ness (antero-posterior diameter). Slight longitudinal fur- 
rows along its anterior and posterior surfaces, show an in- 
distinct tendency toward a division into two lateral lobes, 
although the two halves are structurally continuous with 
each other. In this connection it is worthy of note that in 
some animals the prostate consists of two separate lobes. 

That portion of the gland lying between the ejacula- 
tory ducts and the urethra (pars supra-montana, Mer- 
cier), is usually known as the middle lobe (Home). Situ- 
ated upon the floor of the urethra, just at the entrance to 
the bladder, it often forms a little prominence continuous 
with an elevation of the vesical floor (uvula vesicz). 


Prostate. [ses, 


The portions of the gland behind and in front of the 
urethra, connecting the lateral lobes, are known as the 
posterior and anterior commissures, 

The substance of the prostate is made up mainly of 
three tissues: 1, Glands; 2, unstriped muscular fibres, 
and 8, fibrous tissue. 

The glands are of the acinous variety, and are most 
abundant in the lateral portions of the organ, their ducts 
coalescing and opening along the floor of the urethra. 
The muscular fibres are disposed in circular bands which 
are continuous at the junction of the bladder with the cir- 
cular fibres of that viscus. Hyrtl also describes a system. 
of these fibres radiating from the caput gallinaginis. 
The fibrous tissue forms a firm enveloping capsule which 
sends off-shoots through the substance of the gland. 

Just below the point of entry of the urethra the two 
ejaculatory ducts enter the prostate, one on each side, and 
running forward through its substance and converging, 
they enter the floor of the urethra. 

The prostatic urethra (pars prostatica urethre) is slightly 
narrower where it enters and leaves the gland than it is 
within it. The hollowed floor of this portion of the 
canal is called the sinus prostaticus, and is divided into 
two equal furrows by a longitudinal ridge (verumonta- 
num), the end of which furthest from the bladder is 
composed of erectile tissue, and is capable of considerable 
dilatation into a little round prominence which, with the 
verumontanum running back from it, preseuts a fancied 
resemblance to the head of a snipe—hence its name caput 
gallinaginis. 

On the top of this little eminence is the opening of 
a minute sac—the utricle or sinus pocularis—which is 
thought to be the analogue of the uterine cavity in the 
female. Close to the edge of this sinus, and sometimes 
within it, are the orifices of the ejaculatory ducts. Along 
the sides of the verumontanum open the prostatic glands 
proper, to the number of from twenty to thirty. 

The prostate is enclosed in a tough fibrous capsule 
which is a part of the pelvic fascia. Besides its attach- 
ments to the bladder and deep perineal fascia, it is further 
held anteriorly by the pubo-prostatic ligaments, and pos- 
teriorly by the recto-vesical fascia. Its slight mobility 
is provided for by the levatores prostatee—muscular bun- 
dles, really parts of the levator ani—which, arising from 
the posterior surface of the pubes, are inserted along the 
lateral borders of the gland. 

Its blood-supply is derived from the internal pudic, the 
vesical and heemorrhoidal arteries, and the veins which 
form a plexus around the gland empty through the hy- 
pogastric vein. The nerves are branches of the hypo- 
gastric plexus of the sympathetic. 

PuystoLocy.—The prostate is a sexual gland. After 
birth it remains in a quiescent state up to puberty, when 
it begins to increase in size and development. It attains 
its full growth about the twenty-fifth year. 

The secretion of the glands, which are especially ac- 
tive during sexual excitement, is a clear fluid of neutral 
reaction, with a specific gravity of 1.010. 

It is especially rich in chloride of sodium (one per 
cent.) and as solutions of this salt are known to excite 
the spermatozoa to movement, its presence in the pros- 
tatic fluid is thought by some to perpetuate their activity. 
Probably the most important function of this secretion 
is, however, as a lubricant to the urethra. 

The prostate, further, in its character as a muscular 
organ, acts as an involuntary sphincter of the bladder. 
As the urine accumulates a point is finally reached at 
which the tension of the detrusor urinze muscle pulls 
open the rings of involuntary fibres around the neck of 
the bladder and allows the urine to enter the pars prosta- 
tica urethre. Its presence there causes an urgent desire 
to urinate, and the escape of the water is then only pre- 
vented by the compressor urethre muscle, which is the 
voluntary urinary sphincter. If this muscle does not 
relax and allow urination to be completed, the prostate 
closes down and forces the contained urine back into the 
bladder, where it stays until the further increased tension 
brings on another ‘‘ besoin d’uriner.” 

Malformations.—The prostate may be wholly wanting, 


39 


Prostate. 
Prostate. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


in connection with a general lack of development of the 
urinary organs. 

In exstrophy of the bladder there is no roof to the 
prostatic urethra, and the gland-ducts may be seen open- 
ing through the mucous membrane over the site of the 
organ. 

Gite and Wounds.—The deep-seated position of the 
prostate makes it little liable to injury from without. 
In severe crushes of the pelvis with fracture about the 
pubes, it may be wounded. In perineal lithotomy it is 
always incised, and often somewhat contused by the ex- 
traction of the stone. If the crushing and laceration 
of the parts have not been serious, healing usually takes 
place kindly. 

Injury of the prostate occasionally results from the 
passage of instruments through the urethra. This oc- 
curs most commonly in cases of hypertrophy, where the 
irregular enlargement of parts of the gland has made the 
canal tortuous. 

A specimen in the Museum of the Harvard Medical 
School, shows a very much enlarged middle lobe which 
so obstructed the entrance of the catheter, that the instru- 
ment had been forced directly through it and had entered 
the bladder beyond. 

The knowledge that such injuries are possible should 
lead to their avoidance. Much force is never needed in 
the passage of an instrument which is properly guided ; 
but a thorough understanding of the nature of the possi- 
ble obstacles, and considerable patience and care in over- 
coming them, are necessary to success in these cases. 

INFLAMMATION OF THE PROSTATE — PROSTATITIS— 
may be either acute or chronic. 

Acute prostatitis is commonly the result of the exten- 
sion of an inflammation from adjacent parts. 

A gonorrheeal urethritis is by far the most usual excit- 
ing cause. In this case the inflammation runs back along 
the urethra to the prostate. That this is not the usual 
course of a gonorrhea is due to the protection afforded 
by the constrictor urethre muscle. This sphincter, sur- 
rounding the membranous urethra, prevents the discharge 
from penetrating to the prostate and bladder, and usually 
protects these deeper parts from participation in anterior 
inflammations. Occasionally the passage of an instru- 
ment, or the forcing of an injection through the con- 
strictor, may convey infective discharges past this natu- 
ral barrier. 

A non-specific urethritis or an inflammation of the 
bladder may, in similar manner, extend to the prostate. 
Acute inflammation of this gland may also be excited by 
mechanical irritation. This may proceed from the pas- 
sage of instruments, from the application of caustics, 
from the use of strong injections, from the presence of 
calculi in the bladder or prostate, from accidental inju- 
ries, or from operations. 

Among other causes cited as occasionally giving rise 
to prostatitis, may be mentioned sexual abuses, acrid irri- 
tating conditions of the urine, the use of stimulating 
diuretics such as cantharides and turpentine, the abuse of 
stimulants, and the presence of inflammation in the rec- 
tum. Probably these conditions are rarely, if ever, com- 
petent to excite an acute prostatitis in a healthy state of 
the gland, but only act to aggravate an already existing 
inflammation. 

A stricture of the urethra greatly aggravates any deep 
inflammation of that canal, and makes its extension to 
the prostate much more liable to occur. 

Pathology. In acute inflammation the prostate is 
much congested, with great swelling and cedema, which 
extend to the surrounding parts. The prostate itself 
may be enlarged to three or four times its natural size, 
and even with this degree of inflammation, resolution 
and a return to a comparatively normal condition is pos- 
sible. 

If, however, the inflammation runs a more acute 
course, it may lead to the formation of abscesses, which, 
starting as minute points of pus, may gradually enlarge 
and coalesce until, in an extreme case, the whole organ 
may be reduced to one abscess-cavity. 

Spontaneous opening may take place backward into 


40 


the rectum, into the urethra, or bladder, and the pus 
may even occasionally find its way down through the 
ischio-rectal fossa, or into the perineum, and point exter- 
nally. Rarely, the abscess may open into the peritoneal 
cavity, or into an adherent coil of intestine. 

Symptomatology. The prominent symptoms are pain 
deep in the perineum and in the rectum, with tenesmus 
of the bladder and the,rectum. Urination is very fre- 
quent, and is accompanied by great pain, especially dur- 
ing the passage of the last few drops of water, which 
are frequently colored with blood. 

Accompanying these local symptoms, there is usually 
considerable fever, which may, or may not, be ushered 
in by a chill. There is, also, often severe pain in the 
back, loins, and thighs. 

As the inflammation increases the pains become even 
more severe, the urine in its passage scalds intensely, the . 
pressure and throbbing pain in the rectum become very 
distressing, and defecation, which is constantly desired, 
is, when it happens, a new source of suffering. 

The stream of urine becomes small and hard to start, 
owing both to the swelling of the prostate and to the 
spasmodic contraction of the constrictor urethre muscle, 
and finally complete retention may result. 

If a gonorrhcal discharge previously existed, it may 
disappear at the onset of prostatic inflammation, or it 
may be changed into a slight mucous discharge. 

There is usually a good deal of tenderness in the peri- 
neum, and sometimes also close above the symphysis pu- 
bis. A rectal examination is difficult on account of the 
extreme sensitiveness of the parts, accompanied by spasm 
of the sphincter muscle. 

If the inflammation gives rise to an abscess, its forma- 
tion is often heralded by rigors with high fever. If the 
abscess breaks into the urethra or bladder, there may be 
a sudden escape of pus in the urine, with an improve- 
ment of the general symptoms. 

If the pus-cavity attains any considerable size, its char- 
acter may be made out through the rectum, where it is to 
be felt, first as a hard, boggy swelling, which later softens 
and gives evidence of fluctuation. 

If the abscess extends into the loose cellular tissue 
along the rectum, pyemic symptoms may develop, and 
in case of rupture into the peritoneal cavity the charac- 
teristic symptoms of peritonitis will come on abruptly, 
with a speedily fatal issue. 

Treatment. Absolute rest is the first and most impor- 
tant measure when acute inflammation of the prostate 
makes its appearance. 

The patient should keep in a horizontal position with 
the hips somewhat raised. 

If severe pain is present—especially if frequent spasms 
of the bladder are aggravating the inflamed gland—opi- 
ates should be given; and it is to be borne in mind that 
these, by inducing rest from spasm, exert a really cura- 
tive effect. _Morphia and atropia subcutaneously, or opi- 
um and belladonna suppositories, may be administered 
under these circumstances. 

All irritations from instrumentation, injections, or 
stimulating diuretics, should be avoided. 

The bowels should be kept gently open by aperients, 
if necessary, and this point should be carefully looked 
after when opiates are being used. 

The urine should be rendered as unirritating as possi- 
ble by the use of diluents and alkaline diuretics, and 
nourishment should be given in a bland, unstimulating 
form. Farinaceous gruels, milk, and light broths may 
form the bulk of the diet. Alcohol should be entirely 
avoided in the acute stage of the disease. 

If at the outset the fever runs high, it may be some- 
what mitigated by the use of quinine or some more 
temporary febrifuge, such asaconite or antipyrine. Late 
in the disease, when it has run a severe course—especially 
in case of exhausting suppuration—strong concentrated 
foods and alcoholic stimulants may be required. 

Locally, all possible measures for limiting the severity 
of the inflammation should be employed. In an early 
stage of the disease, leeches applied to the perineum may 
be of considerable service. From six to eight should be 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Prostate. 
Prostate. 


put on along the raphé and close to the anus. The 
bleeding may be encouraged, especially in plethoric per- 
sons, until from fourteen to sixteen ounces have been 
withdrawn. 

Hot applications, either by fomentations or by hot 
water bottles, to the perineum and over the pubes, are 
useful in diminishing pain and spasm, and probably as- 
sist somewhat in lessening the inflammation. Hot hip- 
baths are recommended for this same purpose ; but the 
exertion and the unfavorable position required for these, 
add so much to the pelvic congestion as to greatly 
diminish the otherwise favorable effect of the heat. If 
used, they should not be prolonged for more than five or 
eight minutes, as the maximum effect on the surface is 
produced in that time. 

If retention of urine occurs, it must be relieved by the 
careful introduction of a small, soft catheter (Nos. 12 to 
14 French scale). 

Sometimes, when there is a spasmodic stricture at the 
compressor urethre, a soft catheter will not pass, and a 
stiff instrument must be used, requiring, of course, the 
greatest gentleness of manipulation.* 

When the retention persists and requires repeated 
catheterization, an instrument tied into the bladder (sonde 
a demewre) will often cause less irritation than would its 
frequent introduction. 

The possibility of abscess formation is always to be 
kept in mind, and the condition of the gland should be 
watched by rectal examinations. If fluctuation is made 
out, the abscess should be opened at once. This may 
usually be done through the rectal wall with a curved 
bistouri caché, and the opening should be rather a punct- 
ure than a long incision. This is for the purpose of 
avoiding hemorrhage ; and it isa good plan, with this 
same object in view, to make a careful examination before 
the puncture, to see that no vessel of any size in the rectal 
wall stands in danger of injury by the knife. In case of 
bleeding, ice pellets should be introduced into the rectum, 
and if these fail, pressure should be applied by a thorough 
plugging of the lower part of the bowel. 

If examination shows that the abscess is working 
toward the perineum, it may be opened by an incision 
from that direction, and thus a urethro-rectal fistula with 
prolonged suppuration may be avoided. 

When the abscess communicates with the rectum 
thorough irrigation of the bowel should be carried out, 
and an antiseptic, free from poisonous properties, should 
be selected, on account of the absorptive power of the 
rectal mucous membrane. 

If the disease ends in resolution, care should be 
taken that the recovery is complete, for an acute inflam- 
mation may, if neglected, leave a chronic condition 
which is sometimes extremely hard to relieve. 

Chronic Prostatitis. —Chronic inflammation of the pros- 
tate may, as has been said, follow an acute attack. It 
may, however, on the other hand, originate as a chronic 
or subacute affection. 

What has been said in regard to the etiology of acute, 
will for the most part apply to chronic, prostatitis ; but 
while the former is seldom the result of sexual errors 
alone, these are not infrequently almost wholly responsi- 
ble for a chronic inflammation of the gland ; and it is to 
be noticed that the imperfect sexual indulgence of mas- 
turbation, or partial intercourse, is much more productive 
of prostatic trouble than is the normal excitement of 
proper coition. This is probably due to the unrelieved 
congestion of the gland, left after these unnatural prac- 
tices. . 

Pathology. A chronically inflamed prostate is usu- 
ally somewhat enlarged, but may be natural or dimin- 
ished in size. The gland is less firm than in health, and 
its texture is more open and spongy. Upon section the 
cut surface is red or dusky in hue, and moister than nor- 
mal, Little points of suppuration may exist, but are usu- 
ally few and small. 

The mucous membrane has an increased vascularity 


* For the discussion of catheterization see under Hypertrophy of the 
Prostate. 


and may be thinned, particularly if the prostatic urethra 
is dilated in consequence of an anterior stricture. It 
may, on the other hand, be thick and spongy, denuded 
partly of epithelium, or much roughened with spots of 
ulceration. Sometimes, in cases of long standing, it is 
pigmented. The sinus pocularis and dilated gland-ducts 
about it may contain pus. Sometimes an abscess-cavity 
exists in communication with the urethra. 

Symptomatology. Patients with chronic prostatic in- 
flammation are troubled with increased frequency of 
micturition, which in a mild case may be scarcely notice- 
able, but is often very troublesome—occurring sometimes 
with intervals of less than an hour. 

There is usually pain of a dull, heavy character, re- 
ferred to the perineum and lower rectum. There may 
also be considerable pain low down in the back, with 
twinges shooting into the thighs and testicles. 

The bladder, when full, may make its condition known 
by a feeling of discomfort or actual pain, with intensely 
urgent call to urinate. 

The passage of urine may be accompanied by slight 
scalding sensations, and there may be a twinge at the end 
of micturition, when the bladder shuts down upon the 
sensitive prostate. Occasionally tenderness in the peri- 
neum may be felt upon deep pressure. 

The urine is usually cloudy and contains, more or less 
abundantly, clumps of muco-pus mixed with epithelial 
cells. These are little accumulations of secretion washed 
out of the dilated gland-ducts, and differ from the loose 
threads of mucus so common in chronic urethritis in 
being smaller, more coherent, and rounded in form. 
When the urine is passed in two portions, the first part 
is apt to be more cloudy and to contain these clumps of 
mucus more abundantly than the second part. Not in- 
frequently, however, even when the inflammation is con- 
fined to the prostate, the pus is distributed throughout 
the urine and both portions are cloudy. The reason for 
this has been very clearly stated by Ultzmann,* and is as 
follows: The internal sphincter of involuntary fibres 
surrounding the vesical orifice of the urethra is compar- 
atively feeble, while the compressor urethre muscle, 
just in front of the prostate and surrounding the mem- 
branous urethra, is strong and competent, and being 
under the control of the will, it forms the voluntary 
sphincter of the bladder. 

As discharges collect in the prostate they cannot force 
their way forward past the constrictor, but readily es- 
cape backward into the bladder, where they diffuse them- 
selves through the urine. Even in these cases, however, 
when the urine is universally cloudy, the first portion 
will still be somewhat more cloudy than that which fol- 
lows, and will contain many more of the mucous pros- 
tatic clumps. 

The urine, when examined microscopically, will often 
be found to contain, besides the pus, a considerable num- 
ber of blood-cells, and occasionally also a few sperma- 
tozoa. The blood may not infrequently be perceived to 
come at the end of micturition, when the bladder closes 
down upon and squeezes the congested prostate. 

A chemical examination frequently shows the presence 
of a little albumen, often in larger quantity than the pus 
and blood would account for. In other respects the 
urine is usually normal. 

If the character of the stream is noticed, it will often 
be found that its force is decidedly diminished, and that 
after the completion of urination a few drops dribble 
away. Sometimes partial or total retention may occur. 

This interference with urination is to be partly ac- 
counted for by the swelling of the prostatic mucous mem- 
brane, but is often largely dependent on a spasmodic con- 
traction of the constrictor urethre muscle ; and if under 
these circumstances a sound is passed, it will meet with 
decided resistance when it reaches the voluntary sphinc- 
ter. 

This spasmodic stricture may be so close as to greatly 


‘aggravate the difficulty and pain of micturition, for, as 


the bladder forces the urine into the prostatic urethra, if 


* Pyuria, p. 26. 


4] 


Prostate. 
Prostate, 


its further escape is prevented, the undue pressure in this 
sensitive part is productive of very great suffering. Usu- 
ally the spasm of the constrictor is finally overcome by 
the accumulating intra-vesical pressure, and urination, 
beginning first by drops, presently comes with more or 
less freedom. 

As we have said, the constrictor muscle prevents pros- 
tatic secretions from escaping anteriorly and appearing 
as a urethral discharge. Not infrequently, however, in 
these cases a glairy discharge of prostatic mucus is pressed 
out and escapes while the patient is at stool ; especially is 
this the case when the bowels are constipated and much 
straining is required. This is commonly interpreted by 
the patient as an escape of semen, and he becomes con- 
vinced that he is a victim of spermatorrheea. 

Usually the microscope fails to find spermatozoa in this 
discharge, which consists mainly of mucus, with some- 
times a little admixture of pus and blood. 

Besides the local symptoms and manifestations that 
have been described, we see in these prostatic cases often 
marked changes in the general condition of our patients. 
They are nervous and hysterical, or may be depressed 
and despondent, with often a hypochondriacal over-esti- 
mate of the gravity of their trouble. Sometimes a true 
neurasthenic condition may be induced in a case of long 
standing. Digestive disturbances and palpitation of the 
heart may occur. 

Physical Signs. An examination of the prostate 
through the rectum shows it sometimes slightly enlarged, 
but often normal or diminished in size. In consistency 
it is usually somewhat softer than in health. 

If the urethra is explored with an instrument it is com- 
monly very sensitive, but may be anesthetic; the latter 
condition being noticed usually in old cases. The ure- 
thra should be carefully examined fora possible stricture, 
and it is to be remembered that the constrictor muscle 
will be often found to make a spasmodic contraction 
just behind the triangular ligament. The passage of the 
sound through the prostatic urethra is almost always 
painful, and may excite an intense desire to urinate, or an 
ejaculation of semen. 

Diagnosis. The disease which we are considering is 
peculiar to young and middle-aged men, and is to be kept 
distinctly separate from hypertrophy of the prostate, 
which only occurs in the old. Inflammatory symptoms, 
it is true, are not uncommon in this latter affection, and 
will be discussed later. 

Tuberculosis of the prostate offers many points of re- 
semblance to chronic prostatitis, and a differential diag- 
nosis is often difficult, and may be for a time impossible. 
The constitutional tendencies of the patient should be 
taken into consideration, and a careful search should be 
made for evidences of tuberculosis in other organs. An 
examination of the urine for tubercle-bacilli may help to 
a solution, but a failure to find them even after careful 
search leaves the question where it was before, for they 
are often sought in vain in undoubted cases of genito- 
urinary tuberculosis. 

The discrimination between prostatitis and deep urethri- 
tis after gonorrhea, is sometimes almost impossible. The 
rectal examination of the prostate may help to a decision, 
but not infrequently gives negative results. 

A microscopical examination of the discharge obtained 
by pressure on the prostate through the rectum may give 
valuable information, but ‘this, too, is often misleading. 
The discharge in either case contains pus and large and 
small round epithelial cells. Amyloid bodies and cylin- 
der or caudate epithelium may be found in considerable 
abundance when the discharge is prostatic. 

The formation of Bottcher’s crystals upon the addition 
of a drop of a one per cent. solution of phosphate of am- 
monia to a drop of the secretion, shows beyond question 
that it contains prostatic fluid. 

This reaction should be conducted on a microscope 
slide, under a cover-glass, and within an hour, usually, 
crystals such as are shown in Fig. 3113 make their 
appearance. They are composed of a phosphate formed 
from a base which exists in prostatic fluid, and which is 
supposed to impart to it its peculiar odor. Unfortunately, 


42 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the mixture of urine with the secretion prevents the for- 
mation of these crystals, and so limits very much their 
diagnostic usefulness. 

It is always to be borne in mind that a combination of - 
urethritis and prostatitis is not uncommon. 

Treatment should be addressed to both the general and 
the local condition. 

The general treatment should be tonic, especially in 
the cases where much nervous depression exists. 

A generous, unstimulating diet, with moderate exercise 
in the open air, and with cold sponge-baths in the morn- 
ing, when the patient’s strength will admit of them, are 
to be advised. 

The laws of sexual hygiene should be carefully ex- 
plained to the patient, and the importance of their observ- 
ance made plain to him. 

Preparations of strychnine and iron are often of benefit, 
and they may be advantageously combined with quinine 
or ergot, both of which seem to exert a soothing influ- 
ence upon the prostate. Iodide of potash may be of as- 
sistance when the inflammation affects the glandular por- 
tions of the organ, and the addition of bromide of potash 
is sometimes distinctly useful in quieting sexual excite- 
ment. 

If the urine is highly acid or otherwise irritating, its 


Fig. 3113.—Sediment from Prostatic Discharge, Containing Pus and Epi- 
thelial Cells, Granules, Amyloid Bodies, and Béttcher’s Crystals. 


character should be modified by demulcent drinks and 
by alkaline diuretics. 

For a more direct local effect, cantharides, turpentine, 
sandal-wood oil, or copaiba may sometimes be adminis- 
tered with advantage, especially when the inflammation 
e mostly confined to the prostatic urethral mucous mem- 

rane. 

Various local measures of treatment may be expected 
to contribute to the cure. 

Counter-irritation to the perineum, either with tincture 
of iodine or with fly-blisters, is often of great use. Can- 
tharidal collodion is a convenient blistering medium, and 
should be applied to a small surface close to the raphé. 

Whatever counter-irritant is used, careshould be taken 
that it does not come in contact with the scrotum or anus. 
After the application is dry, it is a good plan to fix a pad 
of absorbent cotton in the perineum with a T-bandage. 
This takes up the perspiration and prevents the blister 
from pene to the side opposite to that where it was 
applied. 

When there is much pain in the prostate and rectum, 
hot injections into the bowel may help to palliate it, and 
to reduce the congestion in the same manner that hot 
douches act upon the female pelvic organs. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


The most important local treatment, 
however, is that applied directly to the 
prostate itself, and consists in the passage 
of sounds, and in applications and injec- 
tions into the prostatic urethra. 

The use of sounds in chronic inflamma- 
tion of the prostate has long been recog- 
nized as of advantage, and the benefit from 
them has been variously explained. 

Some surgeons think that they should be 
used cold, and ascribe their efficiency to 
the astringent action of the cold. Others 


tate exerts some beneficial influence by 
pressing the blood out of the gland. 

While some good may perhaps be at- 
tained in either or both of these ways, it is 
probable that the stretching of the con- 
strictor urethre muscle, and the consequent 
relief from spasmodic contraction of the 
same, will account, in a large measure, for 
the good results that follow their use. As 
has been said above, this sphincter is not in- 
frequently put in a spasmo- 
dic state of contraction by 
the proximity of the pros- 
tatic inflammation, and in 
this state of stricture it has 
a tendency to aggravate the 
deep inflammation, just as 
an organic stricture tends 
to increase and perpetuate 
a urethritis posterior to it. 
It can be readily under- , 
stood, therefore, that the 
relief of this spasmodic 
contraction would act fa- 
vorably upon the inflam- 
mation behind it. 

As large a sound as will 
pass comfortably through 
the urethra should be used, 
and it should be introduced 
with the greatest gentle- 
aie: cea is ness. A sound passed 

tor, Consists TOUgHLy down through the 

ofahollowtube anterior urethra will some- 

Serer acs times find the constrictor 

tightly closed against it, 

Beer tea when, had more care been 
exercised the urethra would not have re- 
‘sented its introduction, and it would have 
readily passed the moderately contracted 
sphincter. 

If the spasmodic stricture is a tight one, it 
will sometimes be found necessary to precede 
the introduction of the sound by the passage 
of a French, olive-pointed, conical bougie ; 
which, insinuating its point through the ob- 
struction, readily dilates it and prepares the 
way for the larger instrument. 

When excessive irritability or an access of 
inflammation make the application of cold 
to the prostate desirable, it may best be ac- 
complished by the use of the cold sound. 
This is a hollow instrument, which after its 
introduction can be chilled down by a stream 
of water through it. It should usually be 
kept in place for about five minutes. 

_ We now come to speak of local applica- sha dna ted ete 
tions to the prostatic urethra, and in these jnge for the in- 
we recognize the most efficient means at our troduction of 
command for subduing chronic inflamma- f$"°S Sit 
tion of this part. curve of this 

The cases which are particularly suited to and of the irri- 
this form of treatment are those in which $#4ns catheter 
prostatic clumps are present in the urine, fromUitzman’s 

with or without a purulent secretion; in 
short, where the mucous membrane is dis- 


Prostatic Syr- 
inge, A capil- 
lary tube and 


instruments. 
See text. 


consider that their pressure within the pros-. 


Prostate. 
Prostate. 


tinctly affected. Medication may be conveyed to the 
pars prostatica urethre either in the form of soluble 
bougies, by the injection of a few drops of a strong solu- 
tion, or by irrigation with considerable quantities of a 
weak solution. 

Soluble bougies are useful when it is desired to intro- 
duce an insoluble drug. They are made with gelatine or 
cocoa butter, in the shape of little rods about two inches 
in length, and are put in place with a urethral supposi- 
tor. lJodoform may be conveyed into the urethra in this 
way, and is often of considerable service in these cases. 

The application of soluble drugs to the prostatic urethra 
is probably best accomplished by the injection of solu- 
tions. 

The constrictor muscle, situated just before the pros- 
tate, prevents the penetration of an ordinary urethral in- 
jection, and special instruments are therefore needed for 
medication in the urethra posterior to it. Figs. 3115 and 
3117 represent such catheters for prostatic medication. 

The curve shown in these instruments has advantages 
both in the ease of introduction, and in the readiness with 
which the loca- tion of the point can be deter- 
mined from the position of the handle. 

When the in- strument is vertical * the point 
necessarily rests just in front of the triangular 
ligament ; now, upon bringing it down .to an 
angle of forty- five degrees, and at the same 
time advancing it slightly, the point slips on 
through the con- strictor muscle, but never pass- 
es beyond the prostate unless a special effort 
is made to push it on toward the bladder. Fluid 

imjected 
_» through the 
ve , Catheter, 
each when in this 
AL position, can- 
at not pass for- 
ward through 
the constric- 
tor, but washes 
out the pros- 
tate and es- 
capes back- 
ward into the 
bladder. 

Of the vari- 
ous drugs used 
for prostatic 
application, nitrate of sil- 
ver is perhaps the most 
valuable. 

Two or three minims of 


1 I 
i 

| 
iy 


Fie. 8116.—Diagram showing thatif a 
short-beaked instrument is held with gq one to two per cent. so- 


the handle vertical, the point rests * x 
just at the triangular ligament. The lution should be thrown 


dotted figure shows howthe pointslips into the prostatic urethra 
pate tele erage muscle ie through ; the capillary 
sie age onan op ams abeid ot codhater (Mga S115). © 
the body. Some pain of a burning 
character, with often con- 
siderable tenesmus, follows the application ; but this usu- 
ally passes off in the course of an hour or two. The in- 
jection should be repeated every four or five days, and its 
effect may sometimes be heightened by the previous pas- 
sage of asound. As convalescence is established, the in- 
tervals in the treatment should be gradually lengthened. 
Irrigation of the prostatic urethra may often be practised 
with great benefit. In case there is much irritability of 
the neck of the bladder, with considerable muco-purulent 
secretion, a soothing antiseptic wash is of use. A two per 
cent. solution of borax or boracic acid, with the addition 
of a little glycerine, is a good injection for this purpose. 
If the use of an astringent wash seems indicated, any 
of the mixtures useful in gonorrhcea may be tried. Per- 
haps a one per cent. solution of acetate of zinc is as good 
asany. The irrigating fluid, after washing out the pros- 
tate, flows back into the bladder, as has been said, and 


* Throughout this article, when the manipulation of instruments is 
described, it is supposed that the patient is in a horizontal position. 


43 


Prostate. 
Prostate. 


from there it may either be withdrawn by slightly ad- 
vancing the catheter, or it may be passed by the natural 
efforts. 

After any manipulation or treatment of the prostatic 
urethra the patient should keep quiet, if possible recum- 
bent, until all serious discomfort passes away, and should 
avoid any exposure to chill or fatigue for several hours. 

HYPERTROPHY OF THE PROSTATE, ENLARGED PROs- 
TATE.—Ltiology.—The causes of enlargement of the pros- 
tate are difficult to establish by 
any adequate proof. 

The one thing which seems 
to be essential to the existence 
of the disease, is the advanced 
age of the patient. Hyper- 
trophy of the pros- 
tate is practically un- 
known before the age 
of fifty, whereas after 
that it is extremely 
common. 

Stone in the blad- 
Mild der, stricture of the 
ig) urethra, irritation by 
Hf the frequent use of 
ii instruments, seden- 
m tary habits, gouty or 
# rheumatic diathesis, 
f| and exposure to cold 
H and damp, have all 
im been cited by surgi- 
# cal writers as predis- 
posing circumstances; 
H but none of these con- 
| ditions has ever been 
positively shown to 
} stand in a causative 
|) relation to the disease. 
On the other hand, 
7 there is no doubt that, 
# when prostatic hyper- 
| trophy exists, any of 
f, these conditions may 
| greatly aggravate its 
| symptoms; and 
besides those al- 
ready named we 
may mention ex- 
| cesses in drink or in 
mm Venery, prolonged 
| } voluntary retention, 
lig and the recumbent 
lim posture as familiar 
lig) causes of increased 
1 | prostatic congestion. 
ig) Harrison comes for- 
lag, ward, in a recent pa- 
fm per, and tries to estab- 
j lish the position that 
hypertrophy of the 
prostate is secondary 
to a condition of par- 
tial retention. 

He says: ‘‘ Assum- 
ing that from any 
cause, such as long reten- 
tion of urine, habit, posi- 
tion of the body, or the 
weakness connected with 
advancing years, the tri- 
gone, or non-contractile part of the bladder, becomes per- 
manently depressed or altered in form, so that the person 
finds himself unable to get rid of the last half-ounce or 
so of urine, the effect will be frequently repeated efforts 
in all the muscles immediately adjacent to a part which, 
by reason of its connections and structure, has but little 
power of expelling. 

‘‘This will eventually lead, as I have shown, to the hy- 
pertrophy of the muscular fibres between the orifices of 


44 


Zz 


CODMAN& SHURTLEFF, BOSTON. —__ 


Fig. 3117.—Irrigating Catheter. 
ter Ultzman.) 


(Af- 


) tres. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the ureters—the inter-uretal bar—as well as, I believe, 
to that of the muscular fibres so largely entering into the 
composition of the prostate. In this, I submit, will be 
found the immediate cause of prostatic hypertrophy.” 

It is difficult to see how, if we accept as true this theory 
of Mr. Harrison, we shall be able to explain the ab- 
sence of prostatic hypertrophy in those cases of stricture, 
occurring in young or middle-aged men, where all of the 
expulsive muscular apparatus of the bladder is greatly 
hypertrophied, and still the prostate does not increase in 
size. This, too, at an age when the tendency to muscu- 
lar hypertrophy is much greater than it is later in life. 
Mr. Harrison’s theory also does not explain those cases 
of hypertrophy in which the hyperplasia affects mainly 
the glandular portions of the organ. 

Pathology.—Hypertrophy of the prostate may occur 
through hyperplasia of the glandular portions of the 
organ, of the interstitial tissue, or of both. 

As the normal size of a particular prostate can never 


- be known, it may be hard to say, even on post-mortem 


examination, whether a given specimen is enlarged or 
not. For approximate determination, however, a pros- 
tate weighing six drachms may be regarded as normal 
in size, and anything over that is to be considered as hy- 
pertrophied. 

Upon section of a prostate which is hypertrophied, the 
cut surface bulges irregularly above the capsule. It 
may be grayish-yellow in color or mottled with blotches 
of red, yellow, and gray, with occasional dark pig- 
mented spots. 

If the glandular element predominates the surface is 
soft, and exudes a fluid rich in cells. In interstitial 
QQ. hyperplasia the 

\Y surface is dryer 
and firmer. 

Sometimes lit- 
tle projecting 
bunches an- 
nounce the for- 
mation of fi- 
brous or glan- 
dular tumors 
within the or- 


Fra. 3118.—Diagram to show the Shape of the 
Urethra in a Vertical Section through a Pros- 


an. 
tate with an Enlarged Middle Lobe. Usually the 


hypertrophy af- 
fects all parts of the gland simultaneously, but not all in 
the same degree. 

The shape of the prostatic urethra—a matter of the first 
clinical and surgical importance—depends largely upon 
the partial or general character of the hypertrophy. If 
the enlargement is pretty evenly distributed throughout 
the organ, the urethra is in the first place considerably 
lengthened, sometimes measuring even seven centime- 
When the hypertrophy is partial the elongation is 
less, though it is still marked. 

Furthermore, in cases of general hypertrophy, as the 
lateral lobes enlarge they compress the urethra from the 
sides, until it becomes a slit-like canal with tolerably firm 
walls in close apposition. As the lateral diameter is thus 
diminished, the antero-posterior diameter is correspond- 
ingly increased. 

It will be readily seen that, as long as the enlargement 
is symmetrical, the direction of the urethra is not ma- 
terially altered ; but on the other hand, it is equally evi- 
dent that if the hypertrophy is partial, and not evenly 
distributed, the unequal pressure from one side or the 
other of the canal will cause lateral deviations, and that, 
if the middle lobe is unduly enlarged, the posterior por- 
tion of the urethral floor will be raised, causing a devia- 
tion upward or toward the pubes (see Fig. 3118). 

The projection upward of this lobe may make the in- 
ternal urethral opening crescentic in shape, and if the 
middle coalesces with either of the lateral lobes this ori- 
fice is pushed over toward the opposite side. 

Sometimes the middle lobe grows out into the bladder 
as a distinct tumor, which may be attached by a broad 
base, or may stand off in a pedunculated polypoid form. 

Besides the changes in the prostate itself, there are 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Prostate. 
Prostate, 


other alterations in associated organs which we must 
consider in connection with this disease, as they are in- 
strumental in producing many of the symptoms which 
we shall have to study. ' 

As the prostate enlarges the internal meatus is raised 
and a pocket is formed in the bladder just behind the 
enlarged gland. The bladder- 
wall also becomes thickened, 
partly in consequence of hy- 
pertrophy of the muscular < 
coat, owing to the increased 
resistance against which it has \ 
to work, and partly owing to 
a sclerosis of the interstitial 
fibrous tissue, like that which 
has occurred in the prostate. 

Interlacing muscular bands 
often stand out from the vesi- 
cal wall under these circum- 
stances, forming trabecule be- 
tween which there are, not 
infrequently, considerable 
pouches of mucous membrane. 

The walls of the ureters and \ 

elves of the kidneys may also - 
re somewhat thickened and “Y fe neal ey 
the interstitial renal tissue un- see Mecues msbheil oe 
dergoes frequently: a hyper- same Organ, showing how 
plasia. the urethra divides and goes 
As a later result of the pros- on either side of the middle 
tatic obstruction the bladder, ‘°°* 
ureters, and pelves of the kidneys may become greatly 
distended. 

Guyon and Lannois have laid particular stress upon 
the fact, already hinted at and partly understood by 
earlier writers, that, coincident with these changes in 
the urinary tract, a general sclerosis, affecting specially 
the walls of the blood-vessels, is going on throughout the 
body. ‘ 

sates from any cause inflammation of the bladder, 
ureters, or kidneys has associated itself with hypertrophy 
of the prostate, we have the familiar pathological appear- 
ances of cystitis, pyelitis, and 
pyelo-nephritis engrafted upon 
the organs already seriously 
altered by the prostatic ob- 
struction. 

For a full consideration of 
these complications see under 
Bladder and Kidneys in this 
HANDBOOK. 

Natural History.—The prog- 
ress of the disease is slow. 
The organs affected are not 
of vital importance, and the 
changes in them may reach a 
very advanced state before 
: they seriously threaten life. 

yj Yj Guyon has divided the his- 

Lf Yy YY Uj tory of the disease into three 

Vy periods: First, that of con- 

Vi ‘ gestion, affecting mainly the 

Wid _ prostate, but also in less de- 
Fra. 3120.—Diagram of a Hori- oree the bladder and kidneys. 

zontal Section through a @ ° 

Prostate in which the right Secondly, that of partial re- 

lobe, A, is moderately enlarged, tention of urine. And, thirdly, 

the left lobe, B, somewhat less that of distention of the blad- 
much enlarged and is joined der with usually secondary 
to the left lobe, causing ade- changes in the kidneys. 

viation of the vesical end of This somewhat empirical di- 

See oe er ceDs vision gives us perhaps as good 
a framework as any for the classification of the clinical 
phenomena. 

In the first stage, that of congestion, we have some 
enlargement of the prostate and functional disturbances, 
especially in the matter of urination. This condition 
may persist for a long time, and in certain cases, where 
for any reason the calibre of the urethra is not greatly 
interfered with, it may exist almost indefinitely without 


) 
Yj 
“ 


A? 
y 


showing any tendency to pass on to the second stage, that 
of retention. 

Usually, however, sooner or later the obstruction to 
the passage of the urine becomes greater than the force 
of the bladder can overcome, and a state of habitual par- 
tial retention is the result. 

When this condition comes on slowly the accumulation 
of residual urine may be very insidious, and escape the 
observation of patient and physician alike ; on the other 
hand, an increase in the prostatic obstruction may occur 
suddenly, and the unexpected complete stoppage of the 
urine may be the first announcement of trouble. 

When the retention of the second stage of the disease 
develops gradually, and is not discovered and treated, 
the point may be finally reached where the bladder has 
completely lost its tone and is so distended, that the urine 
escapes almost constantly by an overflow (retention with 
incontinence). This same condition of things may follow 
also an acute retention which has not been relieved by 
catheterization and in which nature has finally estab- 
lished a leakage. 

The third stage of the disease is now entered upon, 
and if nothing is done for such a case the distention of 
the bladder becomes extreme, and a secondary dilatation 
of the ureters and of the pelves of the kidneys takes place. 
This is soon followed by atrophy of the secreting portion 
of the kidney, and an increase of its interstitial tissue (in- 
terstitial nephritis). 

The secondary changes in the heart and blood-vessels, 
usually associated with chronic nephritis, are likely to 
make themselves noticed at this time, if they have not al- 
ready done so, and the disease becomes a constant and 
serious menace to life. 

It is in this advanced stage of the disease that inflam- 
matory processes, starting in the bladder, rapidly extend 
backward to the kidneys, and uremic symptoms presently 
usher in the closing scene. 

Symptomatology.—F rom what has been said in regard 
to the history and progress of the disease, it will be seen 
that the symptoms of the first stage are mainly dependent 
upon the condition of congestion in the prostate, bladder, 
and kidneys. And as this congestion is most consider- 
able in the prostate, the most noticeable symptoms caused 
by it are disturbances of micturition and of sensation, due 
to the irritated state of the neck of the bladder. 

In the second and third stages we have, in addition, a 
series of symptoms due to the mechanical obstruction to 
micturition, and to the changes in the bladder and other 
organs consequent upon this obstruction. 

We shall have finally to consider the symptoms arising 
from various morbid conditions likely to appear as com- 
plications in the course of prostatic disease. 

The first appearance of symptoms usually announces a 
morbid condition which has already been coming on for 
some time. When the enlargement takes place in such 
direction as not to encroach seriously on the calibre of 
the urethra, it may reach very considerable proportions 
before it causes any inconvenience to the patient. 

One of the first symptoms to be noticed is an increased 
frequency of micturition, which is especially marked at 
night or early in the morning. Guyon regards this as 
evidence of congestion, which is aggravated during 
recumbency and sleep. He calls attention, also, to the 
frequent existence of erections in these patients, on 
waking, as further evidence of an increased congestion’ 
of the prostate during sleep. 

Pain is ordinarily not very noticeable in the early 
stages of the disease, although a dull aching, or heavy 
dragging, sensation in the perineum, rectum, and behind 
the pubes is not uncommon. 

If attention is paid to the manner in which urination 
is accomplished, it will be found that early in the dis- 
ease the stream is slow to start and diminished in force, 
This is due largely to a loss of power in the bladder, but 
is to be partly explained by the swelling in the prostate, 
and by a spasmodic contraction and stammering action of 
the constrictor muscle. 

The diminution in the force of the stream in a pros 
tatic patient differs from that seen in cases of stricture, 


45 


Prostate. 
Prostate. 


in that, while astrictured patient can, by voluntary effort, 
increase the force of his stream, a man with enlarged 
prostate cannot do so. 

Second Period. The symptoms which have their 
origin in congestion continue during this period, and are, 
indeed, intensified. Added to them we have other 
symptoms due to the retention, which is the characteristic 
condition of this stage of the disease. 

The retention may be complete or incomplete. 

Complete retention may be acute and appear suddenly, 
or it may be preceded by a period of partial retention 
which always develops slowly. 

The symptoms which accompany a complete retention 
are easy of recognition, and a physical examination re- 
veals the bladder distended above the pubes. Incom- 
plete retention, on the other hand, comes on very insidi- 
ously, and is often overlooked for a long period, at just 
the time when recognition and treatment of the condition 
are of great importance. 

Although, as has been said, partial retention comes on 
quietly, still a careful examination of the symptoms will 
usually elicit evidence of a changed condition of things, 
at or soon after the time when the bladder begins to fail 
of emptying itself. The feeling of weight behind the 
pubes is likely to be increased, and the frequency of 
micturition, which during the first stage was decidedly 
more pronounced at night, begins to be almost equally 
noticed in the daytime. The intervals between the acts 
of urination become short, and the call isimperative. In 
short, the bladder being always partly full, it takes but a 
small additional quantity to distend it to its full ca- 
pacity. 

The only positive means of determining the condition 
of the bladder is by a physical examination, and this 
should be made in every doubtful case. 

Sometimes the bladder shows extraordinary tolerance, 
and the distention becomes so extreme as to Cause incon- 
tinence from overflow, before the patient feels obliged 
to call upon a physician; and sometimes also, unfortu- 
nately, before the medical attendant recognizes the na- 
ture of the difficulty. 

This incontinence is evidence of a very great degree 
of distention, and shows that the disease has entered 
upon its third stage. Usually, before it appears, the dis- 
ease has already extended backward and has begun to 
affect the kidneys. 

There is one symptom which may appear and give 
evidence that the disease has reached the third stage, be- 
fore incontinence begins. This is polyuria. If the 
quantity of urine in the twenty-four hours is measured, 
it will be found to considerably exceed the normal. 

Pain, which was an insignificant symptom in the first 
stage, may assume considerable importance in the second 
and third stages. 

Besides the discomfort in the perineum and back due 
to the congested and irritated prostate, there is also con- 
siderable pain before and during micturition, caused by 
the distention of the bladder and its unavailing or par- 
tially successful attempts to empty itself. The passage 
of the urine through the prostate is also sometimes pain- 
ful, and this is especially the. case where the occurrence 
of inflammation has rendered the urine pungently alka- 
line and has made the parts particularly sensitive. 

The examination of the urine may give negative results 
during the early stages of prostatic disease; but when 
the congestion of the kidneys is considerable there may 
be albumen, and even afew casts. During the last stage 
of the disease, when polyuria has established itself, the 


specific gravity is low (1.003 to 1.006) and there may be 


a small amount of albumen, although this is often not 
present. A few casts may be found at this time, too, but 
they are often absent even when the kidneys are exten- 
sively diseased. 

In the presence of inflammatory complications the 
character of the urine is greatly changed, as we shall see 
later. 

In addition to the more local symptoms which we 
have been considering, there are also certain general 
disturbances which are likely to appear in advanced 


46 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


prostatic disease. 
febrile. 

Obstinate indigestion in an old man, especially if ac- 
companied by nausea, should always lead us to take the 
condition of the prostate into consideration. These pa- 
tients are also very liable to a low feverish condition, 
with extremely dry mouth and tongue, and this may an- 
nounce the extension of inflammation from the bladder 
back into the kidneys. 

We now come to the consideration of the complications 
which are likely to arise in prostatic cases, and of the 
symptoms, or variation in symptoms, to which they give 
rise. 

They are cystitis, pyelitis (pyelo-nephritis), hzeematuria, 
and stone in the bladder. 

Cystitis is so common in prostatic hypertrophy that it 
may be looked upon almost as a necessary result. It 
sometimes appears without apparent cause, sometimes 
in consequence of excesses in drink, or from exposure 
to cold. Far more commonly, however, it follows asa 
consequence of the use of the catheter or other instru- 
ment, and when it is once established it is rarely got rid 
of—but may, as we shall see, by appropriate treatment, 
be kept within very reasonable bounds. 

When the inflammation of the bladder is at all acute, 
the pain and frequency of micturition are greatly in- 
creased. If the prostate shares in the inflammation, a 
great weight and bearing-down pain in the rectum may 
be felt, with a frequent urgent desire for defecation. 

The urine becomes thick from the admixture of pus 
and mucus, which often settles at the bottom of the 
vessel in a thick, ropy mass. Presently, in the majority 
of cases, it undergoes alkaline fermentation, becomes 
ammoniacal, and has a strong pungent, often fetid, odor. 
The sediment now contains, besides the pus, abundant 
crystals of triple phosphates, often associated with finely 
granular amorphous phosphates. 

If the inflammation extends from the bladder back 
through the ureters to the kidneys, the resulting pyelitis 
or pyelo-nephritis makes itself known by pain in the 
back, high fever, more or less diminution or even sup- 
pression of urine, and uremic symptoms. 

This course of things is especially liable to occur late 
in the disease, when neglect of catheterization has al- 
lowed the ureters to become greatly distended. Under 
these circumstances, any exposure to cold or instrumen- 
tation may be sufficient to start the fatal access of inflam- 
mation. ; 

Occasionally; when the use of the catheter has been 
neglected after the time when it should have been be- 
gun, the final entrance upon the catheter life, instead of 
being a conservative measure, gives the final push to- 
ward a fatal issue. The existence of polyuria, with urine 
of a low specific gravity, should always lead us to fear 
this result. : 

Stone in the bladder not infrequently occurs in prostatic 
patients as a consequence of cystitis, in which case the 
stone is of the soft phosphatic variety ; or a stone com- 
posed of uric acid, oxalate of lime, or cystin may form, 
and owe its origin primarily to a constitutional condi- 
tion. 

In either case the prostatic hypertrophy may be re- 
garded as partly responsible for the formation of the cal- 
culus. 

In the first case, of the phosphatic stone, the obstruc- 
tion, by causing the cystitis and fermentation of the urine, 
stands in a pretty close causative relation to the calculus. 
In the second case, in which the deposit of crystals from 
the urine is due to a constitutional tendency, the obstruc- 
tion at the prostate may be the condition which decides 
whether a stone shall form or not. For, when the blad- 
der is completely emptied at each urination, the crystals 
as they form are thrown out and do no harm, whereas 
when a pocket has been formed behind the prostate in 
which there is always residual urine, the sand collects 
there and soon agglomerates itself into a concretion. 

When a stone forms behind an enlarged prostate the 
pain is usually much increased, and is less amenable to 
treatment. It is referred often to the glans penis, and is 


These are of two kinds, digestive and 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


greatly aggravated by motion, especially by riding in a 
jolting vehicle. It is commonly less marked at night or 
during rest. 

Heematuria in case of stone is very likely to appear 
after exercise or riding, while prostatic haemorrhage from 
congestion seems to be independent of any jarring of the 
bladder—in fact, is rather more likely to come at night, 
when recumbency favors prostatic congestion. 

The sudden stoppage of the stream in the midst of uri- 
nation, by the rolling of the stone against the opening of 
the urethra, is less likely to occur in case of an enlarged 
prostate than in a healthy bladder, owing to the lodge- 
ment of the stone behind the prostate, below the urethral 
orifice. 

If the presence of the stone affects the frequency of 
micturition, it tends to increase it rather in the daytime, 
when motion causes the stone to move about, than at 
night, when it is at rest. 

Hematuria, as has been said, may result from the con- 
gestion of the prostate or from the presence of a stone. 
We may also have hemorrhage of considerable amount 
and duration, following the use of instruments; and, 
lastly, the too sudden emptying of an over-distended 
bladder may lead to an attack of hematuria, from the 
capillary oozing from the vesical wall. 

Sometimes clots of large size may form in the bladder, 
and cause.much pain and discomfort before they are 
broken up and expelled. 

Physical Haamination.— Having decided from the 
symptoms that there is a probability that prostatic hy- 
pertrophy exists, a thorough examination should be made 
of the prostate and bladder. 

The objects of this investigation are, to ascertain the 
stage at which the disease has arrived, to learn the amount 
of obstruction and the configuration of the prostatic ure- 
thra, and to discover any complicating conditions which 
may exist. . 

The patient should first empty the bladder, so far as 
possible by the natural efforts, and the hypogastrium 
should then be explored by palpation and percussion, to 
see whether enough distention of the bladder remains to 
be detected in this region. The normal variations in the 
position of the bladder and intestines render this exami- 
nation often unsatisfactory, especially when the abdomi- 
nal wall is thick or rigid. 

The examiner should then explore with the forefinger 
the rectum. Thisis best done with the patient on the back. 

If the prostate is enlarged it will be felt pressing down 
the anterior rectal wall. Its size, shape, and consistency 
should be noticed. 

The relative enlargement of the lateral lobes can usu- 
ally be well made out, and nodular projections are some- 
times felt, caused by irregularities in the hypertrophy of 
different parts of the gland. Rectal examination, unfor- 
tunately, gives little or no information in regard to the 
condition of the third lobe, which is so often the cause 
of a serious obstruction to the flow of urine. 

Incidentally the degree of tenderness to palpation will 
be discovered. 

The condition of the prostate itself having been deter- 
mined, the examining finger should be carried up along 
the posterior vesical wall, if that be possible, and the 
condition of the bladder should be learned. In this in- 
vestigation the bi-manual manipulation between the fin- 
ger in the rectum and the hand above the pubes, so com- 
monly practised in examinations of the female pelvic 
organs, is useful, and by it the amount of distention of 
the bladder can often be most accurately made out. 

Lastly, the urethra and bladder should be explored. 

The existence of a stricture will probably be detected in 
the passage of instruments for deeper exploration. But 
in case of doubt the canal may be thoroughly examined 
with large bulbs. A short-beaked sound should be passed, 
and as it runs through the prostate deviations of the ure- 
thra will often be shown, by the feeling of resistance on 
one side or the other and by the turning of the handle. 

The sound in entering the bladder may sometimes be 
felt to slip up over a bar, or may turn to one side around 
a prominent third lobe. 


Prostate. 
Prostate, 


After a proper search has been made for a possible 
stone, the sound should be depressed until it lies in the 
axis of the body, and then withdrawn until the concave 
side of the beak comes against the neck of the bladder ; 
it may then be rotated, and, as the beak sweeps the vesi- 
cal face of the prostate, any irregular outgrowths or pro- 
jections will be felt to arrest its movements. 

If the sound has been felt to ride over an obstruction at 
the neck of the bladder and, after it is in, rotates firmly, 
this points to a bar rather than to a globular enlargement 
of the third lobe, which last would arrest the beak of 
the sound in rotation. 

As the instrument is withdrawn slowly through the 
prostate, the deviations due to projections into the ure- 
thra are often felt even more plainly than during intro- 
duction. 

Finally, the urine may be withdrawn with a catheter 
and the exact amount of residuum thus discovered. This 
will be found to vary much -at different times, and de- 
pends somewhat upon the amount of urine which the blad- 
der contained before the last urination. 

When the bladder is full and the urine consequently 
rushes out with some force in a considerable stream, it 
will often be found that there is much less water left in 
the bladder than is the case when urination has been at- 
tempted before complete distention has been reached. 

Diagnosis.—The conditions with which enlarged pros- 
tate is likely to be confounded are stricture of the ure- 
thra, stone in the bladder, cystitis, cancer or other tumor 
of the prostate, tuberculosis of the prostate, and tumor of 
the bladder. 

The physical examination, if thoroughly made, usually 
enables us to eliminate the first two of these conditions, 
and if enlargement of the prostate with residual urine is 
found we may, in the absence of other discoverable cause, 
decide an existing cystitis to be dependent upon the pros- 
tatic trouble. 

The decision between a tumor of the prostate and sim- 
ple enlargement is extremely difficult, unless the tumor 
has assumed considerable proportions or has begun to in- 
vade surrounding parts. The physical examination by 
the rectum gives us our best help in diagnosis, but the 
irregular growth of a tumor may at first simulate the 
irregularities sometimes seen in hypertrophy. 

The pain attendant upon the growth of a tumor is more 
severe than that appearing early in hypertrophy, though 
this is by no means constant. , 

In case of a cancer the enlargement of neighboring 
glands may help us to the right solution of the question. 
Not infrequently, however, it will be necessary to wait 
until the progressive growth of the tumor declares its 
character, 

Tuberculosis of the prostate usually occurs earlier in 
life than we couid look for hypertrophy. In case of 
doubt, tuberculous deposits must be sought for in other 
organs (epididymis, seminal vesicles, lungs, etc.). 

A tumor of the bladder may give rise to hemorrhages 
and difficulties of micturition which simulate those 
caused by enlargement of the prostate. Also a tumor 
may be present in the bladder behind an enlarged pros- 
tate, and so complicate the symptoms. 

The hemorrhage from a tumor is ordinarily very much 
greater than that from a congested prostate. But this is 
not always the case, and whenever there is persistent or 
intermittent hematuria, however slight, a careful search 
should be made for villi or other bits of the tumor which 
may be detached and passed in the urine, and which may 
be recognized under the microscope. 

Examination of the bladder with the sound may, when 
a tumor is there, reveal a projection somewhere from its 
wall. But sensations of this sort are very misleading, 
and it is well, after a thorough sounding, to wash out the 
bladder with the litholapaxy evacuator, with the object of 
obtaining bits of the tumor, if one is there. 

After definitely settling the diagnosis of prostatic hy- 
pertrophy, it is always important to go further, and to 
decide in what stage the disease is, as we shall see that 
the treatment should vary according to the varying con- 
ditions. 


47 


Prostate. 
Prostate. 


The steps to this decision have been sufficiently in- 


dicated above. 

Treatment.—As has been described, the disease under 
consideration consists essentially in a tendency to con- 
gestion of the prostate, bladder, and kidneys, with an 
accompanying hypertrophy and sclerosis. 

For convenience we have divided it into three stages: 
first, of congestion, with functional disturbances ; sec- 
ond, of simple retention; and, third, of retention with 
distention, often incontinence, and perhaps involvement 
of the kidneys. 

First we will consider those measures of treatment, 
hygienic and medical, which are applicable to all stages 
of the disease. 

Anything which has a tendency to increase the conges- 
tion, should be carefully avoided. A chill of the surface 
should be especially guarded against. The patient should 
wear flannels next the skin, and should carefully avoid 
draughts or long exposure to chilly and damp air. 

The feet should be kept dry and warm, and if the 
patient gets up at night to pass water, use the catheter, 
or for other purpose, he should cover his feet and 
legs warmly. Neglect of these precautions may at any 
time bring on an attack of retention, cystitis, or even of 
pyelo-nepbritis. 

Excesses in eating and drinking are to be avoided. 
Large quantities of rich or highly seasoned food must not 
be indulged in, and wine or beer are for the most part 
better left alone. This caution should be understood to 
apply only to overeating, as a sufficient quantity of 
nourishing food is of importance. If the patient has 
been in the habit of taking a stimulant, a little light 
claret, or some whiskey and water, may be allowed with 
meals. 

Especial warning should be given against holding the 
water over the ordinary time, particularly if any call to 
pass it is felt. An attack of complete retention or of 
cystitis may result from disregard of this rule. 

Venereal excesses are, of course, to be avoided. 

The effect of sedentary habits and of horizontal decu- 
bitus in increasing the passive congestion, must be borne 
in mind, and moderate gentle exercise is to be advised. 
The patient will do well, when engaged in any occupation 
that keeps him long in one position, to take an occasional 
turn through the room; and at night or in the morning, 
when up for the purpose of emptying his bladder, a short 
walk about his chamber will often materially assist him 
in making his urination thorough and satisfactory. 

Constipation should be carefully guarded against. In 
prescribing for this condition, the violently acting drugs, 
which produce more or less congestion of the pelvic or- 
gans, should not be used. 

The greatest assistance will often be obtained from 
rectal injections. These are especially useful when the 
mechanical obstruction of the prostate, pressing upon the 
rectum, is largely responsible for the failure of the bow- 
els to act. 

Cold injections are usually to be avoided, though they 
may sometimes render good service in helping to restore 
the functions of an atonic bladder. Hot injections (112° 
to 115° F.) will sometimes assist in reducing congestion. 

The functions of the skin should be stimulated as far 
as possible. Rubbing and massage are to be employed 
to this end, and baths also serve a useful purpose if care 
is taken against a subsequent chill. A hot bath ending 
with a sponge off in cold water, and vigorous friction 
with a rough towel, may be of real benefit, by bringing 
the blood to the skin and so relieving internal congestion. 

In selecting a climate for a prostatic patient, prefer- 
ence should be given to dry inland localities, where sud- 
den changes of temperature are less likely to occur than 
on the sea-coast. Sometimes, however, when the general 
condition is depressed and a stimulating climate is desir- 
able, the sea-side may be tried, special precautions being 
taken against surface chills. 

General medication directed against the disease itself 
has but little to offer. 

The iodides may have a trial, in virtue of their reputa- 
tion in the treatment of sclerotic conditions of the blood- 


48 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


vessels and other organs. If used they should be per- 
sisted in for a long time, with occasional intermissions, 
They have the disadvantage of sometimes disagreeing 
with the stomach, and it may be necessary to discontinue 
them on this account. 

Of the medication required in the various morbid con- 
ditions which may from time to time need correction, we 
shall speak in considering the treatment of the various 
periods. 

Treatment in the First Period isalmost wholly hygienic 
and medical. 

In the absence of complications, and before there is 
any retention, the less instrumentation the better, as it 
only aggravates the congestion, and introduces the danger 
of infection from dirty instruments. 

If the urine is irritating from too great acidity, an al- 
kaline diuretic, such as citrate or acetate of potash, is in- 
dicated. 

In case of pain, belladonna or hyoscyamus should be ad- 
ministered either by the mouth or by the rectum. Opi- 
ates should be avoided, if possible, as they derange the 
stomach and constipate the bowels. When urgently re- 
quired, however, they may occasionally be resorted to. 

Ergot, strychnia, or nux vomica in some form, and 
quinine, are sometimes useful, and act apparently by di- 
minishing the congestion, and perhaps also by stimulat- 
ing the contractions of the bladder. If the circulation 
is not good, cardiac stimulants may be of assistance. 

Second Period. When the stage of partial retention 
has set in and the patient passes water, but is not able 
to completely empty the bladder, it is necessary to 
resort to the use of the catheter. So important is 
this, that every patient who is seen in the first // 
stage and put upon general treatment, should be /@ 
warned that the time will B ] 
almost certainly come when 
catheterization will be re- 
quired, and that as there is 
no sure means by which he 
can tell when he reaches 
this state, he should occa- 
sionally present himself for [//f 
examination to de- 
cide this point. 

Sometimes the 
partial retention is @ye 
due to some acci- 
dental increase of 
congestion, which 
may disappear under the use of antiphlogistics. In such 
a case the patient may be put to bed with leeches to the 
perineum, followed by hot applications assisted by opi- 
ates, if necessary. 

If these measures fail, it will be necessary to draw the 
water, and it will sometimes be found that, after a short 
systematic use of the catheter, the bladder will recover 
itself and again become able to fully expel its contents. 
Thus the disease may occasionally be moved back from 
the second period into the first. 

When complete retention comes on suddenly the cath- 
eter is indispensable, but in this case again its use may 
perhaps later be given up. 

When entering upon the use of the catheter, we may 
often learn whether it is really needed by noticing the 
effect upon the symptoms. If these are relieved or ame- 
liorated, we are evidently on the right track. 

It is to be remembered, however, that not infrequently, 
on commencing catheterization, a cystitis develops itself, 
owing either to the too sudden evacuation of a distended 
bladder, to the introduction of dirt upon the catheter, or 
simply to the irritation from the constant use of instru- 
ments. It is important that the aggravation of symp- 
toms caused by this inflammatory onset shall not lead 
the patient or doctor to infer that the catheter is doing 
harm and should be given up, for it is by continuing its 
use that the attack of cystitis may be most quickly and 
surely relieved, 

Let us now consider how and with what instruments 
the catheterization is to be carried out, 


Fra. 3121.—Soft-rubber Catheter. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


As has been described, the walls of the urethra are 
pressed together and may be somewhat deviated by the 
inequalities of the lateral lobes. The posterior part of 
the urethral floor is also often raised by the projection 
of the third lobe. 

Our object is to reach the bladder through this sinu- 
ous passage with 
the least possible 
amount of irritation. 

If a soft, red rub- : 
ber catheter will find @a—=—=e——— 
its way into the blad- , 
der itis, by alleddat Fig. 3122, pores ma (Sonde Coudée 
the best instrument 
to use. It requires no skill for its direction, and can do 
no damage to the urethral walls—a point of great impor- 
tance, as it enables us to entrust its use to an unskilful 
patient. 

When, owing to the narrowness or tortuousness of the 
urethra, the rubber catheter will not pass, we must re- 
sort to a stiffer instrument, and must adapt its form in 
reference to the difficulties which it has to overcome. 

The obstructions which it will meet project from the 
lateral walls and floor of the canal, and our effort must 


CODMAN &SHURTLEFF. 
Fie. 3123.—Double Elbowed Catheter (Sonde Bicoudée). 


be to carry the point of the instrument along the upper 
or anterior wall. 

Mercier devised for this purpose a flexible webbing 
catheter with the point sharply turned up (sonde coudée), 
so that it might ride over the obstructions on the floor. 

For those cases in which the hypertrophy of the third 
lobe was very pronounced, he used a catheter with a 
second bend, designed to lift its point still higher. 

In introducing these instruments, care should be taken 
that the point be kept turned toward the roof of the 
canal, and after it has passed the triangular 
ligament the penis should be depressed as much 
as possible between the thighs, so that the ca- 
theter may be pushed straight upward in the 
axis of the body. 

The English gum-elastic catheter may often 
be used with advantage, either with or without 
its wire stylet. If introduced without a stylet 
it is a good plan to exaggerate the curve of the 
instrument, as has been suggested by Thomp- 
son. When used thus it should be introduced 
cold and carried as rapidly as possible through 
the anterior urethra, for as it warms it becomes 
flexible and loses its 
form. By passing it 
rapidly but carefully, 
its curve often carries 
it over the obstruct- 
ing third lobe. 

If it meets an ob- 
struction and, warm- 
ing in the urethra, 
becomes flexible, the 
forefinger in the rec- 
tum should be used 
to lift the point of 
the catheter into the 
prostate, while at the 
same time the handle 
should be brought 
down to the axis of the body, and the instrument, which 
is then practically straight, should be pushed steadily into 
the bladder. This should be done without the exercise 
of much force, as the point, when properly guided, slips 
along quite easily and when it catches there is danger of 
its making a false passage if pushed. 

If the gum-elastic catheter is introduced with a stylet 


Vou. VI.—4 


wATTLUOHS = Nenao 
2 


Fi@, 3124.—English Gum-elastic Catheter 
with Exaggerated Curve on Stylet. (After 
Thompson. ) 


‘Prostate. 
Prostate, 


it should be curved into the form of a prostatic silver 
catheter. Sometimes, when the point catches it may be 
lifted over the obstruction by the simple manceuvre of 
slowly withdrawing the wire while slightly advancing 
the instrument. This curls the point upward and often 
enables it to ride over the obstacle. 

Occasionally, when other flexible instruments fail, the 
French conical bougie catheter will succeed in worming 
its way through the canal. It should be used with great 
caution, as its comparatively sharp point may catch in and 
perforate the mucous membrane. 

Failing with other instruments, we may have recourse 
to a metallic catheter of large curve. 

The beak of this instrument should be long enough to 
reach easily through the enlarged prostate, which may be 
one inch and a half longer than in the normal state. If 
the curve is too short the point does not reach the blad- 
der, but being engaged in the prostate, runs considerable 
risk of making a false 
passage when the handle 
of the instrument is de- 
pressed. 

The forefinger in the 
rectum may give great 
assistance in guiding the 
passage of this catheter. 

In using any instrument 
in a urethra with false pas- 
sages itis a good plan toalways 
withdraw for a considerable 
distance when the point is 
caught, and then to try and pass 
the pocket by carrying the beak 
down first one wall and then an- 
other until the right passage is 
found. Ordinarily the false pas- 
sages exist in the floor of the ure- 
thra; but this rule has many excep- 
tions. 

If, in a case-of complete retention, 
after careful and thorough attempts we 
do not succeed in reaching the bladder, 
recourse must be had to puncture with tro- 
car or aspirating needle. 

This was formerly done through the rec- 
tum with curved trocar, but as this method 
cannot be used antiseptically the supra-pu- 
bic puncture is to be preferred. This may 
be done with a fine needle introduced 
close above the pubes, and, if necessary, 
may be repeated two or three times 
daily for a considerable time. 
Usually, however, drawing off 
the urine in this way is 
followed by such a sub- 
sidence of the swelling 
as to presently allow the 
introduction of the ca- 
theter. Leeching the 
perineum and the ad- 
ministration of ergot may also be of service in reducing 
the congestion. 

The evacuation of a distended bladder, whether by 
catheter or by aspiration, should be performed slowly 
and carefully. When the distention is extreme, the 
bladder should not be wholly emptied at one time, for if 
the internal pressure is too suddenly relieved we are 
likely to have a great congestion of the vesical mucous 
membrane, with the escape of blood into the urine, fol- 
lowed often by considerable inflammation. 

The greatest care should likewise be taken in the mat- 
ter of thorough antiseptic cleanliness, as the introduction 
of germs into the bladder may start a fermentation of the 
urine with cystitis, It is of course important, whenever 
a catheter is entrusted to a patient, that careful instruc- 
tions should be given to him in regard to this. 

Catheterization having been commenced, how often 
should it be repeated ? | 

In the cases of partial retention with moderate residu- 


49 


Fie. 8125,—Silver Catheters of Curve 
Appropriate for Use through an En- 
larged Prostate, 


Prostate. 
Prostate. 


um, the use of the catheter each night before retiring is 
usually sufficient. As the disease progresses, however, 
a point is presently reached when the bladder habitually 
holds from six to eight ounces of residual urine, and the 
calls to urinate are consequently pretty frequent. Under 
these circumstances the regular use of the catheter is re- 
quired. 

If now the patient can get along comfortably while 
using the catheter four times a day, he is fortunate, and 
may live for twenty or more years with this artificial uri- 
nation. Not infrequently catheterization will be required 
six, seven, or even more times in the twenty-four hours. 
Especially is this the case when cystitis is present. The 
water should always be drawn when the desire to mic- 
turate is urgent and persistent. 

When catheterization is required so often as to become 
a decided source of irritation, and if the bladder is so 
irritable as to be constantly liable to painful contractions, 
it will be found best to tie in the catheter for a time (sonde 
a demeure). Usually in a few days, after the bladder has 
had a rest, the catheter can be again left out and the pa- 
tient can resume regular catheterization. 

Treatment of the Third Period. In this stage of the 
disease, systematic emptying of the bladder is as urgently 
called for as at any earlier time. The serious changes, 
however, which are likely to have occurred in the ureters 
and kidneys, with the condition of passive congestion 
which exists throughout the urinary tract, make the use 
of the catheter a matter of considerable danger, which, 
in some cases, may be so great that it will be better prac- 
tice to leave the bladder undisturbed. 

In these cases the. patient’s condition of comparative 
health—troubled, it is true, by frequent and often partly 
involuntary micturition, but not debarred from ordinary 
occupations—makes a striking contrast with the state of 
things which may rapidly develop upon entering on the 
‘‘catheter life.” For a slight added irritation to the 
bladder may be suddenly followed by a pyelo-nephritis, 
or even more abruptly by renal congestion with suppres- 
sion, uremia, and death. 

These dangers are alarming and imminent enough to 
make us hesitate, but what is to be hoped from allowing 
the disease to take its course ? Nothing but a certainly 
fatal issue, which is likely to come in a few weeks or 
months, and which may be precipitated at any time by 
an exposure to cold, by fatigue, or by a slight indiscretion 
in diet. 

On the other hand, when catheterization is successfully 
established, the disease may be moved back from the 
third to the second stage, and the patient who was in 
such danger may be put in a state of comparative se- 
curity. 

It is, then, of the first importance to distinguish the 
cases in which catheterization is so dangerous that. the 
patient had better be left to follow out the natural course 
of the disease; and in all except these most advanced 
cases the catheter should be used. 

Each case must be decided on its merits, and so much 
depends on attention to detail, that we should sometimes 
be deterred from commencing catheterization with a 
careless and slovenly patient, when we should have re- 
sorted to it could we have counted on his intelligent co- 
operation. 

Guyon has laid down arule of practice for these ad- 
vanced prostatic cases, which is a good one. 

He puts the patient upon general tonic treatment, and 
if he finds that he is wanting in strength sufficient to 
benefit by it, he does not regard him as in a state likely 
to be helped by interference with his bladder. If, how- 
ever, he improves decidedly in his general condition, 
then Guyon regards it as wise to resort to the catheter. 

The precautions to be observed in accustoming the 
patient to the catheter are the same that are required in 
the second stage of the disease, but they are now even 
much more important. 

Especially should the sudden emptying of a distended 
bladder be guarded against. It may often require two 
or three weeks of catheterization before the bladder ac- 
quires such tolerance that it may safely be left empty. 


50 


REFERENCE HANDBOOK -OF THE MEDICAL SCIENCES. 


During the preliminary period the catheter should al- 
ways be passed with the patient horizontal, to guard 
against the too rapid flow of water ; afterward, when the 
complete emptying of the bladder is desired, the vertical 
position is the best for this operation. 

Treatment of Complications. Cystitis, which is the 
most common complication of prostatic hypertrophy, is 
to be treated according to the rules laid down under 
Diseases of the Bladder, on pages 514 and 515, in vol. - 
i. of this HANDBOOK. 

When it occurs in the first stage of the disease, gen- 
eral treatment is to be first thoroughly tried, and local 
treatment through a catheter is to be resorted to onl 
when simpler measures fail. In the second and third 
stages, when partial retention exists, the 
systematic evacuation and irrigation of 
the bladder is the most efficient means of 
treatment at our command. . 

Nephritis, or pyelo-nephritis, must be 
treated on general principles. Mustard 
poultices over the lower dorsal and lum- 
bar regions during the acute stage, with, 
afterward, careful rubbing and friction to 
keep up the action of the skin; a bland, 
non-stimulating, but nutritious diet in 
abundant quantity, and regulation of the 
bowels. If uremia threatens, pilocarpin 
and hot-air baths may be used to promote 
elimination, and to relieve the congestion 
of the kidneys. 

A stone in the bladder can usually be 
removed readily by litholapaxy through 
an enlarged prostate, unless it is of great 
size and hardness, or unless the careless 
use of instruments has produced false 
passages. The pocket behind the pros- 
tate often holds a small stone concealed, 
and makes it hard to seize, in which case 
the hips may be raised so that the stone 
rolls back toward the fundus, where it is 
easily found and crushed. 

When micturition is very difficult, it 
may sometimes be thought wise to remove 
small stones by perineal incision, in the 
hope of, at the same time, relieving the 
obstruction. 

When litholapaxy is impossible on ac- 
count of the size and hardness of the 
stone, it is usually necessary to resort to 
the supra-pubic incision. By this opera- 
tion, too, a prominent middle lobe, or 
other cause of obstruction, may some- 
times be removed. 

RADICAL OPERATIVE TREATMENT, — 
Finally, we have to speak of the various 
operations which have been devised for 
the relief of obstruction in the prostate. 
These may be divided into the internal and 
external operations. 

The internal operations are mainly use- 

et Sear ful in the treatment of those cases in 

and Set-screw, Which the obstruction assumes the form 

Vv, V. ’ of a bar, and are not so applicable to cases 

of greatly hypertrophied and projecting 
third lobe. They may consist in simple incision, or in 
excision, of a portion of the obstructing part. 

Mercier, who was a strong advocate of these opera- 
tions, devised two instruments for their performance. 

One, for making a simple incision, is shaped like a 
short-beaked sound, and carries a concealed knife which 
can be made to cut upon either the concave or convex 
side of the beak. The bar can, therefore, be divided by 
hooking the beak of the instrument over it, and then, by 
withdrawing the blade, making an incision, the length 
of which can be exactly regulated by a set-screw in the 
handle. 

An incision can also be made from before backward 
by placing the heel of the beak in front of the obstruc- 
tion with the point upward, then making the blade pro- 


Fic. 3126.—Mer- 
cier’s Prosta- 
tome, with Cut- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


trude on the convex side and advancing the instrument 
into the bladder. 

When the bar is of considerable width or forms much of 
a projection, Mercier uses another instrument somewhat 

. like a lithotrite. The obstruction is engaged be- 

tween the blades of this, and as the instrument is 

. closed it punches out the part included. If enough 
is not removed the first time the operation is re- 
peated. 

Mercier says that the only difficulty ever experi- 
enced is from hemorrhage, which is usually mode- 
rate and to be overcome by appropriate means. 

He claims that the relief following the operation 
is very great. Other operators have reported dan- 
gerous hemorrhages. 

Gouley has also an instrument not un- 
like Mercier’s, and he claims priority in 
the operation. 

The necessity for an exact diagnosis of 
the nature of the obstruction, and the un- 
certainty in the thorough performance of 
the operation, limit very much its 
usefulness. 

The perineal operation consists 
in a median incision down into the 
Fig, 3127-Blades of Mer- membranous urethra. Through 

Punching outa Piece of this opening the finger is passed 

the Obstruction. along the prostatic urethra, and 

under its guidance a probe-pointed 
‘knife is introduced and a section made through the ob- 
struction. A good-sized tube is then fastened into the 
bladder through this opening. This tube by its pressure 
checks hemorrhage, provides dependent drainage, and, 
by holding the wounded surfaces apart, moulds the ure- 
thra during healing. 

The prostatic urethra admits of such dilatation that, if 
a polypoid projection is found it can be removed with a 
small tonsillitome or wire noose. 

This operation, which owes its present prominence to 
Mr. Harrison, is a very useful one, and has the great ad- 
vantage of giving thorough drainage and a long rest to 
the bladder. The relief to the obstruction is often, if 
not usually, very satisfactory. 

The tube should be kept in place for a number of 
weeks or even months, and before it is finally left out, 
the patency of the canal should be tested. Usually the 
first indication that it may safely be removed is the ap- 
pearance of urine along the urethra. . 

As has been stated above, the prostate may be reached 
and operated on by the supra-pubic incision. This 
method, however, introduces special dangers and has 
no advantage over the perineal operation, except in cases 
complicated by obscure bladder lesions. 

ATROPHY of the prostate may occur as the result of 
- mechanical pressure, or of destruction of portions of the 
organ by inflammation. It may also appear in the course 
of an exhausting disease, or as a consequence of old age. 
It gives rise to no symptoms and calls for no treatment. 

TUMORS OF THE PROSTATE.—These may be classified 
as follows : 


§ Retention Cysts, 


Cystaaeeae | Hydatids. 

Myoma.... 

A dewoma Adeno-myoma. 
Round cell. 

Sarcoma, ..~< Spindle cell. 
Lympho-., 


ae Scirrhus, 
Carcinoma { Colloid. 


Retention cysts formed from dilated gland acini occur 
in many old prostates. They are always small, and give 
rise to no inconvenience. Their contents are sometimes 
inspissated, forming little concretions. 

Hydatid cysts of the prostate are so rare that Thomp- 

son could, in 1888, learn of but one; and even in that 

case it is doubtful whether the cyst started in the pros- 
tate or near it. When discovered they should be at once 
emptied. . 

Pure myoma is very rare; adenoma is somewhat less 


Prostate. 
Prostate, 


so, but adeno-myoma is the most common of prostatic 
growths. Paul thinks ordinary hypertrophy should be 
ranked under this head. 

The universal, symmetrical enlargement can hardly, 
as it seems, be classified as a tumor, and yet the patho- 
logical process is the same in it and in the circumscribed 
masses which we recognize as new-growths. These may 
project into the urethra, the bladder, and in other direc- 
tions, or they may be buried in the midst of the gland- 
tissue, from which they can be easily shelled out. 

These tumors have sometimes been removed during 
section of the gland in lithotomy or other operations, and 
the removal of projections into the urethra has been con- 
sidered above. 

Sarcoma is occasionally observed in the prostate, where 
it may start primarily, or to which it may transplant it- 
self from the testicle or elsewhere. It usually appears 
early, but may develop late in life. 

Carcinoma is still less common than sarcoma, and ap- 
pears ordinarily after middle life. It may assume a 
scirrhus or a colloid type. 

In either of these last two malignant forms of growth 
there may be a good deal of pain and considerable hem- 
orrhages, especially after instrumentation. 

In carcinoma the neighboring lymphatic glands are 
likely to be early involved. ; 

Any cyst or tumor of the prostate may give rise to 
symptoms of obstruction. The difficulty of micturition 
may reach a point to require some operation for its re- 
lief. In opening the bladder for drainage under these 
circumstances, either the perineal or the supra-pubic in- 
cision may be used, and the selection would depend 
somewhat upon the size of the tumor. 

If this is large and of a malignant character which 
makes its removal evidently impossible, supra- pubic 
drainage would be preferable. 

On the other hand, in the case of a smaller or non- 
malignant tumor the perineal incision should be used, as 
by it the exact condition of things can be ascertained and 
possibly benefited. Harrison reports a case in which he 
removed a cancerous growth as large as the last phalanx 
of the thumb from the prostatic urethra. The operation 
was followed by great relief from distress in micturition, 
and the patient lived for fourteen months. 

TUBERCULOSIS OF THE PROSTATE occurs often second- 
arily to tubercular conditions in other parts of the genito- 
urinary tract. It probably also appears sometimes pri- 
marily in the prostate. 

As patients with genito-urinary tuberculosis usually 
die when the disease is far advanced, it is rarely possible 
to decide at autopsy where the disease originated, and as 
the organs are many of them deep-seated and beyond the 
reach of physical examination, it is likewise impossible 
during life to be sure that the prostate was primarily af- 
fected. 

On the other hand, this gland is situated at the junc- 
tion of the genital and urinary passages, is as it were at 
the cross-roads through which any tuberculous material 
from the kidneys or testicles must go in its passage from 
the body. This situation makes it peculiarly liable to 
secondary infection, and, as a fact, it is almost always 


‘sooner or later involved. , 


The tubercles may appear as little isolated gray gran- 
ules, scattered throughout the tissue of the organ, or 
they may be agglomerated into masses which, if they 
reach a moderate size, ordinarily become cheesy in the 
centre and finally break down into abscesses. 

Sometimes almost the whole prostate is thus destroyed, 
and its place is occupied by an abscess which usually 
communicates with the urethra and bladder. It may 
break through into the rectum, forming a recto-vesical 
or urethral fistula directly through the prostate. 

The Symptoms are those of a chronic prostatitis (see 
above) with a special tendency to hemorrhage. They 
may be associated with evidences of tuberculosis else- 
where. 

Physical Examination by the rectum may reveal little 
or no alteration in the gland. Ordinarily, however, 
inequalities are felt which may give it a distinctly 


51 


Prostate. 
Prurigo. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


nodular character. This may be associated with enlarge- 
ment, or the prostate may preserve almost its normal 
size. 

The ejaculatory ducts and the vesicule seminales 
should be felt for, and if the disease has affected them, 
they may be found as thickened, resistant, cord-like 
bodies. This is especially to be observed when the dis- 
ease started in the testicle and worked its way up to the 
prostate. 

Not infrequently a little shot-like mass is felt between 
the rectum and the prostate, or it may be a little behind 
and to one side of the gland. It is not attached to the 
prostate, rectal wall, or seminal vesicles, but is loose in 
the tissues between them. 

Dr. Bryson, of St. Louis, thought that in one case, in 
which he had an autopsy, he made it out to be a cheesy 
mass within avein. Possibly it is sometimes an infected 
lymphatic'gland. 

The testicles, epididymes, and vasa deferentia should 
also be examined, and the urine should be investigated 
for evidences of kidney complication and for tubercle- 
bacilli. 

These last are very difficult of detection in the urine, 
and their apparent absence does not argue against tuber- 
culosis. When unmistakably present they are conclu- 
sive confirmatory evidence. 

The physical investigation should also include the 
examination of the lungs, which may share in the tuber- 
culous process. 

Diagnosis.—The disease may be confounded with 
chronic prostatitis or cystitis, with stone or tumor in the 
bladder, or with pyelitis when accompanied by frequent 
micturition. 

While a careful consideration of the symptoms and 
inherited tendencies of the patient may enable us to form 
a probably correct idea of the condition, it is only by a 
careful physical examination that we can reach a posi- 
tive diagnosis. 

Besides the examination described above, an exploration 
of the bladder, under ether if, necessary, will be needed 
for the detection or elimination of stone and of tumor of 
the bladder. 

There will be a certain number of cases in which a 
diagnosis is at first impossible, and in which the true 
interpretation of the condition can be reached only when 
time has developed characteristic symptoms. 

Treatment.—Most important is the constitutional treat- 
ment with cod-liver oil, hypophosphites, and iodides. A 
healthy out-of-door life, with moderate exercise and good 
food, are to be enjoined. 

Thompson advises against local treatment, and it is 
certainly important to avoid rough manipulation. 

In the early stages of the disease, however, gentle local 
measures may serve rather to allay than to excite irrita- 
tion, and should be tried. 

Irrigation of the prostate and bladder, and the intro- 
duction of iodoform pencils, may be of service. Occa- 
sionally the passage of a sound is useful by removing the 
contraction of the constrictor muscle. The pain and fre- 
quency of micturition may sometimes be much relieved 
by these means. 

While the prognosis is necessarily grave, and the per- 
manence of improvement is always doubtful, still these 
cases are not always hopeless if seen early. 

Prostatic Caucuui.—In the ducts and dilated tubules 
of the prostatic glands are found not infrequently little 
yellowish or brownish bodies, composed of an organic 
substance allied to protein. 

These, if they increase beyond a moderate size, begin 
to have earthy salts deposited in and around them, and 
finally become prostatic calculi, which may reach the 
size of a walnut, or even larger. 

These calculi are usually multiple, and are facetted 
from mutual attrition. They are hard, take a high polish 
like porcelain, and are white or light-brown in color. 

Chemically, they are composed almost wholly of phos- 
phate, with a slight admixture of carbonate, of lime, and 
are to be distinguished from urinary calculi by the fact 
that they do not contain any of the triple phosphate of 


52 


magnesia and lime, which is so large a constituent of 
vesical calculi. 

When prostatic calculi are made out they may be re- 
moved by a median or lateral perineal incision. The op- 
eration is usually one of no serious danger, as the blad- 
der is not opened. Arthur T. Cabot. 


PROTOPLASM. Wherever in nature that group of 
phenomena which we call vital is manifested, we find it 
invariably associated, whether in higher or lower beings, 
in animals or plants, with a particular form of matter 
which is called protoplasm. Protoplasm is living matter. 

The exact chemical constitution of protoplasm is un- 
known; but its proximate analysis, after being deprived 
of its vitality, shows that in this dead condition it con- 
tains proteids, carbohydrates, fats, certain inorganic salts, 
and water. 

Physically, as seen with high powers of the micro- 
scope, protoplasm appears to be nearly homogeneous, or 
to consist of a structureless, semifluid material in which 
are suspended granules and minute fibrils. 

In the higher, and in most of the lower animals and 
plants, protoplasm exists in the form of tiny lumps of 
various shapes and sizes, which are called cells. For a 
detailed description of these cells, and the life-characters 
which they display, consult the article on Cells. 

While the phenomena of life are never manifested ex- 
cept in connection with this particular form of matter 
called protoplasm, whether in animals or plants, we 
should not be led by the apparent simplicity and com- 
prehensiveness of the statement into a belief that we 
know very much about its real nature. ‘‘ Life is a prop- 
erty of a certain kind of compound matier.” To this 
matter we give the general name protoplasm. But it 
should not be inferred from this that protoplasm is every- 
where identical in its constitution. On the contrary, it 
would seem that it must be actually as varied as are the 
manifestations of life which we observe in the different 
forms of cells, although this variation is not evident by 
any chemical or physical means of analysis at present 
known. : 

The term protoplasm is sometimes used in a purely 
anatomical: sense, to signify that part of the cell which 
immediately surrounds the nucleus, and which is more 
properly called the cell-body. 

Parts of certain cells, as the membranes of some forms, 
or the entire body, as in epidermic scales and some of the 
cells of the hair-shaft, may become converted into a dense 
material, which, though contributing to cell-structure, 
does not exhibit the phenomena of life and is often called, 
though the expression is not a proper one, dead proto- 
plasm. T. Mitchell Prudden. 


PRUNE (Prunus, U.S. Ph. ; Prunum, Br. Ph. ; Pru- 
nier commun, Codex Med.). The fruit of the garden 
Plum, Prunus domestica Linn., order Rosacew, dried in 
the sun or by artificial heat. This well-known fruit-tree 
is said in Bentley and Trimens’ ‘‘ Medicinal Plants,” to be 
probably descended from P. ¢nstitva Linn., a thorny shrub 
with pubescent twigs and spherical fruits (purple-black, 
yellow, or green), growing wild in the mountains of West- 
ern Asia, Greece, etc., and also cultivated. The com- 
mon Plum-tree has no thorns, but smooth branches and 
an oval fruit, of blue-black or yellow color, covered with 
a thin layer of waxy ‘‘bloom.”” The varieties are numer- 
ous; of these the source of French Prunes is var. Juliana 
D. C., that of German Prunes var. Giconomica Bork ; but 
other varieties are also dried, and it is to be doubted 
whether the source of any particular, sample can be al- 
ways determined. Plums have been cultivated for more 
than twenty centuries. Prunes need no description, they 
are kept in large quantities by the grocers, in every qual- 
ity, from the poorest, in bulk—small, excessively shriv- 
elled, hard, and nearly tasteless—to the best, imported 
in glass jars or fancy boxes. 

They contain sugars and fruit acids (malic, etc.), ‘‘ pec- 
tic and albuminoid substances,” etc., and are chiefly con- 
sumed as dessert, or in sweet sauces, puddings, or pies. 
In large quantities they are a slightly laxative food ; they 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, 


can scarcely be called medicine, and would be dropped 
from the officinal list, only that they are employed in the 
Confection of Senna (Confectio Senne, U.S. Ph.), of which 
they compose seven per cent. The syrup of ‘‘ stewed 
prunes,” made thick and sweet, is an excellent laxative 
for infants; they take it readily, and it produces very 
little unpleasant disturbance. Dose, a teaspoonful. 

ALLIED PLANTS.—See ALMONDS, 

ALLIED Drues.—Fies, Raisins, TAMARINDS, CASSIA 


FISTULA, etc. 
W. P. Bolles. 


PRURIGO. Syn.: Prurigo (Hebra) ; Juchblattern, Ger. 
Before Hebra described a distinct disease under the name 
of prurigo, the term included a number of affections 
which were dissimilar in various respects. Almost any- 
thing which had ztching as one of the symptoms was 
liable to be put down as a form of prurigo. Pruritus 
was prurigo, and prurigo was pruritus—a confusion of 


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Prostate. 
Prurigo. 


than to the sight. The hand when run over the skin 
feels the minute nodules before the eye can detect them, 
projecting above the level of the surrounding epidermis, 
As time goes on, this roughness of the skin to the touch 
is even more pronounced, so that the hand feels as if it 
were being rubbed upon coarse sand-paper. 

After the papules appear, itching commences, and the 
child is seen to scratch. A drop of clear-colored serum 
forms a vesicle at the top of the papule, the epidermis 
becomes thin, is then scatched off, and the serum escapes, 
while further scratching may rupture the capillaries al- 
ready dilated, forming a crust of blood and serum. After 
years of recurring eruption and scratching, the skin be- 
comes thickened, hardened, brittle, parchment-like, and 
pigmented. The patients are unable to resist the im- 
pulse, and spend the greater part of their lives in scratch- 
ing. Even in sleep there is no cessation. Unconsciously, 
all night long they are at work, so that the regular grat- 
ing sound, coming from the beds of long-suffering pru- 


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Fre, 3128.—Prurigo Papule. 


terms which still to a large extent exists among the older 
general practitioners. They should not be confounded, 
for the dermatologist recognizes prurigo as a disease sw? 
generis, while pruritus is only a symptom. 

Prurigo is a rare disease in North America. The re- 
ports of the American Dermatological Association for 
the last three years give 19 out of a total of 38,320 cases 
of skin diseases reported by the different members. For- 
eign dermatologists are incorrect in suggesting that the 
disease is overlooked in this country. The fact is, it 
hardly exists here ; and if cases are seen, they are most 
often in those who have come into the country from 
abroad, bringing it along with them. 

As described by Hebra, the disease is divided into pru- 
rigo simplex seu vulgaris and prurigo agria seu ferox, 
according to its severity and duration. It always begins 
in early life, and is generally foreshadowed by the appear- 
ance, upon the extremities of an infant, of constantly re- 
curring urticarial wheals. After the second year of life 
an eruption of small papules, the size of a mustard- or 
hemp-seed, makes its appearance, and we then have true 
prurigo. 

Primarily, the papules are more perceptible to the touch 


rigo patients at night, is one of the most weird and un- 
pleasant noises imaginable. It is as regular as their 
breathing. 

The disease most generally begins upon the extremi- 
ties, where it is also most intense. The papules appear 
first in this situation, and then, in order, upon both sides 
of the thorax, the abdomen, the back, and the buttocks. 
They do not appear on the scalp, and seldom in the axilla, 
the palms, the flexor surface of the knee-joint, or on the 
genitals. In cases of long standing the lymphatic glands 
are enlarged. ; 

Histological investigation of the papule, made by the 
present writer,! shows that it is formed by an infiltration 
beginning around the upper layer of vessels of the cori- 
um ; this infiltration, extending upward, surrounds the 
papillary vessels and enlarges the papille, thus pushing 
up the epidermis, which becomes thickened at an early 
stage above them (see Fig. 3128). Finally, this infiltra- 
tion, penetrating the epidermis, forms with its layers a 
small vesicle containing serum, blood, and lymph-cells. 
The signs of infiltration surrounding the hair-sheaths 
and sweat-ducts are secondary, and they play no especial 
part in the process. Their presence in the papule is ac- 


53 


Prurigo. 
Psoriasis, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


cidental, and it is certain that the primary changes in the 
skin are not in connection with them. 

The color of the papule at first does not differ from 
that of the surrounding skin, on account of the depth of 
the slight infiltration with which it begins. At this stage 
there is no itching, but later on, when the infiltration has 
become greater, this symptom begins. 

Hebra says prurigo is incurable ; the symptoms may 
be alleviated by proper remedies, but there is no per- 
manent cure. The therapeutical indications are to re- 
move the dry, brittle epidermis, to soften the skin, and 
to allay the itching. Warm baths, continued for hours 
at a time; stimulating soaps, such as spiritus saponis al- 
kalinus ; ointments of vaseline, lanolin, or simple cerate, 
containing zinc, salicylic acid, or sulphur; medicated 
gelatines, and attention to the general health, are some of 
the means employed to relieve the sufferer. It is a dis- 
ease of the poorest, most ill-fed classes—such classes as 
know no hygienic laws, and have for successive genera- 
tions beenin the same unhealthy condition. Fortunately, 


we have as yet no such classes in this country ; hence the 


rarity of the disease with us. 
Robert B. Morison. 


1 A Contribution to the General Knowledge Concerning the Prurigo- 
Papule, American Journal of Medical Sciences, October, 1883. 


PRURITUS. A neurosis of the skin, characterized by 
local or general itching, without any perceptible primary 
lesion. 

Pruritus UNIVERSALIS usually affects larger portions 
of, or even the entire, surface, and may occur at any age or 
in either sex. Itis not infrequently accompanied by some 
disturbance of the abdominal organs, as granular liver, 
hepatitis, Bright’s disease, etc. In young women, dis- 
turbance of the menstrual functions and, in older women, 
pregnancy sometimes occupy a causal relation to general 
pruritus. In still older persons, and especially in the 
aged, general pruritus not infrequently occurs in its se- 
verest and most stubborn form, probably-in connection 
with the senile changes in the skin, forming a most dis- 
tressing malady. 

Pruritus LOcALIs occurs commonly in certain regions 
by preference. Thus we have pruritus ant, which usually 
occurs in connection with hemorrhoids or, in children, 
with seat-worms. The affection usually first shows itself 
at the muco-cutaneous junction, and spreads forward 
toward the perineum and backward toward the coccyx. 
Pruritus ani is usually worse in the evening on undress- 
ing, and when the patient becomes warm in bed. In the 
semi-unconsciousness of sleep the parts are rubbed and 
scraped until an artificial eczema results, and, in fact, 
more or less eczema is present in most severe cases of 
pruritus ani. 

Pruritus genitalium takes on a somewhat variable 
aspect, according to the sex. In men the scrotum is the 
usual seat of the disease. Pruritus scroti is a not infre- 
quent accompaniment of pruritus ani. In the earlier 
stages of the disease no lesions are perceptible, but after 
the affection has lasted for some time excoriations and 
blood-crusts appear as secondary lesions, the result of 
scratching. Here, too, artificial eczema sooner or later 
results, although the writer has observed numerous cases 
where, even after prolonged and severe pruritus, no per- 
ceptible lesions could be observed upon the scrotum. 
Pruritus scroti is always a stubborn affection, and some- 
times becomes chronic, resisting every attempt at relief, 
and at times driving the patient nearly frantic. 

Pruritus pudendt muliebris commonly occurs in the 
mucous membrane about the labia minora and majora, 
and in the neighboring muco-cutaneous’ surface. Occa- 
sionally it seems to be confined to the clitoris and its im- 
mediate surroundings. In children, ascarides are often 
the cause of the itching; in adult females, uterine dis- 
ease, leucorrhcea, vaginismus, etc., give rise to the trouble. 
Not infrequently, however, no known cause can be as- 
certained, and the affection appears to be purely idio- 
pathic. European writers often allude to this affection as 
the cause of onanism and nymphomania. The writer 


54 


has never observed this result excepting among the in- 
sane, and is not disposed to regard pruritus pudendi as 
a frequent cause of these neurotic manifestations in per- 
sons enjoying the full use of their mental faculties. 
This form of pruritus is connected at times with diabe- 
tes mellitus. 

Pruritus palmaris and plantaris are forms of local 
pruritus which may be mentioned. ‘They are rarely se- 
vere or long continued, and are usually more amenable 
to treatment than the other forms. 

A form of local pruritus due apparently to changes of 
temperature is that first described by Duhring as pru- 
ritus hiemalis, or winter pruritus. This form is com- 
monly observed upon the lower extremities, particularly 
the insides of the thighs and the calves, although some- 
times it may occur upon the upper extremities, and 
may assume an almost universal form. The peculiarity 
of pruritus hiemalis is that it leaves its victim free 
during the summer months, only to return promptly 
with the frosts of autumn, year after year. During the 
winter months a spell of clear, bright, frosty weather 
will bring on a tormenting attack, which will pass away 
when the weather becomes warm and moist. The itch- © 
ing comes on when the patient takes off his clothing at 
night, and seems to be excited by the impact of cold air. 
In the majority of cases it passes off as the patient grows 
warm in bed. Severe cases may, however, continue 
through the entire day, and even torment the patient at 
night. 

The diagnosis of pruritus should give rise to no diffi- 
culty, because, although there are other diseases in which 
itching is a prominent symptom, these are always charac- 
terized by primary lesions of some sort. The history of 
itching as the first symptom, with visible lesions occur- 
ring only secondarily, if at all, is conclusive. 

Old cases of pruritus are almost always accompanied 
by a certain amount of eczema, with scratch-marks, pap- 
ules, fissures, crusts, pigment-deposit, etc., and it may 
at times require careful investigation to ascertain the 
character of the original disease. Of course, the possible 
presence of parasites must always be considered and ex- 
cluded (see Pediculosis). 

The treatment of pruritus is always difficult, and will 
at times require every therapeutic recourse and the most 
careful examination and study of the patient’s whole 
economy. 

There are few skin diseases in which it is more neces- 
sary to examine every possible weak point, and yet cases 
not infrequently occur in which the practitioner must 
proceed on a basis of pure empiricism, and simply em- 
ploy one remedy after another until something or some 
combination is secured which will attain the desired 
end. 

As regards drugs, the usual tonic and alterative medi- 
cines are to be employed. Irregular menstruation must 
be treated by the judicious use of iron or other remedies, 
cod-liver oil, etc. Quinine and strychnine are sometimes 
of use. Recourse may be had to bromide of potassium 
and chloral, alone or together, in order to subdue general 
nervous symptoms. Morphia should in no case be used, 
as it tends to aggravate the itching. 

External treatment affords great relief, and is to be 
used in all cases. Hot and cold douches, used alternately, 
or hot water applied as hot as it can be borne, or plain 
vapor-baths, are often useful. Medicated baths, contain- 
ing from three to six ounces of bicarbonate_of sodium, or 
from two to four ounces of carbonate of potassium or 
borax, to thirty gallons of water, ‘will at times afford 
relief. Sulphuret of potassium and sulphur vapor-baths 
are sometimes used with success. Inunctions with a 
bland oil, as almond-oil, may be practised after these 
baths. 

Lotions of various kinds are the most generally useful - 
applications in pruritus, and those containing carbolic 
acid are by far the most generally efficient. Chloroform ; 
chloroform and alcohol, a drachm to the pint; lead- 
water; dilute water of ammonia; dilute nitric acid, ten 
minims to the ounce of water ; vinegar—are all service- 
able remedies which may be tried singly or in succession 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


in troublesome cases. The following tar-preparation, 
known as liquor picis alkalinus, and introduced by 
Bulkley, is generally useful: . Picis liquide, 64 Gm. 
(Zij.); potasse caustice, 32 Gm. (%j.); aque, 160 Gm. 
(Zv.). M. This is very strong and must be diluted with 
from three to ten parts of water. In some localized 
forms of the disease, ointments are to be used in prefer- 
ence to lotions. One of carbolic acid, ten to fifteen 
grains to the ounce of oxide of zinc, is often useful. 

In pruritus of the female genital organs, water as hot 
as can be borne, sponged upon the parts, forms an admi- 
rable anzesthetic and should be used in all cases, whatever 
other treatment may be added. Following this, carbolic 
lotions, sulphurous acid—sulphite of sodium, in solution 
of a drachm to the ounce of water—and lotions contain- 
ing hydrocyanic acid may be employed. Sometimes an 
emollient poultice of freshly made almond-meal, which 
evolves a small quantity of hydrocyanic acid, will be 
found very soothing. Where the itching is localized, 
particularly about the clitoris, a ten-per-cent. solution of 
hydrochlorate of cocaine, painted on, will give an ex- 
quisite sense of relief for a time, and may even prove 
curative. 

Pruritus of the anus is best treated by oils or oint- 
ments. Carbolized oil, in the strength of twenty per cent., 
and ointments of belladonna or tar are usually beneficial. 
Applications. of hot water should precede the use of the 
medicinal agents. Sometimes a pledget of lint wet with 
a five-per-cent. solution of hydrochlorate of cocaine will 
relieve the pruritus like magic. 

Pruritus of the scrotum is often very intractable, the 
more so because the skin is thin and not infiltrated and its 
surface is intact. It is difficult to get any local remedies in 
direct contact with the diseased parts. The following 
formula is much used: &. Bismuthi subnitrat., 8 Gm. 
(3 ij.); acid. hydrocyanic. dil., 8 Gm. (f 3 ij.); mist. amyg- 
dale, 82 Gm. (f 3 iv.). 

In the pruritus of jaundices, mercurial ointment is said 
to be of value ; also, lotions and baths of vinegar, in the 
proportion of two quarts to an ordinary thirty-gallon 
bath, or of nitric acid, in the proportion of two to three 
ounces to the bath. 

The prognosis of pruritus should be guarded. The 
disease, as a rule, is obstinate; oftenextremely so. The 
prognosis often depends largely upon the cause and our 
ability to remove it. In grave cases melancholic symp- 
toms may be present. Occurring in the aged, the prospect 
of ultimate cure is poor. 

Pruritus hiemalis, though usually less severe, is perhaps 
even more intractable than the other forms of the dis- 
ease. Arthur Van Harlingen. 


PSORIASIS. A chronic affection of the skin, charac- 
terized by the appearance of reddish, slightly elevated, 
dry, inflammatory patches, variable as to shape, size, and 
number, covered with abundant, whitish or grayish 
mother-of-pearl-colored, imbricated scales. The disease 
varies greatly in its extent and intensity in different cases, 
sometimes showing a typical development, in other cases 
represented by one or two obscure lesions. It possesses, 
almost invariably, however, certain characters which 
serve to identify it. The lesions begin as small, reddish 
spots, scarcely raised above the level of the skin, which 
almost immediately become covered with whitish scales. 
They often develop rapidly, reaching the size of coins in 
afew weeks. At other times the course of the disease 
is more sluggish. The extent of the eruption varies 
greatly. A few patches may be all that are present, or 
the entire surface from head to foot may be involved, 
with scarcely a clear spot to be found. Commonly the 
disease shows itself in the form of scaly patches, of vary- 
ing size, scattered over different parts of the body. The 
patches are characteristic. They are usually rounded, 
sharply defined from the surrounding skin, and consist 


of a mass of imbricated, yellowish-white scales on a red 


base. When the scales are picked off, a smooth, shiny, 
reddish surface is shown underneath, on which can be 
perceived a few drops of blood the size of pin-points. 


The abundance of the scales is a marked feature in some - 


Prurigo, 
Psoriasis, 


cases. Where they are formed rapidly—that is, in well- 
developed cases—the patient’s bed may be filled in the 
morning with a handful of scales which have accumu- 
lated during the night. When the disease exists about 
the joints, fissures may show themselves, so deep at times 
as to make movements of the affected limb painful. 
There is no watery discharge at any period of the dis- 
ease. Sometimes the eruption takes on a highly inflam- 
matory -character, with redness, swelling, and severe 
burning and itching, while at other times all these symp- 
toms are much less marked, and; in fact, the patient 
would hardly be aware of the existence of the disease, 
did he not see the eruption. Though the individual 
patches of psoriasis may be, and generally are, small, yet 
they sometimes coalesce into patches the size of the 
HE or larger, or may even cover the greater part of a 
imb. 

Psoriasis may occur on any part of the body, but is 
most apt to be seen on the extensor surfaces of the limbs. 
It is sometimes found on the elbows and knees when it 
shows itself nowhere else. On the other hand, it may 
be absent from these localities, although present at many 
other points. The back is more commonly attacked than 
the chest, and in women a favorite seat of the eruption is 
around the waist where the skirts are tied. The scalp is 
a frequent seat of the disease. In this locality it some- 
times occurs in patches, but more frequently as a diffuse 
and abundant scaliness. It is apt to extend a little be- 
yond the border of the scalp, especially behind the ears 
and on the forehead, and this is quite characteristic. 
Psoriasis does not occur upon the mucous membranes. 
The so-called ‘‘ psoriasis ” of the tongue is probably only 
a precursory hardening leading to epithelioma. Psori- 
asis is not contagious. 

The cause of psoriasis is not known. It is apt to occur 
in well-nourished, rosy-complexioned, light-haired peo- 
ple, the ‘‘ picture of health” excepting that they are apt 
to bea little rheumatic. Now and then, however, it is 
met with in thin, worn persons who are in poor health. 
Greenough’s statistical inquiry into this point confirms 
the writer’s view. Psoriasis is not often encountered in 
children, though Stelwagon has reported a case where it 
occurred in achild between three and four years of age, 
and Greenough’s statistics show of 150 cases 20 which were 
known to have first occurred under the age of ten. On the 
other hand, 6 cases out of those observed by Greenough 
first showed signs of the disease after passing the fif- 
tieth year. It is the opinion of the writer that psoriasis 
occurs much more generally than is supposed at an early 
age, but the disease is not apt to be noticed until it grows 
with the growth of the individual and becomes more 
pronounced. Greenough succeeded in obtaining a his- 
tory of hereditary or family tendency in 31 cases out of 
97, but the tendency to hereditary transmission has not 
been observed by most writers or has been considered 
rather exceptional. Some cases of psoriasis are worse 
in winter and disappear almost or entirely in summer ; 
others are worse in summer. Diet, I believe, has little 
influence in causing the disease, though in some cases 
it may influence its course quite markedly. Psoriasis 
and syphilis are not connected in any way. There isa 
syphilitic eruption sometimes called ‘‘ syphilitic psoria- 
sis,” because the lesions resemble those of psoriasis. 
This most unhappy term has caused much confusion of 
mind, but it must be remembered that the cause, course, 
and treatment of syphilis differ 77 toto from those of pso- 
riasis (see under Syphiloderma). 

The diagnosis of psoriasis is easy when the affection is 
well developed and presents its typical appearance. The 
form and aspect of the lesions, and the history of the 
case, will usually serve to determine its nature. Scanty 
and ill-developed eruptions of psoriasis are, however, at 
times distinguished only with difficulty. Nevertheless, 
it is an important matter to accurately determine the nat- 
ure of the disease, for its treatment is widely different 
from that of the affections with which it is liable to be 
confounded ; its prognosis is also different, and, in addi- 
tion, two of the other affections are contagious. 

Two or three small patches of psoriasis occurring alone 


5D 


Psoriasis. 
Pterygium. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


upon the arms or legs may be mistaken for eczema. Itch- 
ing, however, is almost invariably present in eczema, 
and therefore itching is one sign that an eruption in 
question is not of this nature, though not a sure sign, 
since psoriasis also sometimes itches. 

In the majority of cases of eczema there will be a his- 
tory of moisture at some time. Psoriasis is always dry 
and scaly, never moist. The scales of psoriasis are more 
abundant, larger, and whiter than those of eczema. The 
patches of psoriasis are usually bold and well defined in 
outline, while those of eczema fade into the surrounding 
skin. 

Syphilis in the form of the papulo-squamous syphilo- 
derm is very apt to be mistaken for psoriasis, and vice 
versd. Psoriasis, however, is more apt to be symmetrical 
in its distribution. It often involves a large portion of 
the surface at once, or is found in regions remotely sepa- 
rated, which is rarely the case with the papulo-squamous 
syphilitic eruption. In psoriasis the lesions seem to be on 
the surface, so to speak. They are very scaly, but with- 
out much infiltration. The syphiloderm, on the other 
hand, is deeply indurated, and is only scantily covered 
with scales. In psoriasis the knees and elbows are apt to 
be involved. In syphilis these are not often attacked. 
Occurring on the palms and soles the disease is almost 
certain not to be psoriasis, which is very rare in this local- 
ity. Thecolor, though often deceptive, sometimes aids in 
diagnosis. It is usually much lighter in psoriasis, while 
in syphilis it is apt to be a dusky ham-color. The age 
of the patient and the duration of the disease may give 
a clew to the diagnosis. Psoriasis generally first shows 
itself before the age of twenty ; this form of syphilis, 
later. The history of psoriasis is that of a chronic dis- 
ease lasting for years, continuously or in an intermittent 
manner. Syphilis rarely retains one form for any length 
of time. Other points in the history—infection, the oc- 
currence of other lesions, etc.—may come into use. Itch- 
ing is rare in syphilis, common in psoriasis, but too 
much reliance must not be placed on this symptom. It 
has been the writer’s misfortune to see several lamentable 
mistakes made by the exclusion of syphilis based on the 
presence of itching. Finally, the touchstone of treat- 
ment may be resorted to in very obscure cases. 

Tinea circinata and psoriasis are sometimes mistaken 
for one another, but the patches of tinea are less inflam- 
matory, red, and infiltrated, and are much more super- 
ficial. The scales in tinea are larger and lighter, and the 
patches show no attempt at symmetry. The microscope 
shows the existence of a fungus in the scales of tinea cir- 
cinata, which is absent in psoriasis, and a history of con- 
tagion may often be obtained in the former’ disease, 
which is absent in the latter. 

Psoriasis may occasionally be mistaken for seborrhea, 
-as this disease occurs on the chest and back. A com- 
parison of the description just given of psoriasis with 
that of the former disease will show in what points the 
difference lies, while it may also be kept in mind that 
seborrhea affects a small patch, the size of the hand, 
over the sternum in front and the region of the scapule, 
with the parts between them, behind. From seborrhea 
capitis and from pityriasis capitis, psoriasis of the scalp 
is distinguished by the yellow, friable character of its 
scales and their abundance, the scales of seborrhcea be- 
ing markedly oily and adherent, while those of pityriasis 
are gray, thin, and powdery. 

Psoriasis may occasionally be mistaken for lupus, es- 
pecially lupus erythematosus ; but in addition to the fact 
that lupus erythematosus is most likely to be encountered 
on the face alone, whereas psoriasis is almost always 
found coincidently in other localities, the more scanty 
scaliness of lupus and the greater amount of infiltra- 
tion also serve to distinguish between the two affections. 
The description of both forms of lupus may be referred 
to in this connection. 

It is said that psoriasis may be confounded with lichen 
ruber. This certainly cannot occur very frequently in 
this country, the forms of lichen ruber commonly en- 
countered here being easily distinguishable. Lichen 
ruber usually occurs upon the extensor surface of the 


56 


forearms, at. least in the milder cases; the lesions are 
uniformly of small size, not much larger than a pin-head 
or small split-pea, while the lesions of psoriasis vary 
from the size of a pin-head to that of a coin, with occa- 
sional larger patches. The lesions of lichen ruber have 
few scales, while the lesions of psoriasis are very scaly. 

The anatomy of psoriasis has been made the subject of 
careful study by Robinson, whose description shows the 
affection to consist in a hyperplasia of the rete and cor- 
responding structure of the hair-follicles. In a section 
of a lesion of a few days’ duration the corneous layer is 
found to be but slightly changed. Prolongations down- 
ward of the interpapillary portion of the Malpighian 
layer, which are more extensive in the central, ¢.e., older 
portions of the lesion, are seen in microscopic sections of 
older lesions. In the papillze and superficial part of the 
corium within the psoriasis regions there are seen en- 
larged blood-vessels and round bodies in varying num-- 
bers in the surrounding tissues, while in the non-papu- 
lar region no enlargement of blood-vessels is as a rule 
observed, and also no white blood-corpuscles. The 
deeper parts of the cutis appear normal, as well as the se- 
baceous and sweat-glands. . 

The increase in the thickness of the Malpighian layer 
arises from an increase in the number of rete-cells. This 
increase is sometimes very great. The blood-vessels, also, 
in the papille are more or less dilated, this dilatation, 
together with the emigration of white blood-corpuscles, 
increasing with the duration of the eruption. All the in- 
flammatory changes, however, in the cutis are secondary 
to the hyperplasia of the rete. 

The hair in psoriasis becomes changed at the com- 
mencement. The external root-sheath, the structure cor 
responding to the rete, becomes increased in size in the 
same manner as the latter structure. There is a real 
hyperplasia, with an extension of the hyperplastic struct- 
ure into the surrounding cutis. This growth occurs 
principally at the root of the hair, though it is met with 
also along the rest of the follicle. 

During the period of disappearance of the disease there 
is a gradual return to the normal condition, until the 
hyperplasia, dilatation of the blood-vessels, and ceil- 
infiltration have completely disappeared. The Malpig- 
hian prolongations become smaller and smaller until 
the layer attains its normal size; the blood-vessels 
gradually return to their normal diameter, and the round 
cells and serous exudation to their normal channels. Of 
these pathological processes, the cell-infiltration and 
cedema generally disappear first, and the hyperplasia last. 
Psoriasis may sometimes undergo degenerative changes 
and become changed into epithelioma, as has been shown 
by White. 

The treatment of psoriasis must be in most cases both 
internal and external. The constitutional treatment of 
the affection should be based on a careful study of the 
history and habits of the patient. Attention should be 
given to the patient’s general health and his condition, 
whether stout and well nourished or thin and delicate. 
Regard must be had also to any functional derangement. 
The history of the eruption itself must be inquired into, 
as to its acuteness or chronicity, as to local and constitu- 
tional treatment which may have been previously em- 
ployed, together with the effects of the same. In ad- 
dition, inquiry should be made regarding the influence 
of the seasons, and whether the eruption is apt to dis- 
appear for a time and then to break out again. 

Fortified with this knowledge, the medical treatment 
can be entered into intelligently. In the large majority 
of cases, arsenic is pre-eminently the remedy. But while 
arsenic is as near a specific as, in the nature of things, it 
is possible for any medicine to be, yet it must be em- 
ployed judiciously if its good effects are to be obtained, 
or even if we do not wish to do harm. Arsenic should 
not, as a rule, be administered where there is much gas- 
tric irritation, and it is hardly necessary to say that it 
should not be continued, should it disagree even slightly. 
The patient should be warned of its. possible effects, and 
should be under the constant watch of the physician ; on 
the first symptom of indigestion, pain in the stomach or 


=. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


bowels, or diarrhcea, the dose should be lessened or the 
use of the medicine suspended. Large or almost toxic 
doses do not hasten the cure of psoriasis ; they some- 
times even retard it by upsetting the stomach. Some- 
times only a minute dose, as half a minim of Fowler’s 
solution, is borne at first, when, later, tolerance is gained 
and a full dose may be given. Some persons need and 
will bear large doses of arsenic, but this idiosyncrasy 
must be learned by careful tentative increase of the dose, 
beginning always with a moderate one. Arsenic should 
not usually be given in acute and inflammatory forms of 
psoriasis. Arsenic acts slowly. Where in a case of 
psoriasis it is going to do good, improvement generally 
begins to be shown after two or three weeks ; but to get 
the full benefit of the drug it must be given for several 
months, and its administration should be continued for 
several months after the eruption has disappeared. 

The best form in which to administer arsenic is, in the 
great majority of cases, unquestionably that of ‘‘ Fow- 
ler’s solution ’—Liquor Potassii Arsenitis—of which five 
drops contain about one-twentieth of a grain of arseni- 
ous acid, the average dose. The medicine should never 
be given in drops, as mistakes are likely to occur. A 
very good formula, and the one almost always employed 
by the writer, is the following: K. Liq. potas. arsenit., 
Gm. 8 (3 ij.) ; vini ferri, ad Gm. 128 (fZiv.). M. Sig.— 
Teaspoonful three times a day, after meals. The dose 
here is four minims. The amount may be gradually in- 
creased, say, every three days, until an effect upon the 
eruption becomes perceptible, or until the limit of toler- 
ance is reached. 

Sometimes it is desirable to give the arsenic in pill- 
form: &. Pulv. acidi arseniosi, Gm. .14 (gr. ij.) ; pulv. 
piperis nigra, pulv. glycyrrhize rad., 44 Gm. 3 (9ij.). 


_ M. et div. in pil. No. xl. Sig.—One, after meals. Or, 


occasionally, powders may be preferred : B. Pulv. acidi 
arseniosi, Gm. .14 (gr. ij.); pulv. sacch. lactis, Gm. 10 
(gr. cl.). M. in chart No. xl. div. 

But neither pills nor powders are as effective as Fow- 
ler’s solution, and the writer rarely prescribes them un- 
less forced to do so by circumstances. 

Various other specifics have been recommended for 
psoriasis at different times ; tar, carbolic acid, turpen- 
tine, phosphorus, and iodide of potassium may be men- 
tioned. None of these, however, has stood the test of 
time. 

Some cases of psoriasis require, instead of the specific 
treatment, one directed against the patient’s general con- 
dition. In debilitated cases, cod-liver oil, iron, the hy- 
pophosphites, etc., are useful. In thin, worn-out wom- 
en, as nursing mothers, where the attack has come on 
during lactation, iron is imperatively called for. Next 
to iron is cod-liver oil, and these remedies occasionally 
succeed where arsenic fails. In acute inflammatory 
cases, diuretics are occasionally of service. Acetate of 
potassium, in half-drachm doses, may be given three or 
four times a day, in a wineglass of water. The alkaline 
mineral waters are also of service. 

The local treatment of psoriasis is of more or less im- 
portance, according to the nature of the case. Where 
the lesions are few, small, and widely disseminated, and 
there are no disagreeable subjective symptoms, local treat- 
ment is inconvenient, and need not be employed. Where, 
however, there are a few large patches, or where the 
eruption is situated on some conspicuous part of the 
person, or gives rise to annoying burning or itching, 
local treatment is required, and will be found advanta- 
geous. If there are scales, these should first be removed 
by rubbing with sapo viridis and hot water, or by the 
use of a hot-water bath. If the patches are few in num- 
ber, large, and very scaly, the following solution, well 
rubbed in, will remove the scales readily, and give an 
opportunity for making healing applications: h. Acid. 
salicylici, 4 Gm. (3j.); alcoholis, 64 Gm. (f ij.). 
This is especially useful upon the scalp. After the 
scales have been cleaned off by this means, or by means 
of spiritus saponis alkalinus (two parts of sapo viridis 
dissolved in one part of hot alcohol, and filtered) used 
as a shampoo, an oil composed of one drachm of oil of 


Psoriasis. 
Pterygium, 


cade to the ounce of oil of almonds or alcohol may be 
well rubbed in with the aid of a brush. On the edge of 
the scalp and about the face the best ointment is that 
of ammoniated mercury, twenty to forty grains to the 
ounce, vi 

Where it is desirable to get rid of the scales and patches 
in the most rapid manner possible, chrysarobin is the best 
application. An ointment of half a drachm to a drachm 
to the ounce is very efficient, and will remove a patch in 
a few days, leaving a white spot of skin surrounded by 
a purplish areola in its place. 

There are strong objections to the use of chrysarobin, 
however. It discolors everything with which it comes 
in contact, dyes the hair orange-yellow, and spoils the 
clothes. It cannot be used on the scalp or about the eyes 
and cheeks, because it induces inflammation there, and 
it cannot be trusted in the hands of most patients, be- 
cause, unless used cautiously, it may inflame the skin 
wherever used. G. H. Fox has suggested the following 
solution, which is effectual, though decidedly less so 
than the ointment, and which saves the smearing which 
renders the chrysarobin ointments so annoying and dis- 
agreeable: R}. Chrysarobin, 4 Gm. (3j.); stheris et al- 
coholis, 44 q. s.; collodii, 82 Gm. (%j.). M. Rubupthe 
chrysarobin with a little alcohol and ether and add to the 
collodion. It forms a sort of emulsion, which should be 
shaken before using. By the aid of a camel’s-hair pen- 
cil in the cork this may be painted over the affected 
patches after removal of the scales. When it dries it 
will not come off on the clothes, which is a great advan- 
tage. 

Next to chrysarobin in activity comes pyrogallic acid. 
This may be used in ointment, a drachm to the ounce. 
It is not so effectual, but ismuch more cleanly, although 
it leaves a blackish stain. It should not be employed 
over a very large area at once, for fear of absorption. 

Preparations of tar have been used from time imme- 
morial in the treatment of psoriasis. They are particu- 
larly useful when there is a good deal of itching. Pix 
liquida and oleum cadinum are the forms most commonly 
employed, either in ointment or dissolved in alcohol in 
the proportion of one or two drachms or more to the ounce. 
The solution known as ‘*‘ Tinctura Saponis cum Pice” is 
a useft/l application ; it is composed of-equal parts of 
sapo viridis, pix liquida, and alcohol. Wilkinson’s oint- 
ment is also useful, owing its virtues partly to the sul- 
phur which it contains. The formula for it is as fol- 
lows: RB. Olei cadini, flor. sulphuris, 44 12 Gm. (3 iij.) ; 
saponis viridis, adipis, a 24 Gm. (3 vj.); crete, 1.7 Gm. 
(gr. xxvj.). These preparations should be rubbed firmly 
into the diseased patches, once or twice daily. 

In very severe or extensive psoriasis, baths, with the 
inunction of bland oils and fats, are better than any of 
the applications mentioned. Tar may be used at times, 
but with caution. 

The prognosis of psoriasis, so far as the individual at- 
tack is concerned, is in medium and mild cases usually 
favorable. But the disease is prone to relapse, and the 
patient should be warned that while the attack can be 
cured, the affection is liable to return, and that no treat- 
ment, however well directed, will surely prevent the dis- 
ease from coming back. Severe cases especially, when 
almost the entire surface is covered with the disease, are 
often rebellious to all treatment. 

Arthur Van Harlingen. 


PTERYGIUM (arepvé, a wing). <A circumscribed hy- 
pertrophy of the conjunctiva and subconjunctival tis- 
sue, triangular in shape, more or less vascular, and ex- 
hibiting a tendency to encroach upon the cornea. The 
apex of the growth is always turned toward the centre of 
the cornea, the base toward the equator of the eye. Its 
usual location is to the nasal ‘side of the cornea, over 
the region of attachment of the tendon of the rectus in- 
ternus to the sclerotic; exceptionally it occurs to the 
outer side of the cornea, and still more rarely above or 
below it. It usually develops very slowly, and many 
months, or even years, may elapse without its extending 
far enough toward the centre of the cornea to impair 


oT 


Pterygium. 
Pterygium. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


vision. It is rarely met with in children, and is more © 


prevalent in tropical than in temperate countries. The 
apex of a pterygium not infrequently reaches, but rarely 
passes beyond, the centre of the cornea. The writer has 
met with one case, however, in which a pterygium of 
unusually large size, starting from the nasal side of the 
eye, grew entirely across the cornea to its external mar- 
gin. The other eye of the same individual (a woman, 
advanced in years) also exhibited a large pterygium, 
which had already passed beyond the centre of the cor- 
nea. So long as the growth is confined to the conjunctiva 
and the periphery of the cornea it usually causes little or 
no inconvenience, but as soon as it encroaches upon the 
area of the pupil it greatly impairs vision, not only be- 
cause, being opaque, it obstructs the passage of light into 
the eye, but because the curvature of the corneal sur- 
face about its apex is so altered as to produce a high 
grade of irregular astigmatism. 

In the text-books of forty or fifty years since, four or 
five varieties of pterygium are described. There seems to 
be little reason, however, for making even the two varie- 
ties which more recent authors mention; although, as 
some pterygia are thin and scantily supplied with blood- 
vessels while others are thick and vascular, there is some 
warrant, perhaps, for calling the former variety pterygium 
tenue, and the latter pterygium crassum. 'The pterygium 
pingue of the older authors is the pinguecula of the pres- 
ent day, which is no longer regarded asa variety of pteryg- 


ium; while their pterygium malignum was, as its name 


implies, simply a malignant growth involving the cornea, 
which at the present day we would, of course, not think 


_ Fie, 3129.—Pterygium, 


of confounding with true pterygium. It is possible for 
several pterygia to develop upon the same eye, advancing 
upon the cornea from different directions, and cases of this 
character have been reported, but they are of extreme 
rarity. 

The question of the pathogenesis of pterygium has, 
from time to time, been discussed, and various theories 
have been suggested to account for its development and 
growth. None of those so far advanced seems, however, 
to be satisfactory. Arlt, some years ago, suggested that 
the starting-point of pterygium is the existence of a su- 
perficial ulcer or abrasion at the margin of the cornea, to 
which the neighboring swollen conjunctiva becomes ad- 
herent, and that the dragging and irritation which re- 
sults from this is the cause of its subsequent growth ; 
and this theory has met with very general acceptance. 
It takes no account of the fact, however, that ulcers and 
- abrasions of the cornea are not especially frequent upon 
its nasal margin, while pterygium, as we have seen, oc- 
curs only very rarely elsewhere; nor of the further fact that 
many cases of pterygium can be recognized as such before 
the apex of the growth has even reached the corneal lim- 
bus, and, therefore; before the process which is assumed 
to be the first step in its development has taken place. 
That pterygium is produced in this manner, in excep- 
tional cases, there is no doubt; but this fact was recog- 
nized before Arlt’s day—notably by W. Lawrence,! who 
refers to cases of pterygium following purulent ophthal- 
mia, in which the conjunctiva from the upper part of the 
globe had become adherent to an ulcer upon the lower 


58 


part of the cornea.* He distinguishes, however, between 
these cases and true pterygium, and mentions his sus- 
picion that the pterygia said to have been seen on the 
upper part of the globe were cases of this character, as 
he had never seen true pterygium in this situation. 

It is manifest that any theory which would satisfac- 
torily account for the development of pterygium must 
also account for the fact that it occurs in so large a pro- 
portion of cases to the nasal side of the cornea. This 
Arlt’s theory fails to do; for it is beyond question that 
if pterygium were, as a rule, produced in the way he de- ' 
scribes, we should find it encroaching upon the cornea 
from every possible direction, and not much more fre- 
quently from one direction than from another. The 
theory more recently proposed by Poncet, that pterygium 
is a parasitic disease, and that its advance over the cornea 
is due to the presence of microbia—parasitic ‘‘ vibriones,” 
which he finds beneath the head of the pterygium, and 


‘ which are supposed to tunnel their way under the corneal 


epithelium—fails equally in this respect ; and, besides, the 
precedent ulcer which he regards as the starting-point of 
the process, and as essential to it, has not been clinically 
demonstrated, but, rather, assumed to have been present. 

In endeavoring to reach a satisfactory explanation of 
the origin of pterygium, it is important that we should 
bear in mind the fact (which seems usually to have been 
lost sight of) that in its incipient stage the growth does 
not, as arule, involve the cornea at all, but is confined to 
the sclerotic conjunctiva. As Lawrence very aptly puts 
it: ‘‘It begins with the appearance, in the conjunctiva 
sclerotic, of a few vessels rather larger than natural, 
and running from behind forward nearly parallel to each 
other. After some time the membrane is found, on ac- 
curate inspection, to be a little raised, but the surface is 
smooth and entire. It gradually assumes the triangular 
shape, the basis extending toward the circumference of 
the eye, while the apex passes over the junction of the 
sclerotica and cornea and advances on the latter.”? This 
description of the development of pterygium entirely 
agrees With the writer’s own observations, and it suggests 
at once that the primary cause of pterygium is to be 
sought for elsewhere than in diseased conditions of the 
cornea. 

It has long been taught that the development of pteryg- 
ium is favored by conditions which bring about per- 
sistent hyperszemia of the conjunctiva, as, for example, 
when the eyes are exposed to the heat of a tropical 
sun, as in long sea-voyages, or to the heat from fur- 
naces, as is the case with stokers and founders, or to the 
irritant action of dust and vapors, as in mills and other 
manufacturing establishments ; and the evidence in favor 
of this view is much too strong to be put aside. Assum- 
ing, then, that hypersemia of the conjunctiva is an im- 
portant factor in the production of pterygium, are there 
reasons why this condition should occur especially 
where pterygium usually makes its appearance—to the 
nasal side of the cornea? The writer does not hesitate to 
answer this question affirmatively. He is not aware that 
it has been suggested, heretofore, that the recti muscles 
of the globe have anything to do with the production 
of pterygium; but it seems to him highly probable that 
such is the case. In the first place, it is wel! known 
that it is an extremely rare occurrence to meet with 
a pterygium which does not lie directly over the inser- 
tion of one of these muscles—they scarcely ever approach 
the cornea except in an exactly horizontal or vertical di- 
rection. Again, the vascular system of the conjunctiva 
in the neighborhood of the corneal border (anterior con- 
junctival vessels of Van Woerden) is so intimately con- 
nected with that of the recti muscles, through branches 
derived from the anterior ciliary arteries, that the possi- 
bility of the blood-supply of the former being influenced 
by that of the latter can scarcely be doubted. There is 
nothing improbable, therefore, in the assumption that 
the determination of blood to the recti muscles may bring 


* The writer has also met with a case of this character as a result of 
gonorrhceal conjunctivitis. Only the apex of the pterygium, however, 
was adherent to the cornea, and a probe could be passed between the cor: 
neal surface and the body of the pterygium. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Pterygium. 
Pteryzium, 


about a hypereemic condition of the overlying conjunc: 
tiva, and that this condition, as we have seen, may in 
time lead to the development of pterygium. Moreover, 
it is manifest that the recti interni muscles would be 
likely to exert a much more decided influence in this re- 
spect than any of the others; for they are not only the 
largest of the straight muscles, and the ones which per- 
form by far the greatest amount of work, but their at- 
tachment to the sclerotic is considerably nearer the corneal 
border, and they are, therefore, more intimately con- 
nected with the conjunctiva. Thus the location of pteryg- 
ium to the nasal side of the cornea is at once explained. 

In support of this view as to the origin of pterygium, 
which, to the writer, seems at least to be more satisfactory 
than those which have as yet been offered, it may be men- 
tioned, as a matter of observation, that persons who have 
pterygium not infrequently complain that the pterygium 
itself, and the conjunctiva in its neighborhood, become 
bloodshot when the eyes are much used in near work. 
How far insufficiency of the internal recti muscles may 
influence the development of pterygium is a question 
which at once suggests itself, and which calls for inves- 
tigation. Although the writer has, as yet, but little evi- 
dence to offer bearing upon this point, he is disposed to 
think that this and other disturbances in the muscular 
balance of the eye play an important réle in the patho- 
logical process under consideration. It remains to be 
, added that pterygium sometimes has its origin in trau- 
matic lesions of the conjunctiva, as, for example, to cite 
from the writer’s experience, a burn from a scale of hot 
iron or from partially slaked lime splashing into the eye. 

In regard to the treatment of pterygium, little is to be 
expected except from operative interference. In its in- 
cipient stage, however, its growth may possibly be ar- 
rested by correcting, by means of glasses, any error of re- 
fraction or any muscular defect which may exist; and, 
even when it has reached a more advanced stage, its de- 
velopment may, perhaps, be favorably influenced in this 
way. So, too, after any operation which may be resorted 
to for its cure, the good which glasses may do by lessening 
the tendency to a recurrence should not be lost sight of. 
It should be borne in mind that the asthenopic symptoms, 
of which persons suffering with pterygium often com- 
plain, are much more likely to be due to some error of 
refraction or muscular defect than to the mere presence 
_of the growth. The propriety of resorting to operative 
treatment will be determined by several considerations : 
If the pterygium be confined to the conjunctiva, it may 
be advisable to operate upon it, provided it be narrow 
and well defined. If, on the contrary, it be broad and 
ill defined, it will be wiser not to interfere with it, as the 
condition and appearance of the eye after the operation 
will probably not be better than before. If, however, it 
has encroached upon the cornea, it is better, as a rule, to 
operate, because, as has been said, it usually advances 
farther and farther upon this membrane, and, as it does 
so, it produces such changes in its structure as to leave 
behind a permanent opacity, even when the growth is 
most carefully removed. Patients will frequently assure 
the surgeon that the pterygium is not growing, and that 
for months or years it has made no progress ; but their 
testimony upon this point is not always to be relied upon, 
and to prevent the possibility of the sight eventually be- 
coming impaired, unnecessary delay in resorting to oper- 
ation should be avoided. 

The operative procedures which have been suggested 
for the cure of pterygium are numerous. Until a com- 
paratively recent period, excision was the only opera- 
tion which was in vogue. The results obtained by this 
method were, however, by no means uniformly success- 
ful, the removal of the growth, as it was commonly 
practised, being not infrequently followed by its recur- 
rence. In consequence of this, various substitutes for 
this operation were proposed. For example, Des Marres 
suggested transplantation of the pterygium; Szokalski 
its destruction by strangulation, while Knapp introduced 
a modification of the former, and Galezowski of the lat- 
ter, procedure. Pagenstecher recommended that the 
growth should simply be dissected from its corneal, and 


in part from its sclerotic, attachments, and then be al- 
lowed to atrophy, the edges of the conjunctival wound 
being united beneath the partially detached pterygium 
by means of sutures. Arlt, also, preferred a method 
essentially the same as that of Pagenstecher. In Des 
Marres’s operation the pterygium is detached from the 
cornea and sclerotic quite up to its base, and is then in- 
serted into an incision made in the conjunctiva near the 
lower edge of the cornea, where it is retained by sutures. 
Knapp’s modification of this method, applicable to cases 
in which the pterygium is of large size, consists in split- 
ting the pterygium longitudinally, after having removed 
its corneal portion, and inserting the upper half in an in- 
cision made in the conjunctiva above its base, and the 
lower half in one made below. He also unites the edges 
of the conjunctival wound by sutures, and, to facilitate 
this, separates the conjunctiva from the subjacent tissue 
above and below the wound. In Szokalski’s operation 
the strangulation is accomplished by passing two needles, 
which have been threaded with the opposite ends of a 
fine silk ligature, beneath the pterygium, one near its 
apex, the other near its base, and then, after cutting out 
the needles, by tying together the ends of the three 
threads which are thus left in position, so as to cut off 
its vascular supply near its base, near its apex, and from 
its sclerotic surface. Galezowski, after dissecting up the 
pterygium, ‘‘takes a thread, armed at each end with a 
curved needle, and pierces the apex with both needles, 
so as to include it inasmall loop. Then turning the 
needles inward, he brings them out at the base of the 
growth, one near the upper and the other near the lower 
margin. The two ends are then tied in a tight knot, and 
thus the apex of the pterygium is turned inward toward 
the base, and the latter is strangulated by the knot.” It 
is claimed for each of these procedyires that a recurrence 
of the growth is less apt to happen than when simple ex- 
cision is practised. 

The operation of excision has, in the writer’s experi- 
ence, yielded such satisfactory results that he has not 
been tempted to make trial of any of these newer meth- 
ods. The end which they all accomplish seems to him 
to be the same—to minimize the loss of conjunctival tis- 


‘gue, and this is, undoubtedly, a most important thing ; 


but, if the excision be performed as it should be, the loss 
of tissue is insignificant. Although the ill effects of a 
too free excision of the growth were long ago pointed 
out, especially by Scarpa, the writer is inclined to think 
that the poor results which many have obtained from 
this operation are due to unnecessary loss of conjunc- 
tival tissue. Even when but little more than the apex 
of the growth is removed, the gap which is left in the 
conjunctiva is of considerable size, and when the whole 
pterygium is cut off, the size of the gap which results, 
owing to the retraction of the conjunctiva, is surprising. 
Under such circumstances the healing process is slow and 
difficult, and ultimately a prominent vascular cicatrix is 
apt to.be left, which is as unsightly, and as likely to 
cause trouble, as the pterygium itself. 

Since the employment of cocaine in ophthalmic sur- . 
gery the removal of pterygium has been rendered much 
easier, aS the operation is now entirely painless. The 
method of operating which the writer has adopted, and 
which, as has been said, has yielded satisfactory results, 
being very rarely followed by a return of the pterygium, 
is as follows: The eye having been brought under the 
influence of cocaine, and the patient being seated in a 
chair, the operator standing behind, a stop-speculum is 
introduced. The growth is then seized near its apex 
with forceps, and with an iridectomy-knife, which is but 
slightly bent, is cleanly dissected from the cornea, espe- 
cial care being taken to detach its margins from the cor- 
neal limbus. Its more loose attachments to the sclerotic 
are also separated for a short distance (2 or 3 mm.) from 
the corneal margin. Then, witha pair of slender scissors, 
curved on the flat, the whole of the corneal and a very 
small part of the conjunctival portion of the growth is re- 
moved at a single cut. If decided traction is made with 
the forceps upon the detached portion of the growth while 
the scissors are being used, and if the latter are pressed 


59 


Pterygium, 
Ptomaines. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


against the sclerotic, a very much larger piece of the 
pterygium will be removed than is desirable. Only very 
slight traction, therefore, should be exerted, and in using 
the scissors (the points of which should be turned toward 
the base of the growth) it should be borne in mind that 
we are more apt to remove too much than too little tissue. 
A single stitch of fine black silk will suffice to close the 
conjunctival wound, and, unless more tissue has been 
sacrificed than is necessary, will bring its edges together 
without undue traction. The closure of the wound in 
this way hastens the healing process, and the removal of 
the stitch, on the second or third day, as may seem more 
desirable, can be accomplished without pain by the in- 
stillation of a drop or two of cocaine. The dressing 
most acceptable to the eye is a linen cloth wet with cold 
water, which may be applied at intervals for a few days. 
A collyrium of boracic acid (gr. v.-x. to aq. destill., 3 j.) 
should then be prescribed, to be used three or four times 
a day, as it soothes the eye, lessens the secretion, and 
helps to subdue the inflammation. Should there be 
much ciliary irritation from inflammation of the corneal 
tissue, atropine is indicated, while, on the other hand, if 
there is considerable conjunctival secretion, without cil- 
iary irritation, a very little sulphate of zinc (gr. ++ to 
%j.) or alum (gr. ss.—j. to % j.) may be added, with bene- 
fit, to the boracic-acid solution. The patient should be 
warned that the improvement in the appearance of the 
eye will be slow, else he may suppose the operation has not 
been successful, and may mistake the vascularity which 
remains for some time about the former site of the pteryg- 
ium fora return of the growth. When the pterygium 
has encroached upon the cornea, he should also be made 
to understand that after its removal a more or less per- 
ceptible opacity will remain upon the surface of this 
membrane. Should this opacity involve the central por- 
tion of the cornea, which in exceptional instances is the 
case, an iridectomy may be necessary in order to obtain 
a pupil behind a part of the cornea which is clear. 


Samuel Theobald, 


1 W. Lawrence: Diseases of the Hye, p. 820. London, 1844, 
2-Tbid., p. 317%. 


PTOMAINES—POST-MORTEM ALKALOIDS. Huis- 
TORICAL.—The name Ptomaine, written by some recent 
German authors Piomatine (rréya = that which is fallen, 
a corpse), was first suggested by Selmi, in 1875, to des- 
ignate substances obtained from putrefying organic ma- 
terial and possessed of the general properties which 
characterize the vegetable alkaloids, and which were for- 
merly considered as peculiar to those substances, 

It had been observed in the first half of the last cen- 
tury that certain articles of food, when in a condition 
of incipient putrefaction, not sufficiently advanced to 
awaken suspicion by the liberation of odorous products, 
caused violent symptoms of poisoning and death in the 
human subject. It was also a matter of early experience 
that serious results, and even death, might follow inoc- 
ulation with the juices of the uninjected cadaver be- 
fore putrefaction had progressed to the stage in which 
putrid gases are given off. 

The earlier observers advanced different theories con- 
cerning the nature of the poisonous substances in these 
cases. The earliest of these (1789) accounted for the 
poisoning by the supposition of an admixture of min- 
eral poison. Emmert (1815) sought to show the forma- 
tion of hydrocyanic acid during modified putrefaction. 
Rumpelt, Berres, and Saladin considered the poisonous 
qualities of certain sausages to be due to the formation 
of empyreumatic products related to creasote. The poi- 
sonous qualities of sausages were attributed by Boullay 
to the use of poisonous vegetables by mistake for the herbs 
commonly employed in their manufacture, and by 
Wunderlich to a diseased condition of the animals which 
yielded the meat. Kerner (1820) considered that picric 
acid (Weither’s bitter) was the poisonous agent. Wit- 
ting, Kerner, and Buchner thought it was a product of 
decomposition of the fats,an empyreumatic fatty acid, 
or acrolein. Weiss and Liebig (1824) considered that the 


60 


poison acted chemically upon the blood ‘‘ by catalysis,” 
and was ‘‘ analogous to the typhic miasm.” 

The first to suggest the probability of the formation 
of an alkaloidal poison during putrefaction seems to 
have been Kastner (Arch. f. Gesam. Naturlehre, Bd. i. 
(1824), 448, 488 ; Bd. ii., 499), who advanced the hypothe- 
sis that poisonous sausages contained an ‘alkaloid of 
decay” (Moderalkaloid) combined with an organic acid. 

In 1852, Schlossberger, in an exhaustive paper upon 
the sausage-poison (Arch. f. Physiol. Héilk., Erganz hft., 
1852) supposes ‘‘ the poisonous substances occurring in 
sausages and cheese to be organic bases, which have their 
origin in the deconrposition (Hntmischung) of the pro- 
tein materials rich in nitrogen, under certain conditions.” 
He supports this hypothesis by the following observa- 
tions: 1st, When ammonia is produced in considerable 
amount by the decomposition of animal or vegetable 
substances, it is accompanied by volatile bases (Sten- 
house) ; 2d, by the action of dilute potash upon poisonous 
sausages, much ammonia, ‘‘ accompanied by a peculiar, 
repulsive odor,” is given off ; 3d, the physiological action 
of the putrid poison is very similar to those of the then 
known volatile alkaloids nicotine, coniine, sparteine, and 
to those of the artificial amide, imide, and nitrile bases 
of Hofmann; 4th, one of these bases, trimethylamine, is 
contained in herring-pickle. Schlossberger also suggests 
that fixed as well as volatile alkaloids are probably pro- 
duced during putrefaction. 

Four years later (1856) Panum was probably the first 
to isolate ptomaine, in an impure state however (B7d/. 
for Laeger, 1856; Schmidt's Jahrb., 1859, ci., 218; 
Virchow’s Arch., 1874, 1x., 828-852). This substance 
was designated by Panum as the ‘‘ extractive putrid 
poison.” It is described as being soluble in water, 
from which it is precipitated by alcohol; capable of 
extraction from putrid meat; and not identical with 
known odorous products of putrefaction. It is capable 
of withstanding a boiling temperature, evaporation, and 
the influence of absolute alcohol—conditions inconsistent 
with the presence of lower organisms. Panum further: 
states that it is comparable to the poison of serpents, 
curare, and the vegetable alkaloids in its action on the 
economy. 

During the years 1859 to 1868, the subject appears to 
have remained in the condition in which it was left by 
Panum, although, in 1866, Hemmer, Schwenninger, and . 
Von Raison published dissertations upon the putrid 
poison, In the same year, Bence Jones and Dupré ob- 
tained from animal matter a substance which formed 
precipitates with the general reagents for the alkaloids 
then known, and whose solution exhibited a blue fluo- 
rescence. To this substance they gave the name of 
‘‘animal chinoidine.” 

In 1868, Bergmann and Schmiedeberg obtained a small 
quantity of a crystalline substance, which was poisonous 
to dogs and frogs, and to which the name sepsine was 
applied. | 

In 1869, Zuelzer and Sonnenschein obtained from ca- 
davers a crystalline substance having physiological ac- 
tions similar to those of atropine. 

The discovery in cadaveric matter of alkaloids which 
could not be identified with any then known led Selmi 
to a series of experiments which enabled him to identify 
and characterize those ptomaines with greater precision. 
His first publication upon the subject was a paper read 
before the Academy of Sciences of Bologna, January 
25, 1872. Since that time the contributions of Selmi 
and of his followers—Morrigia and Battistini, Trottarelli, 
Raffaele, Ziino, Albertoni and Lussana, Paterno, Spica, 
Brugnatelli and Zenoni, Bocci, Guareschi and Mosso, 
and Monari—have been voluminous and important. 

Attempts have been made by Arm. Gautier and his 
followers to appropriate the credit due to Selmi 
(Gautier : ‘‘ Ptomaines,” p. 6, Paris, 1886), on the strength 
of unpublished experiments and a vague statement made 
in a work printed in 1874. 

The most important of the numerous recent mono- 
graphs upon this subject are those of L. Brieger (‘‘ Ueber 
Ptomaine,” i., 1885 ; ii., 1885 ; iii., 1886). 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Nencki (‘‘ U. d. Zersetz d. Gelatine,” etc., Bern., 1876) 
was the first to determine the chemical composition of a 
ptomaine, and thus clearly to establish the nature and 
relations of these substances. 

PTOMAINES FORMED DURING PUTREFACTION OF 
MuscuLaR TIssuE AND INTERNAL ORGANS OF MAm- 
MALS.—Cadaveric Alkalotds.—The nature of these bases 
varies with those conditions which have been known to 
modify the progress of putrefactive changes, viz.: 1, 
the nature of the putrefactive ferment—.e., according to 
existing views, the species of bacterium ; 2, the kind of 
albuminoid or gelatinoid undergoing putrefaction ; 3, 
the temperature ; 4, the degree of. moisture ; 5, the ac- 
cess, or non-access, of atmospheric oxygen. 

In.the case of cadaveric putrefaction, as it usually oc- 
curs, when the entire body is subjected to decomposition, 
it is also probable that the nature of the ptomaines pro- 
duced is influenced by the results of the simultaneous 
changes which the carbohydrate and fatty constituents 
undergo. 

As the process of putrefaction is gradual and progres- 


sive, different basic substances are produced at differ- 


ent stages. Therefore, a base obtainable in considerable 
amount from a body during the first days of putrefac- 
tion will have more or less completely disappeared at a 
later stage, when other bases, not previously present, 
will have made their appearance. 

For our present knowledge of the composition of the 
cadaveric alkaloids we are largely indebted to Brieger 
(loc. cit.). 

The numerous substances whose reactions and physio- 
logical properties have been described by Selmi and his 
followers probably consisted, in most cases, of the alka- 
loids mentioned below, mixed with greater or less quan- 
tities of other substances, or of their more or less pure 
products of decomposition. The frequent variations in 
chemical and physiological action of the materials oper- 
ated upon by these observers are due to the fact that they 
consisted of residues whose purity was not assured by 
crystalline form or by chemical analysis. It is also 
probable that the number of existent ptomaines is by no 
means as great as an examination of the literature of the 
subject would lead one to suppose, although it is certain 
that many more will be added to those whose composi- 
tion and character have been already determined. 

Immediately after death the most unstable of the con- 
stituents of the body, lectthin, is decomposed into di- 
stearylglycerophosphoric acid and choline. 

Choline, CsHi5N Ox, is a syrupy, highly alkaline liquid, 
soluble in all proportions in water, whose chloride crys- 
tallizes in colorless, highly deliquescent needles, very 
soluble in water. With platinic chloride it forms aread- 
ily soluble double salt, crystallizing in orange-red prisms. 
With auric chloride it forms a crystalline double salt, 
almost insoluble in cold water, soluble in hot water. 

This base was originally obtained by Strecker from ox- 
bile, in 1849, and was subsequently shown by Diakonow 
to be a constituent of lecithin. It was also obtained by 
Gobley from yolks of eggs, and has since been found to 
be widely disseminated in animal tissues. It has been 
considered by many chemists as identical with the new- 
rine which constitutes a large portion of the protagon 
of Liebreich. The investigations of Baeyer, however, 
have shown that the two bases are distinct. Choline, ob- 
tainable from bile and lecithin, is identical with the syn- 
thetic trimethylhydroxethylene ammonium hydrate, 
(OnE OH) N,OH, while newrine is trimethylvinyl am- 


monium hydrate, ca t IN: OL: 

Choline is non-poisonous, except in large doses, which 
produce effects similar to those of muscarine. 

As putrefaction advances, choline gradually disap- 
pears, its place being taken by trimethylamine, (CHs)3N, 
produced by its decomposition. After seven days, cho- 
line is no longer present. 

Within three days after death another base makes its 
appearance : 

Neuridine, CsHi4N2(?), a diamine discovered by Brie- 


Pterygium. 
Ptomaines. 


ger. The chloride crystallizes in long needles, resem- 
bling urea, and is very soluble in water, insoluble in 
alcohol, ether, chloroform, petroleum-ether, benzol, and 
amyl-alcohol. If, however, it be accompanied by other 
animal substances, it is dissolved in greater or les8 quan- 
tity by the above solvents, and hence may be present 
in the extracts obtained by the Stas-Otto and Dragen- 
dorff methods. Solutions of the chloride give the follow- 
ing reactions with general reagents: Phosphotungstic 
acid, white, amorphous precipitate, soluble in excess ; 
phosphomolybdic acid, white, crystalline precipitate ; 
phosphoantimonic acid, white, flocculent precipitate ; 
picric acid, precipitate, slowly converted into yellow 
needles; auric chloride, crystalline precipitate. With 
other usual reagents, nothing. With platinic chloride it 
forms flat needles of a double salt, readily soluble in wa- 
ter, from which solution it is precipitated by alcohol. 
The picrate is crystalline, and insoluble in water. 

The free base is a gelatinous substance which decom- 
poses even during evaporation of its solution. Its odor 
resembles that of spermatic fluid. It is insoluble in ab- 
solute alcohol and in ether, difficultly soluble in amyl- 
alcohol, readily soluble in water. It forms white pre- 
cipitates with mercuric chloride, and with basic and 
neutral lead acetate. When heated with caustic soda it © 
yields dimethylamine and trimethylamine, a decomposi- 
tion which shows it to be not identical with amylendia- 
mine, with which it is isomeric. 

Neuridine is produced in greatest abundance in putrid 
intestines, while glandular organs yield but little under 
like conditions. It is no longer present after fourteen 
days. It is also found during putrefaction of fish, 
cheese, and gelatine, and is obtainable from fresh eggs 
and human brain-tissue. 

When pure, neuridine is perfectly non-poisonous ; but 
when contaminated by other putrefactive products it ex- 
erts a poisonous action. 

On the third day of slow putrefaction, traces of another 

alkaloid are detectable, which increases in amount as the 
choline and neuridine disappear, and is accompanied by 
trimethylamine : 
, Cadaverine, CsHisNo, a base identical with the penta- 
methylendiamine, NH.—CH.—CH.—CH.-CH.—-CH.-N Ha, 
of Ladenburg, is a thick, transparent liquid, having a 
very disagreeable odor, somewhat resembling that of 
coniine ; boils at 175° C. ; fumes, and absorbs carbon di- 
oxide rapidly when exposed to air, being converted into 
a crystalline compound. Its chloride is crystalline, deli- 
quescent, readily soluble in water and in dilute alcohol, 
but insoluble in absolute alcohol and in ether. With 
platinic chloride it forms crystals, resembling those of 
platinum-ammonium chloride, which are difficultly solu- 
ble in water. 

The reactions of cadaverine chloride with the general 
reagents are as follows: Phosphotungstic acid, white 
precipitate, easily soluble in excess; phosphomolybdic 
acid, white, crystalline precipitate ; bismuth-potassium 
iodide, red, crystalline needles; iodine in potassium 
iodide, or in hydriodic acid, brown crystals ; picric acid, 
yellow needles ; potassium chromate and sulphuric acid, 
red-brown, evanescent precipitate; ferric chloride and 
potassium ferricyanide, faint-blue color. The free base 
Bie distinct blue with ferric chloride and ferricy- 
anide. 

Putrescine, CyHieNe, is another base found by Brie- 
ger to accompany cadaverine. It is a clear, rather thin 
liquid of a disagreeable odor, resembling that of the pyri- 
dine bases; boils at 156°-157° C.; capable of distillation 
unchanged ; absorbs carbon dioxide energetically from 
the air. Its chloride forms long, clear, transparent nee- 
dles, is not hygroscopic, is readily soluble in water, spar- 
ingly soluble in dilute alcohol, and insoluble in absolute 
alcohol. .The reactions of the chloride are: Phospho- 
tungstic acid, white precipitate ; phosphomolybdic acid, 
yellow precipitate ; potassium iodhydrargyrate and bis- 
muth-potassium iodide, amorphous precipitates, becom- 
ing crystalline ; iodine in potassium iodide, or in hydrio- 
dic acid, brown, crystalline precipitates ; picric acid, 
well-formed, broad, difficultly soluble needles. The 


61 


Ptomaines. 
Ptomaines. 


chloroplatinate of putrescine forms six-sided plates, as 
does also the chloraurate. Putrescine is not a homologue 
of cadaverine, but is probably either dimethylethylene- 
diamine or methylethylmethylenediamine. 

Saprine, CsHieNa, is still another base, formed under 
similar conditions with cadaverine, and distinguished 
from it by a greater solubility and different crystalline 
form of its chloroplatinate, by the absence of a compound 
with auric chloride, by the permanence of its chloride in 
air, and by its failure to give the reaction with potassiu 
chromate and sulphuric acid. 

Neither of the above-mentioned alkaloids is possessed 
of toxic qualities, with the exception of choline, and that 
only when administered in large quantity. It is probable 
that the poisonous effects produced by inoculation with 
cadaveric matter during the earlier days of putrefaction 
are due to substances such as the peptotoxine mentioned 
below and produced along with the peptones, which are 
among the first products of putrefaction. 

Brieger obtained from human cadaveric matter two al- 
kaloids possessed of actively poisonous qualities : 

Mydalein, observed in small amount after seven days 
of free exposure to air, and increasing in amount up to 
three weeks. The amount of this base obtained was in- 
sufficient to determine its composition, further than that 
its chloroplatinate contains Pt., 38.74; C., 10.83; H., 3.23 
per cent. ; from which the inference is drawn that it is a 
diamine, closely related to the ptomaines above described. 
The chloride crystallizes with great difficulty, is very 
hygroscopic, and gives the following reactions : Platinic 
chloride, microscopic needles arranged in bundles; auric 
chloride, oily drops; phosphomolybdic acid, yellow, 
amorphous precipitate ; phosphotungstic acid, white pre- 
cipitate, soluble in excess ; potassium iodhydrargyrate, 
yellow, oily drops; bismuth-potassium iodide, iodine in 
potassium iodide, and iodine in hydriodic acid, dirty- 
brown, oily drops; picric acid, a yellow oil; ferric chlo- 
ride and potassium ferricyanide, immediate, intense blue 
color. 

This alkaloid, administered to rabbits and guinea-pigs 
in very small quantity by hypodermic injection, pro- 
duces the following effects: The lower lip becomes, 
moist, the nasal and lachrymal secretions become very 
abundant, the pupils are dilated and insensible to light, 
the vessels of the ear are injected, the rectal temperature 
rises 1° to 2° C., the respiration and cardiac action are at 
first accelerated, the animal exhibits a tendency to sleep, 
and the peristaltic action of the intestines is augmented. 
The symptoms gradually abate and the animal recovers. 

With larger doses (less than five milligrams=+%, grain), 
administered to guinea-pigs, the action is intense and 
terminates in death. The secretion of organs provided 
with unstriped muscular fibres becomes very profuse. 
The pupils are widely dilated. There is exophthalmus. 
The animal falls; the posterior extremities being first 
paralyzed, then the anterior; and there occur fibrillar 
spasms of various groups of muscles. Sometimes the 
animal springs up and immediately falls, making faint 
motions of the legs. The body-temperature falls gradu- 
ally ; the movements become more and more faint, and 
the animal dies. The heart is arrested in diastole, and the 
intestines and bladder are found contracted after death. 

Five milligrams of the chloride administered to a 
small cat caused death. There is immediate dilatation 
and insensibility of the pupils; the lachrymal secretion 
is very abundant. Profuse diarrhoea and vomiting of 
whitish masses follow. The secretion of saliva and 
perspiration become very profuse. The animal becomes 
lethargic, then suddenly springs up with accelerated 
respiration, and immediately sinks back. The secretion 
of alkaline, ropy saliva continues to increase. Violent 
convulsions occur. Soon the posterior extremities be- 
come paralyzed, afterward the anterior, while the ab- 
dominal and dorsal muscles contract spasmodically, and 
the animal lies with the head pressed down and the ex- 
tremities extended. The respiration, at first very fre- 
quent, becomes slow and labored. The animal dies in 
a State of sopor. After death the heart is found to be 
arrested in diastole, and the intestine, whose mucous 


62 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


membrane is somewhat injected, contains a thin, fluid 
secretion. 
_ By the putrefaction of muscular tissue in the presence 
of water, at the temperature of incubation, for five to 
six days, Brieger obtained, besides neuridine, an alkaloid 
possessed of distinctly poisonous characters : 

Neurine, CsHi;NO = Trimethylvinyl ammonium hy- 


(CHs)s } 


drate, (CH) cN ,OH (see choline, supra). A base whose 


chloroplatinate erystallizes in fine, well-defined octa- 
hedra, almost insoluble in water ; and whose chloraurate 
crystallizes in flat prisms. Its chloride behaves with 
general reagents as follows: Phosphomolybdic acid, 
white, crystalline precipitate, insoluble in excess; phos- 
photungstic acid, nothing; phosphoantimonic acid, vo- 
luminous, white precipitate ; potassium iodhydrargyrate, 
voluminous, yellowish-white precipitate ; bismuth-potas- 
sium iodide, amorphous, red precipitate ; cadmium-potas- 
sium iodide, white precipitate ; iodine in potassium iodide, 
iodine in hydriodic acid, amorphous, brown precipitates ; 
tannic acid, voluminous, dirty-white precipitate; mercuric 
chloride, granular, white precipitate. 

When administered to frogs, mice, guinea-pigs, rab- | 
bits, and cats, hypodermically, the chloride of this alka- 
loid produces symptoms closely resembling those caused 
by muscarine. Cats are more susceptible to its action 
than the other mammals experimented on. 

The administration of the poison to rabbits is soon fol- 
lowed by marked moisture of the nostrils and lips. 
Movements of mastication follow, accompanied by the 
discharge of copious, thick, tenacious fluid from the 
angles of the mouth. There is profuse secretion of 
saliva, which is at first thick and viscid, then thin and 
alkaline. The increased secretion of saliva continues 
until the termination of the poisoning, and varies in de- 
gree with the magnitude of the dose. Subsequently 
there is increased secretion from the Schneiderian mu- 
cous membrane and the lachrymal glands, the latter of 
short duration. The respiratory movements are at first 
more frequent and deeper than normal; the extraordi- 
nary respiratory muscles are brought into action, the 
head thrown back, and the nostrils dilated. These symp- 
toms of dyspnecea alter in character as death approaches, 
in that the movements become irregular, superficial, and 
less frequent. The heart’s action immediately after the 
injection is accelerated, so that the pulse cannot be 
counted. Ina short time it becomes slower, and dimin- 
ishes constantly in frequency. The pulsations are at 
first very strong, but subsequently become progressively 
weaker until the heart is arrested in complete diastole. 
The heart’s action continues after cessation of respira- 
tion. Section of the vagi has no influence, and the heart 
responds to artificial stimuli. Occasionally contraction 
of the pupils occurs, an effect which almost always fol- 
lows an application of a strong solution of the poison to 
the eye. Powerful peristalsis is an early symptom, caus- 
ing an uninterrupted voiding of matters, at first consist- 
ent, subsequently watery. Ejaculation and dripping of 
urine also occur. If the abdomen be opened at this 
stage, tetanic contractions of greater or lesser portions of 
the intestine are seen. The spleen is also strongly con- 
tracted. Only when lethal doses are given do strong 
clonic convulsions occur, in which the animal soon dies. 
These convulsions are partially controlled by artificial 
respiration, but they soon recur. Locomotion is inter- 
fered with, the posterior extremities being first paralyzed, 
then the anterior, before the beginning of the convulsions. 
In cats there is an increased secretion of alkaline perspira- 
tion. Atropine is a powerful antidote; but atropinized 
animals are still subject to the action of the poison. 
When taken by the mouth this alkaloid produces the 
same effects as when administered hypodermically, but 
ten times the dose is required. 

Mydine, CzHi:NO, is a base obtained by Brieger from 
human cadaveric matter which had been in putrefaction 
four months at a temperature of +5° to —9° C. in closed 
vessels. The free alkaloid is strongly alkaline, has an 
ammoniacal odor, and is a strong reducing agent. Its 
chloroplatinate is very soluble. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


From auric-chloride solution it precipitates metallic 
gold. Its picrate crystallizes in bruad prisms, which 
fuse at 195° C. Its chloride gives a blue color with fer- 
ric chloride and potassium ferricyanide. It is non-poi- 
sonous. 

From horse-flesh which had undergone four months’ 
putrefaction, at & low temperature and without exposure 
to air, Brieger obtained three poisonous substances. One 
of these is a non-alkaloidal body, C;Hi;,N Oz, probably an 
amido-acid, which acts upon frogs somewhat like curare. 
The other two are alkaloids. 

Mydatoxine, CeHisNO2z. The free base is a strongly 
alkaline syrup, which crystallizes im vacuo ; insoluble in 
alcohol and ether ; decomposed by distillation. Its chlo- 
ride is a colorless, thin syrup, which forms no double salt 
with auric chloride, and with platinic chloride a very 
soluble double salt, which fuses and is decomposed at 
198° C. 

Administered subcutaneously to guinea-pigs, the chlo- 
ride of this base causes increase in the frequency of the 
‘respiration ; at first contraction, and later dilatation and 
insensibility, of the pupils; and diminution of tempera- 
ture, with short chills. Clonic convulsions, frequently 
of such intensity that the animal is involuntarily pro- 
jected forward, recur at short intervals. The secretions 
of the salivary and lachrymal glands become more abun- 
dant. The body-temperature falls, and the respiration 
becomes less frequent. The ears, at first injected, be- 
come pale and cold. The extremities are paralyzed. The 
cardiac action becomes irregular and less frequent. Con- 
vulsions are provoked by striking upon the table sup- 
porting the animal. Shortly before death the convul- 
sions become less strong, the extremities are extended, 
the animal falls upon its side and dies, After death the 
heart is found arrested in. diastole, the intestines strongly 
contracted, and the bladder empty and contracted. 


Methylguanidine, C:H;N; = NH = cg Sree 


Methyluramine, a colorless, highly hygroscopic, and 
strongly alkaline base, whose chloride crystallizes in 
prisms, insoluble in alcohol. The chloroplatinate crys- 
tallizes in very soluble needles. The picrate crystallizes 
in needles, which are sparingly soluble in water, and fuse 
at 192° C. 

This substance is undoubtedly produced by an oxida- 
tion of creatin, to which it is closely related. 

Methylguanidine is poisonous. Administered hypo- 
dermically to guinea-pigs, it causes copious diarrhoea and 
increased secretion of urine. The pupils are rapidly di- 
lated and are insensible to light. The animal remains 
in one position, even when irritated. It soon becomes 
restless and seeks to move with the anterior extremities. 
The posterior extremities refuse to perform their func- 
tion. The respiration becomes progressively deeper and 
more labored. The head is moved from side to side. 
The legs become paralyzed, and there is marked dysp- 
nea. The animal falls upon its side and dies, after short, 
general clonic convulsions. After death the heart is 
found in diastole, the intestine filled with fluid, the blad- 
der contracted, the cortical portion of the kidneys hyper- 
szemic, and the papillary portion pale. 

Gautier and Etard have described two substances ob- 
tained from putrid meat, which they consider as identi- 
cal with the pyridine bases parvoline and hydrocollidine, 
although their analyses do not accord closely with the 
amounts required by theory. The first of these alkaloids 
isan amber-colored oil, boiling at 200° C., sparingly sol- 
uble in water, and forming a very soluble chloroplatinate 
and a. sparingly soluble chloraurate. The second is a 
colorless oil, having a penetrating odor, which becomes 
viscid and resinous when exposed to air; absorbs car- 
bonic acid ; boils at 210° C. Its chloraurate is soluble and 
readily decomposed ; its chloroplatinate, crystalline, pale- 
yellow, and sparingly soluble. : 

Ehrenberg (Zeitschr. f. Physiol. Chem., 1887, xi., p. 2389) 
obtained choline, neuridine, dimethylamine, and _tri- 
methylamine from sausages which had been the cause of 
ea poisoning of a number of persons, of whom three 

ied. 


Ptomaines. 
Ptomaines, 


PTOMAINES FROM PutrRipD Fisn.—Brieger, operating 
with the flesh of a species of cod (Gadus callarias) sub- 
jected to putrefaction with contact of air, obtained, be- 
sides neuridine, three ptomaines, two of which are ac- 
tively-poisonous : 

A base, C2HsNo, isomeric but not identical with ethyl- 
idendiamine, whose chloride crystallizes in long, brilliant 
needles, easily soluble in water, insoluble in absolute al- 
cohol. It does not form a chloraurate. The chloroplati- 
nate crystallizes in small, yellow scales, sparingly soluble 
in water. The chloride forms with phosphomolybdic 
acid a white precipitate ; with phosphoantimonic acid 
a yellowish-white precipitate, soluble in excess ; with bis- 
muth-potassium iodide a red, crystalline precipitate. 
With other general reagents no precipitates are formed. 
The-free base may be distilled from caustic soda without 
decomposition. 

This base, administered hypodermically in small quan- 


tity to mice and guinea-pigs, produces in a short time in- 


creased secretions of the nasal mucus, saliya, and tears, 
which are subsequently temporarily arrested, to begin 
again later. The pupils are dilated and the globes pro- 
truded. There is marked dyspnoea, which continues 
until the death of the animal within twenty-four hours. 

Muscarine, CsH1;NOs, identical with the alkaloid ob- 
tained from Agaricus muscarius and with that obtained 
synthetically from choline, forms a chloride which crys- 
tallizes with difficulty, and a chloroplatinate which crys- 
tallizes in octahedra. 2 

This ptomaine, administered in very small quantities 
to frogs, causes total paralysis and arrest of the heart in 
diastole. The administration of atropine to frogs under 
the influence of this base revives the action of the heart, 
and the effects of the ptomaine are not observed in atro- 
pinized animals. 

Minute doses, administered hypodermically to rabbits, 
cause greatly increased.salivary and lachrymal secretions, 
contraction of the pupils, profuse diarrhcea, ejaculation, 
voiding of urine, and death after convulsions of short 
duration. 

Gadinine, C;H,;,NOz (not to be confounded with the 
brown substance from cod-liver oil, to which De Jongh 
gave the same name), is a base whose chloroplatinate 
crystallizes in golden-yellow scales, sparingly soluble in 
water, and whose chloride crystallizes in thick, colorless 
needles, soluble in water, but insoluble in alcohol. No 
chloraurate exists. Crystalline precipitates are formed 
with phosphotungstic, phosphomolybdic, and _ picric 
acids. It appears to be non-poisonous, 

Bocklisch obtained from putrid fish cadaverine, putres- 
cine, neuridine, methylamine, trimethylamine, and ethyl- 
amine. The most abundant and uniformly present were 
cadaverine, putrescine, and methylamine. In the first 
stages, cadaverine was detected without putrescine, which 
subsequently exceeded the former alkaloid in amount. 
Large quantities of trimethylamine, accompanied by 
methylamine, are formed in the putrefaction of herrings. 
Both of these bodies have been long known to exist in 
herring-pickle. The same pickle also contains choline, 
which yields trimethylamine on decomposition. 

Methylamine is the predominating base produced by 
the putrefaction of pike. 

None of the bases isolated by Bocklisch is actively 
poisonous, although the extracts from which they were 
separated had markedly toxic powers. 

PTOMAINES FROM CHEESE.—F rom cream-cheese which 
had undergone complete putrefaction, Brieger obtained 
neuridine and trimethylamine. 

Vaughan (Zedtschr. f. Physiol. Chem., x., 146) obtained 
from cheese, which had caused symptoms of poisoning, 
a crystalline substance which caused, when placed upon 
the tongue, a sharp, burning sensation, dryness of the 
throat, a sense of discomfort, and diarrhcea. This sub- 
stance, whose composition was not determined, although 
the unusually constructed name tyrotoxicon was given it, 
produces a blue color with ferric chloride and potassium 
ferricyanide, and reduces hydriodic acid ; but it does not 
react with the general reagents for the alkaloids. It is 
readily soluble in water, alcohol, and ether. 


63 


Ptomaines. 
Ptomaines. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


PTOMAINES FROM PUTRID GELATINE.—Nencki, in 1876, 
was the first to determine the composition of an animal 
alkaloid. To the product which he obtained he gave the 
name of collidine, CsHi1.N. This base was produced by 
the decomposition of a mixture of gelatine, ox-pancreas, 
and water, during five days at 40° C. The free base is 
an oily substance, of a peculiar but not disagreeable odor, 
which absorbs carbonic acid from the air, to form scale- 
like crystals of a carbonate. The chloroplatinate crys- 
tallizes in fine, flat needles. Nencki considered this base 
/CHs 
\N Ha 

Brieger subjected a strong solution of glue to putre- 
faction for ten days at 35° C. and obtained considerable 
quantities of neuridine, some dimethylamine, and a small 
quantity of a substance having a physiological action 
similar to that of muscarine. 

ProMAINES FROM Porsonous MussEeits.—In 1885 a 
number of cases of serious poisoning occurred at Wil- 
helmshaven in consequence of eating mussels (Mytilus 
edulis) (see below). From the fresh mollusks (living at the 
outset of the process) Brieger obtained, besides other bases, 
a poisonous alkaloid, to whose action their toxic qualities 
are due: Mytilotovine, CsHisNO2. The free base has a 
disagreeable odor, which it loses rapidly on exposure to 
air, and at the same time it becomes non-poisonous. It is 
decomposed on being heated with caustic potassa. Its 
chloride crystallizes in tetrahedra and is intensely poi- 
sonous, causing the same symptoms as the mussels. The 
chloraurate crystallizes in microscopic cubes, which fuse 
at 182° C. With the customary general reagents only 
oily precipitates are produced. 

The remaining bases are non-poisonous, and consist 
chiefly of betaine=oxyneurine, CsHi,NOsz. 

The poisonous mussels, when allowed to putrefy six- 
teen days, contain no poisonous base, but yield cadav- 
erine, putrescine, and notable quantities of trimethyl- 
amine. 

ALKALOIDS PRODUCED IN THE NORMAL Livine Bopy. 
—In 1849, Liebig obtained creatinine, CsH;N;0, from 
the urine of the dog, and the same body was subse- 
quently obtained by Pettenkofer from normal human 
urine, by Sokoloff from the urine of the calf, and by 
Valenciennes and Frémy from the muscular tissue of 
crustaceans. The occurrence, in the situations named, 
of this substance, which is alkaline in reaction, caustic, 
and capable of neutralizing acids, and of displacing am- 
monia from the ammoniacal salts, proves that an alka- 
loid may be produced in the normal living body. 

It would seem probable that the rapidly lethal secre- 
tion of the poison-glands of certain serpents owes its 
activity to the presence of an alkaloid, yet the researches 
of Gautier (Bull. Acad. d. Méd. d. Paris, 2 Sér., x., 947) 
-with the poison of the cobra capello (Naja tripudians) 
indicate that, although the secretion contains two rel- 
atively non-poisonous alkaloids, the most actively poi- 
sonous constituent of the venom is not alkaloidal in 
character, although it contains nitrogen, 

From the poisonous secretion of the salamander (Sala- 
mandra maculata), however, Zalesky (‘‘ Med. Chem. 
Unt.,” i., 85) obtained an alkaloid capable of producing 
effects similar to those caused by the secretion itself— 
anxiety, trembling, epileptiform convulsions, opisthot- 
onos, and death. This alkaloid, salamandrine, CssH60 
N:;O;, is amorphous, soluble in water and in alcohol, 
and strongly alkaline. 

Gautier (‘‘ Ptomaines et Leucomaines,”’ Paris, 1886) de- 
scribes several bases as having been obtained from fresh 
beef and from Liebig’s meat-extract. For these and 
similar substances produced in the body during life he 
has suggested the name leucomaines (Acvkwua = white of 
egg), as indicating their probable origin from the albu- 
minoids. 

Xanthocreatine, CsHioN.O, crystallizes in thin, sul- 
phur-yellow, micaceous plates, resembling those of cho- 
lesterine in fotm, and greasy to the touch. Its taste is 
faintly bitter and, in quantity, it gives off a faint cadav- 
eric odor. Itis very soluble in water, and soluble in hot, 
strong alcohol. Its reaction is amphoteric. It resem- 


as being isophenylethylamine, CsH;—CH 


64 


bles creatinine in its properties. Potassium iodhydrargy- 
rate and iodine in potassium iodide cause no precipitates 
in the solutions, but phosphomolybdic acid causes a 
grumous, yellow precipitate. ; 

‘‘Xanthocreatine is poisonous in moderate dose. It 
causes depression, somnolence, extreme fatigue, defeca- 
tions, and repeated vomitings in animals.” 

Crusocreatinine, CsHsN.4O, is a crystalline substance of 
an orange-yellow color, feebly alkaline, and slightly bit- 
ter, whose chloride and chloroplatinate crystallize in ea- 
sily soluble needles, and whose chloraurate forms diffi- 
cultly soluble granules, which are decomposed by heat. 
It also resembles creatinine in its properties. 

Amphicreatine, CysHi9N;O.4, crystallizes in brilliant, 
oblique prisms of a yellowish-white color. It is tasteless 
and faintly basic. It resembles creatine in its properties. 

Pseudoxanthine, CsH;N;0, is a sulphur-yellow, crys- 
talline body, resembling xanthine in its chemical and 
physical properties. 

Besides the above, Gautier mentions two unnamed sub- 
stances, C.;HesHi0Os and Ci2HesNii0s, as obtained 
from normal muscular tissue. 

These bodies are closely related to each other, and to 
creatine and creatinine; and the influence of the addition 
or removal of the group CHN in their formation is of in- 
terest, particularly when considered in connection with 
the recent discovery of a polymere of hydrocyanic acid, 
the adenine of Kossel. 

Adenine (aifv = a gland), C;H;Ns, is a basic substance, 
although neutral in reaction, obtained by Kossel (Zeitsch. 
f. Physiol. Chem., 1886, x., p. 250) from the pancreas 
of the ox, and as a product of decomposition of nuclein. 
It crystallizes in long needles, easily soluble in hot but 
difficultly soluble in cold water, insoluble in ether, chloro- 
form, and alcohol. It forms well-defined salts with min- 
eral acids. By the action of potassium nitrite it is con- 
verted into hypoxanthine, C;H,N,O. When heated with 
caustic potash to 200° C. a large quantity of potassium 
cyanide is produced. 

Urinary Alkaloids.—Besides creatinine, whose pres- 
ence in normal urine is unquestioned, other alkaloids have 
been supposed to exist in that liquid. It has further 
been claimed (Picard, Schéltin, Oppler, Chalret, et ai.) 
that the symptoms of urgzemic poisoning are due, not so 
much to the retention of urea, as to the retention of cer- 
tain toxic alkaloidal bodies included in the so-called ex- 
tractive matters of the urine. 

While it may be considered as probable that the urine 
under pathological conditions may contain alkaloidal 
substances, and even possible that such bodies may be 
produced in minute quantity by the normal organism, 
from which it is separated by the urine, the evidence in 
favor of such views is as yet entirely physiological and 
unsupported by isolation and identification of any sup- 
posed alkaloid. 

Charrin and Roger (Comptes Rendus Soc. d. Biol., 
ili., 607, Paris, 1886), experimenting upon rabbits, found 
human urine to be less poisonous to those animals than 
their own. The former in doses of forty cubic centi- 
metres, in intravenous injection, causes punctiform con- 
traction of the pupil immediately, exorbitism and injec- 
tion of the vessels of the ear, followed by a semicomatose 
condition, sometimes interrupted by slight convulsive 
movements, in which the animal dies. With. fifteen 
cubic centimetres of rabbit’s urine there is neither ex- 
orbitism nor dilatation of the auricular vessels, but there 
are extremely violent tetanic convulsions. Immediately 
after death the heart is found arrested. . 

The authors consider that seventy-five to eighty per 
cent. of the toxicity of urine so administered is due to 
the action of the potassium salts. While the potassium 
salts are unquestionably poisonous, and therefore may 
be justly credited with a considerable share in the toxic 
effects of urine, their action does not correspond closely 
with the symptoms described ; and the differences be- 
tween the action of urines of different animals would 
seem to indicate the existence in them of different poi- 
sons, whether they be or be not alkaloidal. 

Peptic Alkaloids.—The actively poisonous effects pro- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


duced by inoculation with recent cadaveric matter cannot 
be ascribed to any of the alkaloids above mentioned, as 
those which are produced during the earlier stages of 
putrefaction are either non-poisonous or only slightly 
toxic, the actively poisonous alkaloids being only pro- 
duced at a later stage. 

One of the earliest products of putrefaction is a sub- 

stance seemingly identical with the peptone produced by 
the action of pepsin or trypsin upon albuminoids, and 
formed, probably, in cadaveric matter in a similar man- 
ner by false ferments, similar to those of the gastric and 
pancreatic secretions existing in the animal tissues. As 
it has been shown by numerous experiments (Schmidt- 
Miihlheim, Hoffmeister, Faus, et al.) that a solution of 
peptone, when injected into the circulation, causes vio- 
lent symptoms of poisoning, the supposition that the poi- 
sonous qualities of recent cadaveric matter is due to pep- 
tone, or to some substance formed at the same time with 
peptone, is not strained. 
_ Indeed, Brieger (doc. c7t., i., 14) has separated from pep- 
tone, produced by the action of pepsin from the pig 
upon fresh fibrin, a substance (or mixture of substances) 
whose composition was not determined, but which pre- 
sents some of the characters of the alkaloids, and to 
which the name peptotoxine was given. 

This substance, which is actively poisonous in minute 
doses, crystallizes with difficulty, passes from both acid 
and alkaline aqueous solutions into amylic alcohol, is 
insoluble in ether, benzol, and chloroform, and very 
soluble in water. It is quite stable, and is not decom- 
posed by boiling, or by treatment with sulphuretted hy- 
drogen or with caustic alkalies. Its solutions are neu- 
tral. With Millon’s reagent it gives a white precipitate, 
which turns bright red on the application of heat.- Its 
solutions form precipitates with phosphomolybdic acid, 
phosphotungstic acid, cadmium-potassium iodide, potas- 
sium iodhydrargyrate, cadmium-bismuth iodide, auric 
chloride, mercuric chloride, iodine in potassium iodide, 
and iodine in hydriodic acid. With potassium ferricy- 
anide and ferric chloride it forms Prussian blue. 

The same -substance was obtained from Witte’s pep- 
tone, and from putrefying fibrin, casein, brain, liver, and 
muscular tissues. If putrefaction has lasted eight days 
it is no longer obtainable. 

PATHOGENIC ProMaAiNEs. —Spica, in 1880 (Gaz. Chim., 
x., 492), seems to have been the first to have obtained a 
ptomaine from a pathological product during life. 

As albuminoid substances, under process of putrefac- 
tion after death, produce alkaloidal substances, some of 
which are non-poisonous, while others are actively toxic, 
it seemed probable at an early period of the history of 
the ptomaines that the same or similar substances might 
be produced during life, and that, if produced, they 
might be the causes of certain pathological manifes- 
tations. 

The researches of Koch and his followers have brought 
to light a number of well-defined pathogenic bacteria, 
the method of whose action seemed to be the most read- 
ily accounted for on the hypothesis that alkaloids or 
other poisons are produced during the processes of nutri- 
tion of these minute organisms. This view was strength- 
ened by the observation of Passet (Portschritte d. Me- 
dicin, lii.), that eight varieties of bacteria, cultivated 
from pus, were capable of producing lactic fermentation 
in sterilized milk ; as well as by that of Brieger, that the 
pneumococcus of Friedlander and Frobenius is capable 
of producing formic and acetic acids and alcohol from 
carbohydrates. 

Within the past two years the labors of Nicati and 
Rietsch, Pouchet, Villiers, and Brieger, have resulted in 
the separation and identification of several poisonous 
alkaloids from nutrient material in which pathogenic 
bacteria had been cultivated, as well as from the tissues 
and dejections of patients suffering from cholera and 
other diseases. 

Ptomaine of Asiatic Cholera.—Villiers (Journ. d. 
Pharm, et d. Ohimie, 1885, Sér. 5, xi., p. 257) isolated 
0.02 gramme of the chloride of a well-defined alkaloid 
from the internal organs of two cholera-patients. This 


Vou. VI.—5 


Ptomaines, 
Ptomaines. 


base as well as its salts gave the following reactions: 
Potassium iodhydrargyrate, white precipitate ; iodine in 
potassium iodide, brown precipitate ; bromine-water and 
picric acid, yellow precipitate ; auric chloride, light- 
yellow precipitate ; tannin and mercuric chloride, white 
precipitates from concentrated solutions ; platinic chlo- 
ride and potassium dichromate, nothing; ferric chloride 
and potassium ferricyanide gave a blue color only after 
a time ; sulphuric acid, a faint violet color, which soon 
disappeared. A guinea-pig which received 0.006 gramme 
of the alkaloid was seized in forty-five minutes with 
violent trembling of the anterior extremities, soon ex- 
tending to the posterior also, and then diminishing and 
disappearing. The animal refused food for four days, 
when it died suddenly. 

Nicati and Rietsch (Journ. d. Pharm. et d. Chimie, 
1885, Sér. 5, xii., p. 292) obtained a fluid alkaloid by the 
Stas method from cultures of the comma bacillus. This 
base is volatile at 100°, and produces the same physiolog- 
ical action as the cultures. They obtained an identical 
substance from the blooa and liver, removed two hours 
after death, from the body of one who had died suddenly 
in the algid stage of cholera. The same authors (doe. cit., 
p. 385), in repeating their experiments under varying 
conditions, found the poisonous alkaloid to be produced 
in greatest amount at 35° after about ten days. 

Pouchet (Comptes Rendus, c., 220-222; ci., 510, 511) 
isolated from the watery and almost colorless feces 
of a cholera-patient an oily alkaloid, soluble in chloro- 
form, possessed of the odor of the pyridine bases. It 
responds to the general reagents for alkaloids, and ener- 
getically reduces potassium ferricyanide, auric chloride, 
and platinic chloride. Its chloride is easily dissociated 
by heat or im vacuo. It produces actively poisonous 
effects, even when its vapor is inhaled. Traces of the 
Same substance were found in the nutrient material of 
Koch’s microbes. _ 

Ptomaine of Typhus.—Brieger (‘‘ Ptomaine,” ii., 68 ; iii., 
85) obtained a base from cultures of the Koch-Eberth 
typhus bacillus in meat at a temperature of 37.5° to 88° 
C. for eight to fourteen days. This alkaloid has the 
composition C;H,;NOsz, and has been named typhotozine. 
The chloride is hygroscopic, forms an easily soluble 
chloroplatinate, crystallizing in needles ; also a difficultly 
soluble chloraurate, crystallizing in prisms, which fuse 
at 176° C., and a difficultly soluble picrate. With re- 


agents it behaves as follows: Phosphomolybdic acid, yel- 


low, crystalline precipitate ; phosphotungstic acid, white, 
crystalline precipitate ; potassium-cadmium iodide, potas- 
sium iodhydrargyrate, iodine in potassium iodide, iodine 
in hydriodic acid, oily, non-crystalline precipitates ; bis- 
muth-potassium iodide, resinous precipitate. With 
Ehrlich’s reagent (sulphodiazobenzol) it gives an im- 
mediate yellow color, which disappears on addition of a 
base. In cultures from which no typhotoxine is ob- 
tained there is much creatine or creatinine, while in 
those giving the best yield of the alkaloid the normal 
constituent of the meat is present in less amount. In 
bouillon, to which three per cent. of glycogen is added, 
the bacilli grow luxuriantly, without any decomposition 
of the glycogen. 

This alkaloid causes a moderate increase in the flow 
of saliva and an acceleration of respiration. Later the 
animals lose control of the muscles of the extremities, 
without suffering true paralysis ; they fall upon the side, 
and, if placed upon their feet, fall back helpless after a 
few steps forward. The pupils gradually dilate widely 
and become insensible. Convulsions do notoccur. The 
frequency of the heart’s action and the respiration gradu- 
ally. diminish. During the entire poisoning there is co- 
pious diarrhoea. After death the heart is always found 
contracted in systole, the lungs are highly hyperemic, 
the other organs pale. The intestines are always strongly 
contracted, and their walls pale. 

Ptomaines of Tetanus.—Brieger (‘‘Ptomaine,” iii., 89 ; 
‘‘Ber. d. Deutsch. Chem. Gesell.,” xix., p. 8119) experi- 
mented with cultures of an anaérobe bacillus found by 
Nicolaier in earth-samples and capable of producing 
symptoms of traumatic tetanus in animals, and with cult- 


65 


Ptomaines,. 
Ptomaines. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


ures of the same bacillus bred by Rosenbach from the 
wound of a man who died of tetanus. Two alkaloids 
endowed with similar physiological action were obtained. 

One of these bases, tetanine, CisH30NoO0u, is produced 
along with much ammonia. It forms a very soluble 
chloroplatinate, which crystallizes from alcohol in beauti- 
ful, light-yellow plates. The chloride is deliquescent 
and forms an easily soluble, crystalline compound with 
phosphomolybdic acid. With bismuth-potassium iodide 
it forms an amorphous precipitate, which soon becomes 

rystalline. The free base is a yellow, strongly alkaline 
syrup, which gives no blue color with ferric chloride and 
potassium ferricyanide. 

The free base or its chloride, injected into mice or 
guinea-pigs, soon causes clonic or tonic convulsions of 
the greatest intensity, which terminate in death. The 
course of the poisoning is divisible into two stages. In 
the first the animal is depressed and lethargic, then it be- 
comes suddenly uneasy and the diaphragm contracts 
energetically. The second stage is marked by convul- 
sions, usually tonic, but occasionally clonic. Death oc- 
curs frequently in a violent convulsion. Frogs with- 
stand the poison relatively better than warm-blooded 
animals, but when they succumb they become perfectly 
rigid in a position of pronounced opisthotonos. Guinea- 
pigs, when thoroughly under the influence of the alkaloid, 
exhibit very clearly the characteristic spasms of tetanus 
in the human subject and marked opisthotonos. 

The other tetanizing ptomaine has the composition 
C;H;,N, and is a volatile substance, boiling at 100° C. 
In relatively large doses it produces in animals fibrillar 
contractions of diverse groups of muscles, particularly 
those of the neck and face. Motion is more and more 
interfered with until paralysis is established. Convul- 
sions increase in intensity, attacking groups of muscles 
very violently. The animal lies with head thrown back 
and extremities extended, and, when pressed upon, makes 
movements as in swimming. Finally the animal falls 
upon its side and dies in a violent convulsion. 

CHEMICO-LEGAL CONSIDERATIONS.—AS the ptomaines, 
both those produced during putrefaction and those occur- 
ying as the products of pathogenic bacteria (the toxines 
of Brieger), as well as the so-called leucomaines, are true 
alkaloids, and as such are members of the same chemical 
group (function) as the vegetable alkaloids, the possibil- 
ity that one of the former may be mistaken for one of the 
latter in a chemico-legal examination of a cadaver is ob- 
vious. 

That such errors have actually occurred there can be 
no doubt. Three such cases are classical, and intimately 
connected with the history of the ptomaines. In the case of 
General Gibbone, who died in Rome under circumstances 
which awakened a suspicion of poisoning, two chemists 
who analyzed portions of the body were led to believe 
that death had been caused by delphinine. Upon a more 
careful examination, Selmi showed that the alkaloid ob- 
tained from the body of the deceased did not respond to 
several of the reactions of delphinine, and that it was not 
that alkaloid, but a ptomaine ; which was also shown, by 
Ciaccia and Vella, to differ from delphinine in that it 
caused arrest of the heart in systole, whereas in poisoning 
by the vegetable alkaloid the heart is arrested in diastole. 

In the case of the widow Sonzogno, who died in Cre- 
mona in 1878, the body was exhumed twelve days af- 
ter death, and the experts who made the analysis testi- 
fied upon the first trial, at Brescia, to having detected 
the presence of morphine, while three other experts con- 
sidered it probable that the substance isolated was a 
ptomaine. Selmi, to whom the matter was referred, 
showed conclusively, by an examination of the chemical 
and physiological properties of the isolated alkaloid, that 
it was not morphine, but a ptomaine. 

In the Brandes- Krebs case, tried in Brunswick in 1874, 
the two chemists who made the analysis claimed to have 
detected, besides arsenic, coniine. Otto, in a revision of 
the work, showed that the substance considered as coniine, 
although very similar to that alkaloid and to nicotine, 
could not be identical with either alkaloid or with any 
other known vegetable base. 


66 


The occurrence of mistakes like those mentioned, and 
the possibility of their recurrence, for a time cast doubts 
on the reliability of the tests for the vegetable alkaloids, 
and even formed an apparent foundation for the claim, 
on the part of defending counsel in cases of trial for 
alkaloidal poisoning, that all analytical results in such 
cases are unreliable and illusory. 

Although this extreme view is not well founded, the 
existence of the ptomaines renders the work of the toxi- 
cologist most difficult in cases of alkaloidal poisoning, 
particularly if the alkaloid used be one of infrequent 
occurrence, and makes it incumbent upon him to exer- 
cise the greatest caution and deliberation before reaching 
a conclusion, which can only be arrived at with certainty 
after an exhaustive analysis with every known test. 

Attempts have been made to devise some test or tests 
by which the ptomaines as a class might be differentiated 
from the vegetable alkaloids. Nosuch reagent has been 
found, nor will it be. The ptomaines are as distinctly 
alkaloidal in their nature as the vegetable alkaloids, and 
are therefore possessed of all the characterizing proper- 
ties of the group, and, consequently, any quality or reac- 


tion common to all ptomaines will be found to be pos- . 


sessed by the vegetable alkaloids as well. No reagent 
is known by which vegetable acids can be distinguished 
from those of animal origin, although such acids were 
among the earliest known organic compounds. 

The principal reagents by which it has been claimed 
that the ptomaines might be distinguished from vege- 


table alkaloids are those of Brouardel and Boutmy,* 


and of Trotarelli. 

The reaction of Brouardel and Boutmy consists in the 
formation of a blue color with ferric chloride and _ potas- 
sium ferricyanide, which, it was claimed, was brought 
about by the ptomaines, and not by the vegetable alka- 
loids. This reaction, due to the reduction of the ferri- 
cyanide to ferrocyanide and the formation of Prussian 
blue, is based upon the facility with which the ptomaines 
are oxidized and their consequent reducing action. There 
exist, however, ptomaines (see tetanine, swpra) contain- 
ing oxygen which fail to respond. On the other hand, 
any substance endowed with reducing powers exhibits 
the reaction, and among such substances are the vege- 
table alkaloids morphine, apomorphine, muscarine, aconi- 
tine, eserine, liquid hyoscyamine, amorphous ergotinine, 
atropine, and strychnine. 

The reaction of Trotarelli consists in the addition of 
sodium nitroprusside and then paladium nitrate to the 
material under examination. With the ptomainesa play 
of colors is observed. The reaction is no more reliable 
to differentiate the ptomaines from the vegetable alka- 
loids than that of Brouardel and Boutmy. 

Notwithstanding the failure of such reactions, it is 
possible to clearly establish the presence or absence of 
vegetable alkaloids without possibility of error due to 
the presence of ptomaines. No single reaction can be 
relied upon, even with alkaloids giving such marked re- 
actions as strychnine and morphine. In cases of sus- 
pected poisoning the identity of the alkaloid should be 
established by adi of its characters, chemical, physical, 
and physiological. Before applying the tests or deter- 
mining the physiological and physical properties of the 
alkaloid under examination, it should be separated in a 
condition as nearly approaching purity as possible. 

Many vegetable alkaloids resemble a corresponding 
ptomaine in one or more of its characters, but a differ- 
ence is found in others which will enable the two to be 
distinguished. Thus Wolkenhaar (Correspondenzbl. d. 
Ver, Anal. Chem., i., 83, 87) describes a ptomaine which 
resembles nicotine in that it is a yellowish liquid, turns 
brown in air, is completely volatile, and has the same 
odor, not disappearing on addition of oxalic acid, as ni- 
cotine, but differing from the alkaloid of tobacco in 
forming a non-crystallizable chloride and in failing to 
give Roussin’s reaction with iodine in ethereal solution. 
In a case tried in Verona, Ciotto mistook for strychnine 


* The reaction was first observed by Selmi, but was not considered by 
him as characteristic of ptomaines. 


e 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Ptomaines. 
Ptomaines, 


a ptomaine which gave crystals with iodine in hydriodic 
acid, was reddened by hydriodic acid, and gave with po- 
tassium dichromate and sulphuric acid a yellow precipi- 
tate and a blue or violet color, although it was not bitter 
and had no tetanizing action. Brouardel and Boutmy 
(Arch. d. Ph., Bd. 219, p. 462) met with a ptomaine in a 
cadaver that had laid in water eighteen months, which 
closely resembled veratrine in that it was colored violet 
when warmed with sulphuric acid, brick-red with sul- 
phuric acid and barium peroxide, and cherry-red when 
warmed with hydrochloric acid. It was distinguished 
from veratrine by the immediate reduction of ferricy- 
anide and the absence of the characteristic muscular 
spasms caused by the vegetable alkaloid. 

So far as known, no ptomaine has been obtained which 
corresponds in a// its characters with an alkaloid of vege- 
table origin, with the exception of muscarine. In a case 
of poisoning by that alkaloid its detection in the body 
after death could only serve as evidence confirmatory of 
that derived from an observation of the symptoms of 
muscarine-poisoning observed during life. 

SAUSAGE-PorsontIne (Allantiasis, Botulism).—In_ the 
latter part of the last and the beginning of the present 
century there occurred in Wirtemberg and the other 
states of Southwestern Germany numerous cases of se- 
rious and fatal poisoning, which were traceable to the 
ingestion of the different varieties of sausage which there 
form a staple article of diet. According to Buchner and 
Kerner, the first published record of a case of botulism is 


in the ‘‘ Acta phys. med. Colleg. Med. Onoldini,” 1735. . 


Schlossberger estimates that, up to 18538, about four 
hundred such cases had occurred in the district men- 
tioned, of which one hundred and fifty had terminated 
fatally. 

Although it is certain that many, if not the great ma- 
jority, of the older cases were not due to a poison, but 
to the then unrecognized trichina spiralis, well-defined 
cases of true botulism, with entire absence of trichine in 
either the sausages or the muscular tissue of the victim, 
have occurred in recent years, not only in Germany, but 
also in France, England, and the United States. 

The poisonous sausages are always liver- or blood-sau- 
sages, or others of large size, smoked, and more or less 
softened in the interior. The central portion is in some 
cases of a grayish tinge, pulpy, and has a rancid or sharp 
and somewhat acid taste. The cortical portion is some- 
times inert, while the central portion is actively poison- 


ous. The odor is sometimes musty, but in most cases in 
no way peculiar. The odor of putrefaction is not ob- 
served. 


It is highly probable that the poisonous character o 
such sausages is due to the formation in them of a pto- 
maine, although efforts to isolate the alkaloid have not 
proved successful. Schlossberger obtained from poison- 
ous sausages an ammonia having a nauseous odor, which 
he could not obtain from fresh ones (Maschka, Hand- 
buch d. Ger. M., ii., 514); and Ehrenberg obtained 
choline, neuridine, dimethylamine, and trimethylamine 
from a similar source (Zevtschr. f. Physiol. Chem., xi., 
239). None of these substances is, however, capable of 
causing symptoms resembling those of botulism, or pos- 
sessed of sufficiently active poisonous qualities to account 
for the violent effects of the sausage-poison. 

The action of the poison is usually manifested in from 
twelve to twenty-one hours after it has been taken, al- 
though Eichenberg (Diss., Géttingen, 1880) mentions a 
case in which two to three hours elapsed, and Kaatzer 
(Deutsch. Med. Wochenschr., 1881, vii.,) cites two cases in 
which the poisonous effects began in one hour. ‘The 
recorded cases with a longer interval than twenty-four 
hours are probably cases of parasitic disease. 

The total duration of the poisoning is very variable, as 
shown by the 48 cases cited by Miller (Deutsche Kl- 
nik, 1869, 1870), of which 6.died upon the first day, 19 
from the second to the seventh day, 16 from the eighth 
to the tenth day, 4 from the eleventh to the twenty-first 
day, and 3 after long illness. Recovery is usually slow, 
and may require several months. 

The earliest symptoms are usually gastric—nausea, ab- 


dominal pain, not intense, but increased on pressure ; 
vomiting of yellow, pulpy, sour, or bitter masses, and, not 
infrequently, purging. ‘These symptoms, which in light 
cases are sometimes the only ones observed, are never so 
intense as in cholera-morbus, and are never accompanied 
by the cyanosis and cramps which occur in poisoning by 
mussels, by certain varieties of fish, and by cheese. 

Following upon the gastric symptoms, either immedi- 
ately or after an interval of a day or more, or, in some 
cases, without the occurrence of gastric symptoms, the 
true poisonous action is established. The secretions are 
much diminished or arrested, the mouth, tongue, and 
pharynx are dry, and neither saliva, perspiration, nor 
tears are secreted. The skin is wrinkled and cool. The 
tongue is covered with a whitish coat, the buccal mu- 
cous membrane is marked with aphthous patches, and 
the pharynx is inflamed or ulcerated and coated with a 
grayish-white deposit. The voice is hoarse, and in some 
cases there is adry cough. The urine seems to be the 
only secretion which is not diminished. The nerve-sup- 
ply of the eye and ocular muscles is markedly interfered 
with. There is diminished vision, which may reach the 
point of temporary blindness ; objects appear colored and 
sometimes double, and the field of vision is traversed by 
sparks, The muscles moving the globe are partially par- 
alyzed and the pupil dilated. Paralysis of the levator 
palpebree superioris, with consequent ptosis, is character- 
istic. Interference with deglutition is a marked and con- 
stant symptom, and is frequently accompanied by inter- 
ference with the movements of the tongue and with 
hoarseness, or even aphonia. 

Apart from the above symptoms, referable to paraly- 
sis of individual cranial nerves, the cerebral functions 
and those of the spinal nerves are but little interfered 
with. Consciousness is perfect, almost up to the time of 
death. The functions of the sensory nerves remain un- 
impaired. There is great and progressive muscular weak- 
ness, which is probably due rather to the same cause as 
the progressive emaciation which also occurs—?.e., inter- 
ference with nutrition by dysphagia or aphagia—than to 
any action upon the motor spinal nerves. The patient 
complains chiefly of the derangements of vision and of 
attacks of suffocation. 

Death is caused in many cases by marasmus. In some 
cases suffocation, with or without preceding convulsions, 
is the cause of death ; or sometimes suffocation due to 
entrance of particles of food into the air-passages. 

The symptoms of botulism present some similarities to 
the action of certain poisons. The solanaceze—bella- 
donna, stramonium, and hyoscyamus, and the alkaloids 
obtained from them—produce not only dilatation of the 
pupil and paralysis of accommodation, but also marked 
dysphagia and diminution of the secretions. But they 
also produce cerebral symptoms—delirium and _ halluci- 
nations—which are absent in botulism. Moreover, the 
pulse is much more rapid in poisoning by the solanaceze 
than in botulism, and the course of the poisoning occu- 
pies much less time. 

The similarity between botulism and poisoning by gel- 
seminum or its alkaloid is still closer. The effects upon 
the eye and its muscles, including ptosis, are the same 
in the two forms of poisoning, which may, however, be 
readily distinguished by the much more rapid and, in 
cases of recovery, temporary action of the vegetable prod- 
uct. 

In trichinosis the mydriasis and paralysis of accommo- 
dation which occur in botulism are of very rare occur- 
rence, while the cerebral symptoms and sopor which are 
observed in the former do not occur in the latter. A 
positive diagnosis may be made after death, or even dur- 
ing life, by microscopic examination of the muscular 
tissue. 

No characteristic post-mortem appearances are recog- 
nizable. The body is emaciated, and the skin bleached 
and parchment-like. Rigor mortis begins early and con- 
tinues longer than usual, and putrefaction is delayed in 
some cases, but very rapid in others, The mucous mem- 
brane of the mouth and pharynx is often white, dry, 
and parchment-like, or horny. The gastric mucous 


67 


Ptomaines. 
Puberty. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


membrane is frequently injected and sometimes ecchy- 
motic. The spleen is sometimes enlarged, congested, 
and extremely soft and friable. The blood, as a rule, is 
dark, and contains no foreign organisms or elements. The 
corpuscles are unaltered. The lungs are frequently con- 
gested and cedematous. 

Porsonous Fisu.—Not only do fish become poisonous 
when putrid, but certain species are either always poi- 
sonous to the human subject or become so at times. In 
some cases the same fish, eaten with impunity by one 
person, proves actively poisonous to another. 

Poisonous fish are usually the inhabitants of warm cli- 
mates. Stuart Eldridge (Med. Times and Gaz., 1879, ii., 
377) mentions a Japanese fish, a species of Tetrodon, 
called by the natives fugu, whose use as food is inter- 
dicted by law. In three cases of poisoning by this fish, 
one of which terminated in death, the symptoms began in 
from fifteen to forty-five minutes. There were headache, 
nausea, great muscular weakness, failure of the pulse and 
respiration, diminution of temperature, and total insensi- 
bility. 

J nee Edwards (Brit. M. Journ., 1884, i., 10) records 
a case of poisoning in a man, aged sixty-eight, by the 
flesh of the ray. In fifteen minutes the face began to 
swell; there was a burning sensation in the hands and 
back of the head ; the feet were cold ; the tongue swelled 
until it filled the cavity of the mouth, causing a choking 
sensation at the root of the tongue ; the eyes were swol- 
len and protruded. The patient suffered no pain but 
great dyspnceea and thirst and an intense itching of the 
skin. Consciousness was perfect. The patient vomited 
freely and soon recovered. 

The roe appears to be the most actively poisonous 
portion of the fish. Belin (France Meéd., ii., 1458, Paris, 
1886) reports the poisoning of a man of thirty, caused 
by eating three roed herrings broiled; the symptoms 
being chiefly gastric, and very violent and persistent. 
The same author refers to cases reported by Goertz, in 
which three members of a family who ate fresh roed fish 
suffered violent symptoms, while the other members of 
the family who ate milt fish were not affected. Similar 
cases are reported by Miinchmeir (Berl. Klin. Wochschr., 
1875, xii., 4) and Naunyn (Schmidt's Jahrb., 1884, 113). 

Remy (Comptes Rendus Soc. Biol., 7 Sér., iv., 14, 268, 
Paris, 1883) also concludes that the ovaries are the seat 
of the poison in poisonous fish. 

It seems probable that fish-poisonings are due to the 
formation, either normally or in a diseased condition of 
the animal, of alkaloidal substances similar to that ob- 
tained by Brieger from poisonous mussels (see above), 
although no such substance has as yet been isolated. 

Poisonous MussEeuts.—The edible mussel (Mytilus 
edulis) frequently becomes actively poisonous, probably 
by reason of changes in the character of the surround- 
ing water. <A case is recorded (Guy’s Hosp. Rep., 1850, 
213) in which serious symptoms and a scarlatinal erup- 
tion were caused by eating two mussels, and another 
(Med. Times and Gaz., 1864, 496) in which similar effects 
followed the ingestion of a single mussel. Death has 
resulted in several instances (Med. Times and Gaz., July 
28, 1860; Lancet, 1878, i., pp. 247, 823; ‘‘ Fodéré Méd. 
Lég.,” iv., 85). 

Farrar (Brit. Med. Journ., 1882, i., 939) reports the case 
of a strong, temperate, well-built man of sixty who had 
been in the habit of eating mussels without ill effects. 
Immediately after eating about twenty, without remov- 
ing the ‘‘ moss,” or byssus, he felt sick and had griping 
abdominal pain. In half an hour he vomited and purged 
severely five or six times. In two anda half hours he 
was in a state of extreme collapse. The hands and feet 
were cold; the radial pulse was almost imperceptible and 
much increased in frequency. The face was pale, except 
occasional hectic flushes on the cheeks, the nose white, 
pinched, and quite bloodless, the pupils normal, the 
tongue clean. ‘There was loud wheezing and rattling 
respiration, with frequent yawning and sighing. The 
patient fainted frequently, in spite of large doses of 
brandy. There were repeated clonic spasms, apparently 
implicating all the muscles of the body. He was per- 


68 


fectly calm and conscious, suffering no pain but great 
thirst and itching over the entire surface. There was 
neither sense of constriction of the throat nor headache. 
Surrounding objects appeared misty. The chest was cov- 
ered with a rash resembling erythema. The next morn- 
ing recovery was complete. é 

It was found by Max Wolff (Arch. f. Path. Anat., civ., 
108, 202) that the mussels which caused the poisonings 
at Wilhelmshaven, in 1885, came from a basin contain- 
ing stagnant water, which was also the habitat of a poi- 
sonous star-fish (Asterias rubeus); but that the mussels 
from the neighborhood of the sluices, where the water was 
changed, were not poisonous. Schmidtman and Virchow 
(Arch. f. Path. Anat., civ., 161, 179) found that the 
poisonous mussels, when transplanted to pure sea-water, 
lost their poisonous qualities completely in from two 
to four weeks; while non-poisonous. mussels became 
actively toxic after two to three weeks’ sojourn in the 
stagnant water of the basin. The poisonous individuals 
have a somewhat lighter and more striped shell than 
such as are innocuous. As mentioned above, Brieger 
obtained a poisonous alkaloid from the poisonous mus- 
sels. | 

Poisonous CHEESE, MILK, BREAD.—It occasionally 
happens that a single cheese, produced along with many 
others at a properly conducted factory, causes symp- 
toms of violent, irritant poisoning in all who partake of 
it, without presenting any peculiarity of appearance, 
odor, or taste which would indicate its poisonous quali- 
ties to the human senses, although dogs and cats are able 
to distinguish the poisonous cheese from a sound one, 
apparently by the sense of smell. 

In cheese-poisoning the symptoms are chiefly those of 


‘irritant poisoning—severe vomiting and purging, dizzi- 


ness, and great prostration, beginning in from one to four 
hours. The pulse is feeble and irregular, and the face 
is markedly cyanosed. Although the symptoms are 
frequently very severe, no fatal case is recorded. 

The poisonous constituent of such cheeses, the so- 
called tyrotoxicon of Vaughan (vide supra), may either 
be produced by incipient putrefactive changes in the 
cheese or may pre-exist in the milk of which it has been 
made. 

Milk has been known to produce serious outbreaks of 
poisoning or disease. In many of these the injurious 
effects are to be attributed, not to the presence of any 
putrid alkaloid in the milk, but to adulteration with 
impure water. Thus, in an outbreak which occurred in 
Aberdeen, in April, 1881, and in which three hundred 
and twenty-two persons were affected and three died, the 
milk as taken from the cows was found to be perfectly 
good, while the water used in the dairy was dangerously 
contaminated with the same material as that found in the 
contaminated milk (Beveridge). 

Moreover, the recent researches of Power and Klein, 
concerning an outbreak of scarlet fever in London, seem 
to show that the disease may be caused in the human 
subject by the use of milk obtained from cows suffering 
from a similar disorder. 

But apart from such instance of disease-transferral, 
cases have occurred in which true poisoning has been 
caused by milk. Firth (Lancet, 1887, i., 218) describes 
the cases of ten soldiers confined in a military prison. 
Of these, one who took none of the milk in question was 
not affected. The other nine were seized with nausea, 
vomiting, dryness of the fauces, a sense of constriction 
of the throat, colic, purging, and a tendency to collapse in 
some, in others a tendency to stupor. All recovered. 
The milk was apparently of good quality. A portion 
was coagulated, filtered, rendered feebly alkaline with 
caustic potash, and agitated with ether. The ether on 
evaporation left a semi crystalline, moist residue, having 
a mawkish, sickly odor and a strongly pungent taste. 
This substance caused nausea, dryness of the fauces, and 
headache in the human subject, and purging and vomit- 
ing in a dog. Attempts to produce the same substance 
from milk kept at 80° F. were only successful after three 
months. Firth suggests the name lactotoxine for this sub- 
stance. Is it identical with tyrotoxicon ? 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Ptomaines. 
Puberty. 


Cases of poisoning by articles of food into whose com- 
position milk enters are of occasional occurrence. An 
interesting instance of this form of poisoning, indicating 
the influence of different degrees of heat upon the toxic 
substance, is reported by Allen (Med. Times and Gaz., 
1878, ii., 519; Sanit. Rec., London, 1878, ix., 257). Two 
bread-puddings were made of bread-scraps, milk, eggs, 
sugar, nutmeg, and currants. One was baked in a quick 
oven and caused no untoward results; the other was 
baked in a slow oven and caused severe poisoning in all 
who partook of it, and two deaths. The symptoms were 
those of violent, irritant poisoning, with severe vomiting 
and purging, greatly accelerated pulse, and rapid uncon- 
sciousness. The pudding which caused the poisoning 
was fed to a six-weeks-old puppy and to mice without 
the production of any toxic effects. It was not bitter in 
taste, did not exhibit the reactions of ergotine, gave off 
an unmistakable odor of herrings (methylamine) with 
caustic soda, and the alkaline solution assumed a brilliant 
lake-red color on standing. When a slice of bread was 
soaked in milk and sugar, and a portion of the poisonous 
pudding placed at one end, the substance giving the above 
reaction was gradually produced throughout the bread. 

Rh. A. Witthaus. 


PUBERTY (Lat. Pudertas, from pubeo, pubere, to be- 
come mature, or fit for procreation). By this term is meant 
that period of life when the human being becomes fitted 
for reproduction, evidence of which is afforded by rapid 
development of the sexual organs; for hitherto these or- 
gans had grown little from the period of infancy, and no 
exercise of their function was possible. Besides, it is 
usual for accelerated growth of the whole body to take 
place at the same time, and in the male the voice under- 
goes change, becoming an octave lower in pitch, from 
enlargement of the vocal organs. During the progress 
of this change the voice is unsettled, and often varies in a 
single utterance from one to the other key. — In both sexes 
the pubic region becomes clothed with a hairy growth, 
followed later by the same growth in the axille, and, 
in the male, by the beard. In the female, particularly, 
there isa rapid deposit of fat in the subcutaneous cellular 
tissue of the breast and extremities, producing that round- 
ness of form which contributes so much to the accepted 
type of beauty, and the deficiency of which is so often 
supplied by art. 

Along with these physical traits a marked change in 
morale takes place. 
consciousness of sexual maturity by newly awakened 
sensibilities toward individuals of the opposite sex, com- 
monly of attraction, but sometimes of repulsion, or, rather, 
timidity and shyness. Inthe female, particularly, an air 
of decorum and dignity is assumed by those of well-bal- 
anced minds; while the ill-balanced become pert and 
forward. Boys, rather than girls, are apt to develop a 
lasting shyness of the opposite sex, greatly to their dis- 
comfort and disadvantage. 

From this time in the male the testes, prostate, and 
Cowper’s glands constantly produce their characteristic 
secretions, unless interrupted by special lesions, or by 
serious general disease. In the female the ovaries begin 
their regular function of discharging perfected ova into 
the uterus, repeated generally at intervals of four weeks, 
and attended with a sanguineous flux from this organ, 
which lasts normally for three or four days. This func- 
tion of menstruation, except when suspended by preg- 
nancy and lactation, should recur regularly throughout 
the reproductive life of woman, which usually embraces 
a period of from thirty to thirty-five years. The devel- 
oped mamme become capable of assuming their func- 
tion, whenever called for by the wants of offspring. 

In the female the condition of puberty is preceded, for 
a varying time and in a varying degree, by certain dis- 
turbances, due to the new determination of blood to the 
sexual organs. Among these, headache, backache, cor- 
poreal and mental lassitude, palpitation, hsemorrhage 
from the nose, the lungs, and the stomach, are most fre- 
quent, and such nervous deviations as result frequently 
in hysteria and sometimes temporary insanity. At this 


The individual manifests instinctive. 


period in both sexes nutrition is at its highest activity, 
and hemorrhages are remarkably well tolerated. An 
inherited proclivity to disease, particularly pulmonary 
consumption, is apt at this time to manifest itself. 

The access of puberty commonly occurs at the age of 
from fourteen to sixteen years in the male, and a year ear- 
lier in the female, for the temperate regions of the world. 
Considerable variation is found, however, beyond these 
limits in both males and females, The researches of 
Thomas More Madden, in the British Isles, have resulted 
in the following table of 497 cases, quoted from Quain’s 
‘Dictionary of Medicine :” 


Under twelve years 4 menstruated for the first time. 
At ss aS 66 CE ay: 6s die 
rc thirteen “ 50 “ tC ea Lines e 
fe fourteen es 94 66 A BY ee ie 
a fifteen “ ~§=6188 “ Rat icekue ae r 
a sixteen “105 “ clea cenanec ae 
os seventeen ‘‘ 65 “6 (Gime scene 6 a 
ie eighteen 6 10 “6 SG esol bics és 
Over ae “ 14 %6 Ot lee = Pact nn 


Puberty is generally admitted by good authorities to 
occur somewhat earlier in hot climates, and the preva- 
lence of very early marriages in tropical regions has in- 
correctly led to an impression of correspondingly early 
puberty. Undoubtedly habits of idleness and luxury 
hasten it, as a life of severe labor, hardship, and priva- 
tion tends to retard it. Late appearance of puberty some- 
times results from ill-health, and is not the cause thereof, 
as is supposed by the laity. In such cases it is sufficient to 
treat the actual disease or condition. Whenever retarded 
menstruation coexists with good general health, with or 
without other signs of delayed puberty, no medical in- 
terference is called for. 

Instances of abnormally early puberty are on record, 
and are quite compatible with good general health. In 
vol. xli. of the ‘‘ Medico-Chirurgical Transactions” is a 
table of 13 cases reported by various medical writers, 
which is here presented : 


Sex. |Age when 
Title of work. Author’s name, menses ap- 
Min le Es peared. 
Philosoph. Trans., 1754, 
VOL Mec occioraias ote « Dra Meadhnaa: Sante LOIS cae aeraare gm ereaia 
Med.-Chir. Trans., vol. i...)Mr.. Anthony White.| 1 | .. | .......... 
+! ee ce: sei so Mr OOokee ti. vac .. | 1 |Never’ men- 
struated. 
“8 = cs toe i /3/Dr: Martin Wall....| .. |, 1, |9 months, 
: Je ‘h ‘¢ iv ./Sir Astley Cooper...) .. | 1 |3 years. 
ss de Ve See X21 Oars JSNeSCHeL. ace 1 aR EE Ac ea cias 
=e Me Hb See xia) Mrs South tes eens IRF] ey | eh aes ee 
Med. and Phys. Jour., vol. 
XKV 1 EA aa aes Dri COOksone anes .. | 1 |3% years. 
Midland Med. Reporter, 
VOl Lids «eect aacel eeiciy ore Dre Burners ctye- trace IRV ROM ARES Bee 
Med. Gazette, 1682........ Drs uedseati 2.4.26 1 {8 years, 
et oe S40 meek. Des Peacocke a: 1 |Nearly 5 yrs. 
North. Jour, Med., 1845... : a A few days 
Taylor’s Med, Jurispr...... { Mr. ere teen oe 1 of age. 
Wancet, 1S48e reese es Mr. Embling 2.2... oe | L. [2 years, 


In the first of the above list the external signs of pu- 
berty (enlargement of the sexual organs) occurred at the 
age of twelve months. This child died in 1752, at the 
age of five years, of pulmonary consumption, having an 
appearance of premature senility. 

The third case had the usual appearances of precocious 
maturity, except size, physiognomy, and intelligence. 
The mamme began to enlarge at the age of eighteen 
months. 

The fifth case, at four and one-half years, had the 
breasts as well developed as a woman of twenty years, 
and was very broad in the chest and loins. At six years 
she was 4 feet 1 inch in height, menstruated every three 
weeks, and had hair in the axille. A sister, then aged 
seventeen, had not yet menstruated. 

The sixth case, at three years of age, was 3 feet 6% 
inches in height, and weighed 50 pounds; had enlarged 
generative organs, with frequent erections and seminal 
stains on his linen. The voice had changed in pitch. | 

The seventh case was unusually large at birth, with 
hair as long and abundant as is usually found at five 


69 


Puberty. [tion. 
Puerperal Condi- 


months, prominent pudenda, and a hoarse voice. At 
four months hair appeared on the pubes, the penis and 
testes began to enlarge, and at fifteen months the glans 
was entirely exposed. Seminal stains appeared soon af- 
ter. At the age of three years and four months he was 3 
feet 7 inches in height, and weighed 64 pounds. Length 
of penis, flaccid, 3 inches ;. erect, 6 inches, 

Another case, not included in the above table, born in 
1806, showed at twelve months of age a change of voice, 
enlargement of generative organs, and hair on the pubes. 
At three years he appeared physically mature, though 
without a beard. Height, 3 feet 44 inches; weight, 514 
pounds ; circumference of cranium, 20 inches ; of waist, 
24 inches. 

The extreme sexual and general physical precocity of 
these cases was not attended with corresponding intel- 
lectual development, and the condition, as a whole, must 
be regarded as an unfortunate one. 

Inasmuch as the period of puberty, especially with 
girls, is attended by an important change in the direc- 
tion of the nutritive energies, and sometimes with alarm- 
ing disturbances of the nervous functions, it is clear that 
the requirements of physical, and still more of mental, 
exertion should be carefully regulated. This has par- 
ticular reference to school duties, which are apt to be un- 
duly imposed by teachers, encouraged or prompted by 
the ambition of doting parents to witness and boast of 
scholastic attainments. The result is liable to be wreck 
of the nervous system, or prolonged nervous and muscu- 
lar prostration. 

The family physician is occasionally asked to relieve 
the painful or emotional phenomena of incipient puberty, 
or more frequently to bring on the menstrual flow. There 
is too great disposition on the part of mothers to request 
active medication. Sometimes it is required, but often a 
placebo is preferable. For headache the alkaline bro- 
mides are suitable, when there is evidence of determina- 
tion of blood to the brain. Hysteria may call for vale- 
rian, asafoetida, or emetics. Persistent pain in the back 
would justify warm hip-baths, or even aloetic purging. 
In case of anemia, quinine and iron would be indicated. 

S. 8S. Herrick. 


PUERPERAL CONDITION. ‘The term puerperal, de- 
rived from two Latin words, puer, a child, and parere, 
to bear, strictly speaking, pertains to the condition or 
state of child bearing ; but usage has restricted its appli- 
cation to that period succeeding parturition which com- 
mences with the completion of labor, and continues until 
the genital organs shall have recovered their normal con- 
dition. This restoration is usually accomplished in about 
six weeks, provided the processes of repair and involu- 
tion are not interrupted by any complication, accident, 
or failure. 

Certain constructive changes in the genital apparatus, 
incident to gestation and parturition, after fulfilling their 
several missions, must undergo destructive metamor- 
phoses ; traumatic lesions need to be healed; and the 
function of lactation is to be established or called into 
renewed activity. 

Familiarity with the physiology of the puerperal state 
is essential, in order that any deviation from the line of 
normal progress may be promptly detected, and that 
dreaded pathological developments may be clearly recog- 
nized, intelligently combated, and, if possible, success- 
fully resisted. : 

SHock.—Immediately succeeding labor, the woman 
experiences a sense of fatigue and more or less shock, 
sometimes verging upon exhaustion. The fatigue and 
shock are generally most marked after severe and pro- 
tracted labors, and in very susceptible subjects. 

Rest, and occasionally an opiate, is the appropriate 
treatment. 

CuiLtu.—The so-called post-partum chill occurs in 
some cases. It follows closely the expulsion of the 
child, and usually lasts several minutes. It possesses 
no pathological significance. 
sudden cessation of the violent muscular effort associ- 
ated with the severe expulsive pains, during which the 


70 


It is probably due to the . 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


surface of the body is profusely bathed with perspiration 
and the superficial vessels are filled with blood. The 
sudden withdrawal of the pressure of the gravid uterus 
and the consequent determination of the blood to the 
abdominal veins, producing a temporary depletion of the 
cutaneous capillaries, has been suggested as a possible 
cause. 

No treatment is required beyond an increased amount 
of covering. The sensation and shivering soon subside, 
and are not followed by appreciable reaction. The oc- 
currence of the chill may, very properly, be anticipated 
by supplying additional covering to the patient immedi- 
ately after the extrusion of the child. 

AFTER-PAINS.—The more or less rhythmical contrac- 
tions of the uterus which occur, notably in multipa- 
rous women, for a few hours after delivery, frequently 
give rise to pains, similar, but by no means so severe as 
those experienced during labor. ‘These pains are called 
after-pains, and.are present in inverse ratio to tonic uter- 
ine contraction. Incomplete contraction allows intra- 
uterine hemorrhage, and the resulting clots provoke ex- 
pulsive efforts on the part of the uterus, which may be 
the cause of very acute pains. Pains may likewise be ~ 
caused without hemorrhage by the contractions which 
follow frequently recurring relaxation. The reflex in- 
fluence produced by the application of the child to the 
breast may also cause these pains. The existence of this 
sympathetic relation is sometimes happily utilized to se- 
cure firm and continuous contraction. After-pains are 
rarely observed in primipars. ‘They are seldom pro- 
tracted beyond twenty-four to forty-eight hours. 

The proper treatment consists in securing and maintain- 
ing tonic contraction of the uterus. External pressure 
and manipulation, and ergot, usually suffice to accom- 
plish this result. Opiates may, in addition, occasionally 
be required, and Dr. Barker! recommends full doses of 
quinine and the application of stimulating liniments to 
the hypogastrium in certain obstinate forms, which he 
regards as neuralgic in character. 

TEMPERATURE.—Before the termination of labor the 
temperature is increased one or two degrees above the 
normal standard. After a day or two it recedes to, or 
even below, the level of health, though transient eleva- 
tions of temperature, are liable to occur throughout the 
puerperal period. The continued increase of more than 
two degrees, especially if it be accompanied by a rapid 
pulse, denotes some complication, and is a sufficient 
cause for anxiety. 

Lusk? considers a rise of from a half to one degree for 
the first six days, with slight evening exacerbations, as 
normal, and he confirms the opinion of Schroeder, that a 
temperature of 100.5° F. belongs within physiological 
limits and, moreover, that a rise even above this is not 
incompatible with a generally satisfactory condition of 
the patient. 

Barnes,’ on the other hand, positively affirms that no 
important increase of: temperature is observed in puer- 
peral women under healthy individual and sanitary con- 
ditions. He repudiates the observations made in lying-in 
hospitals, which show a rise of’over 0.5° F., and declares 
this cannot be accepted as normal. 

A slight fall of temperature, sometimes noticed within 
twenty-four hours after labor, is soon followed by a re- 


_ turn to the standard.- The increased heat is attributed to 


oxidation of tissue in connection with involution of the 
uterus, to the small wounds generally present in the gen- 
ital tract, and to disturbances associated with commenc- 
ing lactation. 

Puuse.—After labor the pulse usually falls from 90 or 
100 to 60 or 50, and, in exceptional cases, even lower. 
This slow pulse may last from three to seven days, and is 
regarded as a favorable indication, while, on the contrary, 
a rapid pulse is deemed an omen of unwelcome import. 

Various hypotheses have been advanced in explanation 
of this clinical fact. Some ascribe it to increased arterial 
tension in consequence of the sudden arrest of the circu- 
lation in the uterus; others to diminished arterial ten- 
sion, and still others to the complete and grateful rest— 
the pervading calm which succeeds the storm. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Puberty. [tion. 
Puerperal Condi- 


Locnta.—The lochia isa term applied to the liquid 
waste discharged from the uterus after delivery. The 
flow generally continues, in diminishing quantity and 
changing quality, for two, three, or four weeks. Excep- 
tionally it ceases after only a few days. At first it is 
composed principally of blood which oozes or flows from 
the placental site, and serves to wash away particles or 
shreds of membrane, clots, and some of the various prod- 
ucts of degeneration. As the blood-corpuscles in the 
lochia gradually decrease, the appearance changes from 
red toa pale greenish or yellowish hue, and, finally, it 
resembles a clear, albuminous liquid. 

The odor is peculiar and more or less offensive, 
though under normal circumstances it should never be 
putrefactive or indicative of organicdecomposition. Not 
infrequently the flow is suspended for a few hours, or is 
greatly diminished about the time the secretion of milk 
commences. Early suppression is not regarded as neces- 
sarily a dangerous symptom, but its sudden subsidence 
may be associated with grave pathological complications, 
If fetor or suppression be accompanied by a quickened 
pulse and an elevated temperature, it may possess im- 
portant significance, and it demands measures of treat- 
ment to be considered hereafter ; otherwise, warm fo- 
mentations or turpentine stupes to the hypogastrium, or 
the warm vaginal douche, will usually suffice to restore 
it. A decidedly offensive odor requires for its correc- 
tion antiseptic vaginal injections: about two drachms 
of carbolic acid to a pint of warm water, or a watery 
solution of the corrosive chloride of mercury—one part 
to two or three thousand parts—every eight, twelve, or 
twenty-four hours, is usually effective. Two or three 
pints of either solution may be used. 

Of recent years antiseptic measures have been given a 
much more prominent position in the management of 
puerperal patients than formerly. Antiseptic vaginal in- 
jections are now recommended and employed by some 
obstetric practitioners in every case, and even uterine 
injections are advocated. The extreme views enter- 
tained by some really eminent authorities, in reference 
to the employment of antisepsis during and subsequent 
to labor, border closely upon the absurd, and do not 
represent the conservative sentiment or the practice of 
the great mass of successful physicians throughout the 
country. 

Without definite indications for their use, uterine in- 
jections should be condemned as dangerous, and even 
vaginal injections, while free from positive danger, as a 
routine procedure in private practice, under usual con- 
ditions, are unnecessary and had better be omitted. 
With fairly good sanitary surroundings, the vast major- 
ity of women recover without a ripple from the effects 
of simple labor, and a physiological lochial discharge, 
like physiological menstruation, may be left to itself, 
thereby avoiding the risks and the annoyance of uncalled- 
for manipulation of the genital organs. 

The so-called antiseptic pad is not requisite. The dis- 
charges may be received with perfect confidence upon 
clean cloths. The external parts should be bathed or 
douched with warm or hot water, containing a little car- 
bolic acid, sufficiently often to maintain a state of clean- 
liness. Sponges should give place to cloths or absorbent 
cotton. 

Any fissures or abrasions about the vaginal outlet may 
be treated by the application of carbolized oil or iodo- 
form ointment. 

In the event that the lochia retains, unduly, its san- 
guineous character, the state of the uterus, as to the prog- 
ress of involution, should be ascertained. 

Tue BLADDER should be emptied six or eight hours 
after labor, the patient remaining on her back, and us- 
ing, if practicable, a bed-pan. In some cases—more par- 
ticularly after difficult and protracted labors, and in ner- 
vous subjects—there is inability to pass urine for the 
first two or three days. The removal of the accustomed 
pressure from the bladder, the flaccid state of the ab- 
dominal parietes, the tumefaction of the urethra and of 
the meatus on account of prolonged pressure, or from 
mechanical injury, over-distention, and the enforced re- 


cumbent position, explain this difficulty. Change from 
the horizontal to a sitting or kneeling posture, small 
doses of ergot, and warm cloths to the hypogastrium 
and vulva, will generally secure relief. Occasionally the 
catheter may be required, though it is better not to be 
officious with instruments in such cases. An ordinary 
gum-elastic or a soft-rubber catheter is to be preferred 
to any rigid metal instrument. Care should be taken 
not to introduce into the bladder, by means of the cathe- 
ter, any of the secretions or discharges contained within 
the vagina, for fear of setting up a cystitis. 

THE BoweEts are almost invariably inactive after de- 
livery, and in the event that spontaneous evacuation does 
not occur, the comfort of the patient will ordinarily de- 
mand some gentle laxative about the third or fourth day, 
to be repeated, as required, every two or three days dur- 
ing her confinement to bed. The various saline aperients 
answer this purpose well. A most acceptable and agree- 
able substitute for the nauseous dose of castor-oil, which 
has the sanction of custom and authority, is the solu- 
tion of citrate of magnesia. A simple enema of tepid 
water is preferred by some practitioners, and, in many 
instances, meets every indication. Calomel and other 
mild cathartics have their advocates, and their appro- 
priate places among useful remedies that may be em- 
ployed. 

THe Urervs.—Immediately after the expulsion of 
the placenta, the uterus, if firmly contracted, may be 
felt like a hard, globular body resting above the pubes. 
The excessive development of the organ incident to preg- 
nancy and parturition is gradually reduced, by a process 
of fatty degeneration, and in about two months, unless 
checked by some untoward circumstance, its normal 
dimensions are attained. At the end of a fortnight after 
delivery, it has retracted below the level of the pubic 
bones ; its weight has decreased from thirty or thirty- 
five ounces to about twelve ounces, and its cavity meas- 
ures only about four and a half inches.* Tonic contrac- 
tion causes intimate approximation of its tissues, and 
effectually closes the sinuses and open vessels, shuts out 
atmospheric air, prevents the formation of clots, and 
promotes involution. The mucous membrane is soon 
restored and involution is complete. 

THE VAGINA, after the enormous stretching to which 
it is necessarily subjected during the passage through it 
of the child, slowly regains its tone and elasticity, though 
it remains permanently wider than in the virgin state. 
All abrasions and superficial ruptures heal ; tumefac- 
tion subsides, and within three or four weeks its normal 
condition is reached. 

THE PERINEUM.—Perineal rupture occurring during 
labor may unfavorably influence involution. Fissures of 
the fourchette or slight lacerations of the perineum 
usually heal if left to themselves, or, at all events, give 
rise to no subsequent inconvenience. More extensive 
lacerations should be immediately repaired. Three or 
four sutures, passed deeply enough to secure close ap- 
proximation of the ruptured surfaces, may be necessary. 
The simple interrupted suture, made of catgut or silver 
wire, or, in the absence of these, of silk, is all that is re- 
quired, 

THE Breasts.—About the third or fourth day the 
physiological activity of the breasts begins to attract at- 
tention. The secretion of milk becomes active. Prior 
to that time, a fluid, differing from milk both in composi- 
tion and appearance, is secreted. This fluid is known 
as colostrum, and it is believed to possess laxative prop- 
erties—a provision of nature designed to clear the child’s 
bowels of the meconium. 

The mamme may be turgid, nodular, and painful, and 
more or less general disturbance may be associated with 
this local condition. The pain sometimes radiates from 
the breasts across the chest and downthe arms. The axil- 
lary glands may also become sensitive and enlarged. 

For the sake of the child, great care should be taken to 
preserve the integrity of thisfunction. If the breasts are 
pendulous, they should be supported by some appropriate 
device. The accumulated milk, which contributes to 
the pressure from within, should, when the child is not 


71 


Puerperal Con- 
dition. 


equal to the demand, be gently drawn from the ducts 
by the lips of the nurse while the breast is supported 
between her hands, moderate friction or expression being 
at the same time made on the gland. Some nurses are 
very skilful in drawing breasts, and depletion by this 
means is preferable to the use of the breast-pump, which 
is attended with some risk. Puppies have been called 
into requisition for the same purpose. 

Topical applications of belladonna, for its anodyne ef- 
fect, are useful. Anointing the breasts with olive-oil is 
recommended. If the milk should not be required for 
the child, belladonna, iodide of potassium, and phytolacca 
decandra may be given internally. If, however, the child 
is to be nursed, great cireumspection should be observed 
in the use of this class of remedies, on account of the 
liability of permanently arresting the secretion. Quinine 
is frequently indicated. 

The constitutional excitement which usually attends 
painfully distended breasts, and which is marked by 
headache, flushed face, anorexia, coated tongue, thirst, 
slight increase of temperature, and some quickening of 
the pulse, was formerly described as milk-fever. 

The very existence of such a disease is now denied, 
and it is characterized as ‘‘a vague tradition that does 
not rest upon classic observation.” Certainly, it is now 
regarded as of rare occurrence. 

According to Galabin,‘ a rise of temperature about the 
third day is often due to some transient septic or trau- 
matic disturbance; but he adds that it may be caused 
about this time by irritation and tension, or by slight in- 
flammation of the breasts. 

Playfair® says it has been immensely exaggerated. It 
is rare in these days, since starving of puerperal patients is 
no longer considered necessary. There does not seem to 
be any sufficient reason for referring it, even when tol- 
erably well marked, to septicemia. The relief which 
attends the emptying of the breasts seems sufficient to 
prove its connection with lactation, and the discomfort 
which is necessarily associated with the swollen and tur- 
gid mamme is, of itself, quite sufficient to explain it. 

Barker ' does not regard the prevailing opinion respect- 
ing this question as change in sentiment merely, or as de- 
pendent upon information derived from the more general 
use of the clinical thermometer, but to the fact that there 
is an actual decline in the occurrence of a veritable dis- 
order in consequence of improved hygienic management 
—in securing rest, in giving good nourishment, and in 
the early application of the child to the breast. 

The nipple, in primiparz,.should be shaped and de- 
veloped by drawing it into an ordinary glass nipple- 
shield, or into the neck of a suitable bottle, which may 
-have the contained air rarefied by filling it with hot 
water and emptying it immediately before it is applied. 
As the bottle cools, the nipple is forced into its mouth by 
atmospheric pressure, 

Sensitive, abraded, or fissured nipples sometimes de- 
mand attention. Sponging with cold water and thorough 
drying after every application of the child to the breast 
may prevent or relieve these troubles. Sometimes as- 
tringent applications, or the solid nitrate of silver in the 
case of obstinate fissures, are required, or the habitual 
use of a nipple-shield may be necessary. The shield 
should have a flaring glass base and a rubber mouth- 
piece. Temporary withdrawal of the child from the 
breast may become necessary. 

Deficient flow of milk, known as agalactia, or exces- 
sive secretion, galactorrhcea, may require interference. 
The former condition may best be treated by attention to 
the hygiene of the woman, and by improving her nutri- 
tion. Milk is especiaily serviceable for this purpose, and 
its good effect is enhanced by the addition of a little 
brandy or whiskey, if the spirit agrees with the patient, 
and is not otherwise contra-indicated.. Porter, ale, malt- 
extract, or beer is used by some persons with satisfaction. 
Of course, organic defects in the gland are beyond the 
reach of these means. In galactorrhcea the milk is apt 
to be of poor quality, and invigorating measures of treat- 
ment are usually indicated. Certain drugs, especially 
belladonna, iodide of potassium, and phytolacca decandra, 


72 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


are reputed to possess the property of directly decreasing 
the lacteal secretion. These may be cautiously used, 
when necessary, in connection with general hygienic 
management. The amount of liquid ingested should be 
restricted as much as possible, and hydragogue laxatives 
may be advantageously employed. 

THE BrnpErR.—The use of the traditional binder after 
delivery appears to be more a matter of comfort than of 
necessity, and as most women prefer it there can certainly 
be no valid objection to its employment, provided it be 
properly applied. It is very doubtful if it contributes to 
the maintenance of uterine contraction, or if it tends to 
the preservation of a symmetrical figure ; but it does afford 
support to the stretched abdominal walls, and does pre- 
vent disagreeable sagging of the abdomen pending the 
restoration of normal muscular contractility. 

Rest for a few hours after labor is very important, 
and very grateful to the patient. The room should be 
pleasantly shaded, avoiding a glare of light on the one 
hand, and darkness on the other. Quiet should be en- 
joined, and every facility for undisturbed repose afforded. 
If necessary an opiate may be administered. 

The time at which a puerperal woman may leave her 
bed with safety cannot be fixed by anyarbitraryrule. It 
varies with the individual, and depends, in part, upon 
her recuperative energy, and the absence of retarding 
complications, the severity of the labor, and the general 
condition of the patient, irrespective of puerperal experi- 
ences. 

Attempts to prescribe a definite period of confinement 
show the futility of all such efforts. One writer (White) 
advocates sitting up a few hours after labor. Others 
(Goodell, Solovieff) fix upon the second day—allowing 
their patients to sit up while the bed is being made, and so 
on until the fifth day, when, if so disposed, they may get 
up and dress themselves. Others ® (Avrard, Chapman) say 
the puerperal woman must keep her bed for three or four 
weeks—often longer, never less. 

Here, as elsewhere, sound common-sense ought to pre- 
vail. This, joined with experience, teaches that the ma- 
jority of puerperal women, under favorable circumstances, 
may leave their beds without detriment from the tenth to 
the fifteenth day, though they should keep their rooms 
for three or four weeks, and avoid physical exertion for 
even a longer period. 

Tue Foon of the puerperal woman should be sufficient 
in quantity, and suitable as to quality. The most extreme 
and unreasonable views are entertained upon both sides 
of the question of dietetics. Because some women have 
been starved, others, forsooth, need not be glutted. The 
golden mean—the middle course is safe. It should be 
remembered that the appetite and the digestion are im- 
paired by the fatigue and anxiety of labor, and. by sub- 
sequent confinement to bed. The stomach should not 
be overtaxed, but adequate support should be secured. 
Liquid food, at first, is preferable. Milk, tea, animal 
broths, and eggs may be gradually supplemented as con- 
valescence progresses. The infiuence of the mother's 
diet upon the nursing infant, through the medium of 
her milk, should not be overlooked. 

The lying-in chamber should be well ventilated and 
comfortably warmed in winter. All soiled clothing, ex- 
cretions, and discharges from the patient must be prompt- 
ly removed. No disinfectant or deodorizer can take the 
place of fresh air, which, without involving exposure, 
should be freely supplied. , 

Good nursing is of inestimable advantage to the pa- 
tient, and a source of great satisfaction and comfort to 
the physician. A quiet, gentle, intelligent, and not over- 
officious attendant contributes largely to the successful 
conduct of a case, and to its auspicious issue. . 

PATHOLOGICAL COMPLICATIONS.—The normal progress 
of puerperal convalescence may be interrupted by the in- 
tercurrent development of a number of more or less grave 
complications, some of which merely retard improve- 
ment and delay recovery, others, of more serious import, 
jeopardize the existence or actually terminate the life of 
the patient, who has survived the manifold perils of preg- 
nancy and parturition, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Puerperal Con- 
dition. 


H4@MORRHAGE. —The hemorrhages of the puerperal 
period are primary, or post-partum, and secondary, or 
puerperal. Post-partum hemorrhage may occur imme- 
diately after the birth of the child and before the placenta 
is expelled, or it may follow the delivery of the placenta. 

It is one of the most serious and alarming accidents 
to which the puerperal woman is exposed, and unless 
the medical attendant is at hand, and is prepared to act 
promptly and courageously, death may ensue in a few 
minutes. In post-partum hemorrhage proper, the blood 
escapes from the open extremities of the uterine vessels, 
which are torn across by the separation of the placenta. 
These vessels are compressed, physiologically, by the 
firm contraction of the uterus, which effectually closes 
them, and they are further occluded by clots which, in 
the form of thrombi, seal up the ruptured ends. 

The condition of the uterus which makes this form of 
hemorrhage possible is imperfect contraction. There 
can be no hemorrhage from the uterine vessels with 
complete, permanent contraction. There is no safety 
without it. 

Any circumstance, whether functional inactivity, or- 
ganic defect, emotional disturbance, or mechanical ob- 
struction to firm closure of the uterus, actsas a cause and 
invites the occurrence of hemorrhage. Likewise, any 
cause that so impresses the constitution of the blood as to 
prevent the formation of thrombi, and any condition that 
interferes with the circulation in such manner as to pro- 
duce congestion of the uterus or of the peri-uterine 
structures, or any derangement of the heart’s rhythmical 
action, predisposes to hemorrhage and may occupy a 
direct causative relation to it. 

If the flow should continue notwithstanding tonic 
uterine contraction, the probabilities are that it comes 
from some laceration of the uterus, cervix, vagina, or 
vulva, and thorough exploration will reveal its source. 

The symptoms vary in severity, according to the sud- 
denness and violence of ‘the occurrence. In general 
there is pallor, faintness, vertigo, impairment or loss of 
vision, thirst, dyspncea, gasping, and a weak, thready, 
sometimes imperceptible pulse. In extreme cases syn- 
cope and, possibly, convulsions speedily follow. There 
is generally a gush of blood from the vagina simulta- 
neously with the occurrence of the first symptoms. The 
flow continues in a more or less copious stream until ar- 
rested. Occasionally there is no external appearance of 
- the hemorrhage, but the blood flows freely into the cav- 
ity of the womb, which becomes rapidly distended by its 
accumulation, and the same train of general symptoms is 
observed. This is denominated concealed hemorrhage. 

Fortunately, this terrible experience may be averted, 
except in very rare instances, by the skilful manage- 
ment of labor. The attention should be directed to secur- 
ing tonic uterine contraction as a prophylactic, and also 
as a curative means when the. hemorrhage occurs. Ex- 
ternal pressure and manipulation with the hand over the 
fundus, and ergot subcutaneously and by the mouth, may 
suffice for this purpose. Two grains of ergotine dis- 
solved in water, or one drachra of the fluid extract of 
ergot, may be used for the hypodermatic injection. If 
immediate contraction does not follow the pressure upon 
the fundus, pass the other. hand into the vagina, and, if 
necessary, into the uterus—continuing to grasp the fun- 
dus—and extract all clots or retained fragments of 
secundines ; or, if the placenta has not been expelled, 
_it must be removed, after gently separating any adhe- 
sions that may be found to exist. In the event this ma- 
nipulation does not cause contraction, pass into the uter- 
ine cavity a piece of ice about the sizeof a hen’s egg, 
apared lemon, gashed about the surface to admit the 
ready expression of the juice, or a clean handkerchief 
or a sponge saturated with vinegar. Bimanual compres- 
sion, whereby the uterus is anteflexed, may serve as a 
valuable temporary expedient. The injection into the 
womb of hot water is an efficient resource. This may be 
readily done by passing the nozzle of a rubber-ball syr- 
inge into the cavity, special care being taken to expel 
all the air from the instrument. The returning stream 
may be received in a bed-pan. The child, meanwhile, 


+ 


should be put to the breast, and an opiate to allay agita- 
tion is usually indicated. Some advantage is derived 
from the ingestion of hot fluids, either milk, tea, or water. 

Injecting the cavity, or swabbing the internal surface 
of the uterus with styptics, remains as a last resort. The 
practice is not free from danger, but under the pressure 
of an immediate and urgent demand it is certainly justi- 


fiable, The tincture of iodine is to be preferred for this 
purpose. It isin effect both an active antiseptic and a 
styptic. The officinal tincture may be diluted with two 


to four parts of water, or used, if considered desirable, in 
full strength. The solutions of persulphate, the subsul- 
phate, or the perchloride of iron—one part, to five of wa- 
ter—are powerful styptics, and may be used instead of 
the iodine; but the hard, disagreeable clots which the iron 
solutions produce constitute a serious objection to their 
employment. 

The womb should be empty when the styptic applica- 
tions are made. If practicable, it is well to wash it out 
with hot water, to be immediately followed by swabbing 
its surface, or by the injection of from one to six or eight 
ounces of the styptic solution. 

After the cessation of the hemorrhage, stimulants to 
sustain the circulation and to prevent syncope may be 
cautiously administered. The head should be kept low. 
If necessary, the foot of the bed may be raised. Abso- 
lute quiet in the recumbent posture should be assiduously 
maintained. Ifthe loss of blood has been great, com- 
pression of the aorta or bandaging the limbs for several 
hours has been recommended. In extreme cases success- 
ful resort has been had to’transfusion. Arterial and ve- 
nous blood, saline solutions, and milk are thus used. 

Arterial blood may be conveyed through the medium 
of a connecting tube and cannula, from the dorsalis pedis 
artery of the donor to the corresponding artery of the 
patient. Venous blood may be obtained from the median 
basilic, or from other superficial veins, and conducted by 
the same apparatus into a vein of the patient ; or venous 
blood may be drawn, defibrinated, and introduced into 
the patient’s veins by means of a funnel, tube, and can- 
nula. Lamb’s blood has been proposed as a substitute 
for human blood. 

A solution of the chloride of sodium—one drachm to a 
pint of water at a temperature of 100° F., to which thirty 
grains of bicarbonate of sodium may be added—has been 
recommended for injection into the veins in lieu of blood. 
A quart or more of this solution may be thrown very 
slowly into one of the veins of the arm. It fills the empty 
vessels, but does not nourish the vital organs. Its reviv- 
ing effect is apt to be only transitory. 

Milk, proposed by Dr. T. G. Thomas, to be used in 
the same manner, has been employed with fair success. 
Good results have been reported from the hypodermatic 
injection. of the warm saline solution, as has been pro- 
posed in the collapse from cholera. 

The practical value of transfusion as a remedy in puer- 
peral hemorrhages is variously estimated. There are 
many impediments to its successful employment, espe- 
cially in private practice. 

Landis’ tersely sums up his conclusions in reference 
to the utility of the measure, by declaring: ‘‘If the pa- 
tient is able to endure the operation, she does not need it; 
if she does need it, she is too weak to bear it.” 

The introduction of the saline solution or of the milk 
is not attended with such difficulties as are inseparable 
from the transfusion of blood. 

Puerperal or Secondary Post-partum Hemorrhage may 
occur at any time from six hours to three or four weeks 
after delivery. The causes are substantially the same as 
in primary hemorrhage. This event need not be feared 
in a healthy subject, with a uterus completely emptied, 
free from disease, and which is firmly and continuously 
contracted. 

The recognized causes of puerperal hemorrhage are : 
Albuminuria, purpura, puerperal poison, malaria, emo- 
tional excitement, secondary inertia, uterine fibroids and 
polypi, adhesions, retained coagula and placental frag- 
ments, inflammatory ulceration and severe laceration or 
malignant disease of the cervix, partial or complete in- 


73 


Puerperal Con- 
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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


version of the uterus, pelvic cellulitis, metritis, perime- 
tritis, uterine displacements, subinvolution, distended 
bladder and rectum, premature sexual intercourse, func- 
tional hepatic derangement, cervical thrombus, cough- 
ing, vomiting, and physical effort.* _ 

These causes may all be grouped in three classes: 1, 
Impoverished blood ; 2, mechanical impediment to uter- 
ine contraction ; 8, disturbances of the circulation, either 
general or local. 

In the management of ‘‘ secondary puerperal metror- 
rhagia” the essential prophylactic means consist in the 
correct conduct of labor and a proper puerperal hygiene. 
If the flow should be profuse, energetic measures are re- 
quired, but if the discharge should be only slight yet 
continuous, less active treatment will suffice. - 

The removal of the offending cause, when practicable, 
is the prime requisite. This consists in the withdrawal 
from the uterine cavity of any substance that may pre- 
vent physiological closure of the womb ; the correction of 
any constitutional vice that may be present, and of any 
functional impediment to the integrity of the circulation. 

The cervix may have retracted, so that dilatation by 
means of sponge-tents may be necessary to make intra- 
uterine exploration and the removal of any foreign ma- 
terial possible. 

The hand laid upon the abdomen will reveal the state 
of the uterus as to contraction or relaxation. When com- 
pression is indicated, it should be made by grasping the 
fundus, aided, if necessary, by passing two fingers of 
the other hand into the vagina and exerting bimanual 
pressure. The vaginal tampon is not trustworthy, espe- 
cially soon after delivery. It may prevent the external 
flow, but possibly, only by converting it into concealed 
hemorrhage. Barker! recommends the cervical tampon, 
unless the os is patulous, allowing it to remain six or 
eight hours, and guarding against distention of the ute- 
rus by a compress over the hypogastrium, secured by 
a firmly applied binder. He has used the sponge-tent 
as a cervical tampon successfully on the third day. In 
any event, he confidently endorses the value of an injec- 
tion into the rectum of one ounce of the oil of turpen- 
' tine and half an ounce of olive-oil, to be retained as long 
as possible. 

The injection into the uterus of hot water or the ap- 
plication of the styptic solutions, as recommended in 
primary hemorrhage, may be demanded. Care must be 
taken, however, to secure a prompt return of the in- 
jected fluid and to avoid the introduction of air. 

Ergot, quinine, and opium, with, perhaps, digitalis and 
strychnine, and stimulants, have their appropriate places 
in the management of these cases. In threatened col- 
lapse the hypodermatic injection of whiskey or ether may 
be necessary, on account of the importance of securing 
the stimulant effect promptly, and in consequence, pos- 
sibly, of vomiting, and of the functional inactivity of 
the stomach. The advantages of position, of undisturbed 
repose, of a thoroughly digestible but sustaining diet, 
should be secured to the patient. 

Faradic electricity has been successfully used to in- 
duce uterine contraction, and it would be entirely appro- 
priate in either form of post-partum hemorrhage, but the 
battery necessary for its production is seldom at hand in 
the emergency. If it is employed, one electrode should 
be applied over the fundus, and the hand, probably al- 
ready in the vagina or in the uterus, may be utilized as 
the other pole by placing the second electrode in con- 
tact with the arm or forearm of the operator. 

Puerperal HKever.—The most formidable complication 
of the lying-in period is the disease known as puerperal 
fever—a term which has been a familiar landmark in 
medical nomenclature for more than a century and a 
half, and with which it would be difficult to dispense 
in the absence of an acceptable and comprehensive sub- 
stitute. 

The nature of this affection has served as the basis of 
many vehement controversies, and it still challenges the 
most earnest discussions between the advocates of the 
different doctrines which are maintained respecting its 
character. 


74 


It has been ascribed to retention of the lochia, to me- ~ 
tastasis of the milk, to failure on the part of the excre- 
tory organs to eliminate effete material, to metritis, to 
erysipelas, etc. But these and other theories, proposed 
from time to time, have, one after another, been aban- 
doned, and now two prominent doctrines are upheld. 
These are: 

First, the doctrine of a fever peculiar to puerperal 
women, the symptoms of which are essential and are not 
the consequence of any local lesions ; a zymotic disease 
resulting from some unknown blood-changes, of the 
specific cause of which changes we are ignorant, but the 
determining cause of which may be epidemic influence, 
contagion, infection, or probably nosocomial malaria. ! 

Second, the doctrine that puerperal fever is puerperal 
septicemia, analogous to, if not identical with, the so- 
called surgical fever, modified by the physiological state 
of the subject, and usually associated with various local 
inflammatory lesions. 

While the theory of septicemia is not free from diffi- 
culties, it is unmistakably evident that the tendency of 
modern thought, in the light of more recent researches, 
is strongly toward the acceptance of this doctrine, and 
that puerperal fever is now generally regarded as an in- 
fectious and contagious disease, produced, for the most 
part, by the absorption of septic matter through wounds 
in the genital tract, caused by the separation of the de- 
cidua and by violence inflicted during the act of par- 
turition, and usually complicating, or complicated by, 


- inflammatory lesions within the pelvis or the abdomen, 


which constitute, in their different forms, the several va- 
rieties of this affection. 

The acute inflammatory lesions referred to as usually 
coexistent with the blood-poisoning, manifest themselves 
primarily as vaginitis, endometritis, metritis, pelvic cel- 
lulitis, pelvic peritonitis, general peritonitis, phlebitis, and 
lymphangitis, and secondarily, in the serous membranes, 
as pleuritis, pericarditis, and meningitis and also in 
purulent inflammation of the joints. Pysemia and cir- 
cumscribed inflammation of the subcutaneous areolar tis- 
sue, terminating by resolution or by suppuration, are 
among the secondary affections. . 

Inflammation of the genital mucous membrane may be 
superficial—catarrhal merely, or granular—and it may 
spread from the endometrium along the Fallopian tubes, 
producing salpingitis ; and by extending still farther, may 
involve the peritoneum and set up a more or less dif- 
fused peritonitis; or the inflammatory action may go 
deeper, resulting in ulceration. ‘These ulcers may as- 
sume a diphtheritic form, especially around the vaginal 
outlet, and round bacteria or micrococci are plentifully 
found in them. With vaginitis are associated painful 
micturition and defecation. 

In metritis, or inflammation of the uterine paren- 
chyma, the tissues become soft and relaxed, and invo- 
lution is retarded or arrested. The muscular wall is 
oedematous, or the connective tissue may be filled with a 
sero-purulent fluid, or small collections of pus may oc- 
cur. The margins of any fissures about the cervix may 
become sloughy or gangrenous. The uterine veins and 
lymphatics most likely share in the morbid process in op- 
eration around them. The inflamed veins are thickened, 
and contain lymph and, rarely, pus. The lymphatics 
are frequently loaded with pus, and upon cross-section 
present to the eye the appearance of intramuscular ab- 
scesses. 

The cellular tissue in immediate proximity to the 
uterus may be invaded, giving rise to what is known as 
parametritis, or the inflammatory action may extend to 
more remote layers of connective tissue within the 
pelvis, thus establishing pelvic cellulitis. More or less 
swelling occurs, caused by the effusion of serum and, 
later, by the exudation of lymph. Suppuration may re- 
sult, with, possibly, burrowing of pus and the formation 
of fistulous openings, or the inflammatory products may 
be absorbed, leaving usually some induration. In the 
more severe septic forms of cellulitis the exudation 
degenerates into a turbid, purulent fluid which fills the 
interspaces of the tissues. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Puerperal Con- 
dition. 


Peritonitis may be limited to that portion of the peri- 
toneum within the pelvis—pelvic peritonitis or peri- 
metritis—or the inflammation may invade the abdominal 
cavity, resulting in general or diffused peritonitis, which 
is usually a prominent, and almost a constant, feature of 
puerperal fever. Tympanitic distention of the intestines 
is a conspicuous and early symptom. In mild cases the 
exuded lymph either floats in the form of flakes in the 
effused serum or it is spread over the surface of the 
abdominal viscera. The peritoneum is lustreless, rough- 
ened, and ecchymosed, and in the severer types contains 
more or less pus. 

The inflammatory affections above described may oc- 
cur as independent lesions, associated with puerperal 
processes, but without clinical evidence of septic infec- 
tion ; and, on the other hand, septiczeemia may run its 
course in rapidly fatal cases and no appreciable disease 
of the genital organs or of the peritoneum be detected 
by ordinary methods of investigation. Nevertheless, 
as remarked by Playfair,® there is little doubt but that 
in these intense cases profound pathological changes 
exist in the form of alteration of the blood and degenera- 
tion of tissue. 

If the disease should be protracted, pyeemia is apt to 
be developed, the prominent symptoms of which are 
frequently recurring rigors, high temperature, profuse 
sweating, and localized inflammations and _ abscesses. 
Pyemic abscesses in the lungs and in the kidneys fre- 
quently result from emboli, formed by the disintegration 
of an infected venous thrombus. 

The appreciable symptoms of puerperal fever are usu- 
ally manifest on the third day after labor. Exception- 
ally, they may be observed on the second, or be delayed 
as late as the seventh day. The attack may be very 
acute in its symptoms and course, or it may be less in- 
tense—a form sometimes described as subacute. The 
onset is frequently insidious. It may be indicated by a 
sharp chill, a slight rigor, or only by chilly sensations. 
The pulse runs up to 100, 120, or 150, or even higher. 
The temperature mounts to 102°, 104°, or 106°. The 
lochia generally becomes offensive and is diminished in 
quantity, or is suspended. The secretion of the milk 
may be prevented or, if it has commenced, is often, 
though not always, arrested ; abdominal pain and ten- 
derness are usually present, though they may be slight 
and are occasionally wanting. Constipation may at first 
be present, and be succeeded by diarrhea. The bowels are 
distended with flatus. Tympanites sometimes constitutes 
the most severe symptom. Nausea and vomiting are apt 
to occur. The vomiting and diarrhoea may seriously 
hamper efforts to nourish the patient, and thus contribute 
directly and indirectly toward prostration. Some cases 
are notably marked by depression, presenting throughout 
an asthenic type, sometimes called typhoid. In this form 
low delirium is apt to be developed at night, and pulmo- 
nary complications are more likely to occur. 

Fatal cases of the intense variety usually run their 
course ina week. Local complications modify attacks 
by interjecting their own peculiar symptoms among the 
general or constitutional symptoms. In some cases one 
train of symptoms predominates, in other cases another 
set of symptoms is more prominent. In grave cases an 
anxious expression of countenance is observed, but it is 
usually unaccompanied by fear of impending danger. 

In the less intense or the subacute form of the disease 
the symptoms are not so active. It develops later, usu- 
ally lasts longer, and may be very mild in its manifesta- 
tions. Some cases are characterized by a succession of 
chills at irregular periods, which may, in spite of all 
treatment, continue to recur over and over for several 
weeks. ‘These symptoms are probably indicative of mild 
pyemia. 

The different pelvic inflammations which belong to the 
clinical history of puerperal fever are not always to be 
discriminated. Several frequently coexist, so as to 
render isolation and differentiation of the individual le- 
sions impossible. 

The cause or causes of puerperal fever, whatever they 
may be, are generally admitted to be influenced by the 


physiological condition of the puerperal woman. The 
state of the blood, of the nervous system, and of the gen- 
ital organs form important elements in estimating cor- 
rectly the effects of pathogenic agencies. Most author- 
ities agree upon the possibility of self-infection, and all 
concur in the certainty of infection from without. 

‘* Puerperal fever is puerperal septicaemia,” is the con- 
cisely expressed creed of Thomas,’ who adds that the es- 
sence of the disorder is a poison absorbed into the blood 
of the parturient woman through some solution of con- 
tinuity. Whatever may be the character of this poison, 
we know that there are two, and only two, methods by 
which it can reach the parturient tract and exert its bane- 
ful influence. First, it may be carried into the vagina 
by the atmosphere, in which it floats as an impalpable 
substance ; and second, it may be carried to any part of 
the genital tract by the fingers of the doctor or nurse, 
by sponges, cloths, towels, and instruments, and by the 
clothing of the patient. 

After reviewing the pathology of puerperal fever, 
Galabin* concludes that the affections which have been 
included under the title of puerperal fever, though they 
have a common element in the reception of some poi- 
son, cannot be reduced to a uniform pathology, but are 
various in their nature and origin. According to the 
new nomenclature of the Royal College of Physicians of 
London, the title puerperal fever is to be discarded, and 
the diseases are to be classed, according to their most 
prominent character, as puerperal peritonitis, puerperal 
cellulitis, puerperal septicemia, puerperal pyzemia, and 
the like. Galabin makes the following classification: 1. 
Endogenetic toxsemia, in which noxious material is pro- 
duced in the blood itself, or retained in it through de- 
ficient action of the organs of excretion. 2. Septic in- 
toxication, in which a chemical poison only is absorbed. 
3. Septic infection, in which organisms multiply in the 
blood or in the tissues, or in both. 

Septic intoxication and septic infection cannot gener- 
ally be practically distinguished. 

Lusk,? who regards puerperal fever as an infectious 
disease due, as a rule, to septic inoculation of fresh 
wounds in the genital tract, says it seems impossible to 
make all of the facts coincide with the theory that the 
genitalia of the puerperal woman are the exclusive point 
of entry of infectious materials into the system. The 
deleterious materials may find other channels of enter- 
ing the system than wounded surfaces; and while he 
cannot go as far as Tarnier, who believes that it is by 
the lungs that poisoning often, if not always, occurs, it 
does not seem time to give up the idea that the respiratory 
and digestive tracts may allow the passage of material of 
a specific character. He attributes to the lochial dis- 
charge much of the unhealthfulness of maternity wards. 

‘“The maligned lochia ” is an expression used by Bar- 
ker,!° who, in the form of a query, intimates that nature 
has wisely arranged to furnish the best fluid for con- 
stantly bathing the bruised and lacerated tissues of the 
parturient canal. 

A number of different poisons or causes, but no spe- 
cific puerperal poison, and no specific puerperal fever, 
represents the views of Leishman.!! 

Parvin ° utterly repudiates the doctrine of the auto- 
genesis of puerperal fever. He considers it a confession 
of ignorance, and the very pessimism of obstetric medi- 
cine. But while decomposing organic matter in the va- 
gina or uterus does not create the disease, it furnishes 
a nidus for the lodgement and propagation of septic 
germs. 

Playfair® holds that the assumption of a puerperal 
miasm is not necessary, and that the most practical di- 
vision of the subject is into cases in which the septic 
matter originates within the patient, so that she infects 
herself, the disease being then properly autogenetic ; and 
into those in which the septic matter is conveyed from 
without, and brought into contact with absorptive sur- 
faces in the generative tract, the disease then being het- 
erogenetic. 

Barnes? declares that puerperal fever is fever in a 
puerpera, and that we must abandon the vain attempt to 


75 


Puerperal Con- 
dition. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


find one definite puerperal fever, and recognize the clin- 
ical truth that there are puerperal fevers—autogenetic 
fevers, resulting from the retention of excretory, and the 
absorption of septic, matter ; and heterogenetic fevers, 
due to the reception of extraneous poisons of cadaveric, 
puerperal, or obscure animal origin, or that can be traced 
to certain zymotic influences. 

The influence of bacteria in the production of puer- 
peral fever has not been definitely established. Authori- 
ties differ widely in their estimate of the importance of 
microbes as an essential agency—some affirming, others 
denying, their potency. There is unquestionable evi- 
dence, however, to sustain the fact of their presence in 
the form of round bodies, or micrococci, which have been 
found abundantly, either singly or united in chains or 
clusters, in the tissues and in some of the fluids of the 
subjects of puerperal and of surgical septicemia and 
pyemia. Micrococci are also found in other diseases, but 
it does not follow, because of similar microscopical ap- 
pearance, that they all possess pathogenic identity. 

The view is generally accepted that diseases clinically 
inseparable from puerperal fever may originate by expo- 
sure to the poisons or to the products of certain zymotic 
diseases—notably scarlet fever, diphtheria, erysipelas, 
typhus, and typhoid fever—and also by contact, direct or 
indirect, with suppurating wounds, decomposing animal 
matter, and, possibly, to the influence of sewer-gas and 
of other impure air; though it appears to be certain 
that exposure to these poisons does not invariably pro- 
duce this disease, and, moreover, according to the obser- 
vation of Playfair,° any zymotic disease may attack a 
newly delivered woman and run its characteristic course 
without any peculiar intensity. 

While puerperal fever is believed to be both contagi- 
ous and infectious, in the sense that it may be communi- 
cated by a virus or by a miasm—by a palpable or by an 
impalpable product—it is more than probable that dif- 
ferent forms vary in respect to their communicability, 
and that some forms of the disease are much more 
readily communicated to susceptible subjects than are 
others. 

The treatment of puerperal fever is prophylactic, 
local, and constitutional. The preventive treatment has 
reference to the judicious management of labor, to the 
strict observance of a conservative and sound puer- 
peral hygiene, and to the conduct of the medical attend- 
ant and the nurse in relation to the conveyance of any 
poison to the patient. Scrupulous cleanliness of the 
hands, instruments, clothing, bedding, and of everything 
surrounding or that may come into contact with the 
puerperal woman, is of paramount importance. With 
absolute cleanliness, the usefulness of antisepsis shrinks 
into comparatively narrow limits. Nevertheless, it is a 
simple matter to use the bichloride-of-mercury or the 
carbolic-acid solutions in washing the hands and in 
cleansing the instruments, and it is certain, with ordi- 
nary care, that no harm will be done, unless, perchance, 
the antiseptic should be relied upon as a substitute for, 
and to the exclusion of, that uncompromising cleanliness 
which is herein earnestly advocated, and which must pre- 
cede or accompany antisepsis if we would not invite dis- 
appointment. 

The duty of the physician in respect to contagious dis- 
eases—to those diseases that are supposed to hold some 
relation to the causation of puerperal fever—and to septic 
material of all kinds, is plain. The danger of infecting his 
patient should deter him from attending her directly after 
contact with such poisons, or when closely confined with 
them. Of course, a physician engaged in general prac- 
tice cannot refuse attendance upon obstetric cases every 
time he encounters infectious diseases or septic matter ; 
yet the risks, under these circumstances, demand the 
observance of extraordinary precautions as to his person 
and his clothing. 

Are antiseptic vaginal and uterine injections to be reck- 
oned among legitimate preventive measures ? If it should 
appear that they are in themselves harmless, then an af- 
firmative answer may be given. If, on the other hand, 
their use involves a risk, even a slight risk, to the pa- 


76 


tient, the propriety of the procedure may be very seri- 
ously questioned. 

Barker’? says: ‘‘ Antiseptic injections, both vaginal 
and intra-uterine, are of great service when the indica- 
tions for their use are clearly shown by local signs or 
general symptoms; but they cannot be recommended 
with safety as a routine practice on theoretical grounds, 
as, for obvious reasons, they may be most detrimental 
in retarding the cicatrization of lesions and the other 
processes of normal convalescence, and are otherwise 
sometimes dangerous.” 

Thomas !'® admits that ‘‘the arguments which have 
been brought up against this practice (antiseptic vaginal 
injections every eight hours after labor), since I read my 
paper, have had great weight with me. I confess that I 
feel less firm upon this point than I did, and that in 
future I shall examine the question carefully before I 
determine to adhere to my plan.” In regard to uterine 
injections, he deprecated the impression which seemed to 
prevail that he resorted to them with very little provoca- 
tion, and adds: ‘‘ No one could have striven more than 
I have done to keep within proper bounds the indiscrim- 
inate use of this dangerous but valuable resource.” . 

Lusk ?° advocates antiseptic vaginal injections after nor- . 
mal Jabor in all cases, and uterine injections after difficult 
labor, where the hands or instruments have been intro- 
duced into the uterus, but says:? ‘‘ I know that of late 
years there has been a strong reaction against the use of 
vaginal injections in normal childbed, but personally I 
have experienced none of the disagreeable effects ascribed 
to them. Indeed, both my hospital and private patients 
speak of them as soothing and grateful. I therefore have 
had no ground to discontinue them. ‘That they are indis- 
pensable, I do not claim. They are no longer used in 
Vienna, in Prague, nor in the New York Maternity, and 
yet, none the less, their results have been in the highest 
degree satisfactory.” 

* At these institutions, however, vaginal disinfection is 
vigorously resorted to during and immediately subsequent 
to labor, and during childbed some form of antiseptic 
pad over the vulva is employed.” 

He adds: ‘‘ Intra-uterine injections should be resorted 
to with great circumspection. They are not indicated 
by a simple rise of temperature, and, unless the infection 
proceeds from the uterine cavity—which is the exception 
—they are unnecessary.” 

Braun von Fernwald, in discussing prophylactic uter- 
ine injections, is quoted as saying: ‘‘ We must protest 
against injections made by physicians into the uterine 
cavity ; such meddlesomeness is more likely to do harm 
than good.” Our author adds: ‘‘ This corresponds to 
my own experience.” 

Galabin* advises antiseptic vaginal injections twice 
daily in all cases, but says of uterine irrigation : ‘‘ Its in- 
discriminate use after all cases of labor has been found 
to be rather injurious than beneficial, and to increase 
rather than diminish the number of cases of septiczemia.” 

Parvin ® thinks that, in the absence of any indication, 
vaginal injections are not necessary. 

Playfair® advises antiseptic vaginal injections when 
the lochia is fetid, and thinks uterine injections should 
not be omitted in cases in which self-infection is possible ; 
‘‘and, indeed, when there is no reason to suspect a local 
focus of infection, the use of antiseptic lotions (intra-uter- 
ine injections) is advisable as a matter of precaution, since 
it can do no harm and is generally comforting to the pa- 
tient.” 

Leishman" recommends antiseptic vaginal injections 
‘if the fetor of the lochia is unusually great, or if the 
parts have been lacerated.” 

Barnes * says: ‘‘ Wash out the uterus twice daily from 
the second day; should there be the slightest rise of tem- 
perature and pulse, the intra-uterine injection is impera- 
tive.” 

Measured by the rule above proposed, in the light of 
the evidence adduced, notwithstanding high authority 
to the contrary, the conclusion is inevitably reached, 
that under normal conditions, with fair sanitary surround- 
ings, neither vaginal nor uterine injections are to be rec- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Puerperal Cone 
dition. 


ommended as a routine practice, upon the theory of fore- 
stalling possible morbid developments, which may, if 
they should occur, produce a state of general septic tox- 
emia. But so soon as a probable diagnosis of commenc- 
ing puerperal fever is made, based upon the presence of 
the usual initial symptoms—a sustained elevated tem- 
perature, associated with a quickened pulse, preceded, 
possibly, by a chill, and accompanied by pelvic pain or ten- 
derness in the hypogastric region, tympanites, headache, 
flushed face, and general restlessness, with, perhaps, an 
offensive lochial discharge and arrested uterine involu- 
tion, occurring about the third or fourth day—a warm 
vaginal injection of carbolic acid Zij. to water Oj., or 
corrosive chloride of mercury one part to water 2,000 
or 3,000 parts, or of tincture of iodine 3 j. to water Oj., 
should be given and repeated two or three times daily. 
Meanwhile, agitation and pain should be subdued by an 
opiate. Morphine, hypodermatically, is usually the most 
available mode of administration. If the symptoms 
continue without abatement or with increased activity, 
the injection into the uterus of one of these antiseptic so- 
lutions should be practised, always by the medical at- 
tendant himself. The several dangers pertaining to this 
procedure—namely, shock, uterine hemorrhage, inject- 
ing air or forcing the liquid into the peritoneal cavity— 
may generally be avoided by observing the utmost gentle- 
ness in all the manipulations, by carefully expelling all 
air from the injecting apparatus, and by warming the so- 
lution to from 100° to 105° F. 

Great care should be taken to secure the ready egress 
of the injected fluid from the uterine cavity. If the os 
is patulous, as it usually is under these circumstances, 
this may be readily accomplished. For injecting the so- 
lution, either an irrigator or fountain syringe, or a hand- 
ball syringe, may be used. 

The nozzle may be passed directly through the internal 
os, or it may be attached, through the medium of rubber 
tubing, to an ordinary gum-elastic catheter—or to some 
of the special tubes or catheters devised for this purpose 
—which should be carefully carried, while the liquid 
is gently flowing through it, into the womb. The return 
current may be received in a bed-pan, or conveyed by 
means of a rubber cloth, depending over the side of the 
bed, to a vessel on the floor. A thorough vaginal injec- 
tion should first be given, to obviate the risk of carrying 
any septic matter from the vagina into the uterus. If 
frequent or very copious injections should become neces- 
sary, the danger of carbolic-acid or mercurial poisoning 
may be escaped by using simply warm water at first, to 
be followed, without withdrawing the tube, by a few 
ounces of the medicated liquid. The advisability of re- 
peating this procedure once, twice, or thrice daily must 
depend upon the results obtained in the first trial. If 
improvement follows, it should be tentatively continued. 
If, on the contrary, unpleasant consequences ensue, it 
may be proper to abandon it at once. 

Any fragment of the placenta or of the membranes, 
and any clot, that may remain in the uterus or the vagina 
should be carefully removed. 

As an antipyretic and, possibly, as an antiferment, 
quinine is of great value in these cases. It should be 
given in full doses repeated twice daily, or, in some 
cases, it may be prescribed in smaller doses at shorter 
intervals. Salicylate of sodium and antipyrin may be 
employed as substitutes, if the quinine should fail or not 
be well borne. In some forms of the disease the remark- 
able tolerance of opium necessitates its free use to ease 
pain, quiet irritability, and secure sleep. Chloral, as a 
hypnotic, may sometimes be advantageously added. Al- 
cohol is of pre-eminent service. It is usually tolerated 
in large doses. It reduces the temperature, prevents waste, 
and wards off asthenia. As a cardiac sedative, veratrum 
viride occupies the first rank. It may usually be given, 
noting the effect, in doses of five drops every three or 
fourhours. Itis not incompatible with opium or alcohol. 
It, too, is a conservator of the vital forces, besides con- 
tributing directly to the comfort of the patient. But let 
it be distinctly understood that neither veratrum nor 
other cardiac sedative is indicated if the rapid pulse is 


the result of a feeble heart. Frequent sponging of the 
body with cold or tepid water, or with alcohol, is bene- 
ficial. The cold bath and the cold pack are recom- 
mended for reducing bodily heat. They are difficult to 
administer in private practice, and are not entirely free 
from danger. Topical cold to the abdomen, as ice or 
cold-water coils, sometimes accomplish good if main- 
tained for anumber of hours; but in some cases the warm 
applications—poultices, turpentine stupes, etc. —are more 
comfortable and appear to act better. Ice to the head is 
sometimes employed. 

To allay nausea, ice, iced champagne, and sinapisms 
to the epigastrium, are among the most trustworthy re- 
sources. Constipation, if it exists, may be overcome by 
enemata or laxatives cautiously given. Puncture of the 
intestines with a very fine, hollow needle, in distressing 
tympanites, has been successfully practised. 

The diet should be nutritious and digestible; only 
liquids, as milk, animal broths, and gruel, should be al- 
lowed. 

Any intercurrent local complication that may develop 
must be treated on general principles. 

In estimating the value of any mode of treatment, it 
should be remembered that a large proportion of the 
febrile attacks of puerperal women pursue a favorable 
course and may be expected to terminate after several 
days, and even under the most discouraging assem- 
blage of symptoms, hope of recovery should not be 
abandoned. 

Phlegmasia dolens, or phlegmasia alba dolens, when it 
attacks the puerperal woman, appears, as a rule, during 
the second or third week after labor. The prominent 
local characteristics, when fully developed, are pain, 
swelling, a brawny hardness, and a glistening white ap- 
pearance of the affected parts. It occurs commonly in 
one or both of the lower limbs, as a rule in one only, and 
exhibits a decided predilection for the left side. When 
both legs are invaded, the manifestations are not simul- 
taneous, but the second is attacked from a day to a week 
later than the first. The disease sometimes occurs in the 
arms, and it has been observed in men. When the arms 
alone are involved, it is not often of puerperal origin. 
The shining whiteness of the skin gave rise to the popu- 
lar appellation of ‘‘ milk-leg,” and suggested, no doubt, 
the early theory of milk metastasis. 

The initial symptom of an attack may be a chill, fol- 
lowed by some reaction, with a sensation of heaviness of 
the limb, and a dull pain increased by motion. This 
may be preceded for a day or two by a feeling of great 
lassitude and depression. As the disease progresses the 
tenderness becomes extreme, and the degree of swelling 
may be enormous, the limb sometimes being double its 
natural size. 

The swelling may commence in the thigh and extend 
downward, or it may first appear at the ankle and spread 
upward. The veins, like hard, knotted cords, may some- 
times be felt in the beginning and during the subsidence 
of an attack. Other veins besides those of the extremi- 
ties may also be the seat of the affection. The lochial 
discharge is frequently uninfluenced. The secretion of 
milk is generally diminished or arrested. In the ordi- 
nary course, after a week or ten days amendment takes 
place ; the swelling gradually subsides, and the limb then 
pits on pressure; the exudation is absorbed, the circu- 
lation is restored, and muscular movements become possi- 
ble. The usual duration of an attack is five or six weeks. 

Under less favorable conditions, suppurative phlebitis 
may ensue, abscesses may develop, and extensive suppu- 
ration of the subcutaneous and intermuscular cellular 
tissue sometimes occurs. Occasionally the affected vein 
is permanently obliterated. A thrombus may undergo 
purulent softening and disintegration, and thus produce 
infected emboli, which may, in turn, originate metastatic 
abscesses at the points of lodgement in various parts of 
the body ; or a large fragment of a thrombus, in conse- 
quence, possibly, of imprudent manipulation or pre- 
mature use of the limb, may be carried by the circula- 
tion through the right side of the heart and produce 
sudden death by plugging the pulmonary artery. 


77 


Puerperal Con- 
dition. 


The pathology of phlegmasia dolens has given rise to 
much controversy, which has served to develop numerous 
specious theories, none of which satisfactorily explains 
all of the morbid phenomena that are observed. 

The doctrines of phlebitis, of venous thrombosis, and 
of inflammation or obstruction of the lymphatics, are all 
maintained. Some authorities now hold to phlebitis as 
the essential lesion, some to peripheral.thrombosis, others 
to the obstruction of the lymphatic ducts and venous 
thrombosis combined—regarding phlebitis, when it is 
present, as secondary to the thrombus or to inflammation 
of the surrounding cellular tissue. The inflammation 
may be limited to the subcutaneous or to the intermus- 
cular cellular tissue, or it may follow the perivascular 
connective tissue ; and secondary thrombosis and obstruc- 
tion of the veins and lymphatics may result from the 
inflammatory thickening of their walls. A predisposi- 
tion to this affection is established in puerperal subjects 
by the hyperinotic state of the blood, by the slow pulse, 
and by the occurrence of copious hemorrhage. Varicose 
veins are also regarded as a predisposing cause. 

The veins commonly involved are the iliac, femoral, 
crural, tibial, and peroneal. Venous thrombus may de- 
velop at any point in the course of a vein, or it may in- 
vade the veins by extension from the uterus. 

A succession of chills occurring in the course of an at- 
tack of phlegmasia dolens, accompanied by high tem- 
perature, denotes some complication. 

Absolute rest, with the leg slightly elevated, and 
with opium to relieve pain, are the principal indications 
for treatment. If constipation exists, laxatives or ca- 
thartics should be prescribed. Quinine in moderate or 
large doses is useful. Painting with tincture of iodine 
along the course of the affected vessels, if they can be 
traced, or over the entire surface of the limb, has been 
practised. Stimulating or anodyne liniments, applied 
with gentle friction after the most acute stage has passed, 
may be used in lieu of the iodine. The limb should be 
protected from the pressure of the bedclothing by a 
frame or cradle, and may be enveloped in cotton-batting 
or flannel, and covered by oil-silk. 

As the swelling subsides some advantage is obtained 
from a well-applied roller-bandage, and the tincture of 
the chloride of iron may be administered. Blisters are 
not admissible, and leeches are not indicated, unless they 
be used with the hope of averting suppuration in some 
localized inflammation. If pus forms, it should be 
promptly evacuated. 

In the employment of friction the possibility of dis- 
lodging a clot, or of separating a fragment from a disinte- 
grating or softened thrombus, should be borne in mind. 
Absolute rest should be punctiliously maintained until 
every vestige of the swelling and of the tenderness has 
_ disappeared. The limb sometimes manifests a tendency 
to swell, after standing or walking, for several months, 
and is apt to be more or less impaired functionally for a 
considerable time. Great comfort and advantage may 
be derived from a close-fitting, long elastic stocking 
when the patient begins to walk about. 

Venous and Arterial Thrombosis and EHmbolism, and 
Other Causes of Sudden Death.—The conditions which 
favor the occurrence of. peripheral venous thrombosis in- 
vite similar formations in any part of the body, without 
association, necessarily, with the anatomical characteris- 
tics of phlegmasia dolens. 

These clots may develop in the right ventricle and, ex- 
tending into the pulmonary artery, cause death from as- 
phyxia by arrest of the pulmonary circulation. Rarely, 
thrombi form in the arteries of the puerperal woman as 
they do in the veins, but circumstances are not so favor- 
able to their development here. 

A thrombus may undergo separation or disintegration, 
and the fragments thus formed, when caught up by the 
circulation and lodged in vessels of smaller calibre, con- 
stitute emboli, which, in turn, may become nuclei for 
fibrinous accretions and the consecutive development of 
other thrombi at the points of lodgement. 

The pulmonary artery is not alone subject to this acci- 
dent, but concretions from the left side of the heart may 


78 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


find their way into the systemic arteries, and especially 
the femoral, brachial, cerebral, and ophthalmic arteries 
may be thus occluded. 

The symptoms depend, of course, upon the character, 
size, and location of the occluded vessel, and upon the 
suddenness with which the arrest of the circulation in it 
may be accomplished. 

Sudden death sometimes overtakes the puerperal wom- 
an when all seems well. No intimation of the impend- 
ing disaster is given, hut after a brief struggle for breath, 
life becomes extinct. 

This distressing result may be due, as has been shown, 
to pulmonary thrombosis or to pulmonary or cerebral 
embolism; to cerebral hemorrhage, or to hemorrhage 
from the rupture of an aneurism or of an abdominal ves- 
sel; to the entrance of air into the circulation, and to ex- 
treme syncope and shock. 

Helampsta.—Convulsions may occur during pregnancy, 
during labor, and immediately subsequent to, or within 
several hours after, delivery. It is the last class only that 
is to be included among the pathological complications of 
the puerperal state. 

If the estimate of one case of convulsions to five hun- 
dred cases of labor is correct, and if the statistical results 
of Lohlein’s investigations (quoted by Lusk?) are ac- 
cepted, namely, that eighty-eight per cent. of puerperal 
convulsions occur in parturient patients, a post-partum 
convulsion must be an exceedingly rare event. It is fort- 
unately true that such convulsions are very infrequent. 
From this reckoning, hysterical and epileptic convul- 
sions, and the convulsions symptomatic of cerebral and 
meningeal lesions, are eliminated. 

The convulsions of this period usually develop sud- 
denly, though the foreshadowing symptoms may have 
been present and passed unobserved during pregnancy or 
parturition. The most constant premonitory symptoms 
and signs are headache, vertigo, low spirits, flashes of 
light, tinnitus aurium, nausea, vomiting, cdema of the 
face, albuminuria, and tube-casts. 

The first convulsive movements may consist of slight 
twitching of the corners of the mouth or of the eyelids. 
Other voluntary muscles, especially those of the neck, 
trunk, and upper extremities, speedily become involved. 
The muscles of respiration are also apt to be affected. 
Consciousness is lost, and the respiration becomes irreg- 
ular and stertorous. After lasting a few moments the 
muscular spasm relaxes, but the consequent sopor is usu- 
ally protracted for from twenty or thirty minutes to sev- 
eral hours. A succession of convulsive seizures may 
occur, and alarming uterine hemorrhages are sometimes 
among the unfortunate results. 

The precise pathological nature of eclampsia has not 
been determined. Though defective renal elimination . 
seems to be an important, if not the essential, factor. 
Changes in the circulation, nervous exhaustion incident 
to labor, morbid sensibility, and moral disturbances may 
act as exciting causes. 

The prognosis is hopeful in proportion to the short 
duration, mildness, and infrequency of the seizures, and 
to the absence of grave fundamental lesions. 

The treatment should be addressed to the prevention 
of the attack if any warning symptoms are present. The 
vicarious elimination of excretory products by the bowels 
and by the skin, and the use of calmative remedies, meet 
these indications. Venesection, so prompt and effective 
as a remedy in ante-partum convulsions, may sometimes 
be valuable in this form, but it should be resorted to with 
discretion. 

Chloroform by inhalation is an indispensable and most 
efficient remedy. After the attack has subsided, the 
chloroform should be watchfully continued at intervals, 
and promptly renewed upon the least intimation of recur- 
rence of a paroxysm. ‘The hypodermatic use of mor- 
phine, the bromide of sodium or potassium, and chloral 
either by the mouth or by the rectum, are serviceable ad- 
juncts. When an attack supervenes, the tongue should 
be guarded from injury by thrusting a cork or a roll of 
cloth between the teeth. The patient should also be pre- 
vented from otherwise injuring herself. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Puerperal Mania is usually developed, when it occurs, . 


within the first two weeks after delivery. 

In some cases the attack is foreshadowed by prodromic 
symptoms, lasting froma few hours only to several days, 
or its advent may be sudden and startling. 

The manner is strikingly changed, and is marked 
either by excitement or by depression. The patient is 
sleepless, watchful, suspicious, talkative but incoherent, 
or maintains a moody silence. Irregular muscular move- 
ments and motiveless actions are generally noticed. 
The symptoms become more intense as full development 
is reached. The patient may be violent in speech and 
act. Profanity and vulgarity frequently characterize 
her expressions. Repeated attempts to leave the bed, to 
remove the clothing, and to inflict personal injury may 
be made. The emotional manifestations are sometimes 
of a pleasurable character, but at other times are pro- 
foundly depressed, and even suicide or infanticide may 
be attempted. 

Attacks of puerperal mania are generally associated 
with a debilitated condition of the system, with defective 
nutrition, an impoverished condition of the blood, and 


some derangement of the cerebral circulation, resulting. 


in a state either of anzemia or of congestion. When cere- 
bral congestion is observed, it may possibly be a tran- 
sient condition of an anemic brain. Mania may be de- 
veloped in connection with any of the severe puerperal 
lesions. 

Heredity is an important element in the causation. 
Social condition and emotional perturbation are influen- 
tial in its production. 

The prognosis is generally favorable. It becomes less 
hopeful if the attack should be protracted beyond sey- 
eral weeks, and should drift into a state of settled mel- 
ancholy. A fatal termination is generally due to some 
intercurrent affection, as metritis, peritonitis, or pneu- 
monia. 

Severe treatment is not admissible. Bloodletting and 
blisters are injurious. The indications point to quieting 
and supporting measures, and include the removal of 
any direct or reflex exciting cause. The hypodermatic 
use of morphine and of hyoscyamine is sometimes effec- 
tive. Chloral and the bromides of potassium, sodium, 
and lithium are particularly trustworthy and valuable. 
These may be administered by the mouth or by the rec- 
tum. Severe catharsis is not required, but laxatives or 
gentle cathartics may sometimes be demanded for the 
purpose of overcoming constipation. Cold to the head 
may be tried when called for by undue heat. 

An abundant, digestible, and nutritious diet is indis- 
pensable. Good nursing is a prime requisite: Tact and 
clear judgment in the nurse, combined with firmness and 
gentleness of manner, contribute largely toward the suc- 
cessful management of these cases. 

Cardiac sedatives may be necessary on account of the 
development of inflammatory complications, which 
should be watched for and appropriately treated when 
they occur. 

Mastitis or Mammitis, and Mammary Abscess.—Inflam- 
mation of the breasts, one or both, may be developed 
irrespective of lactation, but it is much more frequent 
during the functional activity of the gland, and the ma- 
jority of cases occur between the first and fifth week 
after labor. 

Inflammation may invade the subcutaneous cellular 
‘tissue, the glandular tissue, or the subglandular cellu- 
lar tissue. In any of these situations it may terminate 
by resolution, or suppuration may ensue, giving rise, re- 
spectively, to subcutaneous or superficial abscess, to glan- 
dular or parenchymatous abscess, and to subglandular 
or deep mammary abscess. Any one of these forms of 
inflammation or suppuration may exist alone, or any two 
or all may exist simultaneously or consecutively. 

The superficial variety resembles ordinary phlegmo- 
nous inflammation occurring in similar tissue elsewhere. 
It is marked by pain, heat, redness, and swelling, and is 
apt to end in suppuration, either as small boils around 
the nipple or as circumscribed abscesses upon any por- 
tion of the surface of the breast. 


Puerperal Con- 
dition. 


The deeper varieties are accompanied by considera- 
ble constitutional disturbance. Fever, headache, thirst, 
anorexia, and sometimes a rigor, characterize the com- 
mencement of an attack. In the glandular form the 
breasts are excessively tender, swollen, congested, dis- 
tended, and painful. Lobular induration gives to the 
organ a lumpy or knotty feel. Several lobules are gen- 
erally involved, and when suppuration occurs the ab- 
scesses are likely to be multiple—developing in some 
cases one after another, and extending through weeks or 
months. The lacteal secretion is suspended in the af- 
fected lobules. The milk-ducts are narrowed or closed. 
Pus may escape externally by ulceration through the 
skin, sometimes resulting in fistule, or it may penetrate 
one of the larger ducts and be discharged with the milk. 

Subglandular cellulitis can seldom be detected with 
certainty until suppuration has taken place. The gen- 
eral symptoms are the same as those already enumerated. 
The pain is deep-seated and aching in character. The 
breast is greatly enlarged, though smooth and regular in 
outline. The axillary glands are usually swollen and 
tender, and movements of the arm which involve con- 
traction of the pectoral muscles are exceedingly pain- 
ful. The integument may become cedematous, but it is 
not congested or sensitive. If the accumulation of pus 
is considerable, the gland is lifted away from the chest- 
wall and floats upon the liquid base. 

Attacks of mastitis are generally ascribed to cold, to 
blows or bruises upon the breast, emotional disturbances, 
obstruction of the lacteal ducts, and to inflammation of 
the nipples, extending along the milk-ducts or extending 
by the lymphatics to the deeper tissues, 

Circumscribed cellulitis, whether superficial or deep, 
does not necessarily arrest the secretion of milk, even if 
localized suppuration occurs. If the inflammatory ac- 
tion is general, lactation is suspended, but the function 
is not destroyed unless-sloughing or adhesions should 
permanently injure the secretory structures. 

Superficial cellulitis may sometimes be arrested, at the 
very commencement, by the application of the tincture 
of iodine to the inflamed spot, and it may otherwise be 
treated like threatened abscess in any situation. If an 
abscess should form notwithstanding efforts to avoid it, 
recovery will be hastened by early opening in a line ra- 
diating from the nipple. 

Constitutional treatment is indicated in the severer 
forms—sometimes in all. Opiates are frequently required 
for the relief of pain; laxatives or cathartics may be 
necessary. If the temperature or pulse-rate should run 
high, veratrum viride or some other cardiac sedative may 
be advantageously employed. When the excessive secre- 
tion and the accumulation of milk aggravate the pain or 
increase the risk of suppuration by pressure from with- 
in, belladonna or phytolacca decandra may be cautiously 
and tentatively used. Quinine is a valuable remedy, 
and should be given in full doses. In some anzemic and 
feeble subjects, a liberal, tonic, and supporting regimen 
is necessary. 

The local treatment of the subglandular variety consists 
in rest and support of ‘the breast. For this purpose, as 
well as for compression—which should be reserved in 
this form of abscess until after the evacuation of the pus 
—adhesive strips, a roller or a three-tailed bandage, ap- 
plied as the tact, judgment, and experience of the physi- 
cian may suggest, will accomplish the object sought. 
Topical medication is useless. So soon as pus is detected 
by palpation or by the introduction of a long exploring- 
needle, a free exit must be afforded at the lower part of 
the breast. 

The treatment of the glandular form of mastitis is 
more satisfactory. In addition to the general means 
above recited, local treatment is very important. Nurs- 
ing the child from the affected breast should be at once 
prohibited, but the engorgement of the breast must be 
overcome by rubbing from the base toward the apex. 
Po lessen friction, a little olive-oil may be applied to the 
surface. Some persons prefer camphor, on account of 
its reputed property of reducing the secretion of milk. 
The lips of a nurse who understands the art of ‘‘ draw- 


19 


Puerperal Condition. REFERENCE HANDBOOK 


Puerperal Fever. 


OF THE MEDICAL SCIENCES. 


ing breasts,” applied over and around the nipple, will 
materially aid the process of expression. Repetition of 
this procedure, probably twice daily for several days, 
will be required. ; 

The breasts should be supported and compressed either 
by skilfully applied adhesive strips, a bandage, or the 
compressed sponge. The topical use of belladonna is ser- 
viceable. Dry cold is recommended, though warm ap- 
plications are, perhaps, generally preferred. If, however, 
despite well-directed efforts, suppuration should occur, 
so soon as any accumulation of pus can be made out, it 
should be evacuated. 

It is well, in opening and treating mammary abscesses, 
to observe antiseptic precautions. James B. Laird. 

1 Barker: The Puerperal Diseases. 

2 Tusk: Science and Art of Midwifery. 

3 Barnes: System of Obstetric Medicine and Surgery. 

4 Galabin’s Midwifery. 5 Playfair: System of Midwifery. 

6 Parvin : Science and Art of Obstetrics. 

7 Landis: Management of Labor. 

8 Parvin: Gynecological Transactions, 1880, vol. vy.; and Barker ; 
The Puerperal Diseases. 

8 New York Medical Journal, December 15, 1883. 

10 Tbid., February 16, 1884. 

11 Leishman: System of Midwifery. 


PUERPERAL FEVER. Derinition.—This malady 
may be defined as a continued fever following confine- 
ment. The opinion of the majority of pathologists of 
to-day is, that puerperal fever is produced by sepsis. An 
immense amount of labor is being done at present to 
elucidate and define the nature of this septic cause. 

The type of the disease varies greatly, consequently 
its manifestations possess a wide range. This range 
covers, according to recent authors, the following con- 
ditions: puerperal metritis ; metro-pertionitis ; purulent 
infection, or pyemia,; puerperal septicemia ; puerperal 
diphtheria (Garrigues). 

ErroLocy.—The special sources of sepsis are retained 
portions of the secundines, the hands of the physician, 
midwife, or nurse, instruments and sponges, and other 
puerperal-fever patients. 

Among predisposing causes may be enumerated long- 
continued mental depression, blood-poverty, and an un- 
known epidemiological influence. The writer inclines 
to the belief that the accumulation of faeces, with its ac- 
companying ptomaines, in the colon, so often found in 
lying-in women, may contribute to the development of 
this malady. The blood of puerperal-fever patients is 
profoundly affected. Women with fecal accumulations 
in the colon possess a copric blood, which is, possibly, 
fertile soil for the puerperal sepsis. . 

Morpip AnAatomMy.—The autopsy reveals the almost 
innumerable lesions following sepsis. When death has 
resulted in a few hours after the septic invasion, before 
the coarser pathological changes can have developed, 
the ravages of the morbid germ can be detected in the 
‘* beginning inflammation in most of the tissues, such as 
cloudy swelling, and in the granular infiltration and dis- 
organization of the cellular elements” (Playfair). A pro- 
found alteration in the blood is also found, as a great in- 
crease in the white corpuscles, an increase in the fibrin 
and extractive matters, and a decrease in the red blood- 
cells. The blood also contains an excess of urea and of 
carbonic dioxide. 

Generally, in post-mortem examinations after every 
form of puerperal fever, there are found lesions of the 
genital tract, in the shape of lacerations which present 
an unhealthy appearance, their edges being cedematous 
and ragged. The endometrium is commonly found in a 
gangrenous condition. The solutions of continuity found 
in the vulva, vagina, and uterus present the sources of 
entrance of the morbid germ; hence this malady is 
found more frequently in primipare than in multipare. 

At the vulvar orifice these wounds undergo such a 
change that they present an appearance of ulceration, 
denominated ‘‘ puerperal ulceration.” 

These ulcerations sometimes extend up the vagina and 
even into the uterus, are surrounded with much cedem- 
atous infiltration, and are named by Virchow “ malignant 
internal puerperal erysipelas.” 


80 


These extensive ulcerations are denominated, accord- 
ing to their site, ‘‘ puerperal colpitis” or ‘‘ puerperal 
metritis.” 

The pathological changes seen in the uterine paren- 
chyma, in the veins, lymphatics, and pelvic cellular tissue, 
are often extreme. Pus is often found in the uterine lym- 
phatics and veins, showing the existence of metro-lym- 
phangitis or metro-phlebitis. The pus is oftenest found 
at the tubal insertions, and is carried along the lymphat- 
ics into the pampiniform plexus of veins, thus explaining 
the frequency with which para- and peri-metritis compli- 
cate metritis. | 

The peritoneum is nearly always affected. Congested 
patches only may be noticed. Usually the whole mem- 
brane is involved, the intestines being bound down with 
adhesions, thus forming pockets containing pus, with 
flaky lymph in greater or less quantities. Pericarditis, 
pleuritis, and meningitis may be seen also—in short, all 
the serous membranes may be found in various stages of 
inflammation. The joints may be invaded by fluid, se- 
rous or purulent. 

To epitomize: First, in the inflammatory form of puer- 
peral fever will be found lesions confined chiefly to the 
pelvic tissues and to the peritoneum. Second, in the 
pyemic form will be found phlebitis, with metastatic 
abscesses in any of the organs, as the ovary, liver, lung, 
kidney, spleen, eye, muscles, and connective tissue. 
Third, in the septicemic form lymphangitis is the chief 
morbid feature of interest. 

The pathological changes are the most pronounced in 
chronic cases. 

SyMPTOMATOLOGY.—There is a greater latitude in the 
symptoms of this malady that in those of any other disease. 

The only constant symptoms in all forms of puerperal 
fever are the facial expression and the pulse. ‘The symp- 
toms most conspicuous in any one form of this disease 
may be only feebly marked or wholly absent in the other 
forms. Reflection indicates at once that, the pathological 
conditions of puerperal fever being so varied, there must 
necessarily be a great diversity of symptoms manifest in 
this terrible malady. Hence any description of the symp- 
toms intended to cover all cases must be incomplete. The 
following may suflice to give a very brief clinical history 
of the progress of a case of puerperal fever : 

The disease is ushered in, within from two to four 
days after delivery, with a chill—varying anywhere be- 
tween the two extremes of a succession of slight cold 
waves, originating apparently in the spinal cord, to a 
severe prolonged chill lasting an hour or longer. In the 
majority of cases this chill-invasion is insidious ; in some 
cases it is wholly absent. Following it there is an alarm- 
ing increase in the pulse-rate—alarming because it is al- 
ways present in this malady and at once indicates the 
gravest possibilities. It may vary from 100 to 150 or 
more beats per minute. Accompanying this rise in the 
pulse-rate is an elevated temperature, generally to 102°, 
and, in the severest cases, to even 105° or 106°. The 
countenance early becomes sallow and sunken, and has a 
most anxious expression. The skin is hot and dry. The 
lochia are greatly diminished or wholly suppressed, and 
the mammary secretion may be arrested. In many cases 
there is severe general cephalalgia, and oftentimes deliri- 
um is early developed. ‘The absence, or a great perver- 
sion, of sleep is observed. The tongue is heavily coated 
early in the disease, and soon becomes dry and rough, and 
sordes appear on the gums and lips. Vomiting is often 
present, the ejecta being dark and of a peculiar odor. 
Tympanites, with much pain and tenderness aggravated 
by pressure, soon presents itself—although peritonitis, 
with effusion, may arise without these abdominal symp- 
toms. Diarrhcea is often present, the evacuations being 
horribly. fetid. Jaundice may develop. The breathing 
is often short and hurried. Pneumonia, pleurisy, or peri- 
carditis occasionally ensues. The urine is generally 
much diminished, and albuminuria often supervenes. 
In pyeemic cases, suppuration develops in the joints or in 
any organ of the body. When fatal, the disease termi- 
nates usually within a week. The patient dies from ex- 
haustion. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, £2erperal Condition. 


Puerperal Fever. 


The foregoing may be regarded as a condensed and, 
necessarily, an incomplete syllabus of the symptomatol- 
ogy of this disease. It seems expedient to give a more 
amplified description of symptoms met with in a great 
many different cases, arranged under the headings of the 
various systems of the human organism. 

The Nervous System.—In patients about to develop 
puerperal fever will be noticed a condition (properly be- 
longing to the nervous system) of fatigue, as though they 
had not yet recovered from the shock of labor. Later 
the characteristic anxious facial expression is always de- 
veloped. A certain amount of indefinable nervousness 
and apprehension is nearly always present, and is often 
accompanied with precordial distress. The absence of 
these symptoms is very noticeable in women who have 
no puerperal troubles. Headache soon develops in the 
majority of cases. Itis general, and is not confined to 
any single region of the head—as the corona, occiput, or 
temporal region. Sometimes it is very severe; at others 
it is not complained of greatly. 

Later, delirium often arises. At first it is character- 
ized by the patient being dazed for several minutes upon 
_ waking, and unable to tell where she is, or to recognize 
her surroundings or her friends. Some cases present 
delirium early in the course of the fever, and it grows 
more and more pronounced until it is continuous, As 
the patient approaches the fatal issue, the delirium be- 
comes low and muttering. In cases that recover, the 
cerebral nutrition is often at such a low ebb that the 
patient is continually possessed of hallucinations of 
vision and hearing. She sees all sorts of weird objects 
and sights that have no existence, and hears conversa- 
tions that do not occur. This is a condition often seen in 
feeble patients with other diseases. In many fatal cases 
the intellect is singularly clear till within a few hours of 
death, when the low, muttering, lethal delirium sets in. 
_ Oftentimes the delirium is manifested only at night, al- 

ternating with intervals of consciousness. In such cases 
the contrast of the nurse’s night report with that which 
the physician beholds in his patient in the morning leads 
him to suspect the nurse’s accuracy of observation. Oc- 
casionally this intermittent delirium is very severe, bor- 
dering on mania. 

Subsultus tendinum and carphologia are often de- 
veloped in the later stages of the disease. The hands 
and lips may tremble when they touch anything. 

There is generally a chilliness preceding the rigor 
which commonly ushers in puerperal fever. The rigor 
is often absent, or so slight as to escape observation, or 
is attributed to some fugitive cause. In other cases the 
rigor is repeated and very severe, and this is especially so 
in the pyzemic form. Sometimes rigors, with exacerba- 
tions of the general symptoms, are observed on the sixth 
or seventh day ; D’Espinne attributed the occurrence of 
these to fresh accessions to the systemic infection from 
putrid pus in the peritoneal cavity. 

Pain is generally a marked characteristic of peritonitis, 
though not an invariable one. It begins in the hypo- 
gastrium, and soon invades the entire abdomen. Some- 
times the pain is slight. In some cases it is wholly absent, 
and yet peritonitis progresses to its inflammatory se- 
quences, terminating fatally in the great majority of 
Cases. 

The Circulatory System.—The increase in the pulse-rate 
is always present, from 100 up to 150 and higher, often 
reaching an uncountable point before the demise. Accel- 
eration of the pulse from transient causes, as the nervous 
excitement of the advent of the physician, mental annoy- 
ance, hot drinks, etc., is to be excluded from the impor- 
tant symptoms. An unaccountable acceleration of the 
pulse is always alarming in recent puerperal patients. 
A pulse above 180 beats per minute is always of the 
gravest import. The arterial tension is always lowered, 
as is shown by the weak, thread-like pulse. If the pulse- 
rate diminish, and a corresponding improvement obtain 
in other respects, it augurs well. 

The Respiratory System.—The breathing soon becomes 
short and hurried. If tympanites develop, the rate of res- 
piration is greatly accelerated. Later, as the heart grows 


Vou. VI.—6 / 


weaker, the patient becomes cyanotic. Toward the last 
the breath has a heavy, sweetish odor. The respirations 
may be from 50 to 60 or more per minute. Often pneu- 
monitis, or pleuritis, or pericarditis may develop. In the 
cases of purulent infection embolic infarctions supervene 
in the lungs, pleura, or pericardium, often followed by 
suppurative inflammations terminating in abscesses. In 
cases of peritonitis, when the tympanites is enormous the 
breathing is wholly thoracic, the patient lying on her 
back with her knees drawn up. 

The Alimentary System.—The tongue at first presents 
no distinctive character, but later it becomes furred. 
Soon thereafter it is covered with a heavy, deep fur— 
white or brownish. Still later it becomes dry and rough, 
and is often indented with the teeth. Toward the last 
the tongue, gums, and lips are covered with sordes. 

Thirst: is generally great. The more the cutaneous 
transudation prevails, the greater will be the thirst. Its 
absence is a favorable symptom. 

Vomiting does not often occur early. The ejecta are 
dark, like coffee-grounds, and are occasionally very offen- 
sive. Sometimes they are feculent. It often continues 
to the end, or it may be present only a short time. 

Diarrhea is of frequent occurrence. Occasionally it is 
profuse and uncontrollable. In mild cases it is often sal- 
utary. When the case is severe, and the diarrhea in- 
creases and becomes more and more offensive, the outlook 
is gloomy. ‘The more malignant the case, the earlier will 
the diarrhcea-develop. 

Tympanites appears betimes. Sometimes it develops 
within twenty-four hours after the initial chill; at other 
times it supervenes much later. It may arise from diges- 
tive perversion or from peritonitis. Often it is extreme, 
causing the greatest distress, and persisting to the end. 
The meteorism is most marked in cases of peritonitis. 
The muscular coat of the intestine becomes paralyzed and 
the distention of the intestine is enormous. The patient 
occupies the dorsal decubitus, and often cannot bear the 
weight of the bedclothing. Toward the end the disten- 
tion, with its pain and tenderness, often diminishes, and 
thus would mislead the physician but for the ominous 
pulse and facies. 

Occasionally constipation exists, and is inordinately re- 
bellious. 

The Renal System.—The urine is diminished in quan- 
tity, sometimes almost to the point of its total suppres- 
sion. Its watery element is deflected through the cutane- 
ous and alimentary channels in the forms of sweat and 
diarrhoea. Consequently it is very dark from concentra- 
tion, often having the appearance of blood. Albuminu- 
ria is often present. 

The Cutaneous System.—As a rule the skin is dry and 
hot, but later in the disease it is bathed in sweat. An 
occasional case is seen in which sweating is continuous 
throughout ; this Blundell regarded as a distinct variety 
of puerperal fever, calling it ‘‘hidrotid fever.”’ Cases 
occur in which a rigor, a hot stage, and sweating quickly 
follow each other ; they may at first be regarded as ma- 
larial, but as the case progresses they soon declare their 
malign meaning. Often the sweat possesses a peculiar 
odor. Toward the close the skin is always cold, damp, 
and clammy. Now and then a peculiar yellowish discol- 
oration of the skin is observed. Jaundice is occasionally 
developed. Rarely, transient patches of erythema are 
seen on various parts of the skin. An eruption of suda- 
mina commonly results from the profuse sweating. Oc- 
casionally a scarlatinoid eruption is seen. 

GENERAL AND SPECIAL SymMPToMs.—The Temperature. 
—The temperature is always elevated, and is character- 
ized usually by a morning remission and an evening 
rise, or exactly the reverse. In mild cases it rises to 
102° on the second or third day. The sooner after deliv- 
ery that it is observed, the more alarming does it become. 
The fugitive rise of temperature from mammary and ali- 
mentary irritation will be borne in mind while investi- 
gating the possible advent of puerperal fever. In fulmi- 
nant cases the temperature may not rise above 100°, 
while in comparatively mild cases it may rise to 104°, or 
even higher. In large remissions of temperature, not in 


81 


Puerperal Fever. 
Pulsatilla, 


collapse, the outlook is favorable. In severe cases the 
temperature rises at once to 104°, or even to 106°, and it 
is subject to sudden remissions and exacerbations. 

The Lochia.—The discharge is often diminished, and 
in a certain proportion of cases is wholly suppressed. 
When not entirely suppressed it becomes characteristi- 
cally fetid. There are cases in which it is more than 
usually abundant. 

The Mammary Secretion.—Rarely, the flow of milk is 
abnormally large. Diminution, even to the disappear- 
ance, of this secretion is the rule. The breasts often 
become hard and painful. 

The Generative Organs.—Uterine tenderness on press- 
ure, after the second day increasing very markedly, indi- 
cates the development of the endometritis which precedes 
general metritis and systemic infection. The fundus 
can easily be felt through the hypogastrium, and when 
its tenderness is physiological—i.e., when it arises from 
massage to facilitate placental expulsion—Priessnitz com- 
presses will cause its disappearance. 

After-pains continuing or arising after the third day 
in multipare are suspicious of sepsis. When they are 
well marked in primipare they show incomplete uterine 
contractions, which may be followed by infection or by 
hemorrhages. 

The vulva may become cedematous, and be the seat of 
diphtheritic ulcers. 

Localized Inflammations and Suppurations develop in 
the pysemic forms. They may occur in any joint, and 
are always accompanied by the usual subjective and ob- 
jective symptoms characterizing such conditions. Large 
caverns of pus may develop in the muscles and in the 
connective tissues. Any organ may be the seat of ab- 
scess-development. 

ProGnosis.—Until the patient is manifestly improving, 
all attempts at a reliable prognosis are extremely prob- 
lematical. When the disease begins early—within the 
first thirty-six or forty-eight hours—the case will gen- 
erally be a severe one. When the chill is repeated at 
intervals, being preceded by improvement, the danger 
lies in the possibility of the repeated infections fatally 
exhausting the patient. The general condition of the 
patient signifies much—the better it is at the time of 
the attack the better are the chances of recovery. In 
pyemic cases the prognosis is invariably gloomy. Para- 
or peri-metritis followed by abscesses may result in 
chronic invalidism, lasting months or years. 

TREATMENT.—Prophylactic.—This is of prime impor- 
tance. Mindful of the channels of infection, the physi- 
cian is enabled to avoid sepsis in the majority of cases. 
Before touching the patient the hands should be thor- 
oughly disinfected by rinsing in a carbolized solution of 
the strength of 1 to 20, or by anointing with carbolized 
vaseline—1 to 20—after they have been well washed in 
hot water and castile-soap, particular attention being paid 
to the finger-nails. All instruments and sponges used in 
the genital tract should be carefully carbolized. The 

careful and complete delivery of the secundines is abso- 
lutely indispensable. 

When lacerations exist, they should be carefully 
cleansed by irrigation with a 1 to 40 solution of carbolic 
acid and dusted over with iodoform. 

General Treatment.—The source of infection should 
be determined if possible, in the hope of arresting fur- 
ther accessions to the sepsis. In most cases it lies in the 
vulva and vagina. When the attendant is convinced 
that it arises from the uterus, the intra-uterine douche of 
an antiseptic solution should be promptly used. Weak 
solutions of carbolic acid, corrosive sublimate, iodine, 
or Condy’s fluid, can be used through a double-current 
catheter every eight, twelve, or twenty- -four hours. Cor- 
rosive sublimate is much lauded for its germicidal 
properties, and can be used in the 1 to 3,000 solution. 
It is dangerous, cases being recorded in which death 
through toxic nephritis has followed its use. After the 
intra-uterine douche, a bacillus containing 50 to 100 
grains of iodoform should be introduced into the uterine 
cavity. These local applications should be used so long 
as they are of advantage. After the use of the intra- 


82 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


uterine antiseptic douche, the temperature usually falls 
—in some cases from three to six degrees—and often this 
decrease in temperature is final. More frequently, how- 
ever, it is followed by another rise, due to new absorp- 
tion, and the repetition of the douche is followed by an- 
other defervescence, Thus, cases will be found in which 
the repeated fall of temperature and its later rise after 
the douche will extend over many consecutive days. 
Local treatment is more effective and direct than general 
medication. 

Pain.—For this symptom, opium or its derivatives can 
be used. It must be given in quantities sufficient to 
allay suffering, subdue restlessness, and induce sleep. 
Laudanum in poultices over the abdomen often proves 
grateful. “When opium cannot be borne, chloral hydrate 
or cannabis indica may be used. Two parts of extract 
of belladonna and one part of glycerine, thickly spread | 
over the whole abdomen, often relieves the great tender- 
ness found present with extreme intestinal distention. 
In peritonitis hot fomentations are often singularly 
grateful. Turpentine stupes are also of great value. 
Collodion over the whole abdomen is decidedly useful in 
alleviating the pain of this complication. 

Fever.—For this manifestation, quinine is of great ser- 
vice. It should be given fearlessly and continuously— 
say, in ten-grain doses every four or six hours, until def- 
ervescence sets in; when head-symptoms follow its use, 
hydrobromic acid often allays them. The baleful effects 
of quinine on the stomach must be borne in mind. War- 
burg’s tincture has been recommended for the purpose 
of lowering the temperature. Antipyrin has been rec- 
ommended likewise. The theoretical objection to it— 
its cardiac depressing influence—deters many physicians 
from using it. Veratrum viride, in five-drop doses of 
the tincture hourly until the pulse falls below 100, after- 
ward two or three drops every second hour to hold the 
pulse steadily below 100, is greatly praised by Fordyce 
Barker. Aconite may be similarly used. Both of these 
remedies are contra-indicated when the vital powers are 
much prostrated, as is indicated by a weak, thready pulse 
and cold extremities. Cold sponging in sthenic cases has 
its advantages. 

Vomiting is often uncontrollable. Champagne or raw 
brandy will sometimes arrest it. Sulphate of magnesia, 
in thirty- or forty-grain doses in tepid water every hour, 
or every second hour, till the bowels move, often arrests 
vomiting. Three to five grains of calomel every three 
or four hours to purgation will sometimes accomplish 
the same end. The tendency to diarrhoea in this disease 
is not to be forgotten, and its artificial production must 
be undertaken with caution. In persistent vomiting rec- 
tal alimentation can be resorted to. 

Tympanites may often be relieved by the use of the 
rectal tube every three or four hours. It usually mani- 
fests itself first in the transverse colon, and can be de- 
tected by a bulging at the scrobiculum cordis. The use 
of sulphate of magnesia or of calomel to catharsis often 
relieves distention. Placing the patient on her face, with 
her thighs drawn up. under her abdomen, often causes 
enormous expulsions of gas with great relief (Parkes). 
Turpentine internally is sometimes of marked advan- 
tage. 

Diarrhea often occurs in acute cases toward the close 
of the scene, and can be restrained by no remedy. In 
chronic cases it is frequently a prominent symptom, and 
may be checked by the use of the tincture of the per- 
chloride of iron in twenty- or thirty-minim doses. 

Food and Stimulants are to be used frequently and in 
small quantities. Concentrated beef-tea, milk, eggs, 
brandy, and champagne are the main stays in support- 
ing the patient until the effects of the poison are worn 
off. The most abundant supply of fresh air compatible 
with safety should be secured. James H, Hiheridge. 


PULASKI ALUM SPRINGS, Zocation, Pulaski Coun- 
ty, Va. 

Post- -office, Dublin, Pulaski County, Va. 

Accrss.—By the Norfolk & Western Railroad to Dub- 
lin; thence by stage to the springs, twelve miles. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


ANALYSES.—These are, according to Walton, very 
similar to the Rockbridge Alum Springs of Virginia. 
The springs are located at the base of Walker’s Moun- 
tain, on the bank of a creek, in the extreme southwest- 
ern part of Virginia, amid the picturesque scenery of 
that region. There is a hotel at the springs. 
CS dls Fa 


PULEX PENETRANS, chigoe, chiggre, jigger, sand 
flea, rhynchoprion penetrans, is a minute parasite 
abounding in the West Indies and tropical regions of 
the Eastern and Western continents. The female alone 
attacks man, and does so for the purpose of depositing 
her eggs. She penetrates the thin skin between the toes 
or about the toe-nails, and then swells up to the size of 
a pea, forming a bag of eggs; this causes much irrita- 
tion, which often results in suppuration, followed by 
open ulcers. This is generally regarded as a true flea ; 
it oe in dry, sandy places, and multiplies prodigi- 
ously. 

When the chigoe is recognized under the skin, it 
should be carefully removed, or if suppuration has al- 
‘ready occurred, the parts should be washed with 
solutions of carbolic acid, carbolized oil, ete. 

Charles EH. Hackley. 


PULLNA is a village in Bohemia, in which are 
several springs of a bitter water, well known and 
frequently employed in this country as a mild and 
efficacious laxative. ‘The water resembles closely 
that of Hunyadi Janos, but is milder and less cer- 
tain in its action. 

. The composition of the water varies \\ 
within certain limits, but not sufficiently Ss 
to be a matter of any particular impor- 


\, 


tance. The following is the analysis 
given in the U. 8S. Dispensatory (15th 
edition, 1883), after Struve. One pint 
contains : 
Grains 
Magnesium carbonate..............- 6.406 
Calcium carbonate...... ha Pic aeee Sete 6 UY) 
Magnesium chloride :..............; 19.666 
PROPASsI UI, AUIPNALC A ose eae se cae s 4.800 
Skeoehenaayyshibalakie, AA sotor wi enee as Meas 123.800 
Magnesium sulphate ................ 93.086 
@alciumistlipbater..seemaaemeee kes 2.600 
Calciumiphosphate 23.05 .0ie. coals 0.003 


SIUC Se Gap OniaR Ean wO0.0 AGORA Te 
ER OUB Le stage are sttieiya bebe sees cls!s Simos 251.307 


The dose of Piillna water is one or two 
glasses in the morning as a laxative; for its 
so-called alterative effects it may be taken in 
ounce or half-ounce doses, several times a day. The 
water is exported exclusively, and there are no accom- 
modations for visitors at Piillna. fie Ok 


PULSATILLA, U.S. Ph. (Anémone Pulsatiile or Co- 
quelourd, Codex Med.). ‘‘ The herb of Anemone pulsatilla 
Linn., and Anemone pratensis Linn., and of Anemone 
patens Linn., var. Nuttalliana Gray, Order Ranunculaceae, 
collected soon after flowering” (U. 8. Ph.). The Anem- 
ones are perennial herbs, with flowers having the gen- 
eral structure of buttercups, but without petals, the place 
of the corolla being taken by a showy calyx of large col- 
ored sepals (purple, blue, white, etc.), while the calyx 
is simulated in some instances by a conspicuous involu- 
cre. Stamens numerous, the outer sterile; pistils also 
many, small, simple, covering the convex receptacle, and 
ripening into one-seeded achenes, styles persistent, often 
long and plumose. <A. pulsatilla is a low hairy plant, 
with a short, thick stem, and a cluster of doubly pinnate 
and dissected radical, hairy leaves. Flowers solitary on 
hairy scapes, two or three centimetres across, with the 
involucre some distance below the calyx. It is a native 
of England and Northern Europe. A. pratensis has the 
involucre near the calyx, and a less open flower ; it 
grows in the southern part of Europe. <A. Nuwtialliana 
is a native of North America. 


The leaves of Pulsatilla have a very sharp, stinging 


BW 
| a 
J at 


Puerperal Fever. 
Pulsatilla. 


taste, like that of the buttercups, and but little odor: 
they grow insipid by age, and should not be kept more 
than one year. 
Composition.—The Anemones, in common with but- 
tercups and probably some 
other Ranunculacew, contain a 
very pungent, volatile, odl-like 
“, principle, which can be sepa- 
fiz... rated by distillation with water. 
<“t Upon long standing it separates 
two solid substances, anemonin 
and anemonic acid. The former 
is a colorless, crystalline, neu- 
tral substance of 
but little taste when 
cold, but intensely 
pungent when melt- 
ed. Itis but slightly 
soluble in cold alco- 
hol, ether, or water; 
more so in those 
liquids when hot. 
This is the active 
principle. Anemo- 


Fie. 3130.—Anemone Pulsatilla. 


(Baillon.) 


nic acid is a white, amorphous, insoluble substance, of 
neither odor, taste, nor medicinal properties. 

AcTION AND Usze.—Pulsatilla is an old remedy, with 
a good many reputed empirical powers. It has had a 
reputation in chronic eruptions, syphilis, ‘‘ ophthalmia,” 
amaurosis, nasal and bronchial catarrh, etc. It is now 
sometimes given in dysmenorrhea, whooping-cough, 
asthma, etc., with supposed advantage. It is extensively 
used in homceopathic practice. Anemonin is an active 
poison, reducing the heart-beats in number and strength, 
and reducing the number of respirations. Collapse, pa- 
ralysis, stupor, and convulsions have been observed after 
its administration. 

Dose, of Pulsatilla one or two decigrams (gr. ij. ad iij.); 
of Anemonin, one or two centigrams (gr. 4 to 4). 

ALLIED PLANTs.—A number of Anemones are favor- 
ites in the flower-garden, others are well known and 
pretty wild flowers: A. nemorosa, the wind-flower, is re- 
puted to have properties similar to the above. See Aco- 
NITE for the order. 

ALLIED Drues.—There is a family resemblance in the 


83. 


Pulsatilla. 
Pulse. 


actions of a good many of the Ranunculaceew. Anemone, 
Ranunculus, Adonis, Clematis, Delphinum, etc.; Symplo- 
carpus (Skunk Cabbage), and Artsema (Indian Turnip) 
have a similar acrid, benumbing principle. 

W. P. Bolles. 


PULSE, ARTERIAL. With each systole, the left ven- 
tricle of the heart propels into the already full aortic sys- 
tem an additional volume of blood. The time occupied 
by the influx of this volume of blood into the aorta is the 
period from the opening of the semilunar valves until 
the beginning of relaxation of the ventricle. The same 
volume of blood escapes from the arterial system through 
the capillaries in the time occupied by one entire cardiac 
cycle, of which the period of influx is only a part. 
Hence only a part of the volume of blood thrown into 
the aorta escapes during the time of its influx; for the 
remainder room is made for a while by a dilatation of 
the (yielding) arteries. This dilatation takes place first 
in the root of the aorta, is quickly propagated along the 
arterial tree in the form of a wave, and is immediately 
followed at each point by a contraction of the (elastic) 
arterial wall. This alternation of dilatation and contrac- 
tion of the arterial tube is called the pulse. 

The velocity of transmission of the pulse-wave differs not 
only in different vessels, but in the same vessel under 
different conditions. For peripheric arteries, the aver- 
age rate was found by Weber, 9.240 metres per second ; 
Landois determined it 6.481 m. for the lower extremi- 
ties, and 5.772 m. for the upper; Grunmach 6.6 m. in 
the direction of the carotids, 9 m. in the upper extrem- 
ities, 11 m. in the lower; Moens found an average rate 
of 8 to 8.5 m.; Grashey, 8.53 m. ‘‘ The velocity of the 
pulse-wave normal to the individual is closely preserved 
under ordinary physiological variations of the circula- 
tion,” and the pulse-rate has no notable influence over it 
(Keyt!). It is much slower in young children than in 
adults, and increases with increase of age dd.) Rise of 
blood-pressure increases the rate of transmission, and 
vice versa. Morbid processes which affect the diameter, 
thickness, and elasticity of the arteries, affect also the 
velocity of the pulse-wave, according to known laws.* 
Grunmach? saw it diminish in most cases of valvular 
disease of the heart, according to the degree in which the 
functional power of the heart was lowered. Lead-poi- 
soning, digitalis, and caffeine increased it parallel with 
the increased arterial tension ; chloroform, chloral, and 
morphine diminished it. 

The interval between the heart-beat and the radial 
pulse is commonly .15 to .2 second; it is altered in some 
diseases, notably lengthened in mitral, shortened in aor- 
tic insufficiency. In the radial artery, the pulse arrives 
about one-fifteenth to one-tenth second later than in the 
carotid ; Czermak states the difference as .094 second. 
Landois found the difference in time between femoral 
and dorsalis pedis, .154 second ; between axillary and 
radial, .087 second ; between axillary and dorsalis pedis, 
.212 second. Keyt* gives the mean time-difference be- 
tween carotid and radial as .0714 to .0888 ; between car- 
otid and femoral, .050 to .0909 ; between carotid and pos- 
terior tibial behind the malleolus, .125 to .166 second. 
Moens observed, for the latter, .167 to .178 second. 

The pulse is examined by means of palpation, inspec- 


* The rate of transmission of waves in elastic tubes can be calculated 


/gEa 


by the formula of Moens,? Vp = 0.9 a in which V p stands for 


the distance which the wave travels in one second, expressed in centi- 
metres; g for the acceleration of gravity = 980.88 centimetres ; # for the 
coefficient of elasticity of the tube (in grammes per square centimetre) ; 
a for the thickness of the tube in centimetres; d for the diameter of the 
tube in centimetres; A for the specific gravity of the liquid. Hence the 
velocity of transmission varies inversely as the square root of the specific 
gravity of the liquid ; directly as the square root of the thickness and in- 
versely asthe square root of the diameter of the tube; and directly as 
the square root of the coefficient of elasticity of the wall. The first- 
named factor, A, can be disregarded in the case of the arterial pulse, 
since the specific gravity of the blood varies too little to affect perceptibly 
the rate of transmission. Keyt (l. c.) has arrived at similar results, and 
demonstrated some of them in cases of disease. 


84 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


tion, auscultation, and by the graphic method (sphygmog- 
raphy). Apart from murmurs produced in the arteries 
by disease of the walls, and from sounds and murmurs 
transmitted from the heart (which are not within the 
province of this article), there may be heard in some ar- 
teries sounds and murmurs produced by the pulse itself. 
Wolff,’ who appears to have been the most expert aus- 
cultator of the pulse, recommending practice on the bra- 
chial artery in the bend of the elbow, says: ‘‘ With the 
common normal cubital pulse of persons of middle age 
[in lean individuals, especially convalescents], there are 
heard three sound-like murmurs, coalescing when the 
stethoscope is lightly applied, but more or less distinct, 
and therefore shorter, upon closer approximation to the 
artery ; their strength and tempo correspond to the size 
and sequence in time of the three pulse-strokes and the 
three large elevations of the curve.” In the pulse of the 
aged, the first and second murmurs only are heard ; in 
the dicrotic pulse the first and third are heard distinctly. 
The radial pulse has likewise been heard by Wolff, but 
other auscultators have been less successful. Thus far, 
the auscultation of these murmurs has not added to ou 
knowledge of the pulse. i 
Inspection of the skin over superficial arteries some- 


_times reveals the existence of visible pulsation in parts 


where normally no pulse is seen. During excited action 
of the heart, in cardiac hypertrophy, in vaso-dilatation 
of a part, the pulse of some arteries usually concealed 
becomes visible, as in the well-known throbbing of the 
carotids and temporals in congestion to the head, the 
phenomenon of epigastric pulsation, etc. Bettelheim® — 
calls attention to visible pulsation of the brachial artery 
as frequently of diagnostic value. Under normal cir- 
cumstances it is often, but not always, seen in old people, 
only now and then (feebly) in emaciated persons, and 
after violent exercise of the muscles of the arm ; when 
present under other conditions it indicates aortic in- 
sufficiency, arterio-sclerosis, or hypertrophy of the 
heart. 

PALPATIoN.—The act of feeling the pulse was in 
danger of being lost in the present century, when im- 
provements in physical exploration in other directions 
—percussion, auscultation, thermometry, etc.—diverted 
the attention of the physician from the pulse, and the 
traditional habit of placing the fingers upon the patient’s 
wrist began to have little result beyond counting the 
number of pulsations ina minute. The recent applica- 
tion of accurate experimental methods to the investiga- 
tion of the pulse has been the means of once more edu- 
cating the touch to a better appreciation of the movements 
of the artery, to a nearer approach to the tactus eruditus 
of old. 

Palpation of the pulse is performed by placing the 
tips of at least two, better three, fingers close together in 
a line upon the arterial tube, and with a certain practised 
elasticity of touch, the fingers following or yielding to 
the movements of the arterial wall. The (radial) artery 
should, moreover, be put in a favorable position by re- 
laxing the tissues about it, holding the forearm midway 
between pronation and supination, both hand and fore- 
arm being gently flexed. By this means are detected dif- 
ferences as to (1) frequency and rhythm; (2) degree of 
resistance to pressure, compressibility ; (8) magnitude ; 
(4) celerity ; and (5) secondary waves. 

Pulse-rate.—The frequency of the pulse depends solely 
upon the movements of the heart, each pulse-beat repre- 
senting a contraction of the left ventricle. The nor- 
mal pulse of the adult male varies from 60 to 80 beats in 
the minute; the statement that the mean of numerous 
observations in many individuals lies between 71 and 72 
is of no value, because the range of individual variations 
is very great. ‘The range of the pulse-rate in females is 
even greater, not a few having an average pulse of more 
than 80 beats, and some of less than 60; the majority 
show a higher frequency than males. In children the 
pulse is more frequent: At birth, 128 to 144; in the first 
year of life, 120 to 180; at the age of ten years, 90. In 
old age the pulse is usually more frequent than 72, but 
often also much rarer, between 50 and 60. The pulse- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


rate is higher in short than in tall persons.* Habitual 
pulse-rates below 56 and as low as 46 have been observed 
in healthy adults, but they are rare exceptions. 

The pulse-rate varies somewhat with the time of day, 
independently of meals and movements, diminishing in 
the forenoon, rising in the afternoon, sinking during the 
night, and rising in the morning. The first maximum is 
reached between 8 and 11 A.M., the second between 6 and 
8 P.M. 

The frequency of the pulse is increased by the activity 
of the working organs: by muscular labor, by digestion 
(increased glandular labor), by psychical processes (emo- 
tions, pain, intellectual labor). Exposure to heat, and 
elevation of the body-temperature, raise the pulse-rate. 
Position (in accordance with the muscular labor involved) 
affects the pulse-rate, which is higher standing than sit- 
ting, higher sitting than lying. Guy’ found the averages 
in adult males standing, 79; sitting, 70; lying, 67; with 
remote extremes, and the differences increasing with the 
frequency of the pulse. The differences are less marked 
in females, and in early youth. Graves states that in 
hypertrophy of the heart these differences disappear, and 
. the same has been said® of pregnancy.+ 

Rise of arterial blood-pressure diminishes the pulse-rate, 
and, vice versa, a fall of blood-pressure increases the fre- 
quency of the pulse (Foster,? Mahomed !°).t 

Tarchanoff recently studied and reported” the case of 
a young man who had the power of voluntarily accelerat- 
ing the action of his heart, probably the only authenti- 
cated exception to the rule that the pulse-rate is not sub- 
ject to the will. 

Variations in rhythm are more accurately observed by 
instrumental means than by palpation, and will be de- 
scribed later. 

Compressibility.—The degree of resistance to the finger 
depends partly upon the degree of elasticity of the artery, 
becoming greater with increasing rigidity of the tube, as 
in the aged ; partly upon the blood-pressure. In order to 
estimate the mean blood-pressure (not only during, but 
also in the intervals between the beats) it is necessary (1) 
to place the (three) fingers lightly upon the vessel and 
with them move the integument over it in a transverse 
direction, rolling, as it were, the artery under the fingers 
(observation of the size of the artery apart from its dis- 
tention by the pulse is a very important and much neg- 
lected function of palpation ; a pulse of high tension may 
be witnessed in a contracted artery as well as in a large 
artery), and (2) with the finger nearer the heart to com- 
press the artery until the pulse is no longer felt by the 
distal fingers. When the mean blood-pressure is high, 
the artery is felt distinctly as a cord; deeper pressure 
does not readily suppress the pulse, but makes the impact 
of the wave more distinct. In low tension, the artery is 
flattened by moderate pressure and the pulse is easily 
suppressed. The exact estimation of the degree of resist- 
ance by palpation is difficult and requires great attention, 
chiefly because the finger takes cognizance, not of the 
compressibility of the artery alone but at the same time 
of the rigidity of the vessel, its size, and the amplitude 
of the pulse-wave. More accurate results are obtained 
by instruments of precision, as Waldenburg’s Pulsuhr,! 
and v. Basch’s Sphygmomanometer ;!? indirectly, the 
sphygmograph also indicates the tension of the arterial 
wall. 

The other qualities of the pulse which can be perceived 


* So close is the relation of the average frequency of the pulse to the 
body-height, that various observers have been able to propose formulas 
for computing the pulse-rate from the height. According to Vierordt, 
the duration of each pulse increases by about .03 second with every in- 
crease of height of 1 decimetre. Rameaux, by theoretical reasoning, de- 


duced the formula n/ = n eae (n, n’ denoting the pulse-frequen- 
d 
cies, d, d/ the body-lengths), which for adults gives computed pulse-rates 
agreeing very closely with the rates observed (Landois). Volkmann’s 
/ 


: : s n 
formula, written in the same term iss = apes 


+ Contrary to Hohl, who gave the pulse-rate éf pregnant women stand- 
ing, 94; sitting. 83; lying, 77 (Die geburtshiilfliche Exploration, 1835). 

t¢ Landois makes the reverse statement (Lehrb. d. Physiologie, 2. Aufl., 
1881, p. 142), 


Pulsatilla, 
Pulse, 


by the finger are better studied with the help of the sphyg- 
mograph, whose lever magnifies the movements of the 


PISSSISISISIA 


Fie, 3131, 


Fre. 3182. 


Fias. 31381 AND 3132.—Normal Tracings ofthe Radial Pulse by Marey’s 
Sphygmograph. (Breguet.) Pulse-rates, 82, 88, 


artery and registers them, on a surface travelling at a uni- 
form rate, in the shape of a series of curves. (For de- 


NNARAAS 


Fie. 3133.—Normal Tracing, Radial, by Pond’s Sphygmograph. Pulse- 
rate, 56, 


scription of the instruments and their use, consult article 
Sphygmograph. ) 


aN 

Fig. 8134.—Normal Tracing by Burdon-Sanderson’s Modification of 
Marey’s Sphygmograph. ‘Pulse-rate, 72. The above, and subsequent 
tracings illustrating this article, unless otherwise specified, are repro- 
ductions of originals in my possession by photographic means only, 
without drawing or retouching. Those by the Burdon-Sanderson in- 
strument (which has a rapid movement and magnifies more highly than 
the other instruments used) were taken and kindly furnished by Dr. 
William Townsend Porter, late Senior Assistant to the St. Louis City 
Hospital. When the artery is not designated, the tracing is to be un- 
derstood as that of the radial artery. 


SpHyGMoGrRAPHY.—The Normal Pulse-curve.—As the 
artery dilates, the lever of the sphygmograph fises rap- 
idly and marks upon the recording surface a line of ascent 
or up-stroke (Fig. 3185, ab), which is very steep, almost 
vertical; at the end of the dilatation the 3 
lever falls, marking a line of descent or ly 
down-stroke, ba’, which makes a well-de- 
fined acute angle, apex, b, with the line of f 
ascent. This line of descent is sloping,  ° 
and is interrupted by several secondary F'. aaa on 
elevations. The most important of these, 53° ‘(onde 
rarely absent, divides the line of descent 
into two nearly equal parts, the upper half terminating in 
a more or less well-marked depression, the diastolic notch 
of Burdon-Sanderson (Mahomed’s aortic notch, Wolff’s 
grosse Incisur), e, which is succeeded by a new rise of the 
lever marking the dicrotic elevation, f. The line of de- 
scent is further interrupted by minor elevations, the first 


a 


. of which precedes the dicrotic elevation, hence predicro- 


tic wave, d, and is discernible in every well-written nor- 
mal curve, while those which succeed the dicrotic wave 
are commonly faint or may be wanting. 

These divisions of the tracing express the events oc- 
curring in the movement of the arterial wall. The be- 
ginning (basal point) of the curve marks the opening of 
the aortic valves, the line of ascent expresses the influx 
of blood into the arterial tube. This line is not perfectly 
straight ; the lever rises at first with increasing velocity 
and arrives at the apex with lessening velocity, tracing a 
line curved like a very long-drawn italic f. In some 
pathological curves the up-stroke is broken by one or more 
secondary (anacrotic, Landois) elevations ; but this never 
happens in the normal curve. When the moment of 
greatest distention is reached the lever descends at once ; 
the apex is a clean-cut angle. The descent, more gradual 
than the ascent, is due, of course, to the steady outflow 
of blood toward the capillaries. For a short time the 


85 


Pulse. 
Pulse. 


ventricle is held in systole ; at the end of this period, the 
ventricles relaxing, a small reflux of blood closes the 
aortic valves with a short snap, which starts a small posi- 
tive wave, expressed in curves obtained from the largest 
arteries (carotid, axillary, femoral) by a small elevation 
below the apex. This wave is lost before it reaches the 
radial artery. In the radial trace there occurs, neverthe- 
less, a predicrotic wave which is commonly explained * 
as the first, and therefore largest, of a series of wave- 
lets due to elastic oscillations of the tense arterial wall 
(Hlasticitétselevationen, Landois). 

The dicrotic wave owes its origin to a different cause. 
The cardiac systole communicates a progressive move- 
ment to the blood in the aorta, which, in virtue of inertia, 
continues a short time after the closure of the aortic 
valves; a rapid lowering of the blood-pressure in the 
root of the aorta results. The contraction of the arterial 
wall, therefore, drives the blood, not only in the direc- 
tion of the capillaries, but also, for an instant, toward 
this point of less pressure ; a momentary reflux of blood 
upon the (closed) aortic valves ensues, which, rebound- 
ing, starts a positive wave (of recoil, Rickstosswelle, Lan- 
dois ; Schliessungswelle, wave of closure, Moens) that is 
expressed in the pulse-curve by the dicrotic wave. If 
time be given before another cardiac systole repeats the 
cycle of events, the second half of the down-stroke may 
show a (smaller) second wave of recoil, as well as some 
elastic elevations. The elevations occurring in the line 
of descent are known as catacrotic elevations (Landois). 

In the normal radial curve are always seen at least 
three distinct elevations: the primary wave (percussion- 
wave, Mahomed +) or apex, the predicrotic (tidal, Ma- 
homed), and the dicrotic wave ; and, hence, disregarding 
the lesser oscillations which may follow, the normal 
curve is spoken of as “‘ tricrotic.” The relative size and 
position of these waves depend upon the conditions of 
the circulation, viz., the force of the heart’s contraction 
and the amount of blood thrown into the artery, the ten- 
sion and elasticity of the arterial wall, and the freedom 
of the distal outflow. According as these conditions vary 
the form of the curve is modified. 

Amplitude.—The excursions of the lever, z.e., the dila- 
tation of the artery, may be greater or less, depending (1) 
upon the volume of blood propelled by each systole, and 
(2) upon the ratio of propelling force to resistance of the 
arterial wall. (The magnitude of the pulse-curve has, of 
course, no direct relation to the size of the vessel, which 
may be small [contracted] or large [expanded] and 
which must be felt, for the sphygmograph gives no indi- 
cation of its diameter; it must also be remembered that 
a superficial artery gives an ampler tracing than one 
covered by thicker layers of tissue.) A well-filled ven- 
tricle is indicated by great amplitude of curve; but if 
the ventricle pumps only a small quantity of blood at 
each contraction, a low curve results. When the arterial 
tension is low, and the outflow toward the capillaries 
free, the lever falls deeply during the cardiac diastole, 
and a large curve results; but when the outflow is ob- 
structed, and the artery is already full and tense at the 
beginning of the systole, the curve c. p. is small. Thus 
we see a large pulse (pulsus magniws) in hypertrophy 
of the heart, in acute fevers (with low blood-pressure) ; 
a small pulse (p. parvus) in feeble action of the heart, in 
pulmonary obstruction, and in mitral insufficiency (im- 
perfect filling of the left ventricle), and likewise in cases 
of high tension not overbalanced by increased power of 
the heart. 


* Maurer 13 thinks that the predicrotic wave is caused by the closure of 
the aortic valves in all arterial pulses: that only the small wavelets 
sometimes added, most often between the predicrotic and the dicrotic 
wave, are elastic oscillations, I have followed the widely accepted inter- 
pretation of Landois without intention to decide this point. 

+ Mahomed conceived that the lever was thrown violently upward by 
the suddenness—‘‘ percussion ”—of the systole ; that without this percus- 
sion the true apex of the curve would be reached only in the predicrotie 
elevation, which he therefore termed the tidal wave. This view is not 
supported by the measurements. A true percussion-stroke is but rarely 
seen, as in the radial curve in cardiac hypertrophy ; it is well marked in 
the aortic curves, Figs. 3149 and 3150, where the true apex can be readily 
distinguished, soon followed by the wave caused by the closing of the 
aortic valves. ‘The use of Mahomed’s terminology has therefore been 
avoided in the present article. 


86 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


The height of the curve alone does not indicate (as 
is frequently stated) the volume of blood propelled at 
each systole ; this is more properly measured by the area 
enclosed between the curve and the base-line. A yield- 
ing artery (as in fever) is easily dilated, and a curve of 
greater height results than the same volume of blood 
produces in a tense or rigid artery. Increasing volume 
of blood will increase the height of the curve only so 

- long as the force is 
great enough to propel 
it with such velocity 
as to overcome the in- 
creasing elastic resist- 
ance of the artery.’ 
When, however, the 
arterial tension rises considerably, as by contraction of 
the minute arteries, the height of the curve no longer in- 
creases, the predicrotic wave is near the apex, the descent 
is delayed, and the dicrotic elevation is higher above the 
base-line ; 2.¢., the pulse becomes tardus (see below) and 
the area of the curve is increased, though not its height.* 

Celerity.—The rise of the lever may be more or less 
nearly vertical ; 7.¢., the time occupied by the dilatation 
of the artery may be less or greater. It is very brief 
when the ventricle contracts with energy against a yield- 
ing artery; the dilatation is slower when the heart is 
weak, or when the resistance in its front is increased by - 
high blood-pressure, or by rigidity of the artery either 
in its entire course or at some point between the heart 
and the vessel under examination. In the former case, 
the up-stroke is very steep, and in a large pulse almost 
vertical, the apex very acute, and the first portion of the 
descent also steep; the artery is quickly distended, and 
quickly emptied; hence, the pulse is designated as p. 
celer, the quick or short pulse. When, on the other hand, 
the artery is tense or rigid and does not yield readily, 
or when the force of the ventricle is 
small compared to the resistance in 
front, the pulse appears labored, the 
line of ascent is more slanting, the 
artery remains dilated for a time, be- 
cause its recoil is likewise slow, the Fie. 3137.—A, pulse- 
apex is blunted, the space between the rate, 68; duration of 
lines of ascent and descent is widened, Pee eT os of 

is Herc sec. B, 

the first portion of the descent more _ puise-rate, 80; dura- 
gradual. Thisform of curve pictures tion of pulse, .752 
the p. tardus of the older writers, the Se; of ascent, .159 
slow or long pulse. Figs. 3160, 3162, 
3177 to 3179, are examples of p. celer ; Figs. 3155 to 3157, 
3181 to 3184, of p. tardus. In some soft pulses the as- 
cent alone is slow, while the descent is rapid, as in Fig. 
3137, B. 

In judging of the steepness of the up-stroke (or down- 

: stroke) the height of the curve must be 
taken into account; with the same dura- 
tion of the period of distention, the ascent 
must be more nearly vertical in a high . 
curve than in a low curve, as is obvious 
from the diagram, Fig. 3138. The real cri- 
terion is the distance, in time, between the basal point 
and the apex; see remarks on measuring the curves, 
below. 

The Secondary Waves in the down-stroke (catacrotic 
elevations) are subject to variations, both in their posi- 
tion and in their size. The conditions which influence 
them have been investigated by Marey, Landois, and 
many others. It has been shown that the dicrotic wave, 
in common with other waves, loses in distinctness with 
the distance from the heart of the artery examined, and 


Fie. 3138, 


* In Fig. 3136, the area of curve A = 26.36 sq. mm., while the area of 
the higher curve B = only 19.97 sq. mm.; the distention of the artery 
was greater in B, but it lasted longerin A. The areaof C = 15.33 sq. 
mm., while the almost equally high curve D has an area of only 10.55 
sq. mm. 

‘+ The classical terms, ‘* quick” and ‘‘ slow” pulse, are nowadays ap- 
plied so universally, though illogically, to the frequency of the heart’s 
beat, in place of the correct terms ‘‘ frequent” and * rare,” that Burdon- 
Sanderson proposes the words ‘‘ short” and ‘‘long” as the English 
equivalents of celer and tardus.1® Fig. 8187 shows two pulses of about 
equal amplitude, of which the rarer, A, is quicker (more ceder) than B, 
the more frequent one. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


that its distance from the primary wave (apex) is greater 
in the remote arteries than in those near the heart (be- 
cause low waves are transmitted with less velocity than 
higher waves, Moens!*), In the same locality the di- 
crotic wave is increased (1) by a short and energetic sys- 
tole, (2) by diminished arterial tension, and (8) the wave 
is delayed by low tension (Moens !"), 

The development of elastic elevations or oscillations of 
the arterial tube is favored (1) by high tension, and (2) 
by perfect elasticity of the artery. Elastic waves are di- 
minished or prevented (1) by low tension, and (2) by loss 
of elasticity in the vessel through disease of its walls, as 
in atheroma. Hence, in a vessel of normal elasticity, 
the size and number of the elastic elevations depend on 
the degree of tension of the arterial wall. 

Tension.—From these propositions it follows that the 
character of the secondary waves is influenced largely by 


; 
Fia@. 3139.—Normal Pulse of High Tension, 54, (Pond’s.) 


the blood-pressure. While it is not the function of the 
sphygmograph to measure, in any direct sense, the blood- 
pressure, the recorded curve gives indication of the de- 
gree of tension in the artery. A pulse-curve of high 
tension—the hard pulse, p. durus (Figs. 3189 and 3140)— 
is characterized chiefly by (1) early, distinct, and perhaps 


DNS 


Fia. 8140.—Normal Pulse of High Tension, 70. (Marey’s.) 
numerous elastic elevations, the predicrotic wave espe- 
cially is well developed and near the apex, the descent 
of the lever appears delayed ; (2) the dicrotic wave is 
small in proportion to the amplitude of the tracing ; (8) 
the end of the first part of the down-stroke (the diastolic 
notch, ¢) is high above the base-line. In some strictly 
‘normal pulses of relatively high (‘‘ good’’) tension, the 
down-stroke forms an almost uninterrupted straight line 
from the apex 0 to the basal point of the next curve, a’, 
as in Fig. 8158. (Compare also Figs. 3144, 3155 to 3157, 
3171 to 3173.) 

In a curve of low tension—the soft pulse, p. mollis 
(Fig. 3141)—on the other hand, (1) the elastic elevations 
are small or absent, the predicrotic wave, if preserved, 
is comparatively low down in the tracing and small ; (2) 
the dicrotic wave is likewise delayed, but well devel- 

Fre. 3141.—Normal Pulse of Low Tension, 73. (Pond’s.) 

oped ; (8) the first part of the down-stroke makes a steep 
descent, and forms a smaller angle with the second por- 
tion, thus \_, and the diastolic notch is near the base- 
line. Very frequently these modifications coincide with 
the p. tardus and p. celer respectively, so that commonly 
a pulse of high tension is tardus et durus, the pulse of 
low tension celer et mollis. (Compare also Figs. 3147, and 
3161 to 3170.) 

Still further modifications are introduced into the form 
of the curve by the frequency of the beat. The period 
of dilatation of the artery, subject to the variations al- 
ready spoken of (vide Celerity), is not influenced mate- 
rially by the mere frequency of the beat ; the period of 
descent bears no definite ratio to the time occupied by 
the ascent. A frequent pulse is commonly also a p. celer, 
but a rare pulse may also be celer. But when the ven- 
tricular systoles follow each other rapidly, the ventricle 
has not time to fill with the same amount of blood as 
when they occur at longer intervals ; hence the ampli- 
tude of the curve is lessened as the pulse becomes more 
frequent. Moreover, in the frequent pulse the line of 
descent is cut off sooner by the rising wave of the suc- 


Pulse, 
Pulse. 


ceeding beat ; hence, while the period of ascent remains 
nearly the same, the period of descent is abbreviated ; 
the shortening of the curve falls mainly upon the de- 
scent. Usually the rise in frequency coincides with a 
fall in blood-pressure, and vice versa, which is likewise 
expressed in the curve. 

Measuring the Curves.—It is difficult for the begin- 
ner to estimate the described variations in the curve 
at sight ; this art can be best acquired by practice in the 
actual measurement of tracings. 

Curves of the same pulsation, drawn upon recording 
surfaces moving at different 
rates, assume great differences 
of aspect, while yet they re- 4 an 
cord the same facts. This ex- 
plains one of the difficulties in 
comparing tracings by differ- 
ent instruments. Curve A, in 
Fig. 3142, when traced on a plate moving with twice the 
velocity, assumes the shape of B; on a plate moving 
with half the velocity, the shape of c. 

The distance in time between two events of the pulse- 
movement can be measured on an abscissa parallel to 
the direction of movement of the recording surface—or- 
dinarily parallel to the base-line of the curves—by 
means of ordinates drawn through the salient points of 
the curve. The direction of the ordinates is indicated 


Fra, 3142, 


by (parallel to) the directrix, ‘‘ signal line,” or ‘‘ guiding 
line ’—a line usually drawn at the beginning of a tracing 
by the style moving while the recording surface is still at 
rest (4 a, Fig. 3148). 


This, in curves drawn by instru- 


Fre. 3145. 


J 


— 


CAE: 


Fig. 3146. Fie. 3147. 


Fie. 3148, 


Fias. 8143, 3144, 8145 (Pond’s); Fras. 3146, 3147, 3148 (Marey’s).—All 
magnified < 2. These curves were magnified (< 8) by the magic lan- 
tern, the abscissas and ordinates added, and the drawings reduced by 
photography (+ 4). 


ments the marker of which moves in a straight line (at 
right angles to the movement of the recording surface, as 
in Landois’s angiograph, in Pond’s and Dudgeon’s sphyg- 
mographs) is itself a straight line, and vertical to the ab- 
scissa if the movement of the marker is exactly at right 
angles to the base-line, which is not always the case (cf. 
Figs. 3148 to 3145). In curves drawn by a lever that 
moves around a centre and in a plane parallel to the re- 
cording slide (as in Marey’s sphygmographs, and in some 
of the tambour instruments, in Keyt’s cardiograph, etc.) 
the guiding-line, and, consequently, the required ordi- 


87 


Pulse. 
Pulse. 


nate, is the are of a circle whose radius is equal to the 
length of the lever. Figs. 3148 to 3148 are examples of 
such measurements. If the rate of movement of the 
travelling surface is known, the distance in time between 
two points in the curve can be measured by the distance 
in space between the points at which the respective ordi- 
nates cut the abscissa. In Fig. 3143 the time of disten- 
tion of the artery, a }, is measured by the distance a B 
on the abscissa; the time between the apex, 0, and the 
summit of the dicrotic wave, f, is measured by B F, etc. 
The relative height of the events on the curve above the 
base-line can similarly be measured on the guiding-line 
G a as an abscissa, by ordinates drawn upon it from the 
respective points parallel to the base-line. 

Very accurate measurements are obtained by causing 
the lever of the sphygmograph to write on a surface 
fixed upon a vibrating tuning-fork. Landois also meas- 
ured his curves under the microscope by means of an oc- 
ular micrometer. The writer has obtained good results 
by magnifying the curves registered on transparent slides 
by means of the magic-lantern. 

It is not always easy to determine the exact location 
in the curve of the points to be measured. ‘The readiest 
method to determine d and f, the summits of the predi- 
 crotic and dicrotic waves, is to draw parallel with a line 
connecting c and e (for d) or e and @ (for f) a tangent to 
the elevation ; the point of contact must be the highest 
point in the elevation (because the wave is superimposed 
upon the line of descent, which, but for this wave, 
would have been straight, or nearly so); but it is not 
always the point most distant from the base-line. 

The period of ascent—indicating the duration of influx 
of blood into the artery—occupies only a portion of the 
ventricular systole. It is preceded by a period of less 
than one-tenth second from the beginning of the ventric- 
ular contraction to the opening of the aortic valves ; and 
it is followed by a period of about .069 second from the 
time when the influx ceases until the closing of the aortic 
valves. Hence, the systolic portion of the curve (cor- 
responding to the period between the first and second 
sound of the heart = about one-third second) begins be- 
fore the up-stroke and terminates at some point in the 
down-stroke. This point, in successful tracings of the 
carotid pulse is found in the notch preceding the first 
secondary elevation, caused by the closing of the aortic 
valves. In the radial curve this wave is commonly ab- 
sent ; in the majority of cases (if not always—see foot-note 
on p. 86) it coincides nearly with the beginning (or the 
summit, Keyt) of the predicrotic wave ; it is this point, 
not the so-called ‘‘ aortic” or diastolic notch, that may 
serve to mark approximately the end of the cardiac sys- 
tole. 

The period from the beginning of the ventricular con- 
traction to the opening of the aortic valves, the interval 
between the ascent of the cardiogram and the ascent of 
the pulse-curve—the presphygmic interval of Keyt! (sys- 
pasis, Garrod)—is said to have a mean duration of .087 
second by Czermak; .10 to .11 second by Mosso ; .078 
by Rive; (only .02 to .03 by D’Espine ?); .085 by Lan- 
dois; about .08 sec. (with a pulse-rate of 75 per minute) 
by Keyt. The latter author made it the subject of ex- 
tended investigation and demonstrated the importance 
of a knowledge of it in both physiological and patholog- 
ical conditions. It is subject to considerable variation, 
and “‘ varies inversely with the pulse-rate,” ‘‘ being shorter 
with frequent and longer with rare pulsations.” Patho- 
logically, the interval is lengthened, especially by slow 
ventricular contraction, by high arterial pressure, and 
by mitral insufficiency ; shortened by quick contraction 
of the heart, by low arterial pressure, and by aortic in- 
sufficiency. In fever, with a fairly strong heart, the in- 
terval is short. 

The duration of the ascent differs somewhat in indi- 
vidual curves, not only of pulses of different frequency 
and character but also of the same tracing. In typical 
radial curves measured by Landois its mean duration 
was .097 second; in a number of radial curves writ- 
ten with my Marey’s instrument, the period of ascent 
a B = .0903 second ; in some curves by Pond’s sphygmo- 


88 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


graph the average a B = 0.12 second. The variations in 
the duration of the ascent are not as great as of the de- 
scent, nor proportioned to them. A frequent pulse (of 
short duration) does not necessarily have a short period 
of dilatation—in other words it may be tardus as well as 
celer,— 

It is evident that the form of the pulse-curve permits 
us to draw conclusions as to the conditions which con- 


Fie. 3149,—Tracing of an Abdominal Pulsation. 116. (Marey’s.)* 
tribute to determine it; these are, chiefly, the degree of 
tension of the arterial wall; the volume of blood added 
by each systole, and the force with which it is injected. 
Increased tension alters the form of the curve in the di- 
rection of the p. tardus et durus and diminishes its height ; 
diminished tension produces a p. celer et mollis and in- 
creases the height of the curve, the area in each case 
remaining the same. Greater volume of blood likewise 
produces the form of the high-tension pulse, increasing 
at the same time the height and the area of the curve ; 
lessened volume diminishes the area 
and makes the pulse quicker and lower. 
Increased force of systole (as in sim- 
ple hypertrophy) causes a larger and 
quicker pulse; with simultaneous in- 
crease of volume of blood propelled 
the curve is still higher, or at least as 
high, but perhaps more tardy, and the 
area of the curve is greater. Dimin- 
ished force alone makes the curve tar- ° 
dier and smaller; combined with di- 
@ minished volume the curve becomes 
quicker and smaller, or at least not 
higher, and the area of the 

Lf curve less. —— 

In Different Arteries the 
pulse registers different 
forms of curve. The trac- 
ings secured by Penzoldt !8 
in a case of fissure of the 
sternum from the ascending 
Sey Boe Anant ee, revealed an anacrotic 

1G, oloU.— Two Curves of Big. 3149 elevation—probably due to 
ere ere! weiner SS Aenean Sahg ss ae auri- 
cles being communicated to 

the lever of the instrument—and near the apex an eleva- 
tion evidently corresponding to the closing of the semi- 
lunar valves, but no other elevations in the down-stroke. 
I have lately obtained tracings from an abdominal pulsa- 
tion, so well defined that they can fairly be taken as re- 
producing the pulse movements of the abdominal aorta.* 
The curve of the carotid pulse is characterized by con- 
siderable height, a steep up-stroke, an acute apex; on the 
down-stroke, close below the apex, is found the elevation 
attributed to the sudden closing of the aortic valves, 
commonly coinciding with the first elastic oscillation, and 


Hl 


* Mrs. M., fifty-seven years of age, washerwoman; greatly emaciated 
and worn by hard toil; irritable heart ; pulse-rate, 116; pulsation above 
umbilicus so forcible and so distinct to inspection and palpation as to 
have suggested aneurism. It was equally accessible to the sphygmo- 
graph, as the figures show, They reveal a forcible percussion-stroke, p 
(see footnote on page 86); the true apex, b, is soon followed by the wave 
of the aortic valves, 7, at almost the level of the apex, an@ the down- 
stroke is marked by both predicrotic, d, and dicrotic wave, 7. The meas- 
urements agree very well with this interpretation. I have not met in lit- 
erature with any other curves of the abdominal aorta. The tracing 
given by Ozanam (La Circulation et le Pouls, Paris, 1886) on page 694 is, 
of course, ludicrously inexpressive, as are, indeed, all the curves in that 
fearful and wonderful book. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Pulse. 
Pulse. 


constituting the predicrotic wave ; the dicrotic wave is 
small, owing to the high tension in the carotid, and oc. 


Fia, 3151.—Normal Carotid Curves; the first three after Eulenburg, the 
last four after Landois. (Marey’s.) 


curs early in the descent, owing to the nearness of the 
artery to the heart. The swbclavian, and the more ac- 
cessible axillary, arteries yield a similar tracing with a 
larger dicrotic wave. The pulse of the drachial artery in 


UP ee ee 


Fig. 3152.—From Right Brachial Artery of a Child aged Five, 90, 
(Pond’s.) 


Beet Na 


Fig. 3153.—From Right Radial Artery of Same. 


the bend of the elbow differs from the radial pulse chiefly 
by its greater amplitude. In the curve taken from the 
femoral artery, the predicrotic wave is large and so high 
up as to delay the descent and blunt the apex, so that the 
curve looks much like a radial curve of high 
tension ; but the dicrotic elevation is low down 
in the curve. 

Tracings from the dorsalis pedis artery have 
less amplitude than the radial, a more slanting 
ascent, and a distinct but late dicrotic wave, 
while the elastic oscillations are, as a rule, im- 
perfect and weak; the pressure of 
the instrument easily prevents their 
expression in the trace, and we find 
the predicrotic wave only in very 
delicately written curves. Tracings 
can be taken from other accessible 
arteries, as posterior tibial, temporal, 
etc.; in a case of overactive heart, I 
have obtained one from the digital artery of the middle- 
finger. ; 

In Different Individuals, the normal pulse differs widely 
in frequency, celerity, magnitude, and degree of tension. 
These personal variations are, however, remarkably per- 
sistent, so much so that the same person, under ordinary 


Fia. 3154.—From the 
Femoral Artery. 
(Marey’s.) x 2. 


circumstances, always yields the same form of pulse- 


curve. Even when disease, as an acute fever, has altered 
the aspect of the tracing in all essentials, the curve after 
convalescence assumes again the qualities characteristic 
of the individual’s pulse previous to the illness. Various 
physiological states modify the curve for the time being, 
in accordance with their well-known influence on the 
circulation. Thus, muscular labor, digestion, elevation 
of temperature make the pulse larger, softer, and more 
frequent. Cold, whether applied to the entire body or 
only to the part the artery of which is under examination, 
causes a smaller and harder pulse by vaso-constriction 
and rise of tension. Sex has no influence on the form of 
the pulse-tracing. Age, on the contrary, affects it in a con- 
' spicuous manner. Jn the child, the pulse-curve is marked 
only by distinctness of the elastic elevations, especially a 
well-developed and often high-placed predicrotic wave, 
while the dicrotic wave is but little prominent. The reg- 
ularity of rhythm is more easily disturbed in the child 
than in the adult. 

The Pulse of the Aged is very characteristic. ‘The vas- 
cular changes of senile life do not set in at the same age 
in all persons, but sooner or later, almost certainly after 
the sixtieth year, they find expression in the pulse-curve. 
They consist essentially in a loss of elasticity of the 


arterial wall by gradual atheromatous changes. The 
rising blood-wave dilates the arterial tube but slowly, 
at least in the higher degrees of atheroma; once dis- 
tended, the less elastic artery does not contract with the 
promptness required for the normal celerity of the pulse, 
but remains distended for a while ; hence the apex is no 
longer sharp, but rounded or even flattened, all the more 
so because the predicrotic wave is large and near, or on 
a level with, the apex, owing to the high blood-pressure 
developed by the systolic filling of the rather unyielding 
vessel. Subsequent elastic elevations are absent. The 
dicrotic wave is present in moderate degrees of atheroma, 
but in most cases it is small, and in some almost obliter- 
ated. The pulse is eminently tardus. The pulse of the 


SINAN 


Fia, 3155.—Male, Seventy-nine Years of Age. 80, (Marey’s.) 


J 


Fia. 3156.—Male, Sixty-two Years of Age. 66. 


(Marey’s.) 


Peto rine 


Fic, 3157,—Male, Ninety-two Years of Age. 70, (Marey’s.) 


aged must not be confounded with a simply hard pulse ; 
it retains its character of tardity—the labored ascent and 
rounded apex—even when the blood-pressure is dimin- 
ished and the dicrotic elevation reappears with distinct- 
ness, aS in fever. But when the heart is hypertrophied, 
the pulse of the rigid artery may have a steep ascent and 
an acute apex, while the down-stroke retains the charac- 
ters described. 

A sphygmographic tracing—sphygmogram—consists 
of a series of pulse-curves, which enable one to observe 
the rate of the pulse, its rhythm, and rapid fluctuations 
in the mean blood-pressure. The average pulse-rate is 
more readily, and quite as accurately, counted by the 
watch ; slight variations in it are, however, best measured 
in the tracing. Rhythmical fluctuations of the blood- 
pressure and of the pulse-rate are caused in the normal 
tracing by the respiratory movements. All other changes 
in rhythm are pathological. 

The Influence of the Respiration on the pulse is barely 
perceptible in a tracing taken during quiet, superficial 
breathing. Asarule, the basal points of all the curves 
of such a tracing are in a straight line parallel to the 
base line; but when the respiration is deep and slow, 


Fie. 3158.—Male, aged Thirty-two. ‘1. 


MANNA QU SA 


Chronic Parenchymatous Ne- 
(Marey’s.) 


(Marey’s. 


Fic, 3159.—Male, aged Thirty-eight. 
phritis, Dyspnoea at the time. 116. 


ANS Ml MJ ly N NM ‘| M\, 


Fie. 2160.—Female, aged Thirty-two. Tachycardia. Subclavian artery. 
140. (Pond’s.) 


the line connecting the basal points—the ‘‘ respiratory 
line”—is often not straight, but undulating in unison 
with the respiratory movements. In such case, a line 
connecting the apices of the curves is still more undu- 
lating, because the pulses are largest on the summits 


89 


Pulse. 
Pulse, 


of the respiratory curves (as in Fig. 3160)—~?.e., the pulses 
coinciding with expiration are the largest; they also 
have a smaller and higher-placed dicrotic elevation ; 
whereas those which coincide with inspiration are small- 
er, have a larger and lower-placed dicrotic wave, and 
a smaller predicrotic wave ; they ‘‘ begin to be dicrotic.” 
Thus is expressed in the pulse-tracing the fact that the 
arterial blood-pressure rises during expiration and falls 
during inspiration. The inspiratory pulses are also 
somewhat more frequent then the expiratory pulses, the 
slowing beginning a little before the expiration and last- 
ing a little beyond it (Penzoldt). This is particularly 
evident during voluntary slowing of the respiration. 
When, however, the breath is held in deep inspiration, 
the pulse-curve gradually increases in length (becomes 
less frequent), in height, and in area, and assumes the 
form of high tension. 

The respiratory influence on the curves is plainly seen, 
as a rule, in the pulse of children, and is exaggerated dur- 
ing sleep—so much so that in many healthy children it is 
perceptible to palpation, and the pulse seems irregular, 
approaching in character the (pathological) pulsus par- 
adoxus (see below). It is a clinical fact of some impor- 
tance that this irregular pulse in a sleeping child is not a 
sign of disease. 

THE PULSE IN DISEASE.—The more prominent alter- 
ations which the pulse suffers under morbid conditions 
may be classified as, (1) changes in tension, (2) changes 
peculiar to certain diseases of the heart and great vessels, 
(8) local changes in individual arteries or vascular territo- 
ries, (4) changes of rhythm, and (5) changes of frequency. 

1. In health, the average arterial tension differs widely 
in different individuals, and considerable differences in 
this respect are compatible not only with health, but with 
bodily vigor. But it will be noted that in case of either 
extreme the pulse is rather large ; a small and soft pulse 
is frequently associated with low energy, a small and 
hard pulse is more ofterf observed in persons of irritable 
habit and neurotic tendencies. Still, the individual vari- 
ations are so large that in the absence of other signs they 
are of small prognostic value. 

Moreover, in healthy persons, during rest and under 
seemingly unvarying conditions, the tension of the arte- 
ries is subject to frequent changes in degree, so that suc- 
cessive series of curves, taken with an instrument that 
remains in position for some time, show differences of 
form which must be ascribed to alterations of ‘‘ tone” by 
vaso-motor influences, to which the play of mental activity 
and of emotions greatly contributes.!® This mobility of 
the state of muscular contraction of the arteries is so con- 
stant in persons of vigorous health, that G. v. Liebig *° 
considers its absence a sign of diagnostic value. 

Among the influences which alter the tension more de- 
cidedly are cold and heat. <A cold bath, a chilly room 
furnish opportunities for observing the increase in ten- 
sion ; a warm atmosphere, the elevation of temperature 
after a full meal or after vigorous exercise, at once alter 
the pulse-form in the opposite direction, even to dicrotism. 

The alterations in the direction of lowered tension are 
seen in their higher degrees in 

Dicrotism.—The dicrotic form of pulse results when- 
ever the predicrotic elevation disappears, and the dicrotic 
wave is enlarged. Both changes occur when the blood- 
pressure falls sufficiently low, provided the elasticity of 
the arterial walls is intact. A dicrotic pulse is a pulse 
of low tension. Rigidity of the artery, as in atheroma, 
tends to prevent dicrotism. Sudden influx of blood, due 
to a short and energetic systole, assists in the develop- 
ment of the dicrotic curve, but is never alone competent 
to cause dicrotism, whose conditio sine qua non is low- 
ered blood-pressure, especially when caused by relaxa- 
tion of the vascular wall.* The conversion of a curve of 


* For it is by no means certain that the ready and invariable conver- 
sion of a normal pulse into the dicrotic form in fever is due solely to di- 
minished blood-pressure; the altered innervation, or a direct influence 
of the febrile temperature upon the muscular coat, is probably a positive 
factor in this process, as well as an (indirect) means of reducing the blood- 
pressure. Changes in the degree of dicrotism do not always run paral- 
lel with changes in blood-pressure; dicrotism sometimes disappears 
without a corresponding rise of pressure. 


o 


90 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


fair tension into a dicrotic curve can often be seen in 
arhythmical tracings, as in Fig. 3194 (magnified in Fig. 
3145). 

The most conspicuous and best known example of the 
dicrotic pulse occurs in fever. Under the influence of 
greatly elevated temperature, the peripheric arteries re- 
lax, the arterial blood-pressure falls, and the pulse be- 
comes exquisitely dicrotic, as has long been known in 
the case of typhoid fever, but is true of all febrile dis- 
eases. During the initial chill of an acute paroxysm, the 
pulse is small and hard ; as the chill passes off it becomes 
large, full, and bounding (magnus, plenus, celer), even 
hard in the beginning of inflammatory fevers ; but soon 
it becomes soft, easily compressed, and with increasing 
relaxation of the smaller arteries the radial pulse shows 
a dicrotism distinct enough to be appreciated by the 
finger. The influence of lessened tension in causing di- 


IU 


Fre. 8161.—Incipient Phthisis. Temperature, 99.4°; pulse, 114. 
(Marey’s. ) 


Fig. 3162,—Catarrhal Fever, Temperature, 100,2°; pulse, 94, (Marey’s. ) 


Nee LasAORey ler, Vasu Va 


Fia, 163.—Renal Dropsy; Low Tension. 
84, (Pond’s.) 


Temperature normal ; pulse, 
crotism is enhanced by a short and quick systole, and by 
the greater frequency of the pulse. A high pulse-rate, 
as such, does not cause dicrotism, but it assists in bring- 
ing about modifications in the curve that are character- 
istic of the degrees of dicrotism. When the normal curve 
passes into the dicrotic, the predicrotic wave disappears, 
the first part of the down-stroke is steep and long; the 
dicrotic wave, while it grows in height, is delayed; the 
diastolic notch approaches the base line, as in Figs. 3161 
to 3168 ; the pulse is sub-dicrotic. With still lessening 
tension, the great notch reaches the base line, as in Figs. 


Jw 


Fia. 3164.—Typhoid Fever, Third Week. (Pond’s.) 


FAR AUAAVAVATAVAVAVAUANLUAUATVAVACYLUAYLTAWLVSUAGULIS 


Fia. 3165.—Phthisis Pulmonalis. Temperature, 102.3° ; pulse, 114. 
(Pond’s. ) 


3164, 3165, which exhibit full dicrotism, or even falls be- 
low the base line, as in Figs. 3166, 3167, the hyperdicrotic 
pulse. In the first instance, the lever in the second por- 


Fic. 8166.—Continued Fever. Temperature, 103.2°; pulse, 124. 
(Pond’s.) 


Fie. 3167.—Typhoid Fever. Temperature, 103.4° ; pulse, 124. (Pond’s.) 


tion of the descent falls lower than in the first portion ; 
in the fully dicrotic pulse, partly owing to greater fre- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


quency of the heart’s action, the following systole raises 
the lever when it has reached a point as low as the dias- 
tolic notch ; in the hyperdicrotic pulse, the lever is raised 
by a still earlier systole before it has reached that point ; 
the great notch hes below the line connecting the basal 
points. If the frequency of the pulse becomes still 
greater, the succeeding systole lifts the lever when it 
has reached the summit of the dicrotic wave ; the lever 
has not time to make a second descent, and the pulse has 
made only one elevation, one beat—is monocrotic, as in 
Fig. 3168. Thus the degree of dicrotism depends partly 


AVIUKOAUIVAUROLUAULULULBIN]Y 


Fia. 3168.—Typhoid Fever. Temperature, 104.8° ; pulse, 160. (Marey’s.) 


on the delay of the enlarged dicrotic wave and the deep- 
ening of the great notch, and partly on the frequency of 
the pulse. When, however, the usual parallelism be- 
tween the temperature, the relaxation of the peripheric 
vessels, and the beat of the heart is disturbed (as by med- 
ication), it may happen that even very great frequency 


viv 


Fie. 3169.—Typhoid Fever. Under Antipyrin. 
pulse, 140. (Pond’s.) 


Temperature, 100.8° ; 
does not produce a monocrotic pulse (see Fig. 3169). On 
the other hand, monocrotism can occur only in a very 
frequent pulse. 

The degree of dicrotism corresponds in a measure to 
the degree of fever; the higher the temperature, the 
lower the tension; as the fever rises, the pulse-curve 
gradually passes through the successive changes of form 
described. With a temperature of 39° to 40° C. (102° to 
104° F.), we may confidently expect, in acute fevers of 
previously healthy adults, a fully dicrotic pulse ; beyond 
it the curve becomes hyperdicrotic or even monocrotic. 
This parallelism is, however, not at all constant, but sub- 
ject to many influences, one of which is the frequency 
of the pulse, another the strength of the patient. In 
feeble persons, in chronic febrile diseases, in the later 
stages of acute fevers, even, the various pliases of dicro- 
tism are reached with lower temperatures ; thus, at 39° 
C. (102° F.), a phthisical patient may yield a hyperdi- 
crotic curve, while a pneumonic or typhoid patient may, 
at the same temperature, have a sub-dicrotic pulse. In 
individuals who previously had a high-tension pulse, ¢.¢., 
whose usual pulse-curve was farther removed from the 
dicrotic pulse than is the normal, fever develops the 
phases of the dicrotic pulse only with higher tempera- 
tures. 

As the fever abates, the pulse-form gradually returns 
to the normal, but not quite as rapidly asthe tempera- 
ture sinks; and sometimes the pulse remains sub- 
dicrotic during convalescence, or shows the form of 
normal tension only with subnormal temperatures. 

By the finger, dicrotism is recognized most easily when 
the difference in height between the two waves is least, 
and the pulse is neither very frequent nor very small— 
in the fully dicrotic pulse of undulating character. The 
dicrotic beat is also perceived with distinctness in a sub- 
dicrotic pulse of moderate frequency. In the hyper- 


dit ddl 


Fic. 3170.—Pulmonary Hemorrhage. Temperature normal; pulse, 100. 
(Pond’s. ) 


dicrotic puise the second beat is felt as a grace-note to the 
succeeding primary beat, p. caprizans. 

While fever furnishes the most pregnant examples of 
low tension pulse, all other causes of low blood-pressure 


Pulse. 
Pulse. 


have more or less dicrotic forms of pulse. High de- 
grees of anemia, collapse, sudden losses of blood, fatty 
heart, and other conditions of cardiac debility, alter the 
curve in the same direction. Drugs which reduce the 
blood-pressure rapidly are capable of causing dicrotism, 
notably amyl-nitrite. 

The Pulse of High Tension is caused mainly by 
obstructed outflow toward or through the capillaries, as 
by contraction of the arterioles. It is marked by high 
position and large size of the predicrotic wave, and by 
small size of the dicrotic wave. It can be produced 


| ed ea acne ee pn ie} Paes 
Fie. 3171.—Digitalis. 52. (Marey’s.) 


artificially by drugs which raise the blood-pressure, by 
none more readily than digitalis (Fig. 3171). 

Among diseases, lead-poisoning, gout, and Bright’s dis- 
ease, especially the first stage of acute nephritis and 
contracted kidney, furnish the most common examples 
of high-tension pulse. In acute nephritis, the pulse is 
often hard from the beginning and before hypertrophy 
of the heart has been developed, and retains this char- 
acter for some time. In chronic parenchymatous ne- 
phritis we commonly miss this symptom (compare Fig. 
3159). But in contracted kidney, especially the genu- 
ine arterio-sclerotic form, the high-tension pulse (durus, 
tardus, and often magnus) is an early, sometimes the 
earliest, sign, and apt to persist until near the fatal end, 


1 cel gael Gin Sal a 


Fie. 3172.—Female, aged Twenty-two. Contracted Kidney ; Retinitis. 
74. (Pond’s.) 


ia al NPN 


Fie. 8173,—Male, aged Sixty. Contracted Kidney. 56. (Marey’s.) 


enhanced or modified by hypertrophy of the left ven- 
tricle (Figs. 3172 and 3178). 

Hypertrophy of the heart, alone, does not produce the 
high-tension pulse ; 7.¢., the blood-pressure is not neces- 
sarily high between the beats. The energetic contrac- 
tion of a large ventricle, especially when the pulse is not 
frequent, causes a large pulse; but if other causes of 
high tension are absent, if the outflow through the capil- 
laries is free, the pulse does not show the tardity of the 
common p,. durus et tardus ; the up-stroke is very steep, 


1] 
’ 
’ 
I 
’ 
t 
‘ 
| 


Fie. 3174.—Male, 


aged Forty-eight. 
(Marey’s. ) 


Hypertrophy of Heart. 62. 


and although the predicrotic wave may be large and near 
the apex, the fall of the lever immediately afterward is 
sudden, the dicrotic wave apt to be low down and fairly 
developed. Thus the pulse of hypertrophy can usually 
be distinguished from the p. tardus of Bright’s disease 
and of atheroma. 

Pregnancy has been found to induce a high-tension 
pulse ; and in some anemic patients, the arterial tension 
is unexpectedly high. A certain class, too, of nervous 
women of spare habit, suffering from paroxysmal painful 
affections, vague and shifting neuralgic pains or more 
pronounced neuralgias, megrim and other headaches, pre- 
sent a uniformly tense but smal! pulse: This is certainly 
not the pulse of high tension which precedes arterio- 
sclerotic kidney disease, but is owing to irritation or 
abnormal irritability of the vaso-constrictor nerves. It 
has proved valuable to me in arriving at indications for 
treatment. 

2. Valoular Disease of the Heart, modifying the pulse- 


91 


Pulse, 
Pulse. 


movement at its source, impresses its characters on the 
curve, though not so specifically as to enable one to diag- 
nosticate valvular lesions from the pulse-curves, even 
with the aid of cardiograms; the sphygmograph only 
furnishes evidence of the same kind, and of the same 
value, as that which is obtained by auscultation and per- 
cussion of the heart. Mitral regurgitation, so long as it 
is perfectly compensated by the strength of the heart, 
simply lowers the blood-pressure (the ventricle not dis- 
charging all it contains into the aorta), and yet frequently 


Ae 


Fie. 3175.—Mitral Insufficiency, Compensated. 90 to 100. (Burdon- 
Sanderson’s. ) 


Fre. 3176.—Mitral Insufficiency, not Compensated. %5. (Pond’s.) 

increases the height of the curve (by an energetic sys- 
tole) ; hence makes a soft and often large pulse. When 
compensation is (temporarily or permanently) disturbed, 
the pulse becomes frequent and irregular in rhythm, as 
will be described below. In mitral stenosis the pulse is 
small, soft, and sometimes frequent; when the heart’s 
muscular power becomes impaired, it grows more or 


. an dA 


Fic. 31'°%.—Aortic Regurgitation. 98. (Pond’s.) 


less irregular. Irregularity of pulse is a mark of mitral 
affections, rather than of aortic lesions. Aortic regu7gi- 
tation gives, of all valvular defects, the most character- 
istic curve. If perfectly compensated, it can be so only 
by hypertrophy of the ventricle, and this tells its tale in 
the curve ; but if the incompetency of the valves is con- 
siderable and compensation incomplete, signs of the 
regurgitation are visible inthe sphygmogram. The hy- 


sae a 


memene ene anes «oars meee ee 


Fic, 3178,—Aortic Regurgitation with Mitral Insufficiency, the Former 
Predominating. 80. (Burdon-Sanderson’s. ) 


pertrophy causes a high and very steep up-stroke; the 
curve is always large and the descent is rapid at first, 
because during the diastole blood flows back into the 
ventricle as well as onward to the capillaries; the pre- 
dicrotic wave is usually low down and of varying size, 
often small; the dicrotic wave is small and well down 
toward the base line. The artery, then, is quickly and 
forcibly distended, and as quickly contracts again. <A 
pulse of this character is easily recognized by palpation ; 


92 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


——S 


it is eminently celer, quick to come and go, and yet large 
and strong, giving the impression of the rebound of a 


in 


Fria. 3179.— Aortic Regurgitation. 76. (Burdon-Sanderson’s.) 

hammer, or of a bullet passing under the finger; the 
‘“‘shotty ” or “‘ bullet” pulse. It is usually quite regular. 
The normal delay of the pulse as compared with the 
heart’s impulse is abnormally shortened ; Keyt?! deems 
this symptom so characteristic, that in the absence of 


fever it is pathognomonic of aortic insufficiency of high — 


\ 


\ 


Fie. 3180.—Aortic Regurgitation, Traumatic. 
son’s. ) 


120. (Burdon-Sander- 


degree. Sometimes the up-stroke is interrupted by an 
elevation, which Landois interprets as an expression of 
the auricular systole that makes itself felt through the 
partially open aortic orifice. 

The pulse of aortic stenosis is commonly regular, often 
small, and always very tardy, as its mode of formation 


Fie. 3181. 


Fie. 3182. 


Fries. 3181 anp 8182.—Aortic Stenosis. 80. (Burdon-Sanderson’s.) 


Fie, 3183.—Aortic Stenosis. %8. (Pond’s.) 


explains ; the probably hypertrophied ventricle presses a 
limited volume of blood into the artery with difficulty, 
hence slowly ; therefore the up-stroke is slanting, and 
the entire systolic portion of the tracing is prolonged ; 
the ‘‘ apex” is lower than the summit of the curve, and 
constitutes an (‘‘anacrotic”) elevation in the ascent. 
The smallness of the pulse often contrasts strongly with a 
forcible impulse of the heart. 

Valvular defects of the right heart can have only an 
indirect effect on the arterial pulse-curve. Combinations 
of two or more valvular lesions do not yield curves as 
transparent in their meaning as those of pure cases ; yet 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Pulse. 
Pulse, 


even here, comparison of the pulse records with the car- 
diograms and the results of physical exploration is a 
material help in diagnosis. 

Disease of the Arteries manifests itself chiefly in the 
hard pulse of arterio-sclerosis (as in chronic Bright’s dis- 
ease), and in the tardy pulse of atheroma. The influ- 
ence on the pulse of atheromatous disease has been 
noticed in describing the pulse of the aged, the chief 
characteristic of which is its tardity. In high degrees 

omens 
Fig, 3184.—Atheroma. 45, (Burdon-Sanderson’s, ) 
of atheroma we witness the appearance of an anacrotic 
elevation (Fig. 3184). 

Anacrotic Hlevations—secondary waves in the line of 
ascent (Figs. 3181 to 3184)—are found only in disease ; 
they require for their formation a lengthened and labored 
influx of blood, either by reason of great volume of blood 
pressed in, as in dilatation of the left ventricle, or be- 
cause of an unyielding artery, as in Bright’s disease, in 
atheroma, etc. Often both conditions concur. The ana- 
crotic pulse is always ap. tardus. The occasional ap- 
pearance of anacrotism in the pulse of paralyzed parts 
(when the vaso-motor nerves are included in the paraly- 
sis), Landois explains by the loss of active contractile 
power (‘‘ tone”’), slowing of the circulation, venous and 
capillary stasis, and hence increased impediments to the 
influx of blood into the arteries. The anacrotic wave 
which sometimes (rarely) arises in the pulse of aortic re- 
gurgitation has an entirely different origin in the trans- 
mission of the wave of the auricular systole through 
the open aortic orifice. 

3. Local Differences in the Pulse.—At times the pulse 
of one artery is found to differ from that of the corre- 
sponding vessel of the other side—p. differens. Apart 
from anatomical anomalies, the differing pulse is caused 
either by (more or less local) changes in innervation or by 
mechanical means. Among the former class of causes— 
which are very numerous—is cold applied to the part ; an 
arm exposed to cold yields a radial pulse of higher tension 
and less height than its warm fellow. A dicrotic pulse 
confined to one artery or limb indicates paralysis of its 
vaso-motor nerves. In hemiplegia the paralyzed side 
commonly gives a softer pulse, with a more rounded apex, 


oe gS SY ataeE pe 
ee ALIS pak! 


Fig. 3185.—Hemiplegia (cerebral), Recent. Upper trace from left radial, 
normal ; lower trace from right radial, paralyzed. 54. (Pond’s.) 


a high predicrotic and a feeble dicrotic wave ; sometimes, 
indeed, the otherwise rare combination of . mollis et 
tardus. Sometimes the tardity is more pronounced, even 
to anacrotism ; the primary wave does not reach high 
enough to form the apex. 

Among the mechanical causes of the differing pulse are 
compression of the artery, as by tumors, cicatrices, adhe- 
sions, etc.; obstruction of the venous current by similar 
means ; and aneurisms situated between the heart and the 
vessel examined, which do not interfere with the circula- 
tion of the other side. 

Smallness of the left radial pulse, as compared with 
the right, has been observed by Traube” in cases of peri- 
cardial exudation. The phenomenon is explained by 
pressure of the enlarged pericardial sac on the arch of 
the aorta. <A greatly dilated heart has been found to 
produce the same effect, probably in the same manner.”* 

4, Altered Rhythm ; Allorhythmia cordis ; Arhythmia 
cordis ; Intermittent Pulse.—While the normal tracing, 
aside from the slight modifications of rhythm produced 
by normal breathing, shows pulses of almost equal du- 


ration and magnitude, many deviations are met with in 
disease. A frequent occurrence is the feebleness or en- 
tire suspension of a ventricular contraction, resulting in 
the dropping of one beat of the pulse, now and again, 
sometimes at regular intervals, sometimes irregularly— 


PITA AILS 


Fie. 3186.—Intermittent Pulse. 84. (Pond’s.) 


ML 


Fie, 3187.—Intermittent Pulse. Kidney disease consequent upon en- 
largement of the prostate and cystitis, in a patient aged eighty-three ; 
fever. Temperature, 101.6°; pulse, 92, (Marey’s.) 


the intermitient pulse. ‘True intermittence, due to actual 
absence of systole—p. deficiens—can be recognized by ab- 
sence of cardiac impulse and of both sounds. The sys- 
tole may take place, however, yet not be strong enough 
to open the aortic valves against the blood-pressure in 
the aorta, and hence cause no wave in the arterial system 
—p. intermittens , or it may have force to cause a small 
wave, registered by the sphygmograph, but not percepti- 


Behe fe bioal ec sca Nae 


if 


(Pond’s. ) 


Fra. 3188.—Pulsus intercurrens. ‘7, 


ble to the finger, or only felt as a very feeble beat—p. in- 
tercurrens or intercidens. 

In some cases feeble systoles occur with great regular- 
ity ; e.g., they alternate with strong contractions, caus- 
ing an alternation of strong and feeble pulses—p. alter- 


PA fate Je 


Fia, 3189.—Pulsus alternans, Apoplexy, 110. (Pond’s.) 


ha brat beatae 


Fie. 8190.—Pulsus alternans, Chronic Nephritis. 140. (B. Sander- 
son’s. ) 


nans. The feeble pulses may be so small as not to be 
easily perceived by the finger, so that a pulse-rate of 80 is 
counted as 40. Or the feeble systole may take place 
soon after a cardiac contraction of ordinary force ; the 
result is that the pulses appear in pairs, in which the 
first has a high ascent and a short descent, the second a 
short ascent and along down-stroke—p. bigeminus. Sim- 


Do SD USCIS A i Pn claen Ros Seeld 


Fig. 3191.—Pulsus Bigeminus. (Pond’s.) 
ilarly, one strong systole may be followed by two feeble 
ones in quick succession, making a p. trigeminus, etc. 
In certain cases the second contraction, which cuts into 
the diastole of the first, working with an almost empty 
ventricle, has not strength to open the aortic valves, and 
therefore fails to cause a pulse—an alternately intermittent 
pulse, as it were; one pulse to two systoles, or, rather, 
a bigeminous action of the heart in which the futile sec- 
ond twin contraction makes no pulse. 

In the case from which Figs. 3192 and 3193 were taken, 
three sounds of the heart were heard to each pulse at the 
wrist, the third sound being the systolic sound of the fu- 


93 


Pulse. 
Pulse. 


tile systole, which was not followed by a diastolic sound. 
This condition has been described and much discussed *4 


2 
Al 
i ee 
qT Ait 


Fig. 3192.—Cardiogram of Bigeminous Action of Heart. 1, 2, Indicate 
the first and second systole of each twin pair; the lower phases cor- 
respond to inspiration, the higher to expiration. Contractions of heart, 
80. (Marey’s sphygmograph.) 


Fia. 3193.—Sphygmogram of Radial Pulse of Same Individual. Pulse- 


rate, 40. (Pond’s.) 


under the name of intermittent hemisystoly of the heart, * 
and of Herzbigeminie. 

In some cases the pulses vary in regularly graded 
groups, as in Fig. 3194, where an ordinary pulse of fair 


ahah 


Fie. 3194.—Male, aged Twenty-eight. Abuse of Tobacco, 77. (Pond’s. ) 
tension is followed by a smaller and softer one, and that 
again by a still smaller, still softer, dicrotic pulse—such 
groups of three recurring again and again. 

All the foregoing varieties of rhythm have been spoken 
of as allorhythmia cordis—altered rhythm, in which the 
inequalities of size as well as of sequence follow certain 
rules or types—in distinction to the quite irregular ac- 
tion of the heart that wipes out all rule and rhythm— 
arhythmia, atavia, or delirium cordis, of which Figs. 
3195 to 8198 furnish examples. In Fig. 3198, from a 


Fie. 3195.—Mitral Disease: Dilatation of Left Ventricle, some Aortic 
Regurgitation; Compensation Disturbed. (Pond’s.) 


Fia. 3196.—Male, aged forty-nine. Preecordial Oppression ; ‘‘ heart gets 


tangled” occasionally. No physical signs. (Marey’s.) 
Fie, 3197. 
Fie. 8198. 


Fies. 3197 anp 3198.—Male, aged Sixty-five. 


] Atheroma; Disease of 
Coronary Arteries; Angina Pectoris. 


(Marey’s. ) 


patient with atheroma, including the coronary arteries, 
with myocardial changes, who suffered most violent at- 
tacks of stenocardia, one full beat is succeeded by a va- 
riable number of feeble ones, and the very frequent pulse 
is at times utterly irregular. 

All these phenomena of arhythmia and allorhythmia 
are of similar origin ; their fundamental cause is dis- 


* The name Hemisystolie was applied on the hypothesis that a normal 
systole of both ventricles was followed by a systole of the right ventricle 
alone. Sufficient evidence has not been brought to the support of this 
assumption. On the other hand, the occurrence of feeble systoles of the 
entire heart—so feeble that the left ventricle is not competent to open 
the aortic valves—is well known. Fick demonstrated such incomplete 
systoles as occurring in the morphine-narcosis of rabbits (Verhandlungen 
des V. Congr. f. innere Med., p. 97, 1886; and Riegel, ibid., p. 101). 
Compare, also, Marey, Bull de l’acad. de méd, No. 42, 1883; Centralblatt 
f. klin. Med., No. 11, p. 181, 1884. 


94 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


turbed innervation, arising either within the heart (from 
lesions of structure or of circulation in the heart’s mus-_ 
cle) or in the vagus or sympathetic, or coming through 
these nerves from the cerebral centres—either directly, 
as in cerebral disease, disease of the pneumogastric nerve 
(compression by tumors, scrofulous glands, etc.), and in 
psychical disturbances ; or reflexly (as in lesions of di- 
gestion, disease of the liver); or as a result of intoxica- 
tion: (by tobacco, tea, or coffee). These causes operate 
more readily upon the already enfeebled or overtaxed 
heart ; hence we meet with them in anzemic persons, in 
convalescents from acute diseases, in valvular lesions 
which have passed the stage of compensation. Complete 
arhythmia is seen most frequently in chronic diffuse 
myocarcitis,*® of which it is almost characteristic when 
persistent and not merely paroxysmal. In uncompli- 
cated disease of the mitral orifice it occurs more fre- 
quently in paroxysms and varies much in degree; digi- 
talis tends to diminish the irregularity, while in chronic 
myocarditis the same remedy has no influence over it. 

A disturbed rhythm of an altogether different kind is 
the pulsus paradozus of Kussmaul.*® It consists in a 
diminution or total suppression of the pulses which co- 
incide with inspiration. Two distinct groups of cases, 
of entirely different origin, show this phenomenon. One 
group is owing to obstruction to the free ingress of air 
into the lungs, augmenting the inspiratory effort and 
thus intensifying the inspiratory lowering of pressure 
within the thorax—to such an extent that the proper fill- 
ing of the left ventricle is prevented, and the latter, dur- 
ing inspiration, throws into the aorta an amount of blood 
too small to cause a pulse-wave in the radial artery. 
This symptom has been observed in stenosis of the air- 
passages (croup, paralysis of the crico-arytenoid muscles, 
compression of the trachea by tumors), as well as in a 
case of capillary bronchitis (Béumler*’). In this group 
the phenomenon is simply an exaggeration of the (nor- 
mal) influence of the respiratory movements. 

In the second group of cases, the paradoxical pulse re- 
sults from mechanical compression of the aorta by means 
which are brought into action only during inspiration. 
This was first observed (by Kussmaul) in cases of me- 
diastinal adhesions of the pericardium, the fibrous bands 
being put upon the stretch whenever the sternum makes 
its forward movement in*inspiration, and, by constricting 
the aorta, obstructing the flow of blood through it. In 
such case the same compression is exerted upon the venze 
cave, and manifests itself in a swelling of the jugular 
veins with each inspiration. The combination of the 
latter symptom with the p. paradovus is pathognomonic 
of fibrous mediastino-pericarditis. The paradoxical pulse 
alone is not so characteristic, for it has been found 
(Biumler, Hindenlang’*) in cases of hydropericardium 
without fibrous adhesions; here, however, the veins of 
the neck were permanently distended, not more during 
inspiration than during expiration. 

5. Morbid Changes in the Pulse-rate.—The physiological 
conditions which modify the frequency of the pulse, 
when exaggerated in disease, will naturally change the 
rate in the same direction. Increased muscular activity, 
as in tetanus, increased chemical change in muscle or in 
the tissues generally, as in fever (elevation of temperature, 
etc.), raise the pulse-rate; vice versa, lessened muscular 
activity and the lessened production of heat in convales- 
cents from acute diseases lower the pulse-rate. An ap- 
parent exception is observed in convalescence from 
typhoid fever, when the frequency of pulse remains high 
even in the absence of all morbid symptoms (Traube). 
In general, it may be borne in mind that in disease, as in 
health, low blood-pressure commonly goes with frequent 
pulse. The limits of this article forbid entering upon de- 
tails ; only those cases can be alluded to in which morbid 
frequency or rarity of the pulse is the prominent, the 
most telling, symptom. 

In many instances persistently rapid action of the heart 
may be ascribed to weakness of the heart (with dilata- 
tation ?), as in the so-called ‘‘irritable heart,” due to 
either prolonged over-exertion or to sudden strain, as in 
lifting, running, rowing. In other cases it is clearly, or 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Pulse, 
Pulse. 


by exclusion, attributable to lesions of the cardiac nervous 
apparatus ; the great frequency of the pulse in exoph- 
thalmic goitre is evidently of this character. 

The name tachycardia (raxts, quick) has been applied 
to a class of cases in which an habitual high pulse-rate 
continues for a long period (in the absence of fever), in- 
terrupted or not by shorter paroxysms of an enormously 
accelerated action of the heart—a condition to which 
anemic persons seem more predisposed than others. . It 
occurs in the course of organic disease of the heart, or 
more often independently of it. In many instances it 
can be traced distinctly to lesions of the nervous system ; 
among the anatomical lesions, those of the pneumogastric 
nerve, either central (in the medulla oblongata) or periph- 
eral (compression by tumors or by cicatricial tissue *), 
offer the readiest physiological explanation. The affec- 
tion may be accompanied by normal or by lowered ten- 
sion ; in the latter event the paralysis or paresis of the 
pneumogastric, or of the cardio-inhibitory centre, is as- 
sociated with temporary paresis of the vaso-motor centre 
or fibres.°° Tachycardia by irritation of the accelerating 
fibres in the sympathetic is less frequent, rarely of high 
degree, and more often paroxysmal than habitual. Theil- 
haber*! reported a case caused by retroversion of the 
uterus—pulse, 200, temperature, normal ; after reposition 
and retention of the womb by pessary, pulse, 80-90-; after 
removal of the pessary, pulse, 110. Finally, tachycardia 
is caused by toxic agencies—coffee, tea, tobacco—and by 
gout. The paroxysms of extreme frequency may be 
excited by indigestion, flatulence, or any causes which 
ordinarily excite the heart’s action. 

In either form, the paroxysmal or the persistent, tachy- 
cardia may be accompanied by distressing symptoms, as 
palpitation, precordial pain and anxiety, dyspnea, feel- 
ing of ‘‘ goneness,” syncope, cold sweats ; but even the 
palpitation is not always felt, and the amount of suffer- 
ing is not always preportionate to the frequency of the 
pulse, sometimes, indeed, insignificant. The rate of pul- 
sation may rise in the paroxysms to over 200, even over 
300, as in the case of Bristowe, quoted by Broadbent.” 
Between the paroxysms, and in the habitual form, a rate 
as high as 164 has been observed. Of the two vagi, 
lesion of the left nerve seems to give rise to the greater 
acceleration. ‘The tachycardia depending on structural 
lesion of the nervous apparatus is apt to be constant and 
of indefinite duration ; the ‘‘ neurotic” and toxic forms 
are more often paroxysmal. The paroxysms last from 
a few hours to several days; Délger*® relates a case 
in which the severe attack lasted seven days, Broadbent 
one in which for about three weeks ‘‘the pulse was 
never under 200, usually 240.” 

Less often do we meet with slow action of the heart as 
a consequence of morbid conditions. In its minor de- 
grees the rare pulse is induced by morbid rise of blood- 
pressure ; it is also caused by certain poisons, among 
them the bile-acids, whence the low pulse-rate sometimes 
found in jaundice. The rare pulse observed in some 
cerebral affections (¢.g., tubercular meningitis) may be 
due to anemia or venous hyperemia (more especially 
of the medulla oblongata) or to compression of the brain. 
Sudden slowing of a previously frequent pulse often an- 
nounces a serious cerebral complication. In glosso-labial 
paralysis the pulse-rate has been found greatly dimin- 
ished, probably from central excitation of the cardio- 
inhibitory fibres. 

The higher grades of rare pulse—p. rarissimus, brady- 
cardia (Bpadts, slow)—are usually connected with certain 
affections of the heart itself. Nauwerck *4 reported a 
case of inflammation of the parietal endocardium in a 
person sixty years old, with the pulse sometimes falling to 
20 per minute. More often the highest degrees of brady- 
cardia are connected with fatty heart, arteriosclerosis, and 


* A case in point was observed by the writer, in which the right 
pneumogastric and sympathetic were both involved in a deep cicatrix in 
the neck, remaining after a very large and deep-seated abscess. The pulse- 
rate ranged from 110 to 140 and over for several months; pulse of low ten- 
sion; general venous stasis (cyanosis), especially of the extremities and of 
the mucous membrane of the throat (from paresis of vaso-motor fibres in 
the cervical sympathetic ?), more pronounced on the right side. 


especially sclerosis and calcification of the coronary ar- 
teries, by means of their deleterious effect on the nutri- 
tion of the myocardium (?). Such cases abound in litera- 
ture.2° The pulse is usually anacrotic and very tardy. 


ec i 


Fie. 3199.—Female, aged Seventy-seven. Extensive Sclerosis of Coro- 
nary Arteries; Fatty Degeneration of Heart. Pulse-rate, 13 to 14. 
(Marey’s.*) 


It has been suggested that many of these cases are 
really heart-bigeminism, because sometimes the rate 
drops suddenly from, say, 60 to 30, and on improve- 
ment the bigeminous pulse appears as a transition to the 
normal rhythm and rate. But this is not the rule. 

The connection between the structural disease of the 
heart and the lesion of innervation is not clear. Kisch * 
suggests, for the fatty heart of obese persons, that the 
lipemia often found to exist in universal lipomatosis 
exerts the toxic effect of slowing the heart’s action 
which has been obtained experimentally, in animals, by 
increasing the fats in the blood. 

Concomitant symptoms, when present, are chiefly 
dyspnoea and precordial anxiety, Cheyne-Stokes respira- 
tion, vertigo, syncope, and epileptiform seizures.*7 The 
epilepsy, in such cases, seems due to anemia of the 
brain, closely related to the attacks of syncope which 
threaten the patient, especially when he assumes the up- 
right position. Tripier,*® on the contrary, thinks that 
epilepsy is the cause of the slow pulse ; that hemisystoly, 
or heart-bigeminism, is always due to epilepsy, which 
is certainly too sweeping a conclusion ;** the reverse re- 
lation seems to be the usual one. 

THe CAaRDIOGRAM.—A graphic record of the impulse 
of the heart against the chest-wall can be obtained by 
means of sphygmographs constructed on the principle of 
Marey’s; or by modifications of the same for their better 
application to the thorax, as Galabin’s cardiograph ; by 
transmission instruments, after the pattern of the cardio- 
graphs of Marey, Burdon-Sanderson, Meurisse et Ma- 
thieu, the compound sphygmograph of Keyt, and the 
pansphygmograph of Brondgeest. Less perfect tracings 
are made with Pond’s and Dudgeon’s sphygmographs. 

The tracings of the apex-beat registered by these in- 
struments are not as transparent in meaning as the 
sphygmogram, because they represent a greater complex- 
ity of movements, subject to more varying conditions, 
altered by the thickness and varying tension of the soft 
parts overlying the heart in the intercostal space, and apt 


Fie. 3200. 


Fie. 8201. 


Fie, 8200.—Normal Cardiogram. Pulse-rate, 81, 
Marey (Breguet). ) 
Fras. 3201, 83202.—Normal Cardiograms, after Landois. Pulse-rate, 74.2: 
respiration, 113.1. (Marey’s sphygmograph.) 


Fie. 3202. 
(Sphygmograph of 


to be seriously confused by the simultaneous respiratory 
movements of the chest. Hence it may happen that 
only one or a few curves of a series give a complete and 
pure record of theheart’simpulse. The latter is a rhyth- 


* This curve was taken several days before the death of a woman of 
seventy-seven years, who at the time suffered from great debility and had 
some spasms, Chiefly of the muscles of the face and neck. The respira- 
tion was accelerated—26 and over. The pulse-rate on the previous day 
had been 10 per minute, Autopsy revealed a high degree of fatty de- 
generation of the heart and extensive atheroma of both coronary arte- 
ries, the left being very rigid and contracted, for nearly an inch almost 
impervious. 


95 


Pulse. 
Pulse. 


mical elevation and recession over the site of the apex, 
expressing the sum of the movements communicated to 
the chest-wall by the changing position, form, and con- 
sistency of that portion of the heart, and due to the con- 
tractions of the four chambers 
of the heart and to the closure of 
their valves. The normal car- 
diogram is the expression, there- 
fore, of a considerable number 
of conditions, subject to great 
variations in themselves and dis- 
turbed by the acts of respiration. 
Nevertheless the apex-tracing of 
Fie. 3203.—Normal Cardio- healthy persons is a characteris- 


Shige yee ous’ tic curve, the details of which 
, 00. 


graph.) (The lettering is can be recognized in cardiograms 
altered to conform to that of seemingly great disparity, and 
lend themselves in their main 
features to a comparatively simple interpretation. 

The lowest point in the normal cardiogram, a, marks 
the time when the ventricles have fully relaxed, and 
From 


used in the present article.) 


hence lies in the diastolic portion of the curve. 
this point on (toward the right) 
we note a rise in the curve, 
more or less sudden, expressive 
of the filling of the ventricles, 
with one or more minor eleva- 
tions produced by the contrac- 
tion of the auricles. At the 
point 2 begins an abrupt and Fie. 38204.— Normal Cardio- 
higher rise of the lever in obe- gram, after Keyt. Pulse- 
dience to the sudden contraction rate, 72. (Keyts’ compound 
of the ventricles, and the, termi- ee a i Seine 
nation of this rise forms the 
highest point, or apex, of the normal curve, ce. The ven- 
tricles remain in systole for some time longer, during 
which the lever gradually falls to the point ¢. This por- 
tion of the curve is marked by two small elevations, d 
. and ée, which correspond 
to the closure of the aortic 
and pulmonary valves re- 
spectively.* The sudden 
V4 relaxation of the ventri- 
cles now causes an abrupt 
fall of the lever from the 
point e to the lowest point 
of the curve, f (= a@ of 
the following curve). The 
palpable impulse of the heart coincides in time with the 
portion of the curve lying between d and e , the first sound 
of the heart is heard to begin at 0; the second sound co- 
incides with d and e. Landois has demonstrated that 
the aortic and pulmonary valves do not close exactly at 
the same time ; but the interval between the two sounds 
produced is too short (.05 to .09 sec.) to be perceived by 
the ear, so that they are heard as one, while the eleva- 
tions they start in the tracing are separate. It is only 
when the interval considerably exceeds the normal that 
the closure of the two sets of valves is revealed to the ear 
in separate sounds—7.e., the second sound of the heart is 
‘‘reduplicated.” + The cause of the interval is the dif- 
ference in blood-pressure in the aortic and pulmonary 
systems; that in the aorta, being much greater, leads to an 
earlier recoil, even though both ventricles complete their 
systole and relax at the same time. 

The line de may be called the systolic portion of the 
curve; the line from ée to the point 6 of the next curve, 
ef + ab, the diastolic portion, consisting of the pause and 
the auricular systole. The period 0 e (between the first 
and second sounds) commonly measures about two-fifths 
of the entire cardiac revolution. Keyt found, as an ay- 


a 


Fig. 3205.—Normal Cardiogram. Pulse- 
rate, 66. (Dudgeon’s sphygmograph. ) 


* According to the interpretation of Landois. More accurately, I think, 
the moment of closure of the valves is represented by the notches preced- 
ing the waves d and e, 

+ In a case of phthisis (chronic pneumonia with cavities, fatty degen- 
eration of right heart, chronic interstitial nephritis) without valvular 
lesions, in which the second sound was very distinctly reduplicated, 
Maurer (Deutsches Arch. f. klin. Med., 1879, Bd. 24) measured the inter- 
val between d and ¢ = .156 sec., while in a number of normal cardiograms 
he found it to equal only ,092 sec, 


96 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


erage of twenty measurements, with a mean frequency 
of 74.7, or a pulse-length of .8075 sec., the systole = 
.8269 sec., the diastole = .4806 sec. With less frequent 
beats the diastole becomes longer, with greater frequency 
shorter, while the systole may vary in either direction. * 
In the cardiogram taken while respiration is performed, 
the individual curves of the series are of very different 
height, and their details are not nearly so uniform as 
those of the sphygmographic tracing, owing to the dis- 
turbing influence of the respiratory movements of the 
chest-wall. At the height of an inspiration, owing to the 
interposition of the borders of the lung, the apex-beat 
becomes less visible and less distinct to palpation than 
during expiration, and deep respiration increases these 
differences ; in shallow respiration they may escape de- 
tection by the hand or finger, but they are still percepti- 
ble in the cardiogram. (Compare Figs. 3208, 3209.) This 
(normal) behavior of the tracing presupposes that the 
anterior border of the left lung is intact and making its 
normal excursions. Adhesive inflammation, which fixes 
the left lung so that its border does not cover the cardiac 
apex during inspiration, is apt to reverse the differences 
in the curves in such wise that the higher phases of the | 
cardiogram correspond to -inspiration, the low curves to 
expiration, because during inspiration the intra-ventricu- 
lar pressure rises.** . 
Pathological.—In cases of heart disease the tracings of 
the cardiograph may contribute to our appreciation of the 
details of the heart’s action, and hence to diagnosis. Much 
has yet to be learned in this direction. In individual cases 
our knowledge may be further enhanced by tracings taken 
at other points than the site of the apex—e.g., in or to- 
ward the second left intercostal space to demonstrate in- 
creased tension in the pulmonary artery (accentuation of 
the pulmonary second sound), or over areas in which a 
systolic retraction of the chest-wall is visible, where the 
tracing will be in a sense ‘‘negative:” the systolic ascent 
will be converted into a descent, and vice versd, while the 
secondary (valvular) elevations will remain positive. 
Pathological apex-curves exhibit enormous differences 
in height. In hypertrophy with dilatation the excursions 
of the lever of a Marey’s sphyg- 
mograph often amount to several 
inches. In atrophy or degenera- 
tion of the heart’s muscle the 
tracings become so tiny as to lose 
all detail and character, or vanish 
altogether. (It must be remem- 
bered that in some cases — as 
when the apex beats against a 
rib, or in violent dyspnoea—in- 
telligible tracings cannot be ob- 
tained at all.) The effect of sim- 
ple hypertrophy is mainly a 
broadening of the summit of the 
: curve, owing to forcible systole 
Fig. $200,—Hypertrophy nd and early closure of the valves 
in a Case of Aneurism of (recorded by waves placed high 
the Thoracic Aorta. Pulse- yp, near the apex, before the 
ree el * sphyé- Jever has descended much). Dila- 
tation with hypertrophy tends to 
produce curves of great magnitude, the apex very high 
and pointed, followed by a considerable fall of the lever 
before the valves close, as in Fig. 8206. The size of car- 


Se. sees 


g 


* The interpretation here given of the details of the cardiogram is that 
of (Marey and) Landois, adopted by many cardiographers,*° especially Ger- 
man and French. Some English authors (e.g., Bramwell) stili follow the 
labored interpretation of Garrod,4! or the equally artificial one of Gala- 
bin,42 who places the beginning of the systole in about the middle of the 
up-stroke, where he recognizes a small rise (in some of his curves) as the 
expression of the closure of the auriculo-vyentricular valves, and the end 
of the systole at the foot of, or at some point in, the main descent (be- 
tween é€and /), where he sometimes finds a small notch as the indication 
of the closing of the aortic valves. The waves in the plateau (from c to 
é) are explained (d) as due to ‘‘ recoil toward the apex of the blood, which 
had been forcibly impelled against the auriculo-ventricular valves at the 
moment of their closure,” and (e) to *‘locomotion of the heart as a 
whole,” or ‘‘ to the jerking forward of the apex at the end of systole.” 
Keyt divides the curve into systolic and diastolic portions at exactly the 
same points as Landois, but recognizes no indication of valve-action, and 
explains the elevations of the systolic portion by variations in blood- 
pressure and muscle-contraction of the ventricles. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Pulse. 
Pulse. 


diographic curves must be studied with reference to the 
frequency and rhythm of the beat. 

The auricular portion of the curve, @ 0, is well devel- 

oped in proportion to the systolic elevation in cases of 
hypertrophy and overaction of the 
auricles, abrupt rise and increased 
height of the first denoting great 
force of auricular contraction. 
When the auricle is both large and 
strong, the curve may rise suddenly 
into a sharp peak, with a quick de- 
scent down to the point 0, as in Figs, 
.8207 and 8208. Rough presystolic 
murmur—the purring thrill of mi- 
tral stenosis—is often pictured in 
this portion of the curve as a ser- 
rated line. (Compare Fig. 3212.) 

The height of the ventricular up- | 
stroke, be, is proportioned to the dis- Wie. 8207.—-Valvalar Te 
tinctness of the apex-impulse. Itis ‘gions; Mitral Regurgi- 
invariably great in excentric hyper- tation Predominating. 
) trophy of the left ventricle, espe- (Mareys sphysmo- 
cially so in aortic valvular disease oie ne an 
and in combined lesions in which _ produced, butboth show 
aortic insufficiency predominates. Plainly the violent au- 
(Compare Figs. 3206, 8213.) The "wl systole.) 
apex in such cases is apt to be very sharp, the first de- 
scent from it, abrupt. 

The valvular elevations in the descent, or following 
the apex, indicate the tension in the aortic and pulmo- 
nary systems. Increased height of the elevations d and e 
denote, not only high tension in the respective vessel, but 
also testify to its clasticity and tone. When the latter 
properties are impaired by long-continued high pressure, 
dilatation, or atheromatous change, these waves are de- 
layed and small. In some cases the rise of tension in 
the pulmonary artery, of which increased loudness of the 


\ 
{ 
| 

hea 

I) )® 


Fig. 3208.—Mitral Regurgitation. 


itl 
wary ae 


(Marey’s sphygmograph. ) 


pulmonary second sound gives evidence, is well shown 
in the cardiogram by an earlier and higher wave, e, some- 
times an early sign in mitral disease ; if the blood-pressure 
in the aorta is lowered at the same time, @d may be so far 
delayed that the two elevations d and ¢ are merged into 
one, as in Fig. 3208. 

Diseases of the right heart and obstruction of the pul- 
monary circulation affect the cardiogram only by the al- 


Fic. 3209.—Mitral Regurgitation, .(Marey’s sphygmograph. ) 


tered size and force of the right chambers, as above men- 
tioned, and by the altered tension in the pulmonary artery. 
Valvular disease of the left heart is often expressed in 
more characteristic changes. 


Vou. VI.—7 


Mitral Regurgitation commonly shows a marked auric- 
ular portion, a 6, as in Figs. 8207, 8208, 8210, owing to 
dilatation and energetic systole of the left 
auricle; a small aortic wave, d, on ac- 
count of the lowered tension in the aorta, 
and a large and higher-placed pulmonary 
wave, ¢, aS in Fig. 3210, on account of the 
increased tension in the pulmonary artery 
(loud second sound); the latter wave 
may be enlarged and hastened so much 
that it coalesces with the aortic wave, as 
in Figs. 3208 and 8209. The height of the 
whole curve is proportioned to the de- 
gree of enlargement of the heart. Com- Fie. 3210,—Mitral 
paring the cardiogram with the simulta- Insufficiency, af- 
neous sphygmogram (on polygraph or  (farey’s cardio. 
Keyt’s sphygmograph), the presphygmic graph.) 
interval is found abnormally long. 

In Mitral Stenosis the auricular portion is lengthened 
(7.e., of longer duration), and its tracing is higher, be- 
cause the left auricle is dilated, contracts with force, and 


Fie. 3211. 


Fie, 3212. 


Fra. 3211.—Mitral Stenosis, after Galabin. Pulse-rate, 8U. 
” cardiograph.) 
Fie, 3212.—Mitral Stenosis (long, rough, presystolic murmur), after Gala- 


bin. Pulse-rate, 57. (Galabin’s cardiograph. ) 


(Galabin’s 


empties itself with difficulty ; it often bears a series of 
wavelets, giving it a serrated appearance, corresponding 
to the purring thrill felt by the hand. In the systolic 
portion the increased blood-pressure in the pulmonary 
artery makes the wave e conspicuous. In case of redu- 
plication of the second sound, the waves d and @¢ are sep- 
arated by a longer interval; Ott and-Haas* attribute the 
late closure of the pulmonary valves to the diminished 
elasticity of the artery in consequence of 
long-continued high pressure in it. 
Aortic Incompetency alters the apex- 
tracing chiefly through the factors of dila- 
tation and hypertrophy of the left 
ventricle ; the curve is very high, 
its apex pointed, the descent sud- 
den; the pulmonary elevation is 
apt to be conspicuous, higher than 
the aortic elevation, sometimes, 
indeed, enormous, as in Fig. 3214, 
which reproduces a tracing taken, 
not at the apex, but nearer 
3 the pulmonary area. The 


auricular portion of the 
cardiogram is not changed 
in pure aortic insufficiency ; 
sometimes its second wave 
(near 0) becomes very dis- 
Fie. 3213.— Aortic Insufficiency, tinct, as in Fig. 3214. In 
SEE al (Marey’s sphys- free regurgitation the pre- 
; sphygmic interval is short- 

ened ; the radial pulse follows so quickly upon the car- 


MV YW 


Fra. 3214.—Aortic Regurgitation; Great Dyspnea. (Tracing taken in 
fifth intercostal space, one and one-half inch inside of apex-beat.) 
(Marey’s sphygmograph. ) 


diac impulse that this phenomenon becomes a valuable 
diagnostic sign. 


97 


Pulse. 
Punta Rasa. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Aortic Stenosis is said to make the primary ascent small 
and slow (sloping), and the plateau of the systclic por- 
tion large, sometimes rising toward the end of the sys- 
tole, sometimes, also, marked by irregular denticulation, 
answering to the harsh systolic murmur (Landois). The 
total systole is abnormally long. 

BIBLIOGRAPHY.—From the immense literature on the 
subjects treated of in this article, it is possible only to re- 
fer to the larger physiological treatises ; to the fundamen- 
tal works of E. H. Weber (1827-52); Volkmann (‘‘ He- 
modynamik,” 1850) ; Vierordt (‘‘ Lehre vom Arterienpuls,” 
1855, et al.); Valentin (‘‘ Versuch einer physiol. Pathologie 
des Herzens u. d. Blutgefasse,” 1866); Marey (‘‘ Physi- 
ologie méd. de la circulation du sang,” 1868; ‘‘ Du 
mouvement dans les fonctions de la vie,” 1867 ; ‘‘ Tra- 
vaux du laboratoire,” 1876; ‘‘La méthode graphique,” 
1878); O. J. B. Wolff (‘‘Charakteristik des Arterien- 
pulses,” 1865) ; Rive (‘‘ De sphygmograaf en de sphyg- 
mogr. Curve,” 1866); Burdon-Sanderson (‘‘ Handbook 
of the Sphygmograph,” 1867, e¢ al.); Landois (‘‘ Die 
Lehre vom Arterienpuls,” 1872; ‘*‘ Graphische Unter- 
such. tiitber den Herzschlag,” 1876); Moens (‘‘ Die Puls- 
curve,” 1878); Keyt (op. cit. infra) ; and to the manifold 
labors of Mach, Czermak, Anstie, B. F. Foster, Ma- 
homed, Garrod, Galabin, Roy, Broadbent, Fick, Brond- 
geest- Mosso, Frangois-Frank, Waldenburg, Sommer- 
brodt, Riegel, Grunmach, v. Basch, G. v. Liebig, and 
many others. 

G. Baumgarten. 


1 Keyt : Sphygmography and Cardiography. _ New York and London, 
1887. 
2 Moens: Die Pulscurve. Leiden, 1878, p. 89. 
3 Grunmach: Arch. f. path. Anat., Bd. 102, p. 565. 
4 Keyt: Loc. cit., } pp. 52, 53, 
5 Wolff: Charakteristik des Arterienpulses. Leipzig, 1865, pp. 144 et 
seqq. 
6 Bettelheim: Deutsches Archiv f. klin. Med., Bd. 22, p. 230, 1877, 
7 Guy: Guy’s Hospital Reports, 1838, vol. iii. 
8 Jorissenne: Quoted in Med. Chir. Rundschau, Juli, 18838, p. 539. 
® Foster: Textbook of Physiology, 3d ed., London, 1879, p. 178. 
10 Mahomed: Guy’s Hosp, Rep., 1883, p. 98. 
11 Waldenburg: Die Messung des Pulses u. d. Blutdrucks d. Menschen. 
Berlin, 1880. 

12 vy, Basch, Berlin klin. Wochenschr., 1887, Nos. 11-14. 

13 Maurer: Deutsches Arch. f. klin. Med., Bd. 24, 1879. 

14 Compare G. v. Liebig : Archiv f. (Anat. u.) Physiol., 1883, Supple- 
mentband, pp. 17-19. 

15 Burdon-Sanderson : Handb. of the Sphygmograph. London, 1867, 
p. 16. 16 Moens: Loc. cit.,? p. 144. 47 Thid., p. 140. 

18 Penzoldt: D, Arch. f. klin. Med., Bd. 24, p. 525, 1879. 

19 Mosso: Die Diagnostik des Pulses. Leipzig, 1879, p. 7 et seqq. 

20 Liebig, G. v.: Loc. cit.,14 p. 16. 

22 Traube : Charité-Annalen, Berlin, Bd. i., p. 285. 

23 Tuczek: D. Arch, f. klin. Med., Bd. 23, p. 312, 1879. 

24 Leyden: Arch, f. path. Anat., Bd. 44, p. 365 ; Nothnagel: D, Arch. 
f. klin, Med., Bd. 17; Sommerbrodt: Ibid., Bd. 19, p. 892; Bd. 23, p. 
542; Riegel: Ibid., Bd. 27, pp. 393, 417; Bd. 28. p. 823; Stern : Ibid,, 
Bd. 35 ; Hichhorst: Fortsch. d. Med., 1884, p, 750); et al. 
- #5 Riihle: D. Arch. f. klin. Med., Bd. 22, p. 82. 
26 Kussmaul: Berl. klin. Wochenschr., 1873, Nos. 37-89. 
27 Baumler: D, Arch. f. klin. Med., Bd. 14, p. 455. 
28 Hindenlang: Ibid., Bd. 24, pp. 465-66. 
2° Tarchanoff : (Pfliger’s) Arch. f. d. ges. Physiologie, 1885, Bd. 35, 
109. 30 Dehio: Quoted in Centralbl. f. d. med. Wiss., 1887, No. 1. 
31 Theilhaber: Aerztl. Intelligenzblatt, 1884, 42. 
32 Broadbent: Brit. Med. Journal, 1857, p. 659. 
33 Dilger: Zur Tachycardie, Inaug. Dissert. Wiurzburg, 1883, p. 21. 
34 Nauwerck: D. Arch. 7. klin. Med., Bd. 33, p. 216. 
85 Brit. Med. Journal, 1879, vol. ii, pp. 814, 886, 938; Lancet, 1885, 
vol. i., pp. 10, 288, 447; Berl. klin, Woch., 1887, p. 72. 

36 Kisch : Berl. klin. Woch., 1885, p. 215. 

87 Mivart, Gibbings, Bristowe : Lancet, 1885, i., pp. 10, 288, 447; Lon- 
guet: Union méd., 1884, No. 130. 

38 Tripier: Revue de méd., 1883, iii., p. 1001. 

3% Broadbent: Loc. cit.,3? p. 709. 

40 Prochowsky: Congr. pér. international des sc. méd., Copenhague, 
1884. Compte rendu, tome ii., p. 159 (1886). 

41 Garrod: Journ. of Anat. and Physiol., November, 1870. 

42 Galabin: Guy’s Hosp. Rep., 1875, p. 261. 

43 Ott u. Haas: Prager Vierteljahrschrift f. d. pract. Heilk., 1877, 
Bad. 186, pp. 41 et seqq. 


fe 


PULSE, VENOUS. In peripheric veins a pulsation 
has been observed, in exceptional cases, which is simply 
the arterial pulse carried forward through the capillaries 
into the veins. A necessary conditiom for this pulsation 
is, probably, wide dilatation of the minute arteries of the 
part, either by active vaso-dilatation (as in the case of 
the secreting salivary gland) or by paralysis. In a more 
limited and stricter sense, the name ‘‘ venous pulse” re- 


98 


21 Keyt: Loc. cit.,! chapter vii. , 


fers to pulse-movements occurring in the large veins 
near the heart, especially the jugular veins, both in health 
and in disease. 

1. Normau.—Pulsation of the jugular veins has long 
been known as a pathological phenomenon, but the dem- 
onstration of a venous pulse in health is of recent date. 
Potain,! in 1867, published a sphygmogram of a jugular 
pulse from a person in health. Mosso® showed that 
there is a physiological pulse in the jugular veins which 
can often be observed in healthy persons, and that this 
normal venous pulse is negative, z.¢., the reverse of an 
arterial pulse. Riegel? and Gottwalt* further proved 
that a jugular pulse is a constant normal phenomenon in 
dogs and rabbits ; the same pulsation can be observed in 
many other veins, especially in the territory of the infe- 
rior vena cava. The older clinicians who had met with 
this jugular pulse in man, in the absence of valvular dis- 
ease of the heart, had not been able to explain it without 
assuming an insufficiency of the valves of the jugular 
veins. Mosso, first showing the negative character of it, 
connected it with the ‘‘negative pulse of the thorax.” 
Riegel explains it in the simplest manner by the varying 
velocity with which the blood of the jugular veins flows 
into the right auricle during the different phases of the 
heart’s movements. It is approximately an inverse ar- 
terial pulse, making a descent synchronous with the car- 
diac systole, an ascent with the ventricular diastole and 
auricular systole. When the ventricle contracts (auric- 
ular diastole), the flow of venous blood is accelerated, 
causing a systolic venous collapse; but during the dias- 
tole of the ventricle, and especially during the auricular 
systole, the venous flow is retarded, causing a diastolic 
swelling of the jugular veins. Obviously, this process 
does not require for its consummation an insufliciency of 
the venous valves. 

Graphic reproduction of this pulse shows a curve the 
ascent of which is commonly interrupted by a wave, 
while the descent is uninterrupted ; the curve is ‘‘ anadi- 
crotic, catamonocrotic.” The first part of the ascent 
corresponds to the diastole of the ventricle, the second 
ascent to the systole of the auricle, the descent to the 
systole of the ventricle. 

2. ParHoLocicaL.—The jugular pulse seen in heart 
disease is of different character and origin. Contrary to 
the normal negative venous pulse, it is a positive one, 
z.é., its ascent is synchronous with the cardiac systole ; 
and it depends upon a centrifugal movement, a regur- 
gitation of the blood. This can occur only when the 
tricuspid valve is insufficient, and therefore it is a pathog- 
nomonic sign of tricuspid regurgitation—whether the in- 
sufficiency be due to inflammatory disease of the tricuspid, 
or to dilatation of the right heart consequent on disease 
of other valves. This pulsation may be confined to the 
lower portion of the vein, below the first set of venous 
valves ; but when the vein is distended and (or) its valves 
are incompetent, the positive jugular pulse extends higher 
up into the vein. The regurgitation extends into the 
hepatic veins also, where it causes throbbing or pulsation 
of the liver synchronous with the cardiac impulse. When- 
ever the phenomenon is well developed it is not only dis- 
tinctly visible, especially in the right external jugular, 
but equally palpable and accessible to the sphygmograph, 
sometimes yielding a tracing of great amplitude. Yet 
neither does the venous pulse occur in all cases of tri- 
cuspid insufficiency, nor is the amplitude of the pulse- 
wave in the jugular vein an indication of the degree of 
the valvular defect. The form of the sphygmographic 
curve is similar to that of the negative pulse, anadicrotie. 
The criterion of the venous pulse of tricuspid insufficiency 
as the time of tts occurrence ; it ts systolic. The normal 
venous pulse ts presystolic (Riegel). 

The latter is sometimes—in cases of over-distention of 
the right heart, but with competent tricuspid valves—ex- 
aggerated, and is then visible asa presystolic swelling 
of the jugular bulbus. Confounding this presystolie jugu- 
lar pulse with the systolic venous pulse of tricuspid re- 
gurgitation has caused much difficulty of interpretation 
and much confusion on the subject. 

Absence of venous pulse in the presence of extreme 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


venous congestion has been held > diagnostic of tricuspid 
stenosis. 
BIBLIOGRAPHY. 
Stokes: Diseases of the Heart and Aorta, Amer.-ed., p. 214. Philadel- 
phia, 1855. 
Bamberger: Lehrb. d. Krankheiten d. Herzens, p. 99. Wien, 1857; 
Wiirzburger Med. Zeitsch., Bd. iii., 1863. 
Friedreich : Deutsches Archiv f. klin. Med., Bd. i., p. 241, 1865. 

Taylor : On Pulsation of the Liver, Guy’s Hosp. Reports, 1875, p. 37%. 
Riegel: Deutsches Arch. f. klin. Med., Bd. xxxi.; p. 1, 1852; Sammlung 
klin. Vortrage, No. 227, 1883. 
Tripier : Lyon Méd., 1884. No. 42. 

Bramwell: Dis. of the Heart, etc. New York, 1884, p. 291. 
G. Baumgarten. 

1 Potain : Des mouvements et bruits qui se passent dans les veines ju- 
gulaires. Soc. méd. des Hép., 24 Mai 1867. 

2 Mosso: Die Diagnostik des Pulses, etc. 

3 Riegel: Berlin. klin. Wochenschr., 1881. 

4 Gottwalt: Arch. f. d. gesammte Physiologie, Bd. xxv., 1881. 

5 Chauffard: Revue de Méd., July, 1884; Practitioner, December, 
1884, p. 448. 


PUMPKIN-SEED (Pepo, U. S. Ph.). The seed of 
Cucurbita pepo Linn., order Cucurbitaceew, the common 
Pumpkin ; a vine scarcely known in the wild state, but 
probably of Asiatic origin. It has been cultivated from 
time immemorial for its edible fruits. Its seeds, as well 
as those of other species—gourds, squashes, and cucum- 
bers—have long been considered to have medical proper- 
ties (les grosses et les petites semences froides), but their 


Leipzig, 1879, p. 60. 


Pulse. 
Punta Rasa, 


present employment as teenicides is of rather modern 
origin. 

The seeds of several species and of numerous varie- 
ties of pumpkins, squashes, etc., are very similar in ap- 
pearance, and are probably supplied in the market some- 
what indiscriminately ; the officinal description will serve 
to eliminate some of them: ‘‘ About three-quarters of an 
inch (two centimetres) long, broadly ovate, flat, white or 
whitish, nearly smooth, with a shallow groove parallel 
to the edge; containing a short, conical radicle and two 
flat cotyledons ; inodorous, bland, and oily.” The testa 
is tough and flexible, and must be removed when the 
seed is prepared for use; the embryo is exalbuminous 
and has a pleasant, nutty, sweetish, oily taste. 

Pumpkin-seed, besides sugar, mucilage, albuminous sub- 
stances, ferments, and asparagin, contains twenty-five or 
thirty per cent. of a pale yellow, thickish, almost non- 
drying, odorless, and tasteless jived oil, composed of 
glycerides of oleic, palmitic, myristic, etc., acids, and some 
free acids. The medicinal power is contained in the oil, 
but has never been separated. 

Usrt.—This seed is a moderately efficient, agreeable, 
and entirely safe agent for the destruction of tape-worms. 
It should be. preceded by the usual preparatory fasting 
(see Koosso), and be followed by a cathartic. It is not 
quite so certain as koosso and pelletierine, but is much 


Climate of Punta Rasa, Fla.—Latitude 26° 36', Longitude 82° 10'.— Period of Observations, September 1, 1871, to June 15, 
, 1883.—Hlevation of Place of Observation above the Sea-level, 2 feet. 


A AA B Cc D E EF G H 
' oO o bmAd lhe oO 
Bisabeg EEEHEREE 
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a 2 2 aol "Sod 
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af 5 a ga” gles” 8 
= . : TS-4 — oO 
hee a2 a3 Pe Absolute maximum ||Absolute minimum ||..°¢ BS ie zs 
Mean temperature of months o~ Mean temperature ag ah temperature for temperature for || © of noes 
at the hours of sr for period of ob-) go ga period. period. BEE! Ot 
ge servation. Gh E a 2 oe aA 
v oH == Pease ES 
=) q q Ber Slas's 
25 g 2. SEE BESS 
c ie s s Sossigoes 
S S E SPEE|SESS 
t <q ca " Si a8 chen a8 
ie pa a 3 P.M. 11 P.M. Highest. | Lowest. Highest. ; Lowest. || Highest. | Lowest. 
| Degrees. | Degrees. | Degrees. || Degrees, || Degrees. | Degrees. || Degrees. | Degrees. || Degrees. | Degrees. || Degrees. | Degrees. 4 ie 
rE ; % 17 69.6 60.0 71.8 58.6 81.5 74.0 53.0 33.0 
he EE abe a3 es 4 66:3 70 62:8 73.2 60.3 84.0 75.0 52.0 43.0 29 35 
February... 62. i. 5.4 2 70. t 3 tee es Se ey 3H 3 
March......''. 64.8 (3.5 67.6 68.6 (2.5 64.7 6.1 62.7 po pe gs ay ea ae 
April...) 70.2 17.2 71.6 73.0 76.3 69.5 19.9 66.5 83.0 82.0 68.0 46.0 19 21 
May... 74.6 81.0 74.2 16.6 19.3 75.3 83.6 69.8 92.0 85.0 65.0 51.5 19 19 
June.. 79.8 83.6 73.0 80.4 81.7 19.1 87.5 74.3 94.0 89.0 72.9 ee De 18 
itive... c.<| 90.6 84.2 9.1 81.3 82.9 80.3 88.9 15.9 3. 0 13. 67. 28 2 
August... 80.2 83.9 79.0 81.0 83.0 79.5 88.0 75.7 93.0 91. 13.0 70.0 18 
September..| 78.6 83.3 78.3 80.0 81.9 18.8 86.8 74.9 92.0 89.0 72.0 67.0 20 33 
October..... 72.4 79.9 "3.7 75.3 7.3 72.0 82.7 "1.2 89.5 85.0 69.0 54.0 2 3 
November.. 66.0 74.5 68.4 69.6 73.3 66.2 1 64.1 87.0 81.0 51.5 37.0 || 18 28 
December..| 60.3 69.8 63.5 64.5 70.2 59.9 11.9 58.4 82.5 75.0 56.0 34.0. || 2 1 
ee Nt ee Als A wee clas tacseg 72.7 74.3 ie alin | Snipe A Ca Ase ME ak Cum Sie ead Mees, ei) EL oe | ne 
Guuinier Mectcoen Nt Moree» \ktas seas 80.9 82.3 OQ ESIEEE lt ut cc cee MMR Sole Mine ti ye tarart eto bolleMira re soscvatete (libre stalstotoleh lial ce nieue Ml Kiveiw:elne.an! flee saree 
eae Abgkil, oe OOD cll Lb parece. le arte [oe ae Dae ra ee ler eticee at linwcnnimicn -itimaace cs. [isis ce 
Eee ate deca es) at) sacpsiee) ||) teeten t's : ; ED es Teo) See ae ecee e eer gl |e ere eh eee | ere ok) ae A ey een RO MuIROS Cot Perot Mee sien e- fee ae ete 
P| sca tcekcee || Pavcaen 3.4 || 74.2 72.5 Dae a, Wie tN RIG A as PEER | ORO ee 
) 7 A 
RVers ale te tele ho Cgglen Te yry5bs | leak dis greeable than the former. Pumpkin-seed appears 
ac i i RH = ‘es bo to vary considerably in its activity, probably in conse- 
eta ae| a8 |e & Eg 83 quence of coming from different varieties or different 
g3 ae | 88] go | es 3 eg conditions of cultivation, That of the West Indies and 
38} 33S | on] of | of 2 &% | 278 | other southern countries is probably the best. 
Go| ch |g=| #9 | gael & @q | 828 The usual method of administration is as an emulsion, 
+ oe ° . J 
ae] $8 Bo} FS | us 4 BS e283 made by pounding and rubbing the peeled kernels in 
se| = <4 < 67 Sa hiss “c m qor yt ‘ nay 
he a: sala tat | | water; from thirty to fifty grammes (before peeling) is 
c eG : ong ches: Brom Miles the usual dose. The oil, if attainable, would no doubt 
anuary....| 48.5 | 77.6 | 15. 9.8 A ; -H. 4 “Mm. 
February...| 41.0 | 7.8 | 11.4] 115 | 22.9 | 1.2 | NB. | 30.7 be a better form. ‘ 
March...... 40.0). TL VIS 14.7 26.5 1-30 NE. 12.0 ALLIED PLANTS.—See COLOCYNTH. , 
Til...--..| 42.0 | 72.0 | 14.8} 19.1 2.01 ; : any 28. 
AY.....0..| 84.5] 71.6 | 16.5 | 8.8 | 25.3 | 8.61 BE. 10.4 ALLIED Drues.—See Koosso, W. P. Bo 
June.. 27.0 | 74.4 [175] 4.8 21.8 4.97 E. 8.9 
August, -.-| 93:0 | qi |is4| 26 | 20 | rss | em | Bid PUNTA RASA, FLA. The accompanying chart, ob- 
September..| 25.0 | 77.7 | 18.4] 3.4 | 21.8 | 7.23 ee tained from the Chief Signal Office, at Washington, repre- 
eae 50° sO is:4 104 53°8 $03 Ve 10/1 sents the climatic conditions observed at Punta Rasa, a 
December..| 48.5 | 75.3 | 12.8] 12.1 | 24.9 | 1.28 N.E. 10.3 little hamlet situated near the mouth of the Caloosa- 
: : i ne 
Spring...... 54.0] 71.9 | 43.1] 95.6 | 78.7 | 6.92 | E. 11.5 hatchee River, on the Gulf coast of eee oe ae 
Summer...) 27.0 | 7.7 | 57.3} 10.3 | 67.6 | 19.57 ea A hundred and seventy miles §.5.E. of Cedar Keys, a 
Winter n..| si0 | 4d | go2 | ss4 | ee | sae | Nan | 10-4 one hundred and twenty miles N. of Key West. As may 
ear ....--- 61.0! 74.9 '186.2 | 102.9 | 289.0 | 43:54 | NE. | 10.1 | be seen by carefully comparing the charts for these three 


bee 


99 


Punta Rasa, 
Purgatives. 


places, the winter climate at Punta Rasa is in character 
intermediate between that of Cedar Keys and that of 
Key West, except that, in respect to the humidity of its 
atmosphere, it is drier than either of the other places. 
The temperature of the sea-water at Punta Rasa is such 
as to admit of sea-bathing all the year round. As a win- 
ter health-resort, Punta Rasa appears to be as yet but little 
developed ; under proper management and with intelligent 
Sanitary supervision, it is likely to become a useful and 
favorite resort for such as require a very decidedly mild 
winter climate. (See article Florida, in vol. iii. of this 
HANDBOOK ; and also Dr. J. C. Wilson’s ‘‘ Remarks upon 
the Climate of Florida,” read. before the American Cli- 
matological Association in 1885, and published in the 
New York Medical Journal for December 19th of that 
year. ) Wik, 


PURGATIVES, OR CATHARTICS, are medicines 
which are used to produce alvine evacuations. Ac- 
cording to their activity and power, they are divided 
into laxatives and mild and drastic purgatives,. 

Purgatives which act very gently, producing soft, 
feculent stools without notable irritation, are called 
laxatives, This term is also applied to more powerful 
purgatives when they are given in small doses, so as to 
act mildly (see Laxatives, vol. iv., p. 458.) 

Purgatives which operate briskly, usually producing 
more or less fluid evacuations, sometimes with griping 
and tenesmus, but without serious irritation, are called 
mild or simple purgatives. To this group belong some of 
the salts of magnesium, sodium, and potassium, which, 
from their resemblance in chemical and physical proper- 
ties, and in-physiological action, are termed saline pur- 
gatives. 

The term drastic is applied to those purgatives which 
operate energetically, producing numerous evacuations, 
and, in excessive doses, more or less gastro-intestinal irri- 
tation. 

Purgatives which produce watery stools, especially 
the salines and some of the drastics, are called hydra- 
gogues, and those which cause the evacuation of large 
quantities of bile, cholagogues. 

Move or Acrion.—All purgatives accelerate the peri- 
staltic movements of the intestines. Radziejewsky care- 
fully observed the rapidity of peristalsis in dogs, both 
before and after the administration of purgatives. In 
the normal state the movements of the small intestine 
were rapid, those of the large intestine very slow. After 
the administration of purgatives, the movements of both 
became much accelerated, but most markedly those of 
the large intestine. 

It was assumed that purgatives especially the hydra- 
gogues, also induce a discharge of fluid from the intes- 
tinal mucous membrane. Experiments on animals at 
first seemed to show that this was an error. Thiry com- 
pletely separated a portion of the small intestine from 
the rest of the bowel, without dividing its vessels and 
nerves, sewed up one end, which was returned into the 
abdominal cavity, and attached the open end to the 
wound in the abdominal wall. Into the cul-de-sac thus 
formed he introduced croton-oil, senna, and Epsom salt. 
No accumulation of fluid took place. Schiff experi- 
mented in a similar manner with aloes, jalap, and sul- 
phate of sodium, and Radziejewsky with croton-oil and 
sulphate of magnesium, both with the same negative re- 
sult. Radziejewsky also analyzed the feces before and 
after the administration of purgatives. The evacuations 
produced by purgatives contained more water and sodium 
salts than normal fveces, and sometimes products of pan- 
creatic digestion, but never as much albumen as should 
have been present if transudation of fluid from the in- 
testinal blood-vessels had taken place. It was therefore 
concluded by these investigators, and is still maintained 
by some recent authors, that purgatives do not induce 
either transudation or increased secretion, and that the 
watery character of the stools results only from the greatly 
accelerated peristalsis, which interferes with the absorp- 
tion of the fluid normally secreted. 

But subsequent investigations yielded different results, 


100 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Moreau introduced sulphate of magnesium into a por: 
tion of intestine isolated by means of two ligatures, and 
after some hours found a decided accumulation of fluid. 
Brunton, experimenting in a similar manner, found that 
croton-oil, gamboge, elaterin, and Epsom salt caused a 
decided accumulation of fluid. That the accumulated 
fluid was not a transudation was evident from the fact 
that it contained very little albumen. Brieger injected 
into an isolated portion of intestine very small quantities 
of colocynth. No accumulation of fluid took place, but 
the bowel was contracted and slightly reddened. Larger 
quantities of colocynth, as well as croton-oil, caused an 
accumulation of bloody fluid, with decided inflammation 
of the mucous membrane. After injecting calomel, 
senna, rhubarb, aloes, and castor-oil, Brieger found the 
bowel empty and firmly contracted. Sulphate of mag- 
nesium in very dilute solution caused no accumulation 
of fluid, but concentrated solutions of this salt, so also 
Glauber salt, caused very decided accumulation. That 
the fluid was a secretion, and not a transudation, was 
evident from the fact that it readily converted starch into 
sugar and dissolved raw fibrin. 

Thus it has been found in experiments that sulphate 
of magnesium, sulphate of sodium, croton-oil, gamboge, 
colocynth, and elaterin, not only accelerate the peristaltic 
movements of the intestines, but also induce a secretion 
of watery fluid from the intestinal mucous membrane ; 
and that castor-oil, rhubarb, aloes, senna, calomel, and 
minute quantities of colocynth accelerate peristalsis, but 
do not notably increase secretion. 

Hess, in experiments on dogs, endeavored to determine 
the manner in which purgatives increase the peristaltic 
contractions. He made gastric fistule a short distance 
from the pylorus, so that he could easily introduce pur- 
gatives into the duodenum. After having determined 
the quantity of the purgative (sulphate of sodium, castor- 
oil, croton-oil, senna, colocynth, gamboge, and calomel) 
which would act briskly, he introduced into the. duo- 
denum a small, empty india-rubber balloon, to which 
was attached a long, fine india-rubber tube. After this 
had been carried by the normal peristaltic contractions a 
certain distance, which varied in the different experi- 
ments, he filled it with water to such a degree as to ob- 
struct the bowel. The purgatives which previously had 
acted briskly then completely failed. Hess therefore 
concluded that the peristaltic movements excited by 
purgatives are probably not propagated through long 
distances by means of nervous apparatus, or, according 
to Engelmann, from muscle to muscle, but that they are 
reflexly excited in each part of the intestine by direct 
stimulation of its mucous membrane. 

Miup Purearives.—Of the purgatives which act vig- 
orously, without causing severe irritation of the. intes- 
tines, the following are commonly employed: aloes, 
rhubarb, senna, castor-oil, salines, and mercurials. 

Aloes.—In large doses, from five to twenty grains, aloes 
produces semiliquid or liquid stools. The first evacua- 
tion rarely occurs before six hours, and often not before 
ten or twelve hours. Some griping usually precedes the 
evacuations, and they are often attended by a feeling of 
heat in the anus, and by straining, especially if the med- 
icine be repeatedly taken. From the slow action and 
the tenesmus, it is supposed that aloes influences the rec- 
tum more than other parts of the intestines. 

In experiments on rabbits, Kohn found that aloes 
caused moderate hyperemia of the stomach, intestines, 
and kidneys. In various animals large doses of aloin, 
injected into the subcutaneous tissue, were followed by 
gastritis, sometimes with hsmorrhage and ulceration, 
and in dogs and rabbits by degeneration of the epithe- 
lium of the kidneys.’ 

According to the experiments of Rutherford, aloes in- 
creases the secretion of bile, and renders it more watery. 
Various observers have found that it does not act when 
bile is absent from the intestines. 

Aloes was formerly employed in large doses to pro- 
duce brisk purgation, when acute disorder of any organ 
of the body supervened soon after the cessation of an 
habitual hemorrhoidal discharge. It was sometimes 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


given to produce a revulsive effect in cases of conges- 
tion of the brain, apoplexy, hemiplegia, and insanity. 
At the present time it is rarely used, except in small 
doses as a laxative. According to G. B. Wood, it some- 
times quickly cures jaundice when other remedies have 
failed. 

Aloes is contra-indicated in inflammatory affections 
of the intestines and kidneys, in irritable and bleeding 
piles, in uterine hemorrhage, and during menstruation. 

It is generally administered in pillular form, and the 
officinal pills of aloes are preferable to other prepara- 
tions. Each pill contains two grains of aloes. 

Rheum.—In doses of thirty to forty grains, taken at 
once, or ten to twenty grains, repeated several times at 
short intervals, rhubarb produces semiliquid stools in 
from five to ten hours, usually with griping, but without 
severe irritation. Some constipation generally follows. 
Recent experiments have confirmed the ancient opinion 
that rhubarb increases the secretion of bile. 

Rhubarb is a suitable purgative when the bowels re- 
quire thorough evacuation in patients who are occasion- 
ally subject to diarrhoea. Sometimes it is preferred to 
other purgatives in catarrhal jaundice. 

It may be given in the form of powder, fluid extract, 
tincture, or wine. Aromatics are generally associated 
with it to prevent its griping effect. . Pulv. rhei, 


Dij. ; pulv. aromatici, 5j. M. Div.inpulv. iv. Sig. : 
One powder every two hours. They may be conve- 
niently taken in syrup or molasses, or in wafers. The 


fluid extract is given in doses of fifteen to thirty min- 
ims, mixed with syrup and an aromatic water. BR. Extr. 
rhei fluid., 3 jss.; syr. zingiberis, %ss.; aq. cinnam., 
Z iss. M. Sig.: One tablespoonful every two hours 
till the bowels move. The tincture and wine are suit- 
able for feeble patients, especially if they are accus- 
tomed to alcoholic beverages, and may be given in doses 
of half an ounce, repeated, if necessary, at convenient 
intervals. 

Senna.—Senna operates gently and slowly in doses 
of fifteen to thirty grains, producing one or two pulta- 
ceous stools in from five to ten hours. Large doses act 
more briskly. Two or three drachms usually produce 
semifluid discharges in three or four hours. The evac- 
uations are preceded by pretty severe tormina, and some- 
times by nausea andeructations. Borborygmi and occa- 
sional small fluid stools often continue for from twelve 
to twenty-four hours. 

Though it acts vigorously, and produces quite liquid 
stools, containing about eighty-five per cent. of water, 
senna never causes severe irritation or inflammation of 
the intestines. It is supposed, however, that large doses 
may influence the uterus, and, given during pregnancy, 
induce hemorrhage and abortion. 

The watery character of senna stools is generally re- 
garded as evidence of increased intestinal secretion ; 
but in careful experiments Brieger found no accumula- 
tion of fluid in an isolated loop of intestine with which 
senna had been in contact some hours. That it greatly 
accelerates the peristaltic contractions of the small intes- 
tine appears from Radziejewsky’s experiments. This 
investigator found that in dogs, normally, from seven to 
nine discharges took place from a fistula in the ascend- 
ing colon in three or four hours after a feeding ; but 
when senna was administered the discharges began in 
ten or fifteen minutes, and numbered about thirty in 
four hours. 

Cathartic acid, the active principle of senna, in doses 
of two to five grains, produces thin stools with colicky 
pains in from three to fourteen hours. Two grains, in- 
jected into the subcutaneous tissue, were followed by 
copious evacuations in from eight to twelve hours. 

As senna acts rapidly and efficiently, it is suitable when 
the contents of the intestines require speedy removal. 
Combined with Epsom salt, asin the officinal compound 
infusion of senna, it is frequently employed in the early 
stage of inflammatory diseases, except those of the ali- 
mentary canal. It is better adapted than rhubarb and 
some other mild purgatives for patients disposed to cos- 
tiveness. 


Punta Rasa. 
Purgatives, 


Senna, in large doses, is contra-indicated in inflamma- 
tion of the intestines, hemorrhoids, menorrhagia, threat- 
ening abortion, and prolapse of the uterus or rectum. 

It is generally given in the form of the infusum senne 
compositum, which, in quantities of about two ounces, 
repeated several times at intervals of one or two hours, 
soon produces copious watery discharges. The fluid 
extract of senna may be given in doses of half a drachm 
to two drachms with syrup and an aromatic water. Rf. 
Extr. sennee fluid., % ss.; syr. zingiber., % ss.; aq. cinnam., 
Ziij. M. Sig.: A tablespoonful every hour until the 
bowels act. The syrup of senna is a convenient prepara- 
tion for children in doses of one to four drachms. 

Oleum Ricint.—Castor-oil, in doses of half an ounce to 
an ounce, usually produces semifluid evacuations in from 
three to six hours, generally with little or no griping or 
other symptoms indicating irritation of the intestines. 
Nausea and vomiting may occur in very susceptible 
persons, especially if the oil is rancid or the stomach 
disordered. 

From its efficient and speedy operation, castor-oil is 
well adapted to all cases requiring a thorough cleansing 
of the alimentary canal, as when the presence of poisons, 
undigested food, or products of decomposition in the 
intestines indicates the use of a brisk purgative. Its 
gentle, unirritating action renders it suitable when a 
purgative is required in inflammation of the intestines, 
inflamed hemorrhoids, fissure of the anus, metrorrhagia, 
and after parturition. For methods of disguising its 
taste, see vol. iv., p. 459. 

SALINE PurRGATIVES.—The following saline purga- 
tives are commonly employed: Sulphate of magnesium, 
sulphate of sodium, citrate of magnesium, tartrate of 
potassium and sodium, and bitartrate of potassium. 

Large doses of saline purgatives produce copious 
watery stools. This peculiar action was explained by 
chemists as resulting from osmosis, the dense saline solu- 
tions within the intestines causing the less dense fluid of 
the blood to pass through the walls of the blood-vessels. 
But the fact that large doses of salines, when given in 
very dilute solution, so as to be less dense than the fluid 
of the blood, act as efficiently and often more speedily 
than concentrated solutions proved that this theory was 
untenable. Subsequently it was shown, by Buchheim 
and others, that only salts of low diffusibility are efficient 
purgatives, and that this property impedes their absorp- 
tion in the intestines, causing them to pass nearly entire 
into the lower part of the large bowel and to excite 
purgation. 

For atime it was supposed that the accelerated peri- 
stalsis resulting from the presence of saline solutions was 
sufficient to explain their rapid and peculiar action. 
But the investigations of Moreau, Brunton, Brieger, 
Hay, and others, have conclusively shown that dense 
saline solutions produce an active secretion of watery 
fluid from the intestinal mucous membrane. Brieger 
and Hay found that very dilute solutions, although they 
may purge rapidly, do not cause an increase of secretion ; 
and Hay observed that when concentrated solutions are 
given, the quantity of fluid secreted depends upon the 
degree of concentration. Solutions containing less than 
five per cent. of a salt, produce little or no secretion, but 
stronger solutions always have this effect. Under ordi- 
nary circumstances, the amount of fluid secreted corre- 
sponds very nearly to the quantity required to form a five 
per cent. solution of the amount of salt administered. 
In consequence of the secretion of a large quantity of 
fluid, when concentrated saline solutions are given, the 
fluid of the blood becomes proportionately diminished. 
This continues only a short time, as the blood absorbs 
fluid from the tissues until it has nearly regained the 
quantity lost by increased secretion. 

Thus the mode of action of saline purgatives depends 
upon the quantity administered and the degree of dilu- 
tion. Very dilute solutions excite no intestinal secretion, 
but rapidly produce watery stools ; while concentrated 
solutions cause a decided increase of secretion, diminish 
the fluid of the blood, excite absorption of fluid from the 
tissues, and in a short time produce watery evacuations. 


101 


Purgatives. 
Purgatives. 


Saline purgatives are preferred to other mild cathar- 
tics to evacuate inspissated fecal masses. As a rule, 
they should be given in very dilute solution. In the 
early stage of inflammatory diseases, salines are often 
employed for the purpose of lowering temperature and 
blood-pressure, and thus diminishing the inflammation. 
They are of little use in such cases unless given in con- 
centrated solution, so as to excite a decided increase of 
the intestinal secretion. The utility of salines is most 
conspicuous in cases of ascites and general dropsy. Ad- 
ministered in very concentrated solution, they often in a 
short time produce a very notable effect, especially if the 
patient have entirely abstained from food and drink for 
some hours before taking the saline. 

Magnestt Sulphas.—Epsom salt is generally preferred 
to other saline purgatives. In doses of half an ounce to 
an ounce it usually produces watery stools in several 
hours, the first discharge sometimes taking place in one 
hour. This rapid action is rarely attended by severe 
griping. As it is readily soluble in water, it may be 
given in very concentrated solution, a method strongly 
recommended by Hay in cases of dropsy. It is fre- 
quently associated with senna, as in the compound infu- 
sion of senna. 

Its taste is somewhat improved and its activity in- 
creased by sulphuric acid. FB. Magnesii sulph., % j.; aq. 
destill., 3 ij.; acid. sulph. arom., 3 8s.; syrupi., 3 j. ; 
Sig.: One or two tablespoonfuls every hour. The bitter- 
ness of Epsom salt may be disguised by strong coffee 
and aromatics, especially cinnamon-water. Kk. Magn. 
sulph:, 3 j.; aq. scinnam.,,.;241j.;asyt. /aurant., 63.]. 720i: 
Sig.: A tablespoonful every hour. 

Sodii Sulphas.—Glauber salt has a still more repulsive 
taste than Epsom salt. It is therefore rarely employed 
when saline purgatives are indicated. According to re- 
cent researches, it causes a decided increase of the secre- 
tion of bile and renders it more watery. In all other 
respects its action closely resembles that of Epsom salt. 
The following substances have been employed to correct 
its disagreeable taste: Lemon-juice, aromatic sulphuric 
acid, carbonated water flavored with syrup, and extract 
or fluid extract of licorice. 

Sulphate of sodium is the principal constituent of 
Carlsbad water and of the Carlsbad salt of commerce. 
According to W. Jaworski (‘‘ Ueber Wirkung, therapeu- 
tischen Werth und Gebrauch des neuen Karlsbader 
Quellsalzes,” Wien, 1886), the natural Carlsbad Quwell- 
salz contains from 46 to 47.5 per cent. of sulphate of so- 
dium, from 33.5 to 86 per cent. of bicarbonate of so- 
dium, and from 16 to 17 per cent. of chloride of sodium. 

Carlsbad water has been found useful in catarrhal af- 
fections of the alimentary canal, habitual constipation, 
catarrhal jaundice, inspissation of bile and gall-stones, 
fatty liver, cirrhosis of the liver, and excessive obesity. 

According to Jaworski, the natural Carlsbad Quellsalz 
is most advantageously employed as follows: It should 
be taken in the morning, immediately after rising, in suf- 
ficient water to form a two per cent. solution. The dose 
of the salt may vary from five to fifteen grammes( 3 j.-iv.). 
As an occasional purgative the dose is ten grammes 
(3ijss.), which should be taken in cold water or soda- 
water. Used methodically in habitual constipation, the 
dose should not exceed ten grammes, and should gener- 
ally be less, and be taken in cold water. In catarrhal 
jaundice, from ten to fifteen grammes, dissolved in warm 
water (80° to 40° C.), should be taken daily for at least 
two weeks. 

Liquor Magnesii Citratis.—The solution of citrate of 
magnesium has an agreeable taste, and is therefore often 
preferred to other saline purgatives to unload the bowels 
in simple constipation. It is, however, less efficient than 
the sulphates of magnesium and sodium, sometimes oper- 
ating briskly, sometimes producing no purgative effect. 
Usually a whole bottle, containing twelve ounces, taken 
in several portions at short intervals, is required. In 
cases of dropsy and inflammatory diseases other saline 
purgatives are preferable. 

Potassii et Sodit Tartras.—In doses of half an ounce 
to an ounce, Rochelle salt usually produces liquid stools 


102 


REFERENCE HANDBOOK: OF THE ‘MEDICAL SCIENCES. 


in afew hours. As it has a less disagreeable taste than 
Epsom salt, generally agrees well with the stomach, and. 
acts gently, it is often employed when a mild purga- 
tive is indicated in the diseases of children, females, and 
delicate persons. It somewhat increases the secretion of 
bile. From two to four drachms, dissolved in sweetened 
water, may be taken at intervals of two hours till the 
bowels respond. 

Potassit Bitartras.—Large doses of cream of tartar, 
half an ounce to an ounce, are followed by watery 
stools, which are often preceded by flatulence and grip- 
ing. It is rarely used alone, but frequently in combina- 
tion with jalap. When given in large doses, it should 
be suspended in an aromatic water to prevent griping. 

MERCURIAL PuRGATIVES.—Of the preparations of 
mercury which produce catharsis, calomel and blue 
mass are frequently used. Metallic mercury is some- 
times employed in obstruction of the bowels. 

Hydrargyrt Chloridum Mite.—Calomel, in doses of 
from five to ten grains, usually acts in about six or eight 
hours, producing copious semiliquid, dark-brown or 
green evacuations. As arule, no marked incidental ef- 
fects are observed ; but sometimes, especially after the 
larger quantity, the evacuations are preceded by griping, 
nausea, and depression. Smaller doses, one to three 
grains, act slower and very gently. Accurate chemical 
analyses have discovered in calomel stools bile-pigments, 
leucine, tyrosine, peptones, sulphide of mercury, and 
unchanged calomel, but no scatol and indol. 

The presence of bile in the stools was formerly re- 
garded as a certain evidence of an increased secretion of 
bile. But in numerous careful experiments on dogs, and 
in some observations made on patients having accidental 
biliary fistule, it was found that purgative doses of cal- 
omel notably lessen the secretion of bile. To explain 
the presence of bile in the stools notwithstanding dimin- 
ished secretion, it was then assumed that calomel greatly 
increases the peristaltic contractions of the small intes- 
tine, especially of the duodenum, and thus hurries the 
bile already secreted downward so rapidly that reabsorp- 
tion cannot take place. The presence of leucine and ty- 
rosine in calomel stools rendered this view very plausi- 
ble. But the fact that some purgatives, which act more 
rapidly than calomel, and doubtless strongly accelerate 
the peristaltic contractions of all parts of the intestines, 
do not produce markedly bilious discharges seemed to 
show that this assumption was incorrect. 

The recent experiments of Wassilieff show conclusively 
that calomel produces bilious stools, by arresting decom- 
position in the intestines. He divided fresh ox-gall into 
three portions, each weighing two hundred grammes; 
to one portion were added three grammes of calomel, to 
another two grammes, and to the third none. They were 
kept in a warm room, and occasionally agitated. The 
portions containing calomel at once became green, and 
retained this color as long as the experiment was con- 
tinued, which was six days. They readily responded to 
Gmelin’s test for bile-pigment, and showed no trace of 
decomposition. The portion not containing calomel had 
become brownish-yellow in one day, did not exhibit the 
reaction of bile-pigment, and was soon putrid. Doubt- 
less calomel exerts the same antiseptic influence in the 
intestines. Under ordinary circumstances the bile-pig- 
ments, bilirubin and biliverdin, become converted into 
hydrobilirubin, and hence cannot be detected in the 
feces. Calomel prevents this decomposition, and by in- 
creasing peristalsis causes the unchanged bile-pigments 
to be evacuated. In the same manner it prevents fur- 
ther changes of leucine and tyrosine, and the formation 
of scatol and indol. 

Calomel is a very effectual purgative in the morbid 
state called biliousness—marked by a sallow complexion, 
yellowness of the white of the eyes, a bitter taste, defec- 
tive appetite, and sometimes nausea ; headache, mental 
dulness, and depression ; and sometimes by light-colored 
stools and sedimentary urine. By arresting decomposi- 
tion and removing bile and other substances before they 
can be absorbed, it thoroughly relieves both the intes- 
tines and liver. 


REFERENCE HANDBOOK OF: THE MEDICAL SCIENCES. 


In small doses calomel has been found useful in the 
gastro-enteritis of children. Its utility is probably due 
chiefly to its antiseptic action. 

Administered in doses of from five to seven grains, for 
one or two days, in the first week of typhoid fever, calomel 
somewhat lowers the febrile temperature and renders the 
disease milder. As other purgatives are less useful, it 
probably exerts a destructive influence upon the micro- 
organisms which cause the disease. 

As a rule, calomel is indicated as a purgative in all 
acute affections of the intestines resulting from fermen- 
tation and putrefaction. _ 

Together with jalap or rhubarb, it is sometimes admin- 
istered in the early stage of inflammatory disorders of the 
internal organs. Though not useless, it produces very 
much less effect on the quantity of fluid in the blood- 
vessels and on the blood-pressure than large doses of the 
saline purgatives. 

Calomel should not be used in habitual constipation. 

It is usually ordered in powder with sugar, or with 
jalap, rhubarb, or bicarbonate of sodium. kh. Hydrarg. 
chlor. mitis, gr. v.; sacch. albi, gr. x. M. Sig.: Take at 
once. #. Hydrarg. chlor. mitis, gr. iij.; pulv. jalape, 
gr. x. M. Sig.: Take at once in syrup or molasses, 


_. &. Hydrarg. chlor. mitis, gr. v.; sodii bicarbon., gr. xv. 


M. Sig.: Take in molasses or syrup. In all cases, if 
calomel have failed to act after eight or ten hours, a 
saline purgative or castor-oil should be given. 

Massa Hydrargyrt.—Blue mass is a somewhat uncer- 
tain purgative when given in doses of from five to ten 
grains. It is, therefore, usually combined with rhubarb, 
aloes, podophyllum, or compound extract of colocynth, 
or, if given alone, a dose of castor-oil, Rochelle salt, Ep- 
som salt, a senna draught, or a seidlitz powder, is ad- 
ministered after eight or ten hours. It is held to be effi- 
cient in biliousness, and is usually given in the evening. 

Hydrargyrum.—Metallic mercury in large doses quickly 
passes through the alimentary canal in consequence of 
its great weight. Probably the dragging and stretching 
of the mucous membrane, resulting from the presence of 
large quantities, excite very powerful peristaltic contrac- 
tions, which rapidly carry the metal through the intes- 
tines. 

Metallic mercury has been employed in intestinal ob- 
struction when all other ordinary means had failed to 
give relief. Bettelheim (Deutsches Archiv f. kl. Med., 
Bd. 82, p. 53) carefully studied seventy cases of obstruc- 
tion, reported during the last fifty years, in which mer- 
cury was used. In fifty-seven cases a cure resulted, that 
is, the obstruction was relieved either temporarily or per- 
manently. In no case did it cause rupture, inflammation, 
or gangrene of the bowel, while in some instances it 
saved life. Bettelheim therefore considers it proper to 
administer mercury in cases of obstruction due to feces, 
ascarides, and even to intussusception or torsion, if other 
ordinary means have failed to give relief. 

The dose of metallic mercury varies from one to ten 
ounces, 

Drastic Pureatives.—Of the cathartics which operate 
violently and produce serious irritation of the intestines, 
when given in excessive doses, only the following are 
commonly employed: Jalap, scammony, colocyuth, po- 
dophyllum, gamboge, croton-oil, and elaterin. 

Jalapa.—Jalap is the mildest drastic, and resembles 

senna in its action. In doses of fifteen to thirty grains it 
usually soon causes a feeling of discomfort in the epi- 
-gastrium, and sometimes nausea. After two or three 
hours tormina and several liquid stools occur. Smaller 
doses, five to ten grains, act gently, producing one or 
two pultaceous evacuations. In very excessive doses 
jalap causes vomiting and profuse rice-water discharges, 
with great depression. 

The resin of jalap, in doses of one to three grains, acts 
as a laxative, but in larger doses, from five to fifteen 
grains, produces watery stools in a few hours. 

According to recent investigations, jalap does not act 
well when bile is absent from the intestines. In experi- 
ments on dogs it was found to increase moderately the 
secretion of bile. 


Purgatives. 
Purgatives, 


On account of its rapid, safe, efficient, and hydragogue 
action, jalap is frequently employed when a_ brisk 
cathartic is indicated. In cases of acute constipation, 
and in inflammatory diseases, it is usually associated with 
calomel, and in ascites and anasarca with bitartrate of 
potassium, The officinal pulois jalape compositus, con- 
sisting of 35 parts of jalap and 65 parts of cream of tartar, 
is generally preferred to other hydragogues in dropsy,. 
In doses of half a drachm to one drachm, it usually pro- 
duces watery discharges in a few hours. 

The resin of jalap may be given in doses of from one to 
eight grains in powder or emulsion. Jk. Resin. jalape, 
pulv. acaciz, 44 gr. viij.; sacch. albi,3ss. M. Div. in 
part. equal. iv. Sig.: One powder every two hours till 
the bowels move. J. Resin. jalape, gr. viij.; pulv. 
acaciz, sacch. albi, 443 j.; aq. menth. pip., ij. M. Sig.: 
One tablespoonful every two hours. Sometimes resin of 
jalap is given in combination with calomel. J. Resin. 
jalape, hydrarg. chlor. mitis, 44 gr. iv.; sacch. albi, Dj. 
M. Div. in part. equal. iv. Sig.: One powder every 
two hours. 

Jalap is contra-indicated in inflammatory affections of 
the alimentary canal. 

Scammonium.—Scammony resembles jalap in action, 
but is less certain, sometimes producing little or no effect, 
at other times acting harshly, with griping and tenesmus. 
Usually it is followed by watery stools in a few hours, 
The presence of bile in the intestines is necessary for its 
action. It is rarely used except in combination with 
other purgatives, as in the officinal compound cathartic 
pills. The dose of scammony, to act briskly, is from 
ten to twenty grains, and of its resin, from five to ten 
grains. 

Colocynthis.—Large doses of colocynth produce nu- 
merous fluid evacuations, with griping and tenesmus. 
Excessive doses cause sanguinolent stools, great abdomi- 
nal pain, intense depression, and sometimes death. 

Small doses, one to three grains, act gently, producing 
loose stools without notable griping. But if frequently 
repeated, such doses soon cause tormina and tenesmus, 
and slimy stools. 

According to Brieger, small quantities of extract of 
colocynth, 0.02 gramme dissolved in 2.0 grammes of 
water, injected into isolated portions of intestine, produce 
slight hyperemia and peristaltic contraction, but no ac- 
cumulation of fluid. But larger quantities produce de- 
cided inflammation and an effusion of bloody fluid. 

In experiments on dogs Rutherford found colocynth 
to cause an increased flow of watery bile. 

On account of its harsh operation, colocynth is rarely 
employed alone to produce brisk purgation ; but in small 
doses, in combination with other laxatives, it is frequently 
given in habitual constipation. 

The dose of the extract of colocynth, as a laxative, is 
one-sixth to two-thirds of a grain, and of the compound 
extract, from one to five grains. The latter preparation 
is sometimes given in doses of five to fifteen grains, to 
purge briskly. Usually the extract of hyoscyamus, or 
the extract of belladonna, is combined with it, to prevent 
griping. FR. Extr. colocynth., gr. j.; aloes, gr. vj.; 
extr. hyoscyami, gr. vj. M. Ft. pil. vj. Sig.: One pill 
at bedtime. &. Extract. colocynth. comp., gr.: xij.; 
extr. bellad., gr. ij. M. Ft. pil. vj. Sig.: One pill at 
bedtime. 

Cambogia.—Gamboge is held to be still more irritant 
than colocynth. In experiments Rutherford found, after 
large doses, violent irritation of the duodenum and small 
intestine generally, with profuse catharsis, but no in- 
crease of the bile-flow. 

It is, perhaps, never given alone, but is sometimes 
added to other purgatives to increase their action, as in 
the compound cathartic pills. Very small doses, one- 
sixth to one-half grain, are. said to produce pultaceous 
stools without much griping. Generally doses of three 
to four grains cause some nausea and colicky pain, and 
several watery stools. Excessively large doses, one 
drachm, have caused fatal gastro-enteritis. 

Formerly gamboge was frequently employed in obsti- 
nate constipation, ascites, anasarca, paralysis, insanity, 


103 


Purgatives. 
Purpura. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


gout, and skin diseases. Generally it was given together 
with aloes, jalap, bitartrate of potassium, and calomel. 
R. Cambogie, gr. iv.; pulv. jalapea comp., 3ij. M. 
Div. in pulv. iv. Sig.: One powder every two hours till 
the bowels act, in cases of dropsy. 

Pilule Cathartice Composite.—The compound cathartic 
pills contain small quantities of aloes, scammony, colo- 
cynth, jalap, gamboge, and calomel. On account of 
their complex composition they are supposed to affect 
all parts of the intestines, and to increase the secretion 
of bile. One pill usually acts as a laxative, while three 
or four produce free purgation. They are suitable to 
acute constipation not complicated with inflammation 
of the intestines, but should not be employed in habitual 
constipation. 

Podophyllum.—This purgative, even in large doses, usu- 
ally acts slowly, from six to ten hours elapsing before 
the bowels move. Doses of ten grains rarely cause 
marked incidental effects, but twenty or thirty grains 
are usually followed by nausea, and sometimes vomiting 
and depression, and severe colicky pain. The evacua- 
tions sometimes have a dark color, from which it was 
assumed that they contain a large quantity of bile. In 
experiments on dogs Rutherford found that moderate 
doses of podophyllin cause an increased flow of bile. 

The resin of podophyllum, commonly called podophyl- 
lin, is used as a laxative. Doses of one-eighth to one- 
half grain usually produce a gentle movement in eight 
or ten hours. Large doses, from two to four grains, 
cause nausea, sometimes vomiting, severe griping, and 
numerous stools, which may be slimy and bloody and 
followed by intense depression. 

Podophyllin is not suitable in cases requiring brisk 
purgation. But in chronic constipation it is much used, 
because it continues to act for a long time without ne- 
cessitating an increase of dose. It is frequently em- 
ployed when symptoms are present which show that the 
secretion of bile is abnormal. Usually it is given in 
pillular form, with extract of hyoscyamus or extract of 
belladonna. &. Podophyliini, gr. ij.; extr. hyoscyami, 
gr. viij. M. Ft. pil. No. viij. Sig.: One pill at bedtime. 
It has also been given in solution as follows: RB. Podo- 
phyllini, gr. ij.; alcohol. dil., %ij.; tinct. zingiberis, 3 1j. 

Sig.: A teaspoonful in a wineglassful of water. 

Podophyllotoxin is said to act more regularly than the 
officinal resin. It has been given to adults in doses of 
one-sixth to one-fourth of a grain, and to children in 
doses of one-sixtieth to one-twelfth of a grain. Brun 
employed it in alcoholic solution as follows: RB. Podo- 
phyllotoxini, Gm. 0.05; spir. vini rectif., Gm. 7.5. M. 
Sig.: From five to fifteen drops in sweetened water. 

Oleum Tiglit.—Croton-oil is a very energetic drastic, a 
drop sometimes producing from five to fifteen watery 
evacuations. Often the first evacuation occurs in one or 
two hours. 

The susceptibility of different persons to its action 
varies, in some one drop acting intensely, in others pro- 
ducing only a few semiliquid stools. In rare instances 
purgation does not result from the dose mentioned, but 
there takes place general disorder, marked by palpitation 
of the heart, pain in the extremities, severe headache, 
giddiness, and prostration. 

Frequently the action of croton-oil is attended by symp- 
toms indicating irritation of the stomach and intestines 
—a sensation of heat in the epigastrium, more or less 
nausea, sometimes vomiting, borborygmi, colicky pain, 
and tenesmus. 

Excessive doses quickly induce vomiting and purging, 
and great prostration. Twenty drops have proved fatal. 

Croton-oil is used when a powerful purgative is indi- 
cated, and milder medicines have failed to act or cannot 
be administered. Sometimes this is the case in obstinate 
constipation, lead-colic, and diseases of the brain and 
spinal cord, When brisk purgation is necessary, and 
swallowing is very difficult, the oil is preferred to more 
bulky cathartics, a drop being mixed with a little sugar, 
or a little bread-crumb, and placed on the back of the 
tongue. 

The oil has been strongly recommended for the re- 


104 


moval of tape-worm—one drop mixed with one drachm 
of chloroform and one ounce of glycerine, to be given 
early in the morning. 

Croton-oil is usually given in pillular form. &. Ol. 
tiglii, gtt. j.; mice panis,q.s. M. Ft. pil: iv. Sig.: One 
pill every hour. It is said that the oil acts more gently 
when combined with compound extract of colocynth and 
extract of belladonna. §&. Ol. tiglii, gtt. j.; extract. col- 
ocynth. comp., gr. viij. ; extr. bellad., gr.j. M. Ft. pil. 
iv. Sig.: One pillevery two hours. Sometimes itis given 
mixed with sugar. k. Ol. tiglii, gtt. j.; sacch. lactis, 
3j. M. Div. in part. eq.iv. Sig. : One powder every 
hour. It may also be mixed with castor-oil, or made 
into an emulsion, as follows: R. Ol. tiglii, gtt. j-; pulv. 
acacie, 3.ij.; syr. amygdale, %ss.; aq. destill., % iijss. 
M. Ft. emuls. Sig. : One tablespoonful every hour. 

Hiaterinum.—Elaterin is the most powerful and dras- 
tic of all purgative: medicines. The twentieth of a 
grain, given to an adult, will generally produce watery 
stools in one or two hours. Sometimes this speedy ac- 
tion is not attended by marked incidental effects ; but 
often, especially if it is given alone, nausea, severe grip- 
ing, borborygmi, and some prostration are produced. 
Excessive doses may cause intense gastro-enteritis and 
fatal collapse. 

Elaterin is employed in ascites and anasarca, when 
gentler hydragogues have failed to act efficiently. Asa 
rule, it is given only every other day, and not continued 
longer than a week or ten days, lest it excite serious in- 
testinal inflammation. After an interval of a week its 
use, if necessary, may be resumed. It is contra-indicated 
in dropsies complicated with intestinal irritation, and 
must be used with extreme caution in very young, aged, 
and feeble patients. 

It may be ordered in solution, pill, or powder. #. 
Elaterini, gr. 4; alcohol., %s8s.; acidi nitrici, gtt. ij. M. 
Sig. : From twenty to forty drops in an aromatic water. 
BR. Elaterini, gr. +; extr. hyoscyami, gr. vj. M Ft. 
pil. vj. Sig.: One pill every hour till stools take place. 
BR. Elaterini, gr. +; sacch. albi, 3 j.; ol. menth. pip., 
gtt.ij. M. Div. in part. equal. vj. Sig. : One powder 
every hour until the bowels act. 

GENERAL InNDICATIONS.— Purgatives are used (1) to 
evacuate the intestines ; (2) to diminish hyperzemia of re- 
mote parts or organs; (8) to promote the absorption of 
exudations and transudations ; and (4) to eliminate nox- 
ious substances. 

1. All purgatives evacuate the contents of the intestines ; 
but when this is the sole indication for their use, only 
laxatives and mild purgatives should be given. In 
chronic or habitual constipation those laxatives are most 
suitable which act slowly, producing normal or nearly 
normal fecal evacuations, without losing their activity 
in small doses after frequent repetition, and without in- 
terfering with general nutrition. Experience has shown 
that aloes possesses these properties in the most eminent 
degree. Podophyllin, rhubarb, and compound extract 
of colocynth are also eligible. The saline laxatives are 
sometimes used in habitual constipation ; but as their 
prolonged use is followed by impairment of nutrition, 
they should not be given to feeble patients unless re- 
quired by other indications. 

In occasional or acute constipation any laxative or 
mild purgative may be employed. If hardened fecal 
masses are present in the intestines, the saline laxatives 
and castor-oil are most suitable. Sometimes all the mild 
purgatives fail to act in acute constipation, especially 
when the cause of the constipation is still present, as in 
lead-poisoning. Drastics are then appropriate, carefully 
used, and croton-oil is usually preferred. Metallic mer- 
cury has been successfully used after all ordinary purga- 
tives had proved ineffectual. 

To remove poisons and irritating substances from the 
intestines, those purgatives which act speedily and gently 
should be preferred, especially castor-oil and_salines. 
When irritation of the intestines results from decompo- 
sition or fermentation, calomel is the best purgative. 

2. To diminish hyperemia of remote parts or organs, 
purgatives which act rapidly and produce semiliquid or 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


watery discharges are required. Mild purgatives deplete 
indirectly by hastening the intestinal secretions and par- 
tially digested food downward so rapidly that absorp- 
tion is impeded. Saline purgatives, in strong solution, 
excite a copious secretion of watery fluid, and thus di- 
rectly deplete the blood. Drastics act in a threefold 
manner, accelerating peristalsis, increasing secretion, and 
exciting intestinal hyperemia. The choice of a purga- 
tive will, therefore, depend upon the intensity and dura- 
tion of the disease to be influenced, the organ affected, 
and the character of the general symptoms. In conges- 
tion of the liver, calomel, followed by a saline laxative, 
is the most suitable purgative. In congestion or inflam- 
mation of most organs, saline cathartics and compound 
‘infusion of senna are usually employed; but in very 
severe congestion or inflammation of very important or- 
gans—such as the brain and spinal cord—drastics are 
preferred, especially croton-oil. 

3. To promote absorption of exudations and transuda- 
tions, the hydragogues are most suitable. Generally the 
saline hydragogues, given so as to produce copious 
watery stools, soon cause rapid absorption. In cardiac 
dropsy they often diminish the dropsical swelling very 
notably in a few hours. Of the drastic hydragogues 
the compound powder of jalap and elaterin are the most 
useful. Generally the former is preferred on account of 
its mild action. But when it fails to act efficiently, or 
when an effusion of serum occurs rapidly, and in such 
large quantity as to produce extreme distress, such as 
alarming dyspneea in pleuritis, elaterin is usually given. 
Sometimes it so rapidly induces absorption of the effu- 
sion as to give decided relief in a few hours. 

4. To eliminate noxious substances, calomel, salines, 
and drastics are used. The utility of calomel in bilious- 
ness and congestion of the liver is in part due to the 
rapid removal of irritating and decomposing substances 
from the alimentary canal. Saline laxatives, especially 
sulphate of magnesium, are indicated in chronic lead- 
poisoning, to remove the poison from the intestines as 
fast as it is eliminated by the liver. They are also suit- 
able in cases of ureemia, especially if at the same time it 
is necessary to induce absorption. In uremic coma, 
croton-oil is sometimes preferred to milder purgatives. 

CONTRA-INDICATIONS.—AII purgatives are contra-indi- 
cated in peritonitis, intestinal hemorrhage, perforation 
of the bowels, strangulated hernia, and extreme debility. 

Brisk purgatives are generally inappropriate during 
pregnancy, especially if previous abortions have oc- 
curred, and during menstruation. They should not be 
used if there exist severe rectal lesions, or a tendency to 
looseness of the bowels. Even laxatives are contra-in- 
dicated in habitual constipation, until all other known 
means have failed to establish a normal habit of defeca- 
tion. Samuel Nickles. 


PURPURA. A disease of the skin characterized by 


the development of variously sized and shaped, smooth, 
reddish or purplish hemorrhagic patches, which may or 
may not be elevated above the surface, and which do not 
disappear under pressure. 

The affection may conveniently be considered under 
two heads, zdiopathic and symptomatic purpura. 

IpropaTuic PurPurRA is usually considered to include 
two varieties, P. simplex and P. hemorrhagica, although 
these divisions (like those of idiopathic and symptomatic) 
are arbitrary, and the two varieties may run into each 
_ other with intermediate cases. 

Purpura simplex is characterized by the appearance, in 
successive crops, of numerous petechial spots in the skin 
and visible mucous surfaces. These are usually attended 
with little or no constitutional disturbance. Occasion- 
ally, however, malaise, loss of appetite, and fatigue on 
exertion are experienced for some days before the cuta- 
neous lesions appear. ‘These generally make their appear- 
ance suddenly, often in the course of a night, at other 
times more gradually. 

The lesions are usually bright red in color at first, be- 
coming more purplish in hue later. They are sharply 
defined, roundish, ovalish, or irregular, sometimes circi- 


Purgatives. 
Purpura, 


nate in form, and vary from the size of a pin-point to that 
of a.pea or small coin. They usually occur in numbers 
and symmetrically, the lower limbs being a favorite seat, 
and in particular the flexor surface of the thigh. They 
may occur sparsely scattered over the whole body. Usu- 
ally there are no subjective symptoms connected with 
the appearance of purpura simplex ; occasionally there 
is a little itching on the first appearance of the spots, and 
they are not infrequently tender on pressure. 

Purpura simplex is more frequently observed in the 
old than in the young. It may last from a fortnight to 
several months, or even longer, the lesions coming out in 
successive crops. The affection occurs in the well-nour- 
aa and apparently healthy, as well as in the debili- 
tated. 

The immediate cause of purpura simplex is not infre- 
quently found in fatigue, exposure to damp and cold, 
moral shock, and occasionally malarial influences. The 
affection usually lasts a few weeks only, but may be 
prolonged for months, or even a year or more, by the ap- 
pearance of successive crops of eruption. 

Another form of idiopathic purpura is that known as 
purpura urticans. The eruption here shows itself first 
as a roundish papule, which gives place in a few hours 
to a purpuric macule, resembling in every respect the 
macule of P. simplex above described. Occasionally, 
however, a congestive or bright-red circle is seen sur- 
rounding the purpuric spot. The burning, itching, and 
tingling of ordinary urticaria are rarely present. On the 
other hand, there may be pains in the limbs, and, occa- 
sionally, articular swellings ; and localized oedema, some- 
times soft, at other times red and painful, is occasionally 
noticed about the joints or in the length of the limbs. 
The common seat of the lesions is upon the lower limbs. 
The eruption may be preceded or accompanied by slight 
general malaise, and occasionally some feverishness, It 
resembles closely in all other symptoms, course, etc., 
purpura simplex, excepting that it is frequently accom- 
panied by sick headache (migraine), dyspepsia, conges- 
tion about the head, difficulties of sight and hearing, 
hemorrhoids, and rheumatic pains. 

Purpura rheumatica, or peliosis rheumatica (zeAos, 
livid), is usually found occurring upon the lower limbs, 
about the tibio-tarsal articulations or the knees, and on the 
lower and inner aspect of the thighs. The eruption con- 
sists of petechiz, more rarely of true ecchymoses, and is 
commonly symmetrical, although it is sometimes seen 
limited to a knee or an elbow. Urticaria-like papules are 
not infrequently observed co-existent with the petechie. 

P. rheumatica may occur suddenly and without pro- 
dromes. Ordinarily, however, pricking, weight, and 
tension in the part to be affected precedes the appearance 
of the rash, which is accompanied by some rise of tem- 
perature, rarely above 101.3° F. 

The articular pains are usually experienced in the in- 
steps, the knees, and the carpal region. The effusion is 
slight, movement of theaffected jointsis painful, and press- 
ure near the ligaments gives rise at times to sharp pain. 

Cidema of the cellular tissue is often a marked feature 
of the disease. The skin becomes stretched, reddish, pits, 
and is painful on pressure. Sometimes the cedema is ex- 
treme and seems almost phlegmonous in character, with 
extensive ecchymoses. Soyer has given to this variety the 
name of febrile purpuric edema. 

Very exceptionally the rheumatic symptoms may be- 
come generalized, and even heart. complications may fol- 
low, but usually we have purpura complicated with 
slight rheumatism. An acute, febrile, general rheumatism 
with purpura as an accompaniment is very uncommon. 

Though purpura rheumatica is usually a comparatively 
slight malady, yet cases have been recorded .in which 
hemorrhage from the stomach and bowels, gangrene of 
the face, limbs, intestine, etc., have gravely complicated 
the attack. 

The duration of the attack of purpura rheumatica is 
brief, but the disease may be, and usually is, prolonged 
by successive attacks for weeks, and even months. It 
usually terminates in recovery, and relapses are rare. 

The affection is most apt to attack persons in whom a 


105 


Purpura. 
Purpura. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


rheumatic taint exists. Nervous exhaustion, privation, 
and exposure to cold are among the exciting causes. 

Couty and Henoch have described a variety of pur- 
pura to which they attribute a nervous origin. This 
form of purpura is characterized by three symptoms: 
1, a purpuric eruption; 2, gastro-intestinal disorder ; 
3, cutaneous oedema. 

The eruption is petechial and makes its appearance 
suddenly, often assuming the urticarial form and involv- 
ing by preference the limbs, particularly the lower limbs, 
the abdomen, the genitalia, and, exceptionally, the trunk 
and face. The extent of the lesions varies from one or 
two small spots to even sheets of eruption. The duration 
of the lesion is from four to six days. Successive at- 
tacks vary greatly in frequency and severity. 

The gastro-intestinal disturbances are chiefly bilious 
vomiting, and successive attacks of colic, accompanied 
by retraction or inflation of the abdomen, and not fol- 
lowed by stools. These attacks of colic usually last only 
an hour or so, but may continue one or two days. 

The cdema characteristic of this form of purpura 
may be peri- or intra-articular, and may occupy a greater 
or less portion of the limb. Sometimes the affected part 
is pale and painless, at other times it is red and painful. 
Occasionally gangrene supervenes. The various symp- 
toms may occur in regular order in successive attacks, or 
they may be intermingled. 

Under the name of myelopathic purpura Faisans. has 
described a similar form of the disease, the cause of 
which he has traced back, in a number of cases, to some 
nerve disturbance, as chronic affections of the cord, trans- 
verse myelitis, secondary spinal cancer, and tuberculosis. 
Faisans lays stress upon the frequently urticarial form of 
the eruption, on its symmetrical occurrence, and on the 
possibility of the distribution of the spots along the 
course of the sensory nerves, similar to that of herpes 
zoster. 

The arthralgia, in Faisans’ opinion, is a marked symp- 
tom, and is peculiar with respect to its multiplicity and 
extreme mobility. The ankle, knee, wrist, and elbow 
are most frequently attacked, but all the joints may be 
involved in turn. The eruption in Faisans’ cases usually 
was in close connection with the joint-trouble, being 
most marked in the neighborhood of the affected articu- 
lation. Hyperesthesia and anzesthesia were observed in 
connection with the purpura. There was rarely fever. 
While Conty regards the gastro-intestinal attacks as 
analogous to those of lead colic, Faisans looks upon them 
as resembling the pains of locomotor ataxia. The latter 
also regards this form of purpura as rather of a me- 
dullary than of a sympathetic nervous origin. Faisans 
says that the attacks may follow acute hyperemia of the 
posterior fasciculi of the cord, resulting in intense con- 
gestion of theskin, with trophic disturbance of the smaller 
_vessels facilitating their rupture. 

In this connection reference may be made to the inter- 
esting observations of Straus on tabetic ecchymoses. 
These ecchymoses appear in a certain number of ataxic 
patients, following severe attacks of fulgurating pains, 
and occur, like other forms of purpura, chiefly upon 
the limbs. The ecchymoses resemble contusions most 
closely, but are not painful upon pressure. They are 
irregularly circular in form, and vary from the size of a 
pea to that of a silver dollar. The number also varies from 
one to several upon each limb. Their extent seems to be 
dependent upon the severity of the previous attack of 
pain. 

The seat of these tabetic purpuras is of interest. They 
are, aS arule, situated on the member or part which has 
been the chief seat of pain, usually not directly over the 
affected point, but on the proximal side. Occasionally 
the other side of the body, corresponding to that attacked 
by the pain, is the seat of the eruption. According to 
Straus, the lesions do not seem to be arranged along the 
lines of distribution of the nerves. Charcot, however, 
takes a different view. 

As regards the frequency of tabetic purpura, Straus 
has observed it twice in twelve cases of locomotor ataxia. 

Under the name of purpura hemorrhagica has been 


106 


described a group of cases having the one point in com- 
mon, that the eruption on the skin has also been accom- 
panied by hemorrhages from the cavities of the body, 
but otherwise widely differing from each other in the symp- 
toms presented. Recent writers are inclined to separate 
these cases, and assign the greater part to scorbutus, and 
the rest to the other divisions of purpura which have 
been, or are to be, here described. 

The name of Werlhof, a German physician of the last 
century, having been given to this affection (morbus 
maculosus Werlhofii is the entire clumsy title), Laségue 
took the trouble to look up Werlhof’s original paper on 
the subject, in order to find out what that author had de- 
scribed. The affection described by Werlhof is charac- 
terized by the absence of fever, prodromal symptoms, or 
concomitant symptoms worthy of mention. The affec- 
tion begins by a more or less considerable hemorrhage, 
rarely profuse, usually from the gums, only occasionally 
from the nose. There is at this time no hematemesis 
or other visceral hemorrhage. In the course of from 
twenty-four to forty-eight hours after the first symptoms, 
the eruption, more or less confluent, has spread over the 
lower limbs first, and then in some cases over the arms 
and trunk. The face is never attacked. The spots are 
punctate, indolent, and do not blanch under the pressure 
of the finger. 

By the third day larger hemorrhagic patches and sug- 
gillations occur upon the lower limhs, in some cases ac- 
companied by ecchymoses on the mucous surface of the 
mouth. The hemorrhages or hemorrhagic exudations 
continue in variable quantity ; if they are severe, blood 
may be vomited or passed at stools. Weakness with 
slight fever, diminution of appetite, and possibly lassi- 
tude without actual pain in the limbs, are observed. 
When the affection has thus reached its height, rapid im- 
provement takes place, and by the end of from eight to 
fifteen days the patient is well, without having to pass 
through a stage of convalescence and without suffering 
from any sequele. 

From this summary of Werlhof’s views it can be seen 
that writers like Du Castel and Molliére are justified in 
attempting to do away with the terms ‘‘morbus macu- 
losus Werlhofii” and ‘‘ purpura hemorrhagica.” As 
Du Castel says, ‘‘It is not a species, it is a group—I 
should say a medley—where the most dissimilar forms of 
disease swear to find themselves in juataposition,” 

Purpura scorbutica shows itself first by marked con- 
stitutional symptoms. Increasing cachexia, extreme las- 
situde, heavy, dull pains throughout the body, with fa- 
tigue upon the least movement, are among the prodromal 
symptoms. The skin is dry, of a livid yellowish, earthy 
color. ‘The mucous surfaces are pale, and there is fre- 
quently slight bloating of the face. In severe cases vio- 
lent pains in the trunk and limbs, most intense about the 
knees and thorax, are experienced. The thoracic pain 


“sometimes even interferes with respiration, the thorax 


feels as if encircled by a band of steel. 

The first symptoms of purpura, which are apt to show 
themselves after eight days of prodromes, consist in the 
appearance of a sort of purpuric goose-flesh, haemorrhage 
taking place about the hair-follicles of the lower limbs. ° 
According to Laségue and Legroux, in their admirable 
report upon scurvy in Paris during the Franco-German 
war, the follicular petechis appear under the form of 
small roundish elevations of a deep violaceous-red color 
in robust patients, and of a bluish-lilac color in individuals 
much enfeebled by previous disease. The lesion is 
traversed by a hair, or rather a grayish point can be seen 
in its centre, made up of a little heap of dried epidermic 
scales under which a hair curls upon itself. On lifting 
this little epidermic mass with the point of a needle the 
imprisoned hair is released, and is then seen to be vitiated 
in its growth, thinned, twisted, and occasionally split at 
its extremity, or atrophied and deviating from its normal 
direction. 

This goose-fleshlike purpuric eruption is caused by a 
sub-epidermic hemorrhage about the hair-bulbs, and does 
not extend more than one or two millimetres beyond the 
hair which is its centre. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Purpura, 
Purpura. 


This form of purpura occurs by preference upon the 
external and anterior aspect of the leg, and next in fre- 
quency upon the same aspect of the thigh. It is also 
found upon the extensor surface of the forearm, rarely 
upon the trunk. Some single hairs of the eyebrows have 
been observed to be surrounded by the eruption. In the 
case of hairy men the eruption may at times be confluent. 
In women it is usually discrete. In the dirty and care- 
less it is more marked. 

The lesions appear suddenly and simultaneously ; they 
may last from one to two months and then disappear, 
leaving no trace, excepting that some hairs are apt to be 
distorted from pressure upon their roots. 

In mild cases of purpura scorbutica the petechial erup- 
tion may be the only pathognomonic sign. In many cases 
of scorbutic purpura, in fact in most of them, the mucous 
membrane also shows certain symptoms. At first, the 
congested gums show a blue venous band running along 
their free edge, of a millimetre or so in width, while ‘the 
swollen interdental processes look almost like currants. 
In severe forms of the disease the ecchymosed gums may 
be greatly tumefied, even rising up so as to conceal the 
teeth and prevent mastication, being covered with fungous 
growths and bleeding on the lightest touch. The teeth 
are loosened and fall out, the breath is fetid, and in 
strumous persons the sub-maxillary lymphatic glands may 
become inflamed. The maxillary bones may even be- 
come necrosed. Hemorrhagic effusions frequently take 
place into the mucous membrane of the mouth, partic- 
ularly about the hard palate and velum, in the form 
either of petechize or of large ecchymoses. Laségue and 
Legroux call attention to the important fact that the 
gingival changes are often wanting in scurvy, and are far 
from giving a highly characteristic symptom. Though 
this may be the case on land and in certain epidemics, 
yet among sailors the gums are often severely affected. 
Possibly the previous condition of the teeth may influ- 
ence this symptom. 

Ata later period in the course of purpura scorbutica 
more or less extensive and deep-seated ecchymoses, re- 
sembling precisely the effect of ordinary contusions, are 
commonly observed. These are usually found upon the 
lower limbs and on dependent portions of the body, as 
the instep, calf, and popliteal region. However, in per- 
sons who use the arms in working, these limbs, or the one 
of these most used, may be the chief seat of the lesions. 
Old scars are also frequently attacked. 

These ecchymoses correspond to hemorrhagic exuda- 
tions into the subcutaneous cellular tissue or the deep 
muscular masses. Sometimes they are large and ill-de- 
fined, more rarely they may be observed as sharply cir- 
cumscribed tumors. 

The larger ecchymoses may not, at first, give any sign 
of their presence by outward discoloration, but move- 
ments become painful and walking may be impossible. 
In the neighborhood of the effusion the skin is drawn, 
smooth, and hot to the touch. Pressure gives rise to severe 
pain. The muscular masses are peculiarly rigid, the limb 
sometimes looking as if distended by an injection of wax, 
which had penetrated into all the interstices. Cidema, 
hard and localized, may show itself, with diffuse limits ; 
but occasionally these are sharply defined, like the groove 


produced by the garter in a swollen limb. The points . 


most frequently affected are the muscular masses of the 
calves, the fatty areolar tissue about the tendo Achillis, 
the flexor tendons of the thigh, the popliteal space, and 
the posterior muscles of the thigh. 

These infiltrations make their appearance suddenly, in 
the course of a few hours, and may be accompanied by 
slight feverishness. Walking is almost impossible, the 
limbs seem benumbed. Spontaneous internal pain may be 
experienced if the hemorrhagic effusion occurs between 
a bony surface and the inextensible skin. idema also 
occurs at this stage of the disease, due to embarrassment 
of the circulation, and is to be distinguished from the 
cachectic cedema, the latter being increased whenever the 
patient puts foot to the ground. 

When resolution, always a slow process, sets in, the 
skin becomes brown, soft, tense, and shining, the epi- 


dermis looks as it does when an attack of eczema is pass: 
ing off, while the derma is hard, compact, woodeny, and 
almost incompressible. Movement gives rise to pain, the 
limbs are kept immovable, and the joints bathed in the 
infiltration become rigid. Sometimes there is a slight 
intra-articular effusion. As the effusion is absorbed the 
woodeny condition becomes more marked. When the 
patient first begins to walk, a fresh eruption of petechiz 
shows the embarrassment of the venous circulation. The 
color of the skin, after passing through various shades of 
blue, black, green, and yellow, takes on a bronze tint, 
which sometimes lasts a long time. 

dn connection with the purpuric eruption it may be 
noted that abrasions, scratches, etc., are apt to result in 
unhealthy ulcers. 

The urine in purpura scorbutica is scanty and high- 
colored, and yields a smaller amount of urea than normal. 
The albuminoids are increased, and extractive matters 
are also more abundant than normal, showing excessive 
molecular disintegration. 

In severe cases of purpura hemorrhagica, hemorrhage 
from the stomach and intestine, the bladder, the nose, 
the hemorrhoidal veins, etc., may occur. Gingival, nasal, 
intestinal, and uterine hemorrhages are most common. 
In the extreme forms of the disease the cachectic cedema 
spreads and becomes generalized—a very unfavorable 
symptom. Diarrhea succeeds constipation, serous or 
sero-sanguinolent effusion occurs in the larger articu- 
lations, in the visceral serous sacs, and under the de- 
tached periosteum. Scorbutic periostitis, necrosis of the 
maxille or tibiw, separation of the epiphyses, dislocation 
of the callus of old fractures, and sometimes mortal syn- 
cope, may supervene. Death results from a general 
breaking down at all points, the intellectual functions 
alone remaining intact until the last. 

Purpura scorbutica usually runs a rapid course. In 
favorable cases it may last only a week or a fortnight. 
Severe symptoms are not apt to supervene unless the 
affection has lasted for several months. Death may oc- 
cur in syncope, in an attack of dyspneea, or as a result of 
exhaustion from hemorrhage. Convalescence is always 
prolonged, and is accompanied by extreme weakness. 
Fever is usually absent, but may show itself in a slight 
degree after considerable hemorrhages. 

Laségue and Legroux consider two forms of scorbu- 
tus to exist: a sthenic, observed in robust persons, in 
which extensive hemorrhages may occur, and an as- 
thenic, occurring in enfeebled individuals, where there 
is less lability to hemorrhage but more tendency to 
cachexia. 

SYMPTOMATIC PuRPURA.—For the sake of convenience 
this division of purpura is made to include these cases in 
which the eruption is clearly a secondary symptom, oc- 
curring in the course of some well-marked disease, though 
it would be a difficult matter at times to draw the line 
between primary or idiopathic and secondary or symp- 
tomatic purpuras. 

Secondary purpura occurs in the course of advanced 
ecachexiz or of infectious diseases, or from toxic influ- 
ences. It may be simple or hemorrhagic in character. 

Cachectic purpura is observed in the course of diseases 
of slow evolution, as cancer, tuberculosis, diseases of the 
spleen, kidneys, ganglia, etc. It is not until the patient 
has arrived at an advanced stage of cachexia that the 
eruption appears. It runs its course without general 
malaise, without fever, and without pain. Its usual seat 
is upon the lower limbs, and sometimes upon the fore- 
arms, where it occurs in the form of small, slightly ele- 
vated spots, the centre of each usually being a hair- 
follicle. Ecchymoses of any considerable size are rare. 
The gums are not apparently affected. The purpuric 
eruption does not seem in any way to modify the course 
of the disease. In a few cases, particularly of acute 
tuberculosis, internal hemorrhage complicates the affec- 
tion, of course rendering the prognosis more grave. 

Senile purpura is a form of cutaneous hemorrhage 
which chiefly affects the upper extremities of elderly 
women whose arms are exposed to cold and to external 
injuries. It appears on the forearms in the form of spots 


107 


Purpura. 
Putrefaction. 


of varying size. Each spot lasts from seven to ten days, 
but the condition may persist for years. 

Infectious purpura shows itself in the course of severe 
pyrexiz or toxic conditions. It forms one of the series 
of symptoms in such affections as typhus, plague, yellow 
fever, and phosphorus-poisoning ; or it may show itself 
on rare occasions in the severer forms of variola, scarla- 
tina, measles, or cerebro-spinal meningitis. In the former 
class of cases the appearance of purpura does not materi- 
ally increase the gravity of the prognosis, but in the 
latter forms of disease it is a symptom of great gravity, 
and is not infrequently the precursor of a series of severe 


visceral hemorrhages (see Bulkley, Neumann, and other: 


authors on purpura variolosa). 

The cutaneous lesions are diffuse, and may occur on 
any or all parts of the body. They are a mixture of 
petechize and of extensive ecchymoses of a deep livid 
color, sub-conjunctival ecchymoses, hsmaturia, metror- 
rhagia, gastric and intestinal hemorrhages, hemoptysis, 
etc. The general condition is profoundly influenced ; 
high fever with anxious respiration supervenes, and the 
patient rapidly succumbs with symptoms of ataxo-ady- 
namia, or is carried off by excessive hemorrhages. 
The purpuric eruption is often preceded by the appear- 
ance of diffuse exanthemata, as the scarlatiniform or 
rubelliform rash of variola. 

Similar purpuric eruptions occur in connection with 
affections of the liver and spleen, such as icterus gravis 
and leucocytheemia. 

To this class of purpuras belong those caused by the 
ingestion of various medicines, as iodide of potassium, 
salicylic acid, etc., though these purpuras are of a very 
much milder type, resembling purpura simplex, and not 
being accompanied by visceral hemorrhages. 

Mechanical purpura is observed as a result of tension 
in the blood-vessels, suddenly brought about by such 
causes as severe attacks of coughing in whooping-cough, 
or the convulsions of epilepsy. The purpura in this 
case consists in punctate hemorrhages limited to the skin 
about the orbital cavity. It is rare to see generalized 
purpura in this variety ; such an occurrence signifies an 
attack of extreme severity, or a marked predisposition 
to cutaneous hemorrhages. Phlegmasia alba dolens, 
varicose veins, and certain forms of heart disease are apt 
to be accompanied at times by outbreaks of purpura. 
The significance of this form of the disease is trifling. 

Mention may be made under this head of cutaneous 
hemorrhages in hemophilia (see art., Blood) following 
contusions or resulting from flea-bites. These last are 
apt to be mistaken for purpura, and a long article which 
appeared some years ago, from the pen of a Dublin phy- 
sician, On a mysterious epidemic of purpura, was found 
to be based on a mistaken diagnosis in this respect. 

It will be observed that purpura is produced under a 
very great variety of circumstances, and thus the very 
numerous clinical observations of the various forms of 
the affection have tended to overwhelm the student with 
amass of facts which it is very difficult to arrange in any 
satisfactory system, or to approach from any common 
stand-point. The study of the pathology of the disease, 
however, throws light upon the subject, and must there- 
fore be considered with some attention. 

CHANGES IN THE BLOOD IN PurRPURA.—These have 
been studied by a number of observers within the last 
few years, but the results as yet have not thrown much 
light upon the part played by them in the production of 
the purpuric extravasation. A greater or less diminution 
in the number of red corpuscles and in the amount of 
solid matters has been observed, and also inconstant 
variations in the amount of fibrin. In hemorrhagic and 
infectious purpura the fibrin has been found to be di- 
minished in quantity, while in purpura simplex and pur- 
pura scorbutica it has been found in increased quantity. 
In addition, the white corpuscles are frequently increased 
in number, the red corpuscles are altered in form, and 
bacteria and embryonal elements are present. 

These facts are not of the first importance, nor do they 
explain the cause of the disease. It must, however, be 
remarked that an increase in the quantity of fibrin con- 


108 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


tained in the blood does not seem to prevent its escape 
from the vessels. 

LESIONS OF THE BLOOD-VESSELS IN PURPURA.—Fatty 
or amyloid degeneration of the capillaries has been ac- 
cused of inducing hemorrhages through fragility of the 
vascular walls, but positive observations on this subject 
are as yet too few in number to enable a positive state- 
ment to be made. The suggestions of atheroma of the 
capillaries, of thinning, softening, or porosity of the 
walls of the smaller vessels, of congenital or acquired 
fragility, are theories rather than the statement of ob- 
served facts. 

B. W. Richardson describes three varieties of purpura, 
the aqueous, the saline, and the vascular, but these di- 
visions are theoretical and are in some points contradicted 
by facts. For instance, chlorotic and hydreemic patients, 
whose blood is certainly watery to a typical degree, are 
not particularly liable to purpura. 

DISTURBANCES OF CIRCULATION IN PURPURA.—The 
study of the circulation itself in purpura should add to 
our knowledge of the pathology of the disease, but. this 
has not until recently been carried out in a satisfactory 
manner. From recent investigations by French observ- 
ers, it appears that congestion and stasis play an impor- 
tant part in the production of the purpuric lesion. Not 
only do the few microscopic examinations which have 
been made seem to prove this, but the fact that pur- 
pura is seen in connection with congestive rashes like 
those produced by medicines, the exanthemata, etc., 
seems to indicate the same thing. 

We may consider it as probable, then, that disturbance 
of the capillary circulation, and augmentation of the 
blood-tension, are the points of departure of the purpuric 
spot, and that we may look for the origin of heemor- 
rhagic symptoms rather in blood-stasis than in an ill-un- 
derstood condition of fluidity of the blood, or in a still 
less clearly understood vascular fragility. 

As to the question how these disturbances of the capil- 
lary circulation originate, it appears that in many cases 
they seem to arise from some vaso-motor disturbance of 
innervation. The congestive patches, the cedematous 
eruptions, precursors of the hemorrhagic spot in the nu- 
merously reported cases of exanthematic purpuras are in- 
dications of this perturbation. 

The observations of Bouchard, who ligated the aorta 
after division of the cervical sympathetic, with the result 
of producing ecchymoses of the pinna of the ear on the 
corresponding side, support the view just stated. Other 
experimenters have succeeded in producing ecchymoses 
through lesions of the cord, so that experimental as well 
as clinical proof (Faisans, Straus, and others) can be ad- 
duced in support of this theory of the pathology of pur- 
pura. 

DIAGNosIs OF PuRPURA.—The diagnosis of purpura 
rarely offers any difficulty. The essential lesion, an ex- 
travasation of blood into the skin, is different from the 
lesions of all other skin affections. Pressure of the fin- 
ger on the matured lesion fails to make it disappear, a 
condition which does not obtain in the papulo-macular 
syphiloderm or any other skin disease with which pur- 
pura is liable to be confounded. 

TREATMENT.—In the treatment of purpura, attention 
must first be paid to the removal of the cause, if this can 
be ascertained. Nutritious diet, and, above all, if the 
hemorrhage be extensive, rest in the horizontal position, 
are important. In purpura simplex, ergot, the prepara- 
tions of iron, quinine, the mineral acids, together with 
frictions and cold baths, are beneficial. Purpura heemor- 
rhagica calls for prompt and decided treatment. Perfect 
rest in the horizontal position, with the same medical 
treatment as in purpura simplex, is appropriate. Oleum 
erigeron in five- to ten-drop doses on sugar, every two to 
four hours, has been highly recommended. Magee Finny 
says that ergot and belladonna are to be given first, and 
bark, ammonia, and the mineral acids later. In severe 
cases the ergot may be given hypodermically (one grain 
of ergotine repeated in four hours was thus administered 
by Minich successfully). Electricity has been used by 
Shand where other remedies have failed. In ordinary 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


cases, tincture of the chloride of iron, in doses of twenty 
to thirty drops thrice daily, alone or with digitalis and 
ergot, may be given. Turpentine and the acetate of lead, 
with opium, may also be given. Externally, sponging 


with vinegar, solutions of tannin, alum, etc., are often | 


employed. Ice applied locally, and ice-water enemata 
when there is hemorrhage from the bowels, may be em- 
ployed with benefit. 

Proenosis.—The prognosis of a case of purpura will 
depend much upon its nature and variety. That of pur- 
pura simplex or purpura rheumatica, exanthematica, or 
scorbutica, is in almost all cases eventually good, though 
the termination of the disease may long be delayed by suc- 
cessive relapses. On the other hand, infectious purpura 
almost always ends fatally. The prognosis of cachectic 
purpura varies with the cachexia, whether this is due to 
organic disease, to a curable affection, or to bad hygienic 
conditions. Those forms of purpura which occur in the 
course of other diseases, as the result of nervous or me- 
chanical causes, are in most cases mere episodes in the his- 
tory of the affections which they accompany. The febrile 
condition, when this exists, is an important element in 
the prognosis of purpura, rendering it more grave. 


REFERENCES. 


Du Castel: Des diverses Espéces de Purpura. Paris, 1883.* 

Laségue: Etude rétrospective sur la Maladie de Werlhof, Archives Gén, 
de Méd.,, 6e sér., t, xxix., p. 586. 1877. 

Molliére : Nosographie du purpura heemorrhagica et des affect. pétéchi- 
ales, Annales de Derm. et de Syph., le sér., t. v., pp. 44, 104. 1873-74, 

Ib.: Etude clinique sur le Purpura, Annales de Derm, et de Syph., 2e 
sér., t. viii., pp. 232-824. 1887. 

Laget: Purpura simplex a forme exanthématique. 
1875 

Oriou: Des Lésions des Artéres dans le Purpura hemorrhagica rheuma- 
tismal. Thése de Paris, 1877. 

Soyer: De ’Gidéme pourpre fébrile. Thése de Paris, 1878. 

Couty : Sur une Espéce de Purpura d’Origine nerveuse, Gaz. Hebd. de 
Paris, 1876. 

Henoch: Ueber den Zusammenhang von Purpura und Intestinalstér- 
ungen, Berl, klin. Wochens., 1868, No. 50. 

Ib.: Purpura im kindlichen Alter, Berl. klin. Wochens., 1874, No. 51. 

Faisans: Purpura Myélopathique. Thése de Paris, 1882. 

Straus: Des Ecchymoses tabétiques a la suite de Douleurs fulgurantes, 
Arch. de Neurologie, 1881, No. 4, 

Laségue et Legroux: L’Epidémie de Scorbut dans les Prisons de la Seine 
et a ’ H6pital de la Pitie, Archives Gén. de Méd., 1871. 

Neumann: Aerztl. Bericht uber die in Staidte, Com., Spit., Zwischenb., 
etc. Wien, 1874. (Purpura Variolosa. ) 

Penzolt: Blutbefund bei der Werlhofschen Krankheit, Berl. klin. Woch- 
ens., 1878, No. 37. 

_ B.W. Richardson: Certain Morbid Types Comprised under the Name of 
Purpura Heemorrhagica, Lancet, 1874. 

Duhring: Purpura Rheumatica (two cases), Phila. Med. Times, iii., p. 
545, 1872-73. 

tepslaac at : Peliosis Rheumatica, St. Louis Med. and Surg. Jour., March, 
1872. 

Wigglesworth: Purpura Variolosa (Hemorrhagic Small-pox), Boston 
Med, and Surg. Jour., January 7, 1873. 

Sepp Peliosis Rheumatica, Archives of Dermatology, vol. i., p. 193, 
1874-75. 

Pooley : Purpura, Hemorrhage from the ear with, ib., p. 229. é 

Mundé: Purpura Rheumatica (case), Am. Jour. Obstetrics, August, 1874, 

Boisnot: Case of Purpura Heemorrhagica Requiring Transfusion, Phila. 
Med. Times, vol. v., p. 37, 1875. 

Minich: Purpura Hemorrhagica in a Child Successfully Treated by the 
Hypodermic Use of Ergotin, ib., p. 502. 

Stilwell: Purpura from Inhalation of Ammoniacal Vapors, and in Con- 
nection with Typhoid Fever, rb., vol. xi., p. 167, 1880. 

Wigglesworth: Purpura Foliowing a Minute Dose of Sulphate of Qui- 
nine, Bost. Med. and Surg. Reporter, December 20, 1883. 

Rohé: Purpura Variolosa (Heemorrhagic Small-pox), Phila. Med. News, 
July 1, 1882. 

Bulkley : Use of Ergot in the Treatment of Purpura, Practitioner, No- 
vember, 1836. 

Ib. : Purpura Variolosa, Case of Unrecognized Fatai Hemorrhagic Small- 
pox, N. Y. Med. Record, April, 1878. 

_ White : Case of Recurrent Cutaneous Hemorrhage, with Urticarial and 
Bullous Efflorescence, Boston Med. and Surg. Jour., October 10, 1878. 
Wetherill: Purpura (Case of Morbus Maculosus Werlhofii, Complicated 

by Menorrhagia), Phila, Med. Times, vol. xv., p. 427, 1884-85. 


Arthur Van Harlingen. 


Thése de Paris, 


PUTREFACTION. Animal and vegetable tissues and 
juices undergo certain changes after death, if kept under 
proper conditions of moisture and temperature. These 
changes, termed putrefaction, decay, or rotting, amount 
to a mechanical softening in the case of solid substances, 
a discoloration if the material be colored, and, chemically, 


* Particular acknowledgment is due to the author of this admirable ré- 
sumé of our present knowledge of purpura, upon whose work the above 
article is based. 


Purpura. 
Putrefaction. 


a splitting up of complex substances into simpler combi- 
nations, with the formation of ill-smelling products. Un- 
der the term fermentation changes of a similar character 
are also included, and the distinction between fermenta- 
tion and putrefaction is not always an absolute one. The 
former designation is used particularly when the result- 
ing products are of a useful nature, and besides, in the 
special case of transformation of sugar into alcohol under 
the influence of yeast. 

Decay is not due to a chemical instability of dead or- 
ganic substances, as was formerly supposed. It is the 
result of the growth of micro-organisms, especially bac- 
teria, in and upon the material, and if these be excluded 
putrefaction does not occur. In order to explain how 
this statement can be proven experimentally, it is neces- 
sary to premise that bacteria exist throughout the world 
wherever putrescible material occurs ; that these bacteria, 
on account of their ubiquity and: minute size, are carried 
by the atmosphere in the form of dust, and that they are 
hence found deposited on the surfaces of all objects in 
inhabited localities. Wherever material which can serve 
as food for these micro-organisms is exposed, they will 
hence gain entrance into it inevitably. In order to prove 
that organic material can be kept without rotting, if pro- , 
tected against the entrance of bacteria, it must be taken 
from the interior of plants or animal bodies. If glass 
tubes be freed from adhering living bacteria by heat, and 
then be thrust into succulent fruits or vegetables through 
a part of the surface which has been purified by the mo- 
mentary contact of a flame, the unaltered juices can be 
collected in such tubes and kept fresh for an infinite 
length of time (Van der Broeck, Roberts!). In a similar 
manner animal urine or blood can be gathered and kept 
unaltered permanently (Pasteur). The tissues of an ani- 
mal recently killed may be cut out and transferred into 
closed flasks previously heated, where they will remain 
fresh forever (Meissner,? Hauser’). These experiments, 
however, require the utmost precautions. All the instru- 
ments used must be previously heated, and contact with 
the skin of the animal and all foreign objects must be ab- 
solutely avoided. Even in that case success is not invari- 
able, because germs of putrefaction may be deposited 
from atmospheric dust. But with increasing skill of the 
investigator the percentage of successful experiments in- 
creases. Whenever putrefaction does occur in the case 
of any unsuccessful experiment of this kind, bacteria 
can be invariably seen with the aid of the microscope, 
while in those instances in which the material remains 
fresh no living micro-organisms can be found. The 
methods of examining, staining, and cultivating bacteria 
may be found described in the article, Micro-organisms. 

Equally demonstrative experiments can be made in a 
simpler manner by placing organic substances, without 
such special precautions, into clean vessels and subse- 
quently destroying all germs which may be present by 
vigorous boiling (Pasteur). As long as the vessels remain 
properly closed their contents will stay fresh and unalt- 
ered, but on allowing the atmospheric dust to enter them, 
or on inoculating them intentionally with a trace of pu- 
trid material, bacteria will at once begin to develop and 
putrefaction sets in. Pure air is not sufficient to start 
the putrefactive changes. The bottles may be plugged 
with cotton which allows the air to penetrate, but filters 
out the dust, or the air may be allowed to enter through 
narrow and tortuous tubes (Pasteur), in which the dust is 
deposited and caught, without producing any change in 
the contents. In order to perform such experiments suc- 
cessfully, however, it is necessary to know that all ter- 
restrial objects are covered with germs of which a single 
one is sufficient for the development of infinite numbers ; 
and that these germs can be destroyed with certainty only 
by a dry heat of at least 150° C. continued for at least 
three hours, or by steam of the temperature of 100° C., 
acting at least some three minutes (and in exceptional 
cases even a much longer time is required for steriliza- 
tion). These experiments, varied in every possible man- 
ner, have invariably proved successful in the hands of 
those investigators who fully appreciated the difficulties 
surrounding them; while their exactness and absolute 


109 


Putrefaction. 
Putrefaction. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


correctness were denied only by authors negligent in their 
precautions. Since the difficulty of excluding bacteria, 
or of destroying them after their entrance, has been fully 
recognized, all opposition to their importance has ceased. 
It can hence be stated as a well-proven dogma, that putre- 
faction consists in a chemical decomposition of organte sub- 
stances due to the life and activity of micro-organisms grow- 
ing upon them. A notable feature of these changes is the 
large amount of material decomposed by an apparently 
small mass of vegetable micro-organisms. 

The microscope, however, shows that the disproportion 
between the material decomposed and the agency decom- 
posing it, is not so great as it seems at first, since the 
minute size of the individual micro-organisms is fully 
compensated for by their enormous number. 

A clear distinction must be made between the processes 
of putrefaction and fermentation on the one hand, and, on 
the other, chemical changes produced in certain organic 
substances by the action of non-organized soluble chemi- 
cal ferments. 

Instances of the latter kind are the dissolution (and 
peptonization) of albuminoids by pepsine and trypsine, 
the transformatisn of starch into dextrine and sugars by 
animal or vegetable diastase, the splitting of neutral fats 
into free acids and glycerine by ferments of the gastric 
and pancreatic juices, and numerous kindred examples 
occurring in animals and plants. In all such instances 
the active agent is a complex soluble organic, but not liv- 
ing, substance termed a ferment, which is produced by 
the living animal or vegetable cells, and can be extracted 
from them by suitable means. While these chemical 
ferments can decompose an amount of material very 
large compared with their own mass, there is still a limit 
to the possible proportion between chemical ferment 
and decomposed material, while of living micro-organ- 
isms a single one will ultimately multiply sufficiently to 
attack any amount of putrescible material. The essential 
difference consists, therefore, in the power of increase of 
living ferments, which dissolved chemical ferments do 
not possess. Practically it is sometimes difficult, except 
by microscopic investigation, to distinguish between the 
two classes of processes, since both are similarly in- 
fluenced by about the same conditions of temperature, or 
by the addition of favorable or injurious chemicals. The 
formation of chemical ferments isnot limited to the cells 
of higher animals and plants, but occurs as well in the 
bodies of the lowest living forms. In some instances 
they are secreted also by living micro-organisms, like 
yeast-cells and different forms of bacteria, and are 
of advantage to them in their preliminary solution 
and digestion of the material which they decompose. 
However, but few of such instances are as yet known, 
and the assertions of some chemists, that all putrefactive 
changes can ultimately be traced to soluble ferments se- 
creted by the micro-organisms, are unfounded in their 
generality. In the light of our present knowledge, most 
of the instances of putrefactive and fermentative proces- 
ses must be regarded as occurring in the interior of the 
bodies of living micro-organisms. 

CONDITIONS OF PUTREFACTION.—The decomposition 
of putrescible material proceeds at the same rate as the 
growth and multiplication of the bacteria causing it, and 
is subject to all influences affecting the latter. Bacteria 
require a supply of nitrogen, carbon, and mineral salts as 
food, and unless the soil can furnish the necessary ele- 
ments they cannot grow. The nutritive substances may, 
however, exist ina very great dilution dissolved in water. 
Thus even distilled water will allow some forms of bac- 
teria to multiply in it. But there are vast differences 
between different forms of micro-organisms in their abil- 
ity to subsist on soils of greater or less complex chemical 
nature. Thus some varieties can extract their supply 
of nitrogen out of ammonia-salts, while others cannot 
dispense with albuminoids for food. Albuminoids, 
especially in the form of peptone, are, however, the best 
soil for all bacteria. 

Micro-organisms require for their growth a moist soil. 
Thoroughly dry material does not permit the develop- 
ment of bacteria and cannot be attacked by them. An 


110 


acid reaction of the soil is unfavorable to most bacteria. 
Even those varieties which produce acids by their own 
activity, like the lactic-acid bacilli and acetic-acid bac- 
teria, are sensitive to their products and cannot acidify 
their soil beyond a certain degree. Like all higher be- 
ings, bacteria produce substances as the result of their 
tissue-change, which, when they accumulate, are injuri- 
ous to them. In the case of the putrefaction of albumi- 
noids, indol, scatol, and phenol (carbolic acid), substances 
of distinctly antiseptic properties, are among the terminal 
products in an amount sufficient to check further bacte- 
rial activity. Hence the growth and decomposing ac- 
tivity of micro-organisms cease in many instances before 
the soil in which they grow is completely decomposed or 
fully exhausted as food. This self-limitation of bacterial 
activity does not, however, occur in all instances. 

The influence of atmospheric oxygen upon their life and 
activity has received most attention since Pasteur formu- 
lated his view in the striking statement, that ‘‘ fermenta- 
tion is life without oxygen.” ‘This generalization was 
founded upon his researches on alcoholic and butyric- 
acid fermentations, both of which can occur in the ab- 
sence of all free oxygen. He divided micro-organisms 
into aérobes, which require oxygen like all higher beings, 
and anaérobes, which can exist only where free oxygen is 
absent, and claimed that only the latter class can act as 
agents of fermentation and putrefaction. Unbiassed in- 
vestigations, however, by others (Hueppe,' Liborius ‘*) 
have shown that Pasteur’s generalization is altogether 
too dogmatic. There exist all gradations of suscepti- 
bility to oxygen among different bacteria. The life of 
some varieties depends upon the presence of free oxygen 
fully as much as is the case with higher beings, while at 
the other end of the scale are found bacteria which can 
grow only when free oxygen is entirely absent. But the 
majority of bacteria occupy an intermediate position, 
thriving best in the presence of oxygen, but able to con- 
tinue their life and activity without it. Pasteur’s state- 
ment that the fermentations proper can occur only in the 
absence of oxygen has not been confirmed by others. In 
the case of putrefaction of albuminoids it has been de- 
monstrated that, while it may occur when free oxygen is 
absolutely absent, it is then a much slower process than 
in the presence of oxygen (Jeanneret®), and perhaps 
qualitatively somewhat different (Rosenbach). 

Bacterial activity is greatest at a temperature varying 
from 32° to 40° C., according to the variety of bacteria. 
Cold retards it, and at between 5° and 10° C. it practically 
ceases. But extreme cold, as low as can be produced 
artificially, does not destroy bacteria effectually, only re- 
ducing them somewhat in numbers. On the other hand, 
a temperature of 56°, or at the most 60° C., maintained 
for at least twenty minutes, kills all bacteria during the 
period of growth with certainty. If in the dried state, 
however, they require a temperature of more than 100° 
C. for their destruction, while the more resistant spores 
of bacilli can be destroyed only by actual boiling or ex- 
posure to live steam during a period varying from three 
minutes to fully twenty minutes, in extreme instances. 
Dry heat, in order to be effectual in killing spores, must 
be maintained at 150° C. for at least three hours. A 
very reliable method, however, of destroying bacteria 
wherever resistant spores are present, is by means of dis- 
continuous heating. A temperature of 58° C., or more 
if applicable, will suffice to kill all developed and grow- 
ing bacteria, if maintained for a sufficient length of time 
in proportion to the quantity to be sterilized. The spores 
which escape uninjured will then begin to germinate, if 
the soil is kept at a favorable temperature, and in the 
germinating state they are readily destroyed by a second 
heating after the lapse of some hours, after which a 
chance may be given for the development of any spores 
yet dormant. A mild heating thus repeated from three 
to five times in the course of as many days can in this 
manner sterilize any material with certainty. 

Exposure to the rays of the sun is unfavorable to the 
growth of bacteria, and it has even been found that some 
forms may be killed by twelve hours’ insolation in mid- 
summer (Downes and Blunt, Duclaux *), These experi: 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Putrefaction., 
Putrefaction. 


ments, however, have not yet been varied sufficiently to 
do justice to the subject. 

It has further been learned that rapid motion and agi- 
tation of fluids is unfavorable to the growth of bacteria 
in them (Howarth, Reinke). 

Upon our knowledge of the conditions of putrefaction 
are based the various industrial means of preserving food. 
Drying the decomposable material is one of the oldest 
household means; for instance, in the case of fruits and 
thin slices of meat. In smoking meats we avail our- 
selves of the antiseptic properties of the creasote of the 
smoke ; while strong brines or vinegar used in preserving 
articles likewise render the soil unfavorable for the 
growth of bacteria. Sterilization by heat is made use of 
in canning meats and vegetables, and the very success of 
this procedure, carried out on such a vast commercial 
scale, is but a proof of the accuracy of our knowledge 
concerning the causes of putrefaction. 

_ A study of different putrefactive processes teaches that 
the kind of micro-organisms varies with the material and 
mode of decomposition observed. Each special form of 
decomposition is due to a specific form of bacteria. Thus 
the kinds which rot albuminoids are different from the 
kinds which sour milk or decompose urea, and most of 
the disease-germs so far studied are found to exert no 
decomposing influence at all upon the dead soil in which 
they are cultivated. But there exist, in all probability, 
a number of varieties which can decompose a given ma- 
terial, though the resulting products may vary quantita- 
tively and qualitatively according to the species causing 
the decomposition. Thus urea may be transformed into 
carbonate of ammonia by at least four different kinds of 
bacteria, and milk-sugar can be changed into lactic acid 
by two forms of bacilli, and several varieties of micro- 
cocci. Indeed, a form which produces a characteristic 
decomposition of any certain substances need not be 
chemically inert in relation to other substances. A satis- 
factory survey of the field is, however, only possible if 
we take the broad view that there exist numerous va- 
rieties of bacteria separate and distinct from each other, 
each with a given chemical energy peculiar to it. Wher- 
ever, therefore, decomposable material is exposed, the 
variety or varieties of bacteria which can develop in it 
by reason of their adaptation to the soil, or accidental 
introduction in overcrowding number, will determine the 
chemical course of the decomposition. From this point 
of view we will consider, as fully as is consistent with the 
plan of this work, the various kinds of putrefactive pro- 
cesses and the biology of the micro-organisms involved. 

DECOMPOSITION OF ALBUMINOIDS AND OTHER NITRO- 
GENOUS TissuE MarEerIAts.—Of all organic substances 
the complex nitrogenous materials which constitute the 
basis of the animal and vegetable tissue are the most 
readily attacked by putrefactive bacteria. When in the 
solid state, the albuminoids and related substances are 
gradually dissolved by the bacteria—probably by the aid 
of ferments analogous to the pancreatic ferment (try psine) 
secreted by the micro-organisms. This action is illus- 
trated by the liquefaction of gelatine and coagulated 
blood-serum around the colonies of many varieties of 
bacteria growing on such a culture-soil. The transfor- 
mation which then occurs resembles chemically the diges- 
tion of these substances in the alimentary canal, at least 
in the earlier stages of putrefaction. Soluble albuminoids 
are formed, and these in turn are changed into peptones. 
But as fast as any new product occurs it is further at- 
tacked, so that within the first twenty-four hours of ac- 
tive putrefaction a large variety of decomposition prod- 
ucts can be detected in variable proportion. As the 
process continues the amount of the more complex sub- 
stances diminishes, and those built on a simpler chemical 
type augment in proportion. As the principal products 
gradually formed, and in their turn further decomposed, 
may be mentioned soluble albuminoids, peptones, leu- 
cine, sometimes tyrosine, glycocoll, volatile fatty acids, 
viz., butyric and valerianic (with smaller amounts of 
acetic) acids, indol (and in traces also scatol and phenol), 
while the simplest ultimate derivatives are ammonia, 
sulphuretted hydrogen, and carbonic acid. The offen- 


sive smell of rotting material is due to the sulphuretted 
hydrogen, ammonia, indol, scatol, volatile fatty acids, 
and presumably traces of other derivatives not yet identi- 
fied. The chemistry of albuminoid putrefaction cannot 
be stated in any series of formule, since it varies qual- 
itatively, and still more so quantitatively, with the ma- 
terial attacked, the presence of impurities, the temper- 
ature, and probably also the species of bacteria involved. 
Besides the principal products enumerated, smaller quan- 
tities of many other compounds occur temporarily in the 
course of any putrefaction. Of special interest among 
them are a series of alkaloids, which have been termed 
plomaines. ‘They have recently been studied more thor- 
oughly by Brieger,* who has isolated over fifteen alka- 
loids from different putrid materials, some of which are 
intensely poisonous to animals, while others are indiffer- 
ent. These ptomaines exist only in small quantities and 
transiently, being destroyed as the putrefaction proceeds. 
It is probable that these alkaloids or ptomaines are not 
the only poisonous substances formed by putrefactive 
bacteria, since at different stages of putrefaction intensely 
poisonous action can be obtained from extracts of the 
material made with glycerine and other solvents. 

Numerous different forms of bacteria can be found in 
rotting material. The role played by each of the differ- 
ent micro-organisms in putrefaction has not yet been 
ascertained with certainty. There are probably several 
varieties of bacilli able to decompose albuminoids. A 
bacillus has been isolated from the human feces which 
in pure culture decomposes albumen, or any of its de- 
composition products, in the same order as in the usual 
form of putrefaction (Bienstock). This bacillus is char- 
acterized by the transition through different shapes of 
short and long cells and filaments, and the final forma- 
tion of terminal spores, giving it the appearance of a 
drumstick. This form is, perhaps, the most common 
one found in putrid material. Possibly this shape may 
pertain to several separate varieties of bacilli, since Hau- 
ser ® has obtained from rotting solutions three bacilli an- 
swering to this description, but differing from each other 
in the rapidity with which they attack albumen. Char- 
acteristic, also, of the forms studied by Hauser is their 
pleomorphism, the cycle of shapes through which they 
pass in pure culture being made up of elliptic cells, short 
rods, long rods, filaments, and in some cases screw-shaped 
spirilla. 

Several other micro-organisms have been identified by 
Rosenbach !° as the agents of albuminoid putrefaction. 
Three of them were bacilli, of which one is probably 
identical with the bacillus found in feces. A fourth 
form of microbe was an exceedingly small micrococcus. 
These bacteria, when tested in the absence of oxygen, 
were still capable of attacking albumen, only in a much 
slower and less complete manner than when oxygen was 
present. It is probable that micrococci and short forms 
of bacteria (the so-called bacterium termo), found mainly 
in the upper layer of decaying solutions, play a role in 
the oxidation of the various products formed. 

DECOMPOSITION OF UREA.—Whenever urine collects 
under favorable conditions of temperature it acquires 
in the course of some days an ammoniacal odor. This 
is due to the transformation of urea into bicarbonate of 
ammonia, by combining with two molecules of water. 
Although urea undergoes this change readily on boiling 
in alkaline solution, it will not decompose spontaneously, 
and urine caught in vessels free of germs retains its com- 
position unaltered. By means of pure cultures, on dry 
nutritive soil, four varieties of bacteria have been found 
which can produce the hydration of urea (Leube and 
Graser!!), Of these, one was a micrococeus forming 
chains, and three were different forms of short bacilli. 
Other bacteria, as far as they have been tested, did not 
exert such action upon urea. Indeed, urine when al- 
lowed to stand will invariably harbor different varieties 
of micro-organisms, but unless containing one of the. 
specific species of mécrococct or bacilli urew, it may be- 
come putrid without containing bicarbonate of ammonia. 

In consequence of disease of the bladder the urine 1s 
sométimes voided already in a state of ammoniacal de- 


111 


Putrefaction. 
Putrefaction. 


composition. In such instances bacteria are always 
found in it, which have been introduced into the bladder 
by means of impure catheters. But from ammoniacal 
urine a non-organized ferment has been isolated by means 
of precipitation with alcohol, which in aqueous solution 
will gradually transform urea into ammonia carbonate 
without the further presence of bacteria. Whether this 
chemical ferment is formed in the first instance by the 
micro-organisms is as yet an open question, though this 
is the most plausible view. It could not be obtained, 
however, by filtering out through porous clay cells the 
specific bacteria artificially added to normal urine. In 
the older books an acid fermentation of the freshly 
voided urine is described. According to later researches 
(Roehmann !”) this does not exist, except when the urine 
contains sugar or alcohol. 

DECOMPOSITION OF Mitk.—Milk can be obtained from 
the udder without the admission of micro-organisms, but 
only on exercising the utmost antiseptic precautions, 
and even in that case not every attempt is successful 
(Lister,!? Cheyne, Meissner’). In such successful in- 
stances it will remain sweet forever, provided all future 
access of micro-organism is prevented. Ordinarily, how- 
ever, milk sours very speedily, its milk-sugar becoming 
transformed into lactic acid. The curdling of the caseine, 
which occurs when milk sours, is due to the action of the 
lactic acid formed, which latter change is always the re- 
sult of bacterial action. The most common agent of the 
souring of milk isa very short bacillus, which under a low 
power of the microscope might be mistaken for an elon- 
gated micrococcus, there being usually two cells adherent 
to each other (Hueppe!*). This bacillus produces spores 
which require thorough boiling of the milk for at least 
thirty-five minutes before they can be destroyed with 
certainty. Milk-sugar (as well as other varieties of 
sugar) are split by it into lactic acid and carbonic acid. 
The lactic acid stops further bacterial action after ac- 
cumulating to the extent of about 0.8 per cent. In order 
to obtain lactic acid in quantity, it is therefore necessary 
to remove the acidity by means of carbonate of calcium. 
The bacillus just described can act only in the presence 
of oxygen. But another micro-organism, apparently 
identical with this one in shape, growth, and action, 
which has been found in the feces of nursing infants 
(Escherich !), does possess the ability to acidify milk- 
sugar even in the absence of oxygen. Possibly this may 
be but a physiological variety of the first-described bacil- 
lus. Another bacillus, not yet sufficiently described, which 
has been cultivated from the feeces of adults (Bienstock 8), 
decomposes milk-sugar into lactic acid and alcohol. Milk 
can also be soured by the various micrococci found in 
pus, as well as by the micro-organisms of erysipelas and 
pneumonia. 

Lactic acid is transformed into butyric acid by certain 
forms of very large bacilli. They cannot, however, at- 
tack the original milk-sugar unaided by the lactic-acid 
bacteria. Their spores are killed with some difficulty in 
milk, so that, when a number of samples are sterilized by 
boiling, it sometimes happens that the butyric-acid ba- 
cilli escape destruction. In such cases the milk curdles 
subsequently without souring, because these bacilli se- 
crete a ferment of similar action to rennet, which coagu- 
lates the caseine. The curdled caseine is later redis- 
solved by the same bacilli, and changed into peptone 
with the formation of some bitter product (Hueppe). 
The bacilli can transform lactic acid and lactates (as well 
as some other organic salts) into butyric-acid, with the 
liberation of small quantities of butyl alcohol (Fitz). 
The flavor of matured cheeses and milk beverages, like 
koumiss and kephir, is the result of their action. 

The butyric-acid bacilli have been separated into three 
varieties, distinct from each other, by cultivation on dry 
soil in a vacuum (Gruber !"), Of these varieties two are 
strictly anaérobic, and cannot act except in the absence 
of oxygen ; while the third form, though able to dispense 
with oxygen, thrives best when supplied with it. 

Cellulose can be dissolved and decomposed by a large 
bacillus found in the mud of swamps, and also by an 
undescribed micro-organism occurring in the intestines 


112 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


of cattle. It is split into carbonic acid and carburetted 
hydrogen (CH,), or, in alkaline solutions, into carbonic 
acid and free hydrogen. It is probable that the disap- 
pearance of the ingested cellulose in the digestive tract 
of herbivora is entirely the work of micro-organisms 
(Tappeiner !8). 

The turning rancid of fats, whereby they are partly 
decomposed into free fatty acid and glycerine—which 
latter undergoes further change into ill-smelling prod- 
ucts, yet insufficiently examined—is not the result of 
bacterial action. Although this process resembles putre- 


faction in the conditions by which it is influenced, no 


characteristic bacteria could be recognized by the micro- 
scope or culture methods in some unpublished experi- 
ments made by the writer with Mr. Hoskins. It was 
likewise found impossible to hasten the rancidity of fresh 
fats by infection with rancid samples. Duclaux!* has 
since arrived at similar results, and has referred this 
change to oxidation. 

The alcoholic fermentation is ordinarily produced by 
yeast-cells, although some bacteria have been found 
which can likewise form alcohol (Bienstock®, Fitz). - 
Whenever this fermentation occurs at a high tempera- 
ture, as in the distilleries, it is complicated by the pres- 
ence of different forms of bacteria—lactic- and butyric- 
acid bacilli and others—which interfere with the work 
of the yeast quantitatively, besides producing products 
of their own which give an unpleasant flavor to the 
spirits. In observations made in a distillery by the 
writer, with the late Mr. Woltmann, it was found feasi- 
ble to increase the yield of alcohol and improve the flavor 
of the product by employing pure cultures of yeast, and 
excluding bacteria as far as possible. 

The acetic acid fermentation of alcohol is due to a 
micro-organism growing in the form of chains, which 
has not been studied morphologically to a sufficient ex- 
tent, and of which it is uncertain whether it isa large 
micrococcus or a short bacillus. It oxidizes the alcohol 
into vinegar, and hence requires free access of oxygen 
for its action (Pasteur). 

Hygienic Aspects of Putrefaction.—Medical interest is 
deeply concerned in all putrefactive processes, in relation 
both to the biology of the micro-organisms and to the 
chemical or poisonous properties of their products. Some 
of our articles of diet are consumed in a state of partial 
decomposition. For instance, most cheeses have passed 
through a lactic- and butyric-acid fermentation, while in 
some favorite brands actual putrefaction has occurred, as 
the smell plainly indicates. The gamy flavor, or ‘“‘ haut 
gott”’ of meat, demanded by epicures, proves its com- 
mencing decomposition, while in many other instances it 
is placed on the table strongly tainted in the warm sea- 
son, not intentionally, but from want of care in its pres- 
ervation. But no harm results ordinarily from the use 
of such articles. Instances, however, do occur where 
families, or even communities, are poisoned by the con- 
sumption of cheese or meats, especially fish and sausages. 
The symptoms are those of intestinal irritation, vomit- 
ing, nausea, diarrhcea ; furthermore, prostration and gen- 
erally marked dryness of the throat. It is yet an open 
question whether the articles causing such wholesale poi- 
soning must be eaten while in a particular stage of putre- 
faction, or whether their decomposition in such cases is 
due to some specific form of bacteria different from the 
ordinary agents of putrefaction, and capable of forming 
poisonous products peculiar to themselves. 

The latter view is the more probable one, since in such 
instances of poisoning the food does not generally indi- 
cate decomposition by its smell and appearance. The 
rapid onset of the poisoning, and its short duration in 
cases of recovery, suggest that it can only be the effect of 
a chemical poison, and not an infection due to the en- 
trance of bacteria into the system, at least in most of the 
instances reported. Inacase of sausage-poisoning Ehren- 
berg *° found the usual decomposition derivatives of al- 
bumen, including some of the less poisonous ptomaines, 
but still he could not detect the special poison to which 
the observed effects were to be attributed. Heisolated a 
bacillus from the sausage, capable of decomposing albu- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Putrefaction. 
Putrefaction, 


men, but our information is not precise enough to say 
whether this was one of the common forms of putrefac- 
tive bacteria or not. In an instance of poisoning from 
dried beef (in Momence, IJ].) the writer found in differ- 
ent samples of the meat, alternately, a micrococcus and a 
short bacillus present in large numbers, which differed 
morphologically from the organisms found in ordinary 
putrid material. The meat did not appear tainted. From 
cheese which had poisoned a large number of persons, 
and later on, also, from poisonous ice-cream, Vaughan”! 
has isolated a substance which he terms tyrotoxicon, 
and which possesses the characteristic poisonous action 
as tested upon man. He is inclined to consider this sub- 
stance identical with diazobenzol. 

On considering the hygienic relation of putrefaction, it 
must not be forgotten that this process occurs normally 
in the intestines below the stomach. In the mouth of 
all individuals there exist a very large number of micro- 
organisms, many of which are capable of causing pu- 
trefactive and fermentative changes in food (Miller ’). 
While the conditions in the mouth permit them to mul- 
tiply to some extent, they find no material to attack 
except in hollow teeth, or between the teeth and reced- 
ing gums, and in such cases their action reveals itself in 
the tainted breath. It can hardly be expected that these 
parasites are always harmless, although we do not yet 
know fully their etiological significance. 

The hydrochloric acid of the gastric juice has suffi- 
cient antiseptic power to kill all developed bacteria, if 
present to the extent of over 0.16 per cent., but it cannot 
injure spores. Hydrochloric acid, however, does not oc- 
cur in an empty stomach, is not secreted within the 
first few minutes of digestion, and does not reach the 
necessary limit of 0.16 per cent. until about half an 
hour after meals, so that there is plenty of opportunity 
for bacteria to pass through the stomach alive. More- 
over, particles of food shelter them somewhat even dur- 
ing digestion (Miller). Below the point of entrance of 
the bile and pancreatic juice into the duodenum, bacteria 
find the suitable alkaline or, at least, very faintly acid 
reaction, and here their work begins. Chemically, their 
activity reveals itself in the production of substances 
which cannot be formed by the action of the digestive 
ferments in the absence of bacteria—like indol, scatol, 
phenol, sulphuretted hydrogen, and the volatile fatty 
acids. Normal human feces consist microscopically of 
scarcely anything but bacteria, except when a vegeta- 
ble diet adds its undissolved residue. It is not known 
whether the normal intestinal bacteria are of any real ser- 
vice in digestion, but their invariable presence indicates 
that they are harmless to the individual under ordinary 
circumstances. But whether poisonous decomposition- 
products may not be formed and absorbed under some 
conditions—in intestinal obstruction—is an open ques- 
tion. It has been found that among the human intes- 
tinal parasites there occur some forms (Bienstock, Brie- 
ger *’) pathogenic to small rodents. 

The occurrence of putrefactive processes in surgical 
practice was the first incentive to Lister in his earliest 
attempts at antiseptic surgery. At that time (1867) it 
had not yet been proved that the traumatic infectious 
diseases were due to parasites, but it was evident in sur- 
gical practice that the decomposition of pus and other 
secretions exerted an injurious influence upon wounds. 
It has since been demonstrated, step by step, by the in- 
jection of putrid material into the bodies of animals, by 
Weber, Billroth, Panum, and others, by the bacteriological 
examination of Rosenbach on patients, and especially 
by the magnificent results of improved antiseptic sur- 
gery, that the systemic complications of wounds, rang- 
ing from the milder forms of traumatic fever to fatal sep- 
ticeemic blood-poisoning, are the result of the absorption 
of decomposition-products of bacteria. A broad distinc- 
tion must be recognized between actual surgical infec- 
tion, where parasitic micro-organisms are growing in the 
tissues—as, for instance, in erysipelas and pyzemia (metas- 
tatic abscesses)—and putrid poisoning, in which the bac- 
teria exist only outside of the tissues, in the fluids or 
necrotic parts of the wound, from which regions their 


VoL. VI.—8 


chemical products are absorbed. The bacteria which 
can, in the latter case, poison the system may be the com- 
mon forms of putrefaction, which do not possess the 
power of penetrating into the tissues. Quite often, ab- 
scesses with foul-smelling contents harbor putrefactive 
bacilli, together with the specific micrococci causing the 
suppuration. It is evident that those instances of septi- 
cemia in which the cause is outside of the body offer 
an entirely different prognosis from actual infections, in 
which the surgeon’s knife and antiseptic drugs cannot 
follow the bacteria into the tissues. 

Rotting material accumulating around dwellings, the 
refuse of the kitchen, and the contents of cesspools have 
always been regarded with anxiety by sanitarians. It is 
doubtful, however, whether any poisonous products ex- 
isting there can in any way affect us. The foul gases 
—ammonia and sulphuretted hydrogen—though known 
to be poisonous, are not generated in sufficient amounts 
under ordinary circumstances to cause acute poisoning, 
while chronic poisoning from these gases has not yet been 
observed or, at least, recognized. The more serious aspect 
of such collecting filth is the possibility of its harbor- 
ing pathogenic bacteria, for the organic material which 
forms a nutritive soil for putrefactive bacteria may also 
serve as food for occasional parasitic and pathogenic 
forms which find their way into it. It is probable that 
in this way, and only thus, filth plays a réle in the spread 
of some infectious diseases—for instance, typhoid fever 
and cholera. 

Putrefactive processes.play a réle in the household of 
nature, and particularly in relation to agriculture, the 
magnitude of which has only been suspected lately. 
The surface soil, wherever it contains organic remnants 
and is suitably moist and warm, teems with bacterial 
life. Over half a million of germs (in an extreme case 
up to forty-five millions) have been found in a gramme of 
different soils. At a distance of several feet from the 
surface the vegetation of micro-organisms ceases ordi- 
narily (Koch), though in some instances of contaminated 
soils they have been found as low as eighteen feet below 
ground (Beumer*‘), As far asthe bacteria penetrate into 
the soil, they alter its chemical composition continuously 
during the warm season. 

Two classes of processes occur in the ground : on the 
one hand, the ordinary putrefaction of organic remnants, 
resulting in their decomposition, and, on the other hand, 
a slow oxidation of organic substances. The latter 
change can be measured by means of the carbonic acid 
evolved (Wollny **). A study of the conditions influenc- 
ing this oxidation shows it to be due to bacterial action, 
although the forms causing it have not been identified. 
This oxidizing process plays undoubtedly a considerable 
role in the removal of organic remnants from the surface 
of the earth, since none of the characteristic smells of 
putrefaction is noticeable in fields and forests, at least 
outside of marshy parts, although the residue of the last 
season’s vegetation disappears annually. It is not exag- 
gerating the importance of these processes to assert that 
it is only through their instrumentality that plant life is 
possible on the surface of the earth ; for higher plants 
are not able to assimilate nitrogen from the soil except it 
be present in the form of very simple compounds—am- 
moniacal salts and nitrates. It is only through the 
activity of the bacteria that the residue of previous 
vegetation or of animal bodies can serve as food for sub- 
sequent vegetation. 

HistoricAL BrpurioGRAPHY.—Putrefaction was a fa- 
vorite theme with the older medical and chemical writ- 
ers, but was discussed by them only in a speculative 
manner. In 1837 it was first shown, by Schwann, that 
putrefaction and fermentation were due to the action of 
micro-organisms, and this view was later on confirmed 
by Schroeder and Dusch. To Pasteur’s ingenuity, how- 
ever, we owe most of our positive knowledge concerning 
the actual conditions of these processes, and this brilliant 
investigator has shown a rare perseverance in his studies 
of that subject. Passing from alcoholic fermentation to 
putrefaction, he took up in turn lactic- and butyric-acid 
fermentation, and the various changes which caused the 


113 


Putrefaction. 
Pylorus. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


spoiling of wine and beer. His results, published in the 
Annales de Chimie et Physique, 1860 and 1862, and 
also in various proceedings of the French Academy of 
Sciences (Comptes Rendus), are collected to some extent 
in his separate work, ‘‘ Etude sur la Biére,” 1876 (English 
edition by Faulkner & Robb, ‘‘ Studies on Fermenta- 
tion,” 1879). The history of the earlier studies on putre- 
faction can be found in Watson Cheyne’s ‘‘ Antiseptic 
Surgery,” 1882, and in Gradle’s ‘‘ Bacteria, and Germ 
Theory of Disease,” 1888. 

Further studies in the biology of putrefactive bacteria 
have been published by Bienstock® and Hauser.’ But 
we still lack any complete classification of the different 
forms of micro-organisms concerned in these processes. 
The decomposition of milk has been thoroughly investi- 
gated by Hueppe."* The chemical side of putrefaction 
has been most advanced by the labors of Nencki (“‘ Ueber 
die Zersetzungen d. Gelatine u. d. Eiweiss bei der Faul- 
niss mit Pancreas,” Bern, 1876), while the most painstak- 
ing work has been bestowed by Brieger’ on the separa- 
tion and identification of the alkaloidal ptomaines. 

The sanitary, and especially the pathological, aspects of 
putrefaction have been fully discussed, up to 1879, by 
Hiller, in his ‘‘ Lehre von der Faulniss.” The most com- 
plete compilation of the bacteriological side of the sub- 
ject can be found in Fluegge’s ‘‘ Fermente und Micro- 
parasiten ” (‘‘Ziemssen’s Handbuch der Hygiene,” 1st 
ed., 1888, and 2d ed., 1887). HA. Gradle. 


1 Roberts: Philosophical Transactions, 1874. 

2 Meissner: Reported by Rosenbach, Zeitschrift f. Chirurgie, vol. xiii., 
p. 344. 3 Hauser: Arch. f. exp. Path. u. Pharmac., vol. xx., p. 162. 

4 Tiiborius: Zeitschrift f. Hygiene, vol. i., p. 115. 

5 Jeanneret: Journal f. pract. Chemie, vol. xv., p. 353. 

6 Duclaux : Comptes Rendus de l’Acad. des Sciences, vols, c. and ci. 

7 Brieger : Ueber Ptomaine. Berlin, 1885 and 1886 (3 parts). 

8 Bienstock: Bacterien d. Feeces, Fortschritte der Medicin, October 1, 
1883 ; and Zeitschrift f. klin. Medicin, viii., p. 6. 

9 Hauser: Ueber Fiiulniss bacterien und deren Beziehungen z. Septi- 
ceemia, 1885. 

10 Rosenbach ; Micro-organismen bei den Wundinfectionskrankheiten 
d. Menschen, 1884. 

11 Lenbe and Graser: Virchow’s Archiv f. path. Anat., vol. c., p. 540. 

12 Roehmann: Zeitschrift f. phys. Chemie, vol v., p. 94. 

13 Lister: Transactions of the Path. Society of London, 1878. 

14 Hueppe: Zersetzungen der Milch, Mittheilungen, a. d. k. Gesund- 
heitsamt, vol. ii., 1884; and Deutsche medicinische Wochenschrift, 1884, 
No. 48, etc. 

15 Escherich: Darmbacterien d. Saeuglinge, Fortschritte d. Medicin, 
17 and 18, 1835. 

16 Fitz: Berichte d. deutschen chemischen Gesellschaft, 1873, 1878, 
1879, 1880, 1882, and 1883. 

17 Gruber: Centralblatt f. Bacteriologie, vol. i., No. 12, p. 87. 

18 Tappeiner: Berichte d. chemischen Gesellschaft, vol. xv., p. 999, 
and vol. xvi., p. 1734. 19 Duclaux : Comptes Rendus, 1886. 

20 Hhrenberg: Zeitschrift.f, phys. Chemie, vol. xi., p. 239. 

- 21 Vaughan ; Ibid., vol. x., p. 187; and Phila. Medical News, April 2, 
887. 

22 Miller : Deutsche med. Wochenschrift, 1885, No. 49. 

23 Brieger : Berliner klin. Wochenschrift, 1884, No. 14. 

24 Beumer : Deutsche med. Wochenschrift, 1886. : 

25 Wollny: Centralblatt f. Bacteriologie, vol. i., Nos. 5, 15, 16. 


PYLORUS, RESECTION OF; PYLORECTOMY. The 
operation for the removal of the diseased (usually can- 
cerous) pylorus is the legitimate outcome, on the one hand, 
of the recent progress of surgery as based on physiolog- 
ical and pathological studies, and, on the other, of an in- 
creasing boldness—begotten of success—in operative at- 
tacks upon the digestive tube. Among these latter we 
may mention gastrotomy, gastrostomy, and resection of 
varying lengths of the pharynx, cesophagus, and intestine. 
In fact, scarcely any portion of the alimentary tract has 
been exempt from the surgeon’s knife. Twenty years 
ago, indeed, Torelli excised a considerable portion of the 
stomach-wall, which, with two penetrating wounds with- 
in its limits, had prolapsed from an incised abdominal 
wound; his patient recovered and lived for many years. 
This was possibly the first stomach-resection, though not 
a resection of the pylorus. 

Induced thereto by previous surgical exploits, several 
workers began experimenting upon animals. Merrem, in 


1870 ; Gussenbauer and Winiwarter, in 1876; and Czerny, ~ 


in 1878, had made it clear that a partial, even an entire, 
resection of the stomach could be made upon dogs, and 
with success. All this having been demonstrated, it 
needed only a surgeon with sufficient boldness, and a 


114 


willing patient, for a practical test of the feasibility of 
the operation in the human subject. In 1877, Billroth 
asserted that there was no reason why the operation 
should not succeed; in 1879 he went further, and said 
that it must succeed; but it was reserved for Péan, of 
Paris, to make the first essay. In April, 1879, he yielded 
to a positive demand for relief on the part of a patient 
with cancer of the pylorus. This patient died five days 
later of inanition, after two blood-transfusions. In No- 
vember of 1880, Rydygier, of Kulm, made the second 
operation, his patient dying twelve days later of collapse. 

Three months later Billroth reported a third case, the 
first successful one. His patient made a brilliant recov- 
ery, but died at the end of four months in consequence 
of a return of the disease. : 

InpIcaTIons.—We may hold that resection of the 
pylorus is indicated in: | 

1. Irritable and intractable pyloric ulcer, leading to 
spasmodic stenosis. 

2. Simple fibrous or cicatricial stenosis. 

3. Circumscribed cancer, without adhesions to the 
pancreas or spleen. 

By a legitimate extension of our limited subject we 
may further say that resection, either of the pylorus or 
of any other part of the stomach, would be indicated 
in: 

4, Hemorrhage from ordinary gastric ulcers, by which 
life was threatened. 

5. Perforation of a gastric ulcer. 

6. Gunshot or stab wound, if ragged or irregular. 

%. Hernia of the stomach complicated with any of the 
above conditions. 

tand2. Ordinarily, ulceration of the stomach does not 
become so aggravated as to call for operative interference, 
but when the symptoms dependent thereon pass endur- 
ance, or when, the active process having subsided, the 
lesions are succeeded by stenosis, so that the patient must 
be fed by enema or starve, then drugs can give no relief. 
It is in cases of this class, though few in number, that 
the operation has been brilliantly successful, five patients 
out of eight having been cured. In cases included under 
the second indication, the resection-method, to be sure, 
has now to compete with Loretta’s method by digital di- 
vulsion ; of the former it may be said that even if it be 
the more dangerous (though not much more so) it is the 
more effective. 

3. It is in cases of cancer that this operation has been 
most frequently resorted to. It is worthy of especial 
note that the pylorus is by far the most common seat of 
cancerous disease of the stomach. Gussenbauer and 
Winiwarter investigated the records of the Vienna Patho- 
logical Institute, embracing a period of fifty-six years. 
Out of 61,287 autopsies, cancer of the stomach was found 
903 times. In 542 of these the disease involved the 
pylorus. In 223 of the 542 cases no metastatic deposits 
could be found, and in 172 of them the tumor was found 
to be non-adherent, 7.e., in a condition most favorable 
for operation. Moreover, Rokitansky’s observation, that 
cancer of the pylorus rarely involves the duodenum, is 
worth remembering in this connection. 

Obviously the matter of diagnosis is one of prime im- 
portance. It is not merely the question of malignancy 
that is to be decided, but also that of the extent of the 
disease and of adhesions to the neighboring viscera. An 
uncomplicated case is one favorable for operation ; on the 
other hand, involvement of the peritoneum, liver, or mes- 
enteric glands, and firm adhesions to the colon or pan- 
creas, make it most unadvisable. The experiments of 
Rydygier and Senn have shown that a piece of the pan- 
creas may be removed with success, provided its duct be 
not occluded ; but the difficulty of effecting this in a liv- 
ing patient would deter most men from the attempt. It 
is true, also, that a portion of the mesentery or of the co- 
lon may be excised, but the operation is thereby the more 
prolonged and complicated. For the symptoms and diag- 
nosis we must refer the reader to the appropriate heading 
(see Stomach, Organic Diseases of). To illustrate the 
difficulty of diagnosis in these cases, the writer would 
adduce the case in which Billroth and Bamberger having 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Putrefaction. 
Pylorus, 


both diagnosed cancer of the pylorus, the former operated 
and found an anomaly of the kidney. 

At all events, there can be no objection, in a case of 
proposed pylorectomy, to perform a diagnostitial lapa- 
rotomy, limiting the opera- 
tion to this in case the con- 
ditions thereby revealed 
make it improper to pro- 
ceed. This has been done 
a number of times without 
giving occasion for regret. 

4 and 5. These indica- 
tions are theoretical rather 
than founded on experi- 
ence; yet a moment’s re- 
flection will show that they 
are not chimerical. 

6 and 7. That these in- 
dications are of practical 
bearing the case of Torelli, 
quoted above, and various 
recent experiences and 
studies fully demonstrate. 

PREPARATION FOR Op- 
ERATION.—The absence of 
any very unfavorable 
symptoms having led toa 
determination to operate, 
the patient should be care- 
fully prepared for the or- 
deal. To this end the diet, 


cede: 


PBGLULUEEE HAT Lies Fear poo ne 


thats ess 


Fig. 8215.—Rydygier’s Clamp, with Parallel Bl 
ered with rubber tubing. 


doubtless already restricted, must be simplified or reduced 
to milk only. The stomach should be washed out daily 
once or oftener, and in case. the gastric symptoms have 
been very distressing the better way would be to feed by 
nutritive enemata and to frequently cleanse the stomach. 
Careful attention must also be 
given to the bowels, and, in fact, no 
precaution which careful laparoto- 
mists adopt should be omitted. 
OPERATION.—Hitherto an anes- 
thetic has always been adminis- 
tered, preferably chloroform. 
This should be preceded by a full 


Lines indicating shape of exsected por- 
tion. 


Fie. 8216.—Cancer of Pylorus, 


hypodermic dose of morphine. The stomach should al- 
ways be washed out with a weak salicylic solution, as a 
preliminary to the operation, either before or just after 
the anesthetic. A recent experience which the writer 


’ Fr@, 3219.—Cancer of Pylorus. 


has enjoyed leads him to think that, after inducing a 
mild morphine-narcosis, cocaine used hypodermically 
and locally might suffice. Work- 
ing thus with cocaine alone, he 
has been able to make a success- 
ful gastrostomy without anything 
more than some slight local dis- 
comfort. 

By some operators the incision 
in the linea alba has been pre- 
ferred ; some have made it 
parallel to the left costal 
cartilages, others 
parallel to those on 


Fig, 8217.—Cancer of Pylorus. Same case as above, showing lines of 


suture. 


the right side. An opening by which one or both recti 
may be severed has its obvious disadvantages, while for 
some of the cases the median in- 
cision, would not give sufficient 
room. The best rule is to let the 
exact location and size of the in- 
ternal tumor determine where and 
in what direction to cut. 

The tumor having been cut ¢ 


oe 
SSS SSE 
= 
SSaaSSS=x 
———sSS 
S a 


Fria. 3218.—Cancer of Pylorus. Showing portion to be removed. 

down upon and exposed, as are other abdominal tumors, 
the surgeon must first convince himself that no contra- 
indications exist, especially in 
the way of secondary affection 
of the pancreas, liver, gall-blad- 
der, or inaccessible mesenteric 
glands. Being satisfied in these 
respects, he should then draw the 
tumor as far forward as is judi- 
cious, and begin the task 
of separating it from its 
surroundings. These are 


Same case as that represented in Fig. 
3218. Showing lines of suture. 


particularly the gastro-colic ligament and the lesser omen- 
tum. These must be separated from the pyloric region 
for a sufficient distance to permit the removal of the dis- 


115 


Pylorus. 
Quarantine. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


eased mass, and no farther. This is effected by includ- 
ing small portions between double ligatures and then 
dividing with the thermo-cautery. This part of the op- 
A large sponge 


eration must be done with great care, 


Fie. 3220.—Illustrating Technique. Placing a few retaining sutures be- 
fore complete exsection. 


is now passed under the tumor-mass, to isolate it from 
the rest of the abdominal contents. A couple of clamped 
forceps, or their equivalents, are lightly passed on cither 
side of the tumor, to prevent regurgitation of gastric or 
intestinal contents; or, instead of these, the fingers of 
an intelligent assistant can 
be made to do the work 
as well or better. 

The excision of the can- 
cerous mass is now to be 
undertaken. The lines of 
incision must: be made ac- 
cording to the size and re- 
lations of thetumor. The 
accompanying cuts (Figs. 
3216, 8218, and 8220), from 
Woelfler’s monograph, show what portions were removed 
from three of Billroth’s cases. In other cases the exact 
shape of the excised portion has been different. The en- 
deavor should be to hold the stomach completely flat, so 
that pieces of exactly 
the same shape may be 
removed from its poste- 
rior as from its anterior 
wall. Numerous small 
vessels in the gastric and 
ducdenal walls will be 
found to bleed freely. 
Upon as many as require 
it ligatures of catgut 
may be placed. Hem- 
orrhage having been 
quieted, the operator at once addresses himself to the 
union of the divided parts. 

The question now comes up concerning the best of the 
several intestinal sutures that have been devised. The in- 
herent differences between the commoner and more pref- 
. erable varieties can be 
better recognized by ref- 
i # erence to Figs. 3221, 
-~ 3222, 3223, 3224, than by 
verbal description. Lem- 
bert’s suture takes in both 
the serous and the mus- 
cular coats. Czerny im- 

Ces proved this by an. ad- 

Fig. 8223.— Gussenbauer’s Suture. ditional separate stitch 
fabs ne ee muscular, and mu- through the mucosa. 
Gussenbauer still further 

improved it by combining the two stitches in one act. 
and it is his method which we recommend. Special 
care must be given to coaptation, and in certain cases 
it may be well to place some of the stitches before the 
mass is completely excised, as is shown in Fig. 3220, 
Above all, too much caution cannot be exercised in clos- 
ing the angles marked a and 0 in the cuts, Figs, 3217 and 


Fic. 8221.—-Lembert’s Suture. @, b, c, 
Peritoneal, muscular, and mucous 
coats. 


and mucous 


Peritoneal, muscular, 


coats. 


116 


3219. Should there be a doubt as to the security of the 
closure, it would be better to run another series of fine 
sutures partially or completely around. 

Something must be said concerning the choice of nee- 
dles and suture-materials. The former must be round in 
transverse outline—?.é., without cutting edges—small and 

oy straight, barely large 
we - enough to hold fine 
silk or catgut. For 
suture-material we 
recommend Chinese 


4 “Sf silk which has been 

=. _,, carefully disinfected. 

= 7" Tt is much stronger 

a than catgut of the 

; same size, and is not 

Fia. 3224.\Lembert’s Suture. Applied to sosoon absorbed. Fine 


a small wound. 
catgut may answer 


well for the ligatures, but silk is certainly preferable for 
the sutures. 

The tedious process of inserting all the necessary 
sutures having been completed, the clamps are removed, 
any toilette of the peritoneum that may be called for is 
made, the parts are dropped back, and the abdominal 
wound is closed secundum artem. 'To briefly describe the 
operation does not take long, but to properly perform it 
may consume from one and a half to three hours. It 
calls as much for extreme patience on the part of the 
operator as for skill in technique. 

The patient is now to be treated as after any abdominal 
section, save that nothing but cracked ice, in minimum 
quantity, must be allowed in the mouth for from forty- 
eight to seventy-two hours. After this, feeding by the 
mouth may be attempted with scrupulous care. For the 
first few days feeding must be done mainly by the rectum. 
Every effort to prevent vomiting must be practised. 

ReEsvuuts.— While referring the interested reader to the 
special literature for detailed statistics of cases, we may 
say here that of seventy cases now on record, pylorectomy 
has been done sixty-two times for cancer, with thirty- 
five deaths (57%), and eight times for stenosis, with three 
deaths (387.5%). Considering that every one of these cases 
had that about it which made it inherently fatal, the op- 
eration seems to have been sufficiently successful to jus- 
tify its performance in select cases. Roswell Park. 


PYRMONT is situated inthe principality of Waldeck- 
Pyrmont, in Germany, at an elevation of about four hun- 
dred feet above sea-level. There are a number of iron 
and saline medicinal springs in the place, the best known 
of which are the Stahlquelle, Brodelbrunnen, and Helen- 
enquelle among the iron springs, and the Salztrink- 
quelle, Badequelle, and Bohrlochsoole among the saline. 

The following are the analyses of these three iron 
springs, expressed in grammes per litre. One litre con- 


tains : 
Stahl- Brodel- Helenen- 
quelle brunnen. quelle. 
Bicarbonate of iron.......... 0.077% 0.036 0.074 
Bicarbunate of manganese.... 0.006 0.008 0.007 
Bicarbonate of calcium....... 1.046 1.008 1.246 
Bicarbonate of magnesium... 0.080 0.076 0.012 
Chloride of sodium .......... 0.158 0.174 0.181 
Sulphate of sodium .......... 0.041 0.036 0.043 
Sulphate of potassium........ 0.016 0.015 0.016 
Sulphate of magnesium...... 0.453 0.492 0.604 
Sulphate of calcium.......... 0.792 0.980 0.866 
Organic matter, etc.......... 0.044 0.043 0.052 
FL CURLIROUOS tween eee 2.713 2.858 3.101 


There is considerable free carbonic-acid gas in the 
waters of all these springs. Of the salt springs but one 
is used for drinking purposes. The analysis of this, the 
Salztrinkquelle, is as follows: One litre contains, of 


Gms. 
Ohioride of. sodium’. * ea eee oe dr ene 7.057 
Chioride of lithidm 2 nce ee ee eee 0.006 
“eulphate Of sodium: ace sce. eee et eens ieee 0.120 
Sulphate of magnesitimy. \...cce ee ek eee eden eee ee 0.969 
Bulwhate.of calciam i... ee cece ence een 0.805 
Bicarbonate of) calcitinus.> seats ee see eee 1.688 : 
Bicarbonate of magnesium). 7c... caleak cece cchake 0.024 
Organic matter: ete.) 1.8 ws eee cence eee aa 0.031 
Total solide) x. ixiottaceeaeteaectes oe Pee io 10.700 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Pylorus. 
Quarantine. 


The amount of free carbonic-acid gas is less than is 
found in the chalybeate springs. 

The other saline waters are not drunk, but are used 
for bathing. A course of treatment at Pyrmont is espe- 
cially useful in those cases in which both chalybeate 
and saline waters are indicated, such as various scrofu- 
lous and nervous affections, diseases of the female sexual 
organs, catarrhal conditions, and diseases of the diges- 
tive organs, combined with anemia and debility. 

The season at Pyrmont is from the middle of May to 
the middle of October. In addition to the use of the 
waters, there are facilities for the various forms of 
“cures,” goat’s-milk, whey, pine-needle, etc., so popular 
at many of the German spas. Pele 8 


PYROGALLIC ACID. ‘‘Pyrogallic acid” is the name 
in common use for the phenol pyrogallol, CsH3(OH)s. 
This body is producible by the action of heat on gallic 
acid, whence the name “‘ pyrogallic acid.” Pyrogallic 
acid presents itself in long, flattened prisms ; colorless ; 
bitter to taste ; soluble in two and a half parts of water, 
in alcohol, and in ether. In solution, exposed, the acid 
oxidizes, turning brown. Pyrogallic acid possesses the 
poisonous property, more or less common to the group 
of phenols, of affecting the blood and bringing about 
hemoglobinuria. Administered by injection to rabbits, 
this medicine has speedily caused chill, dyspnea, tre- 
mor of the extremities coming on in paroxysms, and 
death. The urine in such cases has shown the charac- 
teristic features of hemoglobinuria, and the blood has 
exhibited discoloration and destruction of the red blood- 
corpuscles. : In rapidly produced death by large doses, 
the blood has turned black or, in some cases, of a choco- 
late color and jelly-like consistence. In the human sub- 
ject death has resulted, in one instance, from the appli- 
cation, to one-half the body at once, of a ten per cent. 
pyrogallic-acid ointment. In this case a violent chill, 
with vomiting and collapse, set in six hours after mak- 
ing the application of the salve. The patient rallied, 
but forty hours later a second attack ensued, ending in 
coma, with great reduction of temperature. Death oc- 
curred on the fourth day. During the illness the urine 
was much diminished in quantity, and showed, in high- 
est degree, the condition of hemoglobinuria, being dark- 
brown in color and, upon standing, depositing a thick 
sediment of amorphous, blackish material. The blood 
was found, post mortem, disintegrated, and the kidneys 
bluish-black and stuffed with the same material as the 
urinary sediment. Pyrogallic acid has been used in 
medicine almost exclusively as a local application for 
the relief of certain skin diseases, notably psor¢asts—an 
application often successful when other remedies may 
have failed. Applied in solution or in ointment, pyro- 
gallic acid stains the skin somewhat, but the stain speed- 
ily disappears. Linen clothing, however, may be per- 
manently injured by the action of the medicine. To 
avoid this latter effect, a solution of pyrogallic acid in 
flexible collodion has been proposed (Elliot). Such prep- 
aration, when dried toa film upon the skin, seems still to 
exert the therapeutic action of the medicine, but, being 
dried, is without action upon the clothing. Pyrogallic 
acid may be applied in ointment or in solution, and 
strengths are used ranging from five to fifteen per cent. 
of theremedy. The higher percentages, in ointment cer- 
tainly, may irritate severely, and should be used with 
caution. Applications should never be extensive at any 
one sitting, for fear of enough absorption occurring to 
bring about constitutional poisoning. Hdward Curtis. 


QUARANTINE. The ancients during periods of epi- 
demic pestilence sacrificed to their gods or consulted the 
oracles on the best means of appeasing the offended de- 
ities, and in Christian times fasting and prayer have been 
undertaken as a means of preservation from these ‘‘ visi- 
tations of Providence.”” But so long ago as the time of 
Hippocrates more appreciative views of the origin of epi- 
demics were entertained, for that enlightened authority 
combated pestilence in Athens and other Grecian towns 
by directing the citizens to keep great fires burning in the 


streets, and feed them with herbs and drugs of sweet 
odor. This implied a recognition of that subtile atmos- 
pheric cause which even now exists in many lay and 
some professional minds, finding expression in the phrase 
epidemic constitution. 'The doctrine of contagion in rela- 
tion to these diseases appears to have been developed 
slowly and almost insensibly, for although Livy speaks 
of the Roman citizens shutting themselves up in their 
houses and paying attention to nothing except how to 
preserve themselves from the pestilence, the time of Boc- 
caccio was reached before systematic efforts were made 
to exclude contagion from a community. The epidemic 
which the former describes, devastated Rome B.c. 459, 
destroying most of the slaves, half of the citizens, many 
senators, tribunes, and priests, and two successive con- 
suls. The latter refers in his tales to the attempt made 
by Florence to preserve her citizens from the plague 
which overspread Europe in 1348, by denying access to 
all sick persons. 

When contagion was recognized in these epidemics— 
and probably most of them were, from the stand-point of 
to-day, either directly or indirectly infectious—a grand 
advance in preservative methods became possible. All 
European nations enforced laws for limiting the spread 
of leprosy, and these, which had been handed down from 
ancient times, had merely to be modified in their applica- 
tion in order to exercise a controlling influence on the 
spread of fulminant febrile diseases. The sanitary laws 
of Moses provided for the segregation of lepers and the 
fumigation and destruction of infected clothing. Among 
the Gentile nations these unfortunates were also ostra- 
cized ; they gathered in small communities in the out- 
skirts of cities, and ultimately hospitals were built for 
them. Even at the present day the spread of leprosy is 
controlled in the same way. In the Sandwich Islands, 
where two per cent. of the population is affected, the 
isolation of the disease to special settlements has been 
enforced since 1865, for contagion is acknowledged, and 
every leper, whether in the advanced or incipient stage, 
is looked upon as a dangerous focus of the malady. 

- When, therefore, contagion was appreciated asa factor 
in the propagation of wide-spread pestilential epidemics, 
the attempt to exclude it, as at Florence, naturally fol- 
lowed. Sanitary cordons were drawn around healthy 
places to preserve them, and around infected places to 
prevent the spread of their pestilence. Infected persons 
were taken out of the city into the fields, there to die or 
recover, and their attendants were forbidden to associate 
with anyone for ten days. Ultimately it became recog- 
nized that these epidemic diseases had their origin in 
the East—in Asia, Turkey, or Egypt—and entered Eu- 
rope by the Mediterranean seaports. Hence, in periods 
of freedom from pestilence, restrictive measures were 
concentrated at these ports to prevent its introduction. 
Venice at that time was the commercial metropolis of the 
world. Her vessels brought the products of the East to 
the Western nations, and among them, occasionally, the 
plague. A lazaretto was built for the isolation and treat- 
ment of infected sailors as early as 1423, but not until 
about 1484 were laws enacted requiring every vessel from 
suspected localities to undergo a period of detention and 
observation prior to the admission of her crew, passen- 
gers, or cargo. As this period embraced forty days, the 
term quarantine came to be applied to it and all matters 
pertaining to it. Lazarettos and quarantine codes were 
afterward established at other exposed seaports, as at 
Malta, Ancona, Messina, Leghorn, Genoa, Trieste, Mar- 
seilles, etc. As the accommodation for suspects was gen- 
erally insufficient at these quarantine stations, much 
hardship was inflicted during the period of probation. 
The full operation of the system was required only occa- 
sionally, in times of emergency, and as it was rarely 
equal to the occasion, extemporizations were necessitated ; 
but these did little to mitigate the evils of the enforced 
detention of healthy persons in dangerous proximity to 
those who were infected. Thus quarantine, to its victims, 
appeared imbued with a spirit of inhumanity, cruelty, 
and reckless tyranny ; and although its methods at the 
present time are wholly changed, much of the barbarism 


117 


Quarantine. 
Quarantine. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


of former years continues associated with the use of the 
term. 

Unfortunately the seaport quarantines, no matter how 
rigorously enforced, frequently failed in their efforts to 
exclude the plague and prevent its spread into the inte- 
rior. In this event, sanitary cordons became the estab- 
lished method of limiting the progress of the pestilence— 
they constituted, in fact, a species of inland quarantine ; 
and, even at the present day, the panic occasioned by an 
extended prevalence of a deadly epidemic not infre- 
quently calls into existence a vigorous but unnecessary 
policy of non-intercourse, known in Europe as the cordon 
militaire, and in this country as the shot-gun quarantine. 

Improvements in the sanitary condition of Europe, 
consequent on the progress of modern civilization, have 
succeeded in preventing those terrible visitations of the 
plague against which quarantine was first instituted. 
London has not suffered since 1665, and although certain 
sections specially exposed to infection from the East, as 
Egypt, Turkey, Malta, Italy, and Spain, have been visited 
during the present century, the disease is now mainly con- 
fined within the Asiatic boundary and seldom threatens 
the invasion of Europe. But the necessity for quaran- 
tine did not cease on the subsidence of this disease, for 
yellow fever from the West Indies and certain parts of 
tropical America occasionally ravaged the seaports of 
Southwestern Europe, and more recently cholera from In- 
dia has spread epidemically in the pathways of commerce. 
The former was first imported into Spain from Havana 
in 1741 ; but its appearance on European soil exercised 
no modifying influence on quarantine measures—those 
in use against the plague were applied for the exclusion 
of this new exotic. The latter made its first progress 
through Europe in 1830; and as its westward track from 
its origin in India was well recognized, the quarantines 
at the Mediterranean ports became considerably relieved 
and Western civilization protected by the establishment 
of special quarantine stations for the interception of the 
disease in the Red Sea and at points on the overland 
route. 

About this time the severity of the requirements of 
quarantine became lessened. The natural history of epi- 
demic disease was better known, and instead of an arbi- 
trary detention of so many days the period became based 
on that of the incubation of the disease to be excluded. 
Thus in France, in 1847, vessels from infected ports in 
Turkey and Egypt were admitted without restraint, if 
ten days had been consumed in the voyage and no dis- 
ease had appeared on board in the meantime. An im- 
perial decree, in 1853, admitted such vessels at once into 
the Atlantic ports of France, and into the Mediterranean 
ports if eight days had elapsed since leaving the port 

of departure. Steamers from Alexandria to Marseilles 
landed their mails at once, however short the voyage, but 
passengers were detained until the period of eight days 
had passed. Vessels from infected ports were quaran- 
tined for ten days after arrival at any of the ports of the 
empire, and their cargoes for ten days after their removal 
at the quarantine station. These regulations had regard 
to plague. With respect to cholera, vessels from infected 
ports were, in the Mediterranean, subjected to a quaran- 
tine of five days including the voyage, and in the Atlantic 
ports to one of three to five days when one or more cases 
of the disease had occurred on the voyage ; but no quar- 
antine was imposed on the cargo. Vessels from places 
infected with yellow fever were quarantined from three 
to seven days at the Mediterranean ports, but had free 
entry on the Atlantic coast if no sickness or death had 
occurred during the last ten days of the voyage. 

In this country quarantine was instituted against yel- 
low fever from Barbadoes, and typhus and small-pox 
from the other side of the Atlantic. Philadelphia suf- 
fered from the Barbadoes distemper in 1699, and in the 
following year the Province of Pennsylvania endeavored 
to secure protection in the future by passing an ‘‘ Act to 
prevent sickly vessels from coming into this Govern- 
ment,” which required, under penalty of one hundred 
pounds, that such vessels should come no nearer than 
one mile to any of the towns or ports of the province, 


118 


nor land goods or passengers until they had received a 
license from the proper authorities. Massachusetts en- 
acted a quarantine law in 1701 against vessels infected 
with plague, small-pox, pestilent or malignant fever, or 
other contagious disease, or coming from places where 
such maladies prevailed, prohibiting all communication 
between the infected or suspected vessels and the shore. 
In 1758 the colonial legislature established quarantine at 
New York by an act to prevent the bringing in and 
spreading of infectious diseases in the colony. After the 
successful passage of the Atlantic by cholera in 1882, 
this disease became added to the list of exotic pestilences 
which it was the object of quarantine to exclude. 

Based originally on the theory of contagion, quarantine 
measures were directed to the detection and isolation of 
infected individuals, but the transmission of disease by 
fomites placed restrictions also upon goods, particularly 
such as experience had shown to be efficient carriers of the 
morbific matter. This interference with the liberty of 
the individual, combined with the financial interests in- 
volved, raised a continued opposition to quarantine de- 
tention, which became more outspoken on every fresh 
demonstration of the inability of this measure to accom- 
plish its object. Indeed, the burdensome nature of the 
restrictions led in many instances to their evasion and 
consequent failure to protect the community. Unfortu- 
nately there were many such failures in the operation of 
every quarantine ; and the opposition did not hesitate to 
affirm that the quarantine system was a barbarous impo- 
sition of the middle ages, of no value as a protective 
measure, and operating merely as an impediment to 
commerce. The reply to this acknowledged the inabil- 
ity of quarantine to guarantee protection, but claimed 
that the chances of importation were reduced in propor- 
tion to the care with which the regulations were enforced. 
‘‘Shall we,” as Sir Sherston Baker says, ‘‘ abolish the 
fire brigade because a row of houses are burned down ? 
Shall we dismiss the police force because a dozen bur- 
glaries have occurred? Shall we denounce the system 
of railway signalling because a false signal has caused a 
fatal catastrophe ?” 

The immense importance of her commercial relations 
to England has made that country a leader in the estab- 
lishment of a sanitary system which will give adequate 
protection without imposing the burdensome restraints 
of former times. Originally her quarantines, directed 
against the plague, were formulated on those in exist- 
ence at the Mediterranean seaports; but since cholera 
became the pestilence specially to be guarded against, a 
system of sanitary inspection has been urged for adop- 
tion at the Red Sea stations, and accepted as the only 
needful measure at her home ports. 

Quarantine regulations did not take practical shape in 
Britain until the beginning of the present century. Con- 
sular officers at foreign ports furnished bills of health to 
vessels clearing for the United Kingdom. A clean bill 
implied that no infectious disease existed at the port of 
departure at the time of sailing, nor had existed for forty 
days prior to that time. This did not entitle the vessel 
carrying it to free pratique unless the superintendent of 
quarantine was satisfied that her crew and cargo were 
free from suspicion; and, indeed, all vessels laden with 
cotton from Alexandria were obliged to undergo quaran- 
tine irrespective of the character of their bills of health. 
A suspected bill was given to vessels when.the port of de- 
parture, although free from disease, had commercial rela- 
tions with infected ports or places. <A foul bill was issued 
when the port of departure was itself infected. All ves- 
sels coming from a port which had been officially declared 
dangerous in view of the existence of plague or other in- 
fectious disease or distemper, and all vessels, boats, per- 
sons, or goods that had been in communication or contact 
with any vessel so coming or having touched at an in- 
fected port, were declared liable to quarantine. Against 
yellow fever from America or the West Indies an inspec- 
tion station was provided, that the health of the crews of 
incoming vessels might be ascertained, but such vessels 
were not subjected to quarantine unless specially ordered. 
The Privy Council was authorized to make such orders, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


upon emergencies, as it might consider necessary. Mas- 
ters of vessels from foreign ports were required to give to 
pilots an accurate account of all the places at which they 
had touched on the homeward voyage ; and it was incum- 
bent on the latter to give information of any change in 
the regulations, involving the liability of a vessel to quar- 
antine restrictions, that masters might be assumed to be 
ignorant of by reason of their recent voyage. At the 
port of destination, in suspicious cases, a quarantine in- 
spector interrogated the incoming vessel from a proper 
distance, to ascertain the sanitary condition of the port 
or ports at which she had touched on her homeward voy- 
age, and the history and character of any sickness that 
may have affected the crew or passengers ; if he found 
her liable to quarantine, she was obliged to proceed to 
the station, as the naval, military, and civil powers of the 
government were subject to calls for the enforcement of 
the laws.. When the vessel reached the quarantine sta- 
tion a full record of her sanitary condition and history 
was made, and if she was reported by the superintendent 
as fit for entry into her port of destination without fur- 
ther detention, the Privy Council was authorized to di- 
rect her immediate release. Vessels with clean bills of 
health from the Mediterranean and West Barbary on the 
Atlantic Ocean were required to undergo a limited quar- 
antine, for the purpose of breaking open the cargo and 
airing it prior to delivery ; and certain places were ap- 
pointed as quarantine stations for this purpose, such as 
Standgate Creek for vessels bound for the ports of Lon- 
don, Rochester, and Faversham; Milford Haven for 
Carlisle, Liverpool, etc.; Inverkeithing Bay for the east- 
ern ports of Scotland ; and so for other sections of the 
coast. These vessels were detained fifteen days from 
the date of their arrival, during which time all goods 
were aired on deck; but if the cargo of the vessel con- 
sisted in whole or in part of certain classes of goods con- 
ceived to be of a retentive or dangerous character, these 
were required to be removed for aération to a special 
quarantine float, and the detention of fifteen days dated 
from the time of the discharge of the cargo. The list of 
dangerous articles was long, and included all cotton, 
silk, and woollen goods, furs, straw, etc. Vessels with 
suspicious bills were detained at the station for thirty 
days, during which they were daily subject to inspection ; 
and if at any period of their. stay a pestilential disease 
was discovered among the crew or passengers, the quar- 
antine period was recommenced and the vessel treated 
as newly arrived and plague-stricken. Vessels liable to 
quarantine were required to indicate their condition when 
passing other vessels or approaching the coast by flying 
a yellow flag or showing a light at the mainmast-head. 
Merchant-vessels with foul bills, but not having the 
plague on board, were restricted in their choice of quar- 
antine stations to Standgate Creek and Milford Haven, 
where there were better facilities for caring for the sick 
and handling suspected cargoes. War-ships under sim- 
ilar circumstances repaired to a special station at Mother- 
bank, where a floating lazaret was established for their 
benefit. If plague appeared on a vessel while en route, 
she was required, if to the southward of Cape St. Vin- 
cent, to proceed to some lazaretto in the Mediterranean, 
there to undergo quarantine ; and on her arrival on the 
coast of the United Kingdom she reported to the super- 
intendent of the station most convenient for her, and 
awaited the special orders of the Privy Council in her 
ease. All other plague-stricken merchant-vessels re- 
paired to the quarantine grounds marked out at Milford 
Haven by twelve yellow buoys. Here guardians were ap- 
pointed to see that these ships were thoroughly searched 
and cleaned after the removal of their cargoes. No com- 
munication was held with them except by letters which 
had been dipped in vinegar and fumigated ; and nothing 
was delivered without the quarantine lines from on board' 
except on the order of the superintendent. The sick 
were transferred to a floating hospital ; separate accom- 
modations were provided for the healthy and for conva- 
lescents and invalids during the period of their detention ; 
the cargoes were unloaded for aération and disinfection, 
and the vessels subjected to thorough cleansing and 


« 
Quarantine. 
Quarantine, 


fumigation. In case of death at quarantine the body 
was required to be sewed up in canvas, weighted with 
one and one-half hundredweight of iron, and committed 
to the deep, the infected clothes and bedding being de- 
stroyed. The government provided medical attendance, 
medicines, disinfectants, and the use of the quarantine 
floats, shelters, furniture, and appliances, free of expense 
to the detained vessels, and no quarantine fees were 
charged. 

In 1871 the powers and duties relating to quarantine 
and public health vested in the Privy Council were, as 
regards England and Wales, transferred to the Local 
Government Board. Two years later, when cholera was 
prevalent in certain parts of Continental Europe, the 
Board issued orders with a view to the better protec- 
tion of the country from epidemic invasion. The officer 
of customs was required to detain any suspected vessel 
for inspection, immediately notifying the port or local 
sanitary authority ; but if no action was taken thereon 
within twelve hours, he was authorized to release the 
vessel. The local sanitary authority was required to 
cause the immediate inspection of any suspected vessel, 
whether detained by the officer of customs or not, to as- 
certain whether she was infected. Healthy persons were 
permitted to land without delay; those affected with 
diarrheea or other suspicious sickness were detained on 
board or in some previously appointed place for a period 
not exceeding two days, for the determination of the 
character of their illness ; those certified as affected with 
cholera, and those suspects who developed disease during 
their temporary detention, were removed to some ap- 
pointed place, or, if unfit for removal, were retained on 
the vessel, which they were not permitted to leave save 
on the authority of the proper officer. The vessel and 
her contents were required to be disinfected, dangerous 
articles; such as the clothing and bedding of those who 
had suffered, being destroyed if considered necessary. 

The local authorities of English ports, under the super- 
vision of the Local Government Board, make provision, 
at the present time, for the relief of vessels suffering from 
other dangerous infectious diseases, as diphtheria, ery- 
sipelas, measles, small-pox, scarlet, enteric, typhus, and 
relapsing fevers ; and for this purpose floating hospitals 
are sometimes used. That launched at Newcastle-on- 
Tyne in August, 1886, may be instanced as one of the 
best construction, not only as being the latest, but as the 
product of a port noted for its ship-building industry (see 
Fig. 8225). Itis built on ten cylindrical iron pontoons re- 
sembling huge boilers, each 70 feet long, 6 feet in diameter, 
and having a buoyancy of 584 tons, so that the floating 
power of the hospital is equal to 535 tons. On each pon- 
toon are seven saddles, which support a strong framework 
of longitudinal rolled-iron girders braced together by di- 
agonal T-iron, ‘This supports a deck of creasoted timber, 
which constitutes a platform on which the hospital is 
erected. It is surrounded by a neat handrail, and access 
from the river is obtained by a gangway in the front cen- 
tre of the protection-rail. The deck is partly occupied by 
three main buildings, six smaller structures, and a mort- 
uary. Each of the main buildings, 65 x 234 x 20 feet, is 
divided into two wards, one containing six, the other four, 
beds. The interiors are spacious, lined with polished 
pitch-pine in narrow strips, well lighted and ventilated by 
inlet apertures near the floor and a shaft through the roof 
fitted with Kiles’ patent ventilator. Between the two 
wards of each building is an apartment for the nurse, fit- 
ted on either side with glazed doors to afford full view of 
each ward. The three buildings are all fitted up alike, 
and are so arranged that each can be completely isolated. 
As the platform is 140 feet long by 80 wide, there is 
ample space in front of the buildings for the recreation 
of convalescents. Beneath the floor is a clear space of 
ten inches, to secure free access of air between it and the 
deck ; and between the platform and the water-level is a 
space of four feet. The rise and fall of the tide and the 
current in the spaces between the pontoons prevent the 
possibility of any impurity beneath the hospital. The 
space between adjoining pontoons is 144 feet from centre 
to centre, and each is detachable for cleaning, painting, 


119 


Quarantine. 
Quarantine. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Fra. 3225. 


or repairs; they may also be revolved in their places 
without removal. 

The gradual progress of the emancipation of commerce 
from the onerous impositions of earlier times, and the 
better protection of Europe from plague and cholera by 
measures based on the scientific study of disease, may be 
best appreciated by following the history of the interna- 
tional conferences that have been held from time to time. 

In July, 1851, an international conference on the sub- 
ject of quarantine was held at Paris, delegates from most 
of the European states being present; the results of 
its deliberations were subsequently ratified by France, 
Sardinia, Portugal, Tuscany, and Turkey. Only foul 
and clean bills of health were recognized by the conven- 
tion, the first for the assured presence of the malady, the 
second for its attested absence; and for the more easy 
application of quarantine Measures a maximum as well 
as a minimum of detention was agreed upon. For the 
plague, ten to fifteen days; for yellow fever, three to 
seven days for vessels without casualty during their voy- 
age, and seven to fifteen days for those having had sick- 
ness en route ; for cholera, three to five days, including 
the duration of the voyage, but if cases occurred en 
route the time occupied by the voyage was not taken into 
account. Merchandise was divided into three classes: 1, 
Articles subject to an obligatory quarantine and purifi- 
cation—these included old clothes and articles of common 
use, rags and waste-paper, leather and skins, feathers, 
hair, and, in general, any parts of animals, and, lastly, 
wool and silk stuffs ; 2, those liable to quarantine, ‘includ- 
ing cotton, flax, and. hemp ; and 8, those exempt from all 
restrictions, comprising all articles not belonging to the 
first or second class. Each of the contracting parties 
agreed to furnish and maintain the lazarets required by 
the exigencies of the public health, the convenience of 
tr avellers, and the requirements of commerce ; and in or- 
der not to impose on the shipping of their respective 
states more than the charges needful to cover the ex- 
penses of maintenance, certain dues and taxes were in- 
dicated. Sanitary councils were established in the prin- 
cipal ports and cities, and the consuls of states accepting 
the terms of the convention were entitled to be present 
at the deliberations of these councils and to be heard 
when the interests of their country were involved. The 
regulations provided for the thorough cleaning of all 
merchant-vessels at the port of departure before taking in 
their cargo, and for the medical examination of the crew 
and passengers. Certain measures of cleanliness and 
ventilation were required to be carried into effect during 
the voyage. On arrival at the port of destination the 
vessel was inspected and admitted to free pratique or de- 
tained to effect the requisite cleanliness, for a quarantine 
of observation, or for the performance of a strict quaran- 
tine, as seemed necessary from her history and condition, 


120 


Strict quarantine involved purification and disinfection. 
The occurrence of yellow fever, cholera, or plague during 
the period of detention necessitated a renewal of strict 
quarantine. Regulations were formulated for the arrange- 
ment, supervision, and interior management of lazarets, 
including the disposition of cargoes, wearing-apparel, and 
mails. Provision was also made for the sanitary super- 
vision of Turkey and Egypt. The Superior Council of 
Health at Constantinople, which was to superintend this 
service, had added to its membership a number of dele- 
gates from the states signatory to the convention equal 
to that of the Ottoman functionaries and having equal 
voice with them in the deliberations. At Alexandria a 
similar board of health was constituted. Medical in- 
spectors, appointed by the powers interested, were distrib- 
uted over the East to study, in relation to the public 
health, the country in which they were stationed, its cli- 
mate, diseases, and characteristics, and the means adopted 
to combat the disease ; and to this end they were required 
to make tours of inspection through their respective dis- 
tricts as often as deemed desirable. In case of an epi- 
demic or suspicious outbreak these inspectors were re- 
quired to report immediately to superior authority. These 
regulations were in force for five years, but were not re- 
newed at the end of that period. 

The Conference of Constantinople, in 1866, enunciated 
certain guiding principles of practical action, It recog- 
nized the origination of cholera under certain unknown 
conditions and its endemic existence in India, particu- 
larly in the valley of the Ganges ; the possibility of its 
naturalization on European soil was considered problem- 
atic. Its propagation was effected, not by atmospheric 
conditions, but by the agency of man, and with a rapid- 
ity proportioned to the speed of his methods of travel. 
The cholera patient, or person suffering from premoni- 
tory diarrhoea, was the chief agent in its spread, the 
choleraic discharges being regarded as the dangerous 
element. The period of incubation did not exceed a 
few days. It was considered reasonable to suppose that 
living animals were capable, in certain cases, of trans- 
porting the disease. Articles in common use by chol- 
eraic patients and their attendants were efficient trans- 
mitters—even from afar, if protected during transporta- 
tion from the action of the air. The possibility of its 
transmission by merchandise was admitted, in the ab- 
sence of proof, and it was pronounced safest to consider 
as infected and dangerous all productions of an infected 
locality. Moreover, although there was no positive evi- 
dence of danger from the bodies of choleraic dead, it 
was considered prudent to regard and treat them as in- 
fected. Sea and railroad travel were announced as the 
most dangerous methods of communication, while des- 
erts traversed only by caravans were regarded as an ef- 
fectual barrier to the transmission of the disease. All 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Quarantine. 
Quarantine. 


aggregations of men, pilgrimages, fairs, armies, etc., fa- 
vored the extension of cholera, while its violence was 
proportioned to the absence of immunity on the part of 
individuals and to general insanitary conditions, as pov- 
erty, overcrowding, deficient ventilation, and impurity 
of soil, particularly if the impurity is in part derived 
from choleraic dejections. On shipboard, intensity is 
proportioned to overcrowding with susceptible material ; 
but the danger of importation has no relation to this 
intensity. So, in a lazaret, the aggregation of persons 
coming from a place where cholera prevails does not 
produce a great increase of the disease among them, ow- 
ing to their relative immunity ; but such a lazaret is 
dangerous to its susceptible neighborhood. 

As relating to prevention : The conference appreci- 
ated the efforts of Britain to restrain and extinguish the 
disease in India by general and special sanitary meas- 
ures, but concluded that as these could not be efficient 
at an early date, it was meanwhile needful to guard 
against importation. For this purpose a system of mar- 
itime sanitation was suggested, and it was advised that 
there should be: Competitions and prizes for discoveries 
or improvements the immediate results of which would 
promote the sanitary condition of vessels, the health of 
their crews, and the well-being of their passengers; a 
manual of hygiene for the use of the merchant-marine of 
every country, the most important rules of which should 
be obligatory ; and encouragement by premiums and 
rewards to those who should distinguish themselves by 
the excellent management of their vessels and crews. 
The sanitary conservation of ports was considered as of 
great importance ; this included the exclusion of city sew- 
age from the waters of the harborage and measures of 
general cleanliness, having reference to purity of air, wa- 
ter, and soil, particularly the protection of the last from 
choleraic infection. It was held that restrictive meas- 
ures, properly applied, did less harm to commerce and 
international relations than the disturbances consequent 
on epidemic visitation, and that quarantines, based on 
rational and scientific views concerning the transmissibil- 
ity of cholera and its mode of propagation, were an efli- 
cient: barrier against its importation. As the disease 
came from India by way of the Red Sea, overland 
through Persia, or from secondary foci in Arabia, all 
these modes of progress were reviewed, and appropriate 
recommendations given. The establishment of a quar- 
antine-station in the Red Sea, under international con- 
trol, was advised, with special stations for vessels carry- 
ing pilgrims. <A sanitary service for the protection of 
the overland route was suggested, with a quarantine of 
ten days when the arrivals had not been more than three 
days on the journey ; the immediate sequestration of 
first cases was approved, together with the early isola- 
tion of an infected locality and the use of sanitary cor- 
dons, which, although of uncertain value and often dan- 
gerous in wide-spread epidemics and dense populations, 
were regarded as affording good results in limited local- 
ities or sparsely settled countries, as in some parts of 
Asia. A special sanitary service was also recommended 
for the Hedjaz and its pilgrimages, involving non-inter- 
course between Arabian and Egyptian ports during the 
progress, and for fifteen days after the cessation, of any 
cholera epidemic among the aggregations of pilgrims. 
Islands otherwise unoccupied, or isolated localities dis- 
tant from centres of population, with good air and wa- 
ter, a rocky and non-malarious soil and ample harborage, 
were recommended as quarantine sites. Floating lazarets 
were not considered satisfactory. Quarantine quarters 
were to consist of one-story cottages, each of four rooms, 
with accommodation for five persons ina room ; the dis- 
tance between adjacent houses to be twenty metres, and 
that between adjacent rows one hundred metres. The 
hospital, including officers’ quarters, dispensary, wards, 
kitchen, laundry, and store-rooms, to be at least two 
hundred metres distant from the quarters, and to be 
formed of a similar series of detached cottage-buildings, 
each ward to contain from five to ten beds. Two land- 
ings to be provided, one for persons and goods subject 
to quarantine, and the other for unrestrained commerce ; 


warehouses to be near the landings, with special accom- 
modation for goods requiring purification, and stables 
and sheds for animals. Movable vessels, charged with 
disinfectants, to be used in the privies of all sections of 
the establishment, their contents thereafter to be buried 
under quick-lime and animal-charcoal. Quarters of the 
quarantine guard to be at least two hundred metres from 
other buildings. It was considered advisable that sta- 
tions thus equipped to carry out the measures of a strict 
quarantine in the case of infected vessels should be as 
few in number as was consistent with the requirements of 
the traffic and coast-line of a state. Quarantines of ob- 
servation, which involved watching merely, might be per- 
formed without inconvenience or danger at less elabo- 
rate stations, or even on shipboard in the vicinity of 
large ports. The quarantine period was fixed at ten 
days ; but vessels in which all sanitary precautions had 
been taken, including inspection at the port of depart- 
ure, and which carried a commissioned medical officer, 
had the time spent on the voyage included as part of 


‘ the quarantine period. Vessels on which no suspicious 


disease was developed during the voyage were merely 
detained, or subjected only to such general hygienic 
measures as seemed desirable, and if the voyage had 
lasted fifteen or more days the quarantine was reduced 
to five days. Those which were infected had to dis- 
charge cargo and submit to special means of purifica- 
tion, as by fumigation with chlorine. Those in which 
a severe epidemic had occurred were to be treated with 
the utmost precaution, even to prolonging or doubling 
the ordinary period of detention. 

The Conference of Vienna, in 1874, adopted the con- 
clusions reached at Constantinople concerning the origin 
and. transmission of cholera. Land quarantines were 
rejected as inefficient and impracticable, in view of the 
increasing facilities for communication and the injury 
they inflict on commercial interests. The substitution 
of a system of medical inspection for quarantine at 
European ports, with the establishment of a rigorous 
and truly preservative quarantine during the passage of 
the Red Sea, was strongly urged by Semmola, of Italy, 
in submitting to the conference the report of a sub-com- 
mittee on seaport quarantines. The Red Sea was con- 
sidered the strategic point in the line of defence against 
cholera invasion. Hirsch, of Germany, and D’Alber- 
Glanstatten, of Austria, also spoke in favor of these 
views, which were vigorously attacked by Sousa-Martins, 
of Portugal, who was inclined to hold that, outside of 
quarantine, science recognized no sure means of prevent- 
ing the importation of cholera; that the failure of quar- 
antine measures was caused by the neglect or infringe- 
ment of the laws governing the propagation of the disease, 
and that commerce suffers more from epidemics than 
from quarantines. The committee, he argued, must be 
of the opinion that quarantines were based on scientific 
views, since they had been accepted by its members, who 
were scientific men ; that they were practicable, else they 
would not have been recommended as the only defence 
of Europe against invasion, and that at Suez and Alex- 
andria, at least, they were less to be feared in their eco- 
nomic consequences than the evils consequent on the diftu- 
sion of epidemic cholera. Butwhy confinethe application 
of these accepted principles to the towns mentioned ? 
Was quarantine more efficacious there than elsewhere ? 
Was there more likelihood of arresting the progress of 
an epidemic at its points of irruption than at places 
where its progress was less rapid ? Would cholera be 
less fulminant at Suez, where pilgrims arrived by the 
thousand, than at Marseilles, Gibraltar, or Lisbon ? 
Have the ports of Europe fewer facilities for carrying 
out quarantine measures than those of Egypt, or do 
Alexandria and Suez present topographical conditions 
which do not exist in Europe? He charged the com- 
mittee with conceding that, in the event of the introduc- 
tion of the disease, its epidemic diffusion was certain 
notwithstanding all quarantine measures. Was ampu- 
tation of no avail when gangrene supervened? Yet it 
was acknowledged, by the recommendation for a Red 
Sea quarantine, that the only protection available for 


121 


Quarantine. 
Quarantine. 


Europe lay in these same quarantine measures, There 
was inconsistency in this. ‘The report of the committee 
was defended by several of its members, the principal 
argument being that when cholera passed the Red Sea 
and appeared in Europe, European quarantines could do 
no more than attempt the isolation by sea of countries 
that were in daily communication by land. M. Fauvel, 
in objecting to the withdrawal of European quarantines, 
argued that in some countries sanitary interests, in others 
commercial interests, were prominent, and that the utility 
of quarantine was regarded differently according as one 
or the other of these interests predominated. The north- 
ern countries of Europe, besides having been less devas- 
tated by choleraic epidemics, had more exacting com- 
mercial interests than the southern countries, and were 
therefore inclined to view quarantines only as imposi- 
tions or restrictions on their commercial relations. Even 
the same government did not always view the question 
of quarantine from the same stand-point. England, al- 
though desiring no quarantine at her home ports because 
commercial interests were superior to all others, did not 
hesitate to impose the most rigorous measures where 
these interests demanded the protection of a port from 
infection. At Malta the strictest quarantine of the Medi- 
terranean was in force, and at Gibraltar suspected vessels 
had been refused admittance. In France the channel 
ports coincided in the views of the northern countries, 
the Mediterranean ports with those of the south. All 
are actuated by the dominant interest. To say that sea- 
port quarantines are useless because cholera may come 
by land is an argument invoked only in behalf of inter- 
ests that have not the public health for their objective. 
We know that quarantines prevent importation. They 
do not guarantee safety ; but why should that perfection 
be required of quarantine that is not required of any 
other human institution? It is true, also, that seaport 
quarantines lose much of their value when directed 
against an epidemic in their immediate neighborhood. 
But we must be content with the best possible protection. 
If the means of prevention employed increase in some 
degree the chances of preservation, and do not involve 
sacrifices greater than the guarantee of protection af- 
forded, they should be considered advisable and worthy 
of adoption. As a result of these discussions, the con- 
ference approved the recommendations of the Conference 
of Constantinople concerning the establishment of a 
strict quarantine in the Red and Caspian Seas to prevent 
the introduction of cholera into Europe. In the event 
of invasion a system of medical inspection was recom- 
mended, but for those states which preferred to continue 
quarantine restrictions certain regulations were adopted. 

The inspection system provided that every commercial 
port should have a sanitary service competent to deal 
promptly with all vessels, crews, and passengers. Ves- 
sels from a healthy port, not having touched at an inter- 
mediate suspected port or communicated directly with a 
suspected vessel, and having had no sickness of a sus- 
picious nature during the voyage, were admitted to free 
pratique. Arrivals from a suspected or infected port, or 
those having had compromising relations or suspicious 
sickness during the voyage, were to be submitted to a 
rigorous medical inspection, when, if no infection was 
discovered, the vessel and all on board were granted im- 
mediate admission ; but if it was found that cholera or 
sickness of a suspicious nature had existed on board be- 
fore arrival, the vessel and the clothing and other articles 
in common use by the crew and passengers were to be 
carefully disinfected. If the incoming vessel contained 
persons sick or dead from cholera, the sick were removed 
to a lazaret or other proper place and the dead committed 
to the deep or buried after suitable disinfection, and the 
crew and passengers, their effects, and the vessel itself 
thoroughly disinfected, but the cargo, save when con- 
sisting of rags or other susceptible articles, was admitted 
without treatment. 

The quarantine regulations for arrivals from infected 
ports provided for a period of observation ranging from 
one to seven days when no disease was present on arrival ; 
but at the eastern ports of Europe, and elsewhere in 


122 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


exceptional cases, this period was extended to ten days. 
If proof was found that no suspicious case had oc- 
curred during the voyage, three to seven days’ detention 
was required ; but if the voyage had lasted at least seven 
days, the period of observation was reduced to twenty- 
four hours; and these quarantines might be performed 
on board the vessel, provided she was in suitable sanitary 
condition. When cholera had occurred during the voy- 
age or after arrival, persons not sick, except such as were 
required for the care of the vessel, were isolated in a 
lazaret or other suitable place ; the sick were landed and 
cared for separately, and the vessel and all susceptible 
articles were disinfected, after which those persons who 
remained on board were kept under observation for seven 
days. For arrivals from suspected ports, and in the ab- 
sence of any suspicious accident during the voyage, the 
period of observation was limited to five days. Emigrant 
and pilgrim ships and others deemed particularly dan- 
gerous to the public health became the object of special 
precautions, to be determined by the port sanitary au- 
thority. When the port of arrival was unprovided with 
proper quarantine facilities, an infected ship was to be 
directed to the nearest lazaret after receiving such succor 
as her condition required. A vessel coming from an in- 
fected port, but having touched at an intermediate port, 
where she had received free pratique without having un- 
dergone quarantine, was to be treated as coming directly 
from an infected port. In cases of mere suspicion, dis- 
infection might be resorted to when considered expedi- 
ent by the sanitary authority, but it was not to be re- 
garded as obligatory. A port in which cholera prevails 
epidemically should cease to quarantine, and practise 
only measures of disinfection. For inland river towns 
the system of medical inspection was recommended as 
applicable. It was decided, as pertinent to both the in- 
spection and the quarantine system, that the captain, 
medical officers, and other officers of a ship are bound to 
furnish to the sanitary authority every information con- 
cerning the occurrence of suspicious disease among the 
crew or passengers, and in case of false representations 
or wilful concealment they are liable to penalty under 
the sanitary laws, on which subject it was considered de- 
sirable that there should be an international agreement. 
The details of disinfection were left to the sanitary au- 
thorities of each country. The conference also recom- 
mended the institution at Vienna of a permanent Inter- 
national Sanitary Commission, having for its object the 
study of cholera and other epidemic maladies from the 
stand-points of etiology and prophylaxis, and the co- 
ordination of researches into these subjects undertaken 
by the various contracting states. 

The English delegates at this conference urged the 
adoption of the system.of medical inspection instead of 
arbitrary quarantine rules, and presented a communica- 
tion from the Medical Officer of the Privy Council giv- 
ing the views of the Local Government Board on the 
propagation of cholera in England. These held impor- 
tation of the infection to be of secondary importance ; 
local filth and unsanitary conditions which afforded the 
imported infection a.soil favorable for its development 
were regarded as the principal agencies. The precau- 
tions to be taken embraced the removal of the filth, the 
protection of water-supplies, and, in the event of inva- 
sion, the disinfection of choleraic discharges, in which 
the infective power is known to reside. But the main 
object of England at this conference was evidently to 
secure such action as would permit her vessels from In- 
dia to traverse the Red Sea without embargo by either 
quarantine laws or international inspections. Something 
was accomplished in this direction before the Superior 
Council of Health at Constantinople in 1882. The dele- 
gate from England, in presenting a communication from. 
the Governor-General of India opposing quarantine re- 
strictions on English vessels from India, represented that 
the fears of an importation of cholera were based upon 
the theoretical views of the Conferences of Constantinople 
and Vienna, and not upon facts. Aden, he instanced, is 
in daily communication with Bombay and other Indian 
ports, which are distant but a few days’ journey, yet it 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


has not suffered from the disease during the years 1868- | 


80, and its history, so far as known anterior to 1865, con- 
firms the experience acquired since that time. After full 
discussion the council adopted certain propositions rec- 
ognizing the great danger of the introduction of cholera 
by the often foul and always crowded ships carrying pil- 
grims to Mecca, and authorizing the free admission of 
vessels in good sanitary condition, having no pilgrims on 
board and no suspicion of cholera during the voyage, 
inasmuch as no instance has been recorded of the intro- 
duction of the disease by vessels not carrying pilgrims, 
and permitting arrivals under these conditions from ports 
that are known to be infected to have the duration of 
the voyage considered as part of their quarantine term, 
which shall be completed by twenty-four hours of obser- 
vation. 

Meanwhile an International Conference was held on 
this side of the Atlantic. It was called by the President 
of the United States, in compliance with a joint congres- 
sional resolution, for the purpose of securing an interna- 
tional system of notification as to the actual condition of 
ports and places likely to be infected with cholera or yel- 
_ low fever, and the establishment of a uniform and trust- 
worthy system of bills of health. The exposure of this 
country to yellow fever, and the difficulty experienced 
by our consuls at foreign ports in obtaining the co-opera- 
tion of the local authorities in their efforts to verify and 
improve the sanitary condition of vessels clearing for 
United States ports, were the chief agencies in the incep- 
tion of this conference. It was held in Washington in 
the early part of 1881, and thirty-one governments were 
represented at its sessions. The resolutions adopted 
looked to: 1. The establishment by each government of 
such an organized internal service as would enable it to 
be regularly informed of the state of the public health 
throughout the whole of its territory. 2. The publica- 
tion, weekly, of the mortality statistics of its principal 
cities and ports. 38. Direct communication between the 
sanitary authorities of the countries concerned. 4. The 
creation of international organizations for the collection 
of information regarding the outbreak, spread, and dis- 
appearance of cholera, pest, yellow fever, etc., and con- 
veying such information to the parties interested. 5. 
The acceptance by the authorities of the various coun- 
tries of a bill of health after the form approved by the 
conference. 6. The delivery of the bill at the port of 
departure by the territorial sanitary authorities, and the 
right of the consul of the country of destination to be 
present at the examination of ships, to authenticate the 
bill, and to make thereon such remarks as he might 
deem necessary. 7. Gratuitous issue of the bill. 8. The 
creation of a temporary scientific sanitary commission 
by the nations most directly interested in protecting 
themselves against yellow fever, and of such others as 
might wish to take part in this arrangement, for the pur- 
pose of studying all matters pertaining to the origin, de- 
velopment, and propagation of that disease. 

Had this conference restricted its efforts to the ends 
for which it was specially called, it is probable that a 
convention might have subsequently ratified its conclu- 
sions, and international communication relative to epi- 
demic diseases, with uniform rules pertaining to the 
issuance of bills of health, might have been obtained as 
a protection to both the public health and the interests 
of commerce; but, unfortunately, some enthusiastic san- 
itarians urged the adoption of the eighth resolution, 
which, by calling for the establishment of twenty-two 
international posts for the study of yellow fever, each 
provided with chemical and _ histological laboratories, 
libraries, and expert physicians for their use, with pro- 
vision for an annual conference, at which at least one 
member from each post should be present, implied a 
financial expenditure for its support sufficient to prevent 
any practical action from being taken on the conclusions 
of the conference, if it did not throw doubt upon the 
whole of these conclusions as being apparently the work 
of medical visionaries. As it was, no action was taken 
by the Government to realize any benefit from the delib- 
erations of the conference. 


Quarantine. 
Quarantine, 


The last conference was convoked at Rome, in May, 
1885, by the Italian Government, with the view of set- 
tling the basis of an international agreement as to meas- 
ures of prevention that would be acceptable to all the 
governments, and of forming rules for the application of 
such an international system of sanitary intelligence as 
had been proposed at Washington in 1881. The follow- 
ing summarizes the conclusions of a technical commis- 
sion consisting of the medical delegates, to which the 
duty of preparing suitable resolutions was referred : It 
was considered necessary that there should be in every 
country a central bureau for the interchange of informa- 
tion concerning sanitary conditions, for the publication 
of an international bulletin giving weekly bills of mor- 
tality from all important cities, and for the transmission 
of telegraphic notice to all concerned of the extension of 
cholera or yellow fever to new localities. Under the 
heading of Sanitary Prophylaxis in Cholera, it was con- 
sidered that purification and isolation, in the measure 
indicated by science, of everything that may carry the 
infection of cholera were the best means of preventing 
the importation and propagation of that disease. As 
disinfectants, steam, carbolic acid, and chloride of lime 
were recommended ; for certain articles, boiling in water 
for thirty minutes, and when these measures are imprac- 
ticable, destruction or an aération by exposure for three 
or four weeks. Disinfection of merchandise and mail- 
bags was not considered needful; but superheated steam 
was suggested, parenthetically, as the only available 
means if the disinfection of rags in bale was desired. 
Land quarantines and sanitary cordons were affirmed to 
be useless; the propagation of cholera by land was to 
be combated by general sanitary measures, taken in ad- 
vance, and the prompt isolation of newly developed cases, 
with effective disinfection under the supervision of an 
organized sanitary service. Travel by rail from infected 
places was to be effected under medical guardianship, 
which had at each station means of isolation for cases 
developed en route. In passing into an uninfected dis- 
trict, passengers and freight were to be transferred to 
other cars, that those from the infected territory might 
be retained within it. Disinfection of passengers and 
merchandise was declared to be necessary only when 
there had been contact with choleraic dejections. River- 
ports open to sea-going vessels were considered seaports 
so far as concerned protective measures; but interior 
river navigation required rigorous medical inspection, 
stations being provided for the treatment of infected 
vessels. p 

The importance of general sanitary measures at sea- 
ports was urged. These should be effected under the 
supervision of a special sanitary authority. The consul 
at the port of departure should have the right of assist- 
ing at sanitary inspections of vessels made by the terri- 
torial authority, in conformity with the rules established 
by convention or treaty. The lading of the vessel at the 
infected port should be begun only after thorough clean- 
ing by ordinary means or specially by disinfection, as 
might be required. The crew and passengers should be 
examined, and those suspected of choleraic disease should 
not be permitted to embark, nor should any suspected 
bed- or body-linen or other articles be admitted on board. 
These measures devolve on the captain and medical offi- 
cer of the vessel prior to inspection by the territorial 
authority ; but if the vessel does not carry a medical 
officer, the consul of the port of destination should ap- 
point a suitable person to perform these duties. 

Recommendations were made for the management of 
the vessel during the voyage, and particularly in case of 
the development of choleraic disease. All steamers pass- 
ing through the Red Sea from infected Indian ports 
should be subjected to inspection by an independent, 7.e., 
an international official, and if the medical officer of the 
vessel certifies that all necessary precautions have been 
taken at the port of departure and during the voyage, 
and that there is no one on board affected with cholera 
or any sickness of‘ a suspicious character, free pratique 
should be accorded by the inspecting officer. _ Vessels 
with passengers for the ports of Egypt or the Red Sea 


123 


Quarantine, 
Quarantine. 


should be inspected near the Straits of Bab-el-Mandeb, 
and again on arrival at the port of destination ; but those 
passing through the sea merely en voyage require inspec- 
tion at Suez only. If at the inspection the vessel is 
found to be infected, the passengers should be landed, 
the sick isolated and properly cared for, and the others 
subjected to observation for five days, while the ship, 
clothing, bed-linen, and other suspected personal effects 
are disinfected. Vessels not carrying a medical officer 
should be subjected to two inspections, one within the 
straits and the other at Suez, although they may be 
merely en route to the Mediterranean and have no com- 
merce with the Egyptian or Red Sea ports. Special 
provisions of a more rigorous nature were adopted for 
the treatment of ships carrying pilgrims from India to 
the Hedjaz, and for those returning from the pilgrimage 
to Egyptian or Mediterranean ports. 

On arrival at European ports suspected vessels were to 
be considered entitled to free pratique only when in- 
spection in the daytime by the medical officer of the 
port revealed that all needful precautions had been taken 
before sailing and on the voyage, that no case of a sus- 
picious character had occurred on board, and that ten 
days at least had been spent en voute. If this period had 
not elapsed since leaving port, a detention of twenty- 
four hours was required for observation, with disinfec- 
tion of soiled linen and other suspected personal effects. 
In the case of infected vessels, the port sanitary author- 
ity should cause the landing of the crew and passen- 
gers, the sick to be isolated and cared for, the well to be 
under observation, and the vessel, personal effects, and 
other dangerous articles to be disinfected. The period 
of observation was limited to five days; but if no case of 
cholera had occurred on board for ten days, the deten- 
tion was reduced to twenty-four hours, as in the case of 
vessels merely suspected. Suspected vessels from Medi- 
terranean ports were required to disembark their crew 
and passengers at a suitable place for observation, the 
period to be limited to from three to six days including 
the time spent on the voyage. Infected vessels were to 
be treated as in the case of those bringing the disease 
from India or the Red Sea. 

The summary of the conclusions of the technical 
commission of this conference does not contain the 
word ‘‘ quarantine” in connection with preventive meas- 
ures to be taken at seaports, but it does not follow that 
the abolition of quarantine was recommended in favor 
of a system of medical inspection. On the contrary, the 
commission, while disusing the word, insisted on the 
measure with more force than did the Vienna Confer- 
ence. The latter left the option of quarantine or sani- 
tary inspection to the countries concerned, but the for- 
mer imposed a detention of twenty-four hours in cases 
where the sea-voyage from suspected ports beyond the 
Mediterranean had lasted less than ten days, and a quar- 
antine of from three to six days on suspected vessels 
from Mediterranean ports, with no proposition looking to 
the system of medical inspection as an alternative. 

Having thus reviewed the efforts made by Europe to 
supersede arbitrary time-quarantines by protective meas- 
ures based upon a knowledge of the natural history of 
epidemic diseases, we may turn to this country to learn 
in what manner medical progress has affected the local 
quarantines established in colonial days. It will be seen 
that here, as in Europe, the tendency of the time is to 
secure the greatest possible protection to the public 
health with the least possible injury to commercial inter- 
ests, to abolish quarantine detention, substituting for it a 
system of medical supervision which will obviate the 
necessity for detention except in the case of manifestly 
infected vessels. 

Quarantine powers have always been regarded as be- 
longing to the States, and although several efforts have 
been made to secure the enactment of a general quaran- 
tine law, these have failed, apparently from the disincli- 
nation of the States to cede, their powers in this respect to 
the General Government. ‘The wide-spread devastation 
caused by yellow fever led, in 1796, to the discussion of 
a national bill for the regulation of quarantine. This 


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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


authorized the President to institute quarantine at ports 
of entry, and to specify its duration. Its second section 
directed the use of the revenue service in carrying out 
the quarantine law and the health laws of the States. 
The power of dictating and regulating quarantine, to be 
vested in the President, was voted down by the House of 
Representatives, but the second section was passed. To 


this the Senate attached an amendment, implying the bill to . 


be merely atemporary aid to existing protective measures, 
which should remain in force only until general regula- 
tions relative to quarantine were made by law. But this 
assertion of the power of the National Government to 
regulate quarantine was objected to in the House of Rep- 
resentatives, and the second section of the original bill 
was passed without amendment. This was followed and 
repealed, in February, 1799, by an act in which the posses- 
sion and exercise of quarantine powers by the States was 
fully and distinctly recognized, certain Federal officers, 
such as all officers of the customs, masters of revenue- 
cutters, and military officers commanding posts or sta- 
tions on the seacoast, being required to aid in the execu- 
tion of the quarantine and health laws of the States, 
according to their respective powers and within their 
respective precincts, and subject to the direction of the 
Secretary of the Treasury. 

For nearly three-quarters of a century no further effort 
was made to protect the country by national legislation. 
Meanwhile its quarantine laws became a heterogeneous 
conglomeration of impositions on commerce, without af- 
fording commensurate protection. Some small ports on 
the Gulf and Southern parts of the Atlantic seaboard, 
which, from their relations with the West Indies, had 
more or less familiarity with yellow fever, imposed no 
restrictions on their commerce, and the interior became 
exposed to epidemic invasion through these otherwise 
unimportant places. Other ports had only a nominal 
quarantine, because the revenue from fees was insuffi- 
cient to defray the expenses of its management. Gener- 
ally, however, there was some kind of quarantine reg- 
ulations, but in few instances, save at certain large 
commercial centres, were they efficiently carried out. 
The value of quarantine became assailed on account of 
the inefficiency of its administration, and the opposition 
was for a long time strengthened by conflicting views 
concerning the origin of yellow fever. During the epi- 
demic in Philadelphia, in 1793, the doctrine of its indig- 
enous origin was advanced for the first time, and since 
then this has repeatedly been brought forward as an ar- 
gument against quarantine restrictions. The extended 
experience of recent years has, however, apparently set- 
tled this question. Most of the epidemics have been 
traced to imported infection, although in a few instances, 
as at Newbern, in 1864, and Savannah, in 1876, the in- 
digenous origin of the fever has been strongly urged. 
Moreover, the meteorological and local hygienic condi- 
tions of Southern cities during periods of freedom from 
disease have not differed essentially from those presented 
by epidemic periods. ‘There are, therefore, few sanitary 
officers to-day who do not regard this fever as an exotic 
which may be excluded by suitable quarantine measures, 
but which, in the event of its introduction, may, under 
favorable protective conditions, survive the winter on 
the Gulf coast and reappear during the following sum- 
mer without a fresh importation. 

But although defective in their administration, so far 
as concerned protection, the seaport quarantines seldom 
failed to gather a tax from incoming vessels under the 
form of quarantine dues. Indeed, in some instances 
quarantine resolved itself into the collection of this tax 
in return for the official papers necessary to free pratique. 
According to Dr. Brown, ‘‘ There is a great deal in the 
various laws about inspections of log-books, manifests, 
and bilis of health ; mustering of passengers and crew ; 
examination of masters and others under oath ; but prac- 
tically all these requirements are seldom enforced. What 
actually takes place is for the health-officer to come on 
board as soon as the vessel heaves to off the quarantine 
ground, hurry to the captain’s or purser’s office, and, if 
she come from a non-infected port, simply inquire if all 


 . |. ee 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


are well on board, receive his fee, and depart as soon as 
possible. If from an infected port, he directs the master 
to bring his ship to anchor, and does not concern himself 
further about her unless she have sickness on board. 
During his brief stay on board, the steward of the ship 
is generally engaged in loading the health-officer’s boat 
with fruit, ice, or other delicacies, which are received as 
a matter of course ; and, indeed, any omission in this par- 
ticular has been known to subject certain lines to great 
inconvenience. Lest this may be thought an exaggera- 
tion, I may mention that the health-officer of one of the 
Southern ports told me, some years ago, that he saved 
all his salary, as he was entirely supported by the great 
variety of articles he received in this way. As at present 
administered, the visits of inspection are simply a farce, 
the only object being to collect the fee and receive the 
douceurs which are the perquisites of the health-officer.” 

Quarantine fees at some of the Southern ports, particu- 
larly those of Texas, yielded a considerable revenue, and 
were a corresponding burden to the commercial interests. 
The States, according to Justice Bradley, ‘‘ have a right 
to establish quarantine regulations for the protection of 
the public health, but they have no right to place toll- 
gatherers at the gateways of commerce and lay indiscrimi- 
nate exactions upon all vessels that enter thereby.” Even 
at the port of New York quarantine dues by far exceeded 
the necessities of the occasion, whereby the service and 
its officers became repeatedly subjected to adverse criti- 
cism. 

In 1872, Dr. Harvey E. Brown, U.S.A., made a thor- 
ough inspection of the quarantines of the Southern ports 
exposed to invasion by yellow fever, in accordance with 
a joint resolution of Congress, providing for a more ef- 
fective system of quarantine on the Southern and Gulf 
coasts. In his report this officer stated that these quar- 
antines, being established by State or municipal authority, 
lacked that uniformity which is absolutely necessary to 
their efficiency, were not founded on rational views of 
the pathology of the disease, and were generally defective 
in their administration. To remedy the evil he recom- 
mended the assumption of quarantine by the General 
Government, and its administration by the War Depart- 
ment ; claiming that only in this department of the Gov- 
ernment is found that freedom from political influences 
and that authoritative management which demands abso- 
lute obedience to law, while granting the largest liberty 
to the individual consistent with the public safety. The 
Surgeon-General, in forwarding this report, did not en- 
dorse its recommendation for the transfer of quarantine 
duties to the medical corps of the army, as he conceived 
that the imposition of these responsibilities would materi- 
ally interfere with the interests of the military service. 

As the result of this investigation, a bill for a national 
quarantine passed the House of Representatives at its next 
session, but failed in the Senate. This bill proposed the 
institution of a quarantine board consisting of the Sur- 
geon-Generals of the Army, Navy, and Marine Hospital 
Service, to formulate regulations which should not con- 
flict with existing State regulations—these to be enforced 
by a quarantine officer specially detailed from one of the 
services. Its failure was ascribed to the manifest diffi- 
culty of making effective national regulations without in- 
terfering with the inharmonious requirements of the laws 
of the various States. 

In 1878 a bill was passed by both houses of Congress 
empowering the Surgeon-General of the Marine Hospital 
Service to frame rules and regulations for the purpose of 
preventing the introduction of contagious diseases into the 


United States, which rules and regulations should be sub-. 


ject to the approval of the President, but should not con- 
flict with or impair any sanitary or quarantine laws or 
regulations of any State or municipal authority which then 
existed or might thereafter be enacted. One of the or- 
ders published under the authority of this act prohibited 
from entering any port of the United States all vessels 
from the Black Sea or Sea of Azof conveying rags, furs, 
skins, hair, feathers boxed or baled, clothing or bedding, 
or any similar articles liable to convey infection, and all 
vessels from the Red Sea or Mediterranean having on 


Quarantine, 
Quarantine, 


board such articles coming from Southern Russia. This 
aroused a storm of opposition on the part of the commer- 
cial interests. Nearly one thousand paper-mills were 
affected by the enforcement of the order, and their influ- 
ence, thrown in the baiance against the act, was mainly 
instrumental in modifying subsequent legislation. On 
the other hand, the American Public Health Association 
had for several years been considering and urging the 
advisability of Federal protection against the introduction 
of foreign pestilences. The yellow-fever epidemic of 
1878 brought to the support of this association many 
able men who had witnessed the misery, panic, and com- 
plete cessation of business relations which had overtaken 
the Southern States during the summer of that year. 
Several bills were brought before Congress, all looking 
to uniform quarantine regulations under national super- 
vision. One which appointed a director-general of health, 
charged with the duties of declaring quarantine at his 
own discretion in any part of the United States, and 
making and enforcing quarantine regulations, was lost in 
committee. Another, which appointed a board of health 
to frame the regulations, and a director-general to enforce 
them at any port where the local health-officer failed to 
execute them, was passed by the Senate, but was viewed 
unfavorably by the House of Representatives. 
Ultimately, in March, 1879, an act was passed author- 
izing a National Board of Health, consisting of seven 
members, to be appointed by the President, not more 
than one of whom was to be from any one State, and 
four national representatives, detailed respectively from 
the Attorney-General’s Department and the Medical De- 
partments of the Army, Navy, and Marine Hospital Ser- 
vice. This board was required to obtain information on 
all matters affecting the public health, to advise the sev- 
eral departments of the Government, the executives of 
the several States, and the commissioners of the District 
of Columbia on all questions submitted by them, or 
whenever in the opinion of the board such advice would 
tend to the preservation and improvement of the public 
health ; and in the discharge of these duties it was au- 
thorized to make or cause to be made such special ex- 
aminations and investigations, at any place or places 
within the United States or at any foreign port, as it 
deemed necessary. It was also required to mature and 
report to Congress a plan for a national public health 
organization, the principal sanitary organizations and 
the sanitarians of the several States to be consulted in its 
preparation, with reference specially to quarantine, mari- 
time and inland, and to the regulations which should be 
established between State or local quarantines and a na- 
tional quarantine system. But before action was taken 
on this requirement the law of June 2, 1879, was en- 
acted, imposing on the board certain duties in connection 
with quarantine. These were immediately undertaken, 
and the measures adopted were subsequently approved 
by the Academy of Sciences and the American Public 
Health Association, which advised against any change in 
the organization or methods. The board was required 
to make such rules and regulations as are authorized by 
the laws of the United States and necessary, for sanitary 
reasons, to be observed by vessels at their port of depart- 
ure and on the voyage, when contagious or infectious 
disease was present at the said port ; these rules, after ap- 
proval by the President, to be published, communicated 
to, and enforced by the consular officers of the United 
States. As afterward framed, they required the exclu- 
sion from the vessel, as far as possible, of persons or 
things known or suspected to be infected ; cleanliness, 
ventilation, and disinfection, if needful, preliminary to 
loading ; and a sanitary or medical inspection prior to 
sailing, with the certification of the consular officer or 
medical officer of the consulate in the form of a bill of 
health. Vessels entering or attempting to enter any port 
of the United States without this bill of health, to show 
that they had in all respects complied with the require- 
ments of the act, were to be subject to a fine not ex- 
ceeding one thousand dollars. On its face this bill ap- 
peared to give the board a power over the sanitary 
condition of vessels coming to this country from in- 


125 


Quarantine. 
Quassia. 


fected ports, by imposing a heavy penalty for the in- 
fringement of its rules ; but a proviso, the effect of which 
was unforeseen, deprived the penalty clause of its force. 
To prevent the unwitting contravention of the law, it 
was provided that the penalty should not attach to any 
vessel until the act and the rules and regulations made 
in accordance with its requirements had been promul- 
gated for at least ten days in the port of her departure. 
Under existing conditions of international comity, this 
promulgation of a United States law could not be ef- 
fected at foreign ports, and but for the energy of our 
consular officers the intent of the law would have utterly 
failed. As it was, these officers at infected ports labored 
zealously to have all vessels clearing for the United 
States free from infection and in good sanitary condi- 
tion. They had no support in their efforts, for vessels 
which had not complied with the law, as regards in- 
spection and consular bills of health, very frequently 
found as ready admission into our ports, in the absence 
of infectious disease during the voyage, as those which 
had fulfilled the requirements of the law. Local quar- 
antine authorities, if satisfied that the vessel was not a 
dangerous subject, permitted her to enter without refer- 
ence to bills of health or other: points connected with a 
national quarantine service. Nevertheless, much good 
was accomplished ; for instance, the risk of importing 
yellow fever from Havana was much reduced by con- 
sular medical supervision over vessels sailing from that 
port, which supervision, although non-compulsory in 
character, was generally effected ; and in the exceptional 
cases in which masters of vessels declined inspection, 
the quarantine authorities of the port of destination were 
notified by telegraph, and prepared to make special in- 
quiry into the sanitary condition of such vessels. 

Another section of the act under consideration required 
the board to co-operate with and aid State and municipal 
authorities in the execution of their rules and regulations, 
and authorized it to take steps toward strengthening the 
quarantine of ports at which existing regulations did not 
appear to give adequate protection. If there were no 
local regulations, or if these were defective, at any port, 
the board was called upon to report the facts to the Pres- 
ident, who was authorized, at his discretion, to order the 
board to make rules and regulations for the port in ques- 
tion, to be enforced by the State authorities ; but if the 
State authorities failed or declined to enforce them, the 
President was empowered to detail an officer or appoint 
a proper person for that purpose. Under this call to co- 
operate with and aid State and local boards, and in the 
exercise of the advisory duties imposed by its consti- 
tuting act, the board, after full consultation with local 
health authorities and the sanitarians and commercial 
men of the country, drew up a system of quarantine 
rules, which it recommended for adoption at the various 
ports, and which were adopted by nearly all the local 
authorities, thus overcoming the difficulty of formulat- 
ing rules which should not conflict with local laws. 
These rules recognized as contagious or infectious dis- 
eases, cholera, yellow fever, plague, small-pox, and ty- 
phus; as an infected port, one at which cholera, yellow 
fever, or plague exists, or at which small-pox or typhus 
prevails as an epidemic; and made use of the word 
quarantine as meaning the administration employed to 
determine the presence or absence of the causes of contagious 
or infectious diseases tn vessels arriving at a port, and to 
secure, tf present, the removal or destruction of such causes. 
They prescribed the accommodations and equipment of a 
quarantine station, and the general principles of detention 
for observation in the case of suspected vessels, and for 
medical and sanitary treatment, in the case of infected 
vessels. Persons under observation for yellow fever 
were to be detained until, in the judgment of the local 
authority, they might be safely permitted to go on shore, 
but this period was in no case to be less than five days 
from the time of the last exposure. The period of in- 
cubation of the disease or diseases for which the ship 
Was quarantined was to be held in view in considering 
the duration of the detention of persons who had been, or 
were supposed to have been, exposed to infection. 


126 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Also, in aid of the local authorities, certain refuge sta- 
tions for infected vessels were established on the coast. 
One for ports on the Gulf coast at Ship Island, Miss., a 
second for the Southern ports on the Atlantic coast at 
Sapelo Sound, Ga., and athird in Hampton Roads. Un- 
der the law these were not national quarantine stations, 
but lazarets or refuges for suspected or infected vessels 
refused admission by the local authorities of ports which 
had no facilities for the accommodation of suspects, the 
treatment of sick, and the proper handling of infected 
ships and cargoes. These stations were of immense ad- 
vantage to the coasts which they covered, each acting as 
a local lazaret for the many small ports which were in- 
capable of supporting an institution of that character, 
rendering unnecessary a multiplication of infected foci, 
and affording, under national auspices, better care to the 
stricken vessels than had been available prior to their 
establishment. The principle was by no means new. 
The English quarantine law, as has been seen, required 
all infected vessels approaching the coast of the United 
Kingdom to proceed to the thoroughly equipped station 
at Milford Haven; and in this country the quarantine 
establishment of the port of New York had always been | 
open to vessels bound for the ports of New Jersey and 
Connecticut, and the Boston station to vessels for other 
New England ports. But the system was peculiarly 
suited to the needs of this country, in view of the rela- 
tions of the National and State governments with respect 
to quarantine, the latter wielding the power under the 
law, and the former restricted to aid and co-operation. 
The local authorities of pcrts within the range of the 
refuges were enabled to operate efficiently in the exercise 
of their quarantine powers, by concentrating their re- 
sources on the management of a service of inspection 
and observation which granted admission to port or sent 
the vessel to the national refuge station, as might be 
deemed best under the circumstances. 

It was the intention of the board to establish refuge 
stations at certain points from Galveston to the Delaware 
Breakwater, that the whole line of coast might have 
readily available support. Each station was to be provid- 
ed with places for loading, detaining, cleansing, and dis- 
infecting vessels ; hospital accommodations for the sick, 
and quarters for passengers and crews held under ob- 
servation ; wharves, warehouses, and fumigating houses 
for the handling of infected cargoes; steam-tugs, boats, 
etc., for the proper administration of the station ; medical 
supervision and attendance, and the personnel needful to 
carry out the purposes of the establishment, with quarters 
for their accommodation. But these intentions were 
frustrated by the action of Congress in locking up the un- 
expended balance of the fund originally appropriated for 
such purposes. This appears to have been done under a 
misapprehension of the character of the proposed stations, 
which were at the time frequently spoken of as national 
quarantine stations, and must be construed as an expres- 
sion of the disinclination of Congress to warrant national 
interference with State and local authority. The station 
established at Ship Island, Miss., for co-operation with 
the Gulf ports, was well outfitted with pavilion quarters 
and hospital, wharves, storehouses, boats, a steam-tug 
for boarding vessels, and a sloop for communication with 
the mainland. The Sapelo Sound station was in efficient 
working order, and gave much satisfaction to the quar- 
antine authorities of Georgia and South Carolina, al- 
though much of its accommodation was of a rude and 
makeshift character. At Norfolk a barge was fitted up 
as a floating hospital for the relief of any infected vessel 
that might put into Hampton Roads for assistance. 

The board was also required to co-operate with and 
aid State and local authorities in preventing the spread 
of epidemic disease from one State into another, and 
very shortly after its organization the Memphis epidemic 
called forth every energy for its limitation. During the 
epidemic of the previous year, 1878, self-preservation im- 
posed the policy of non-intercourse on most of the South- 
ern communities, and what was known as the shotgun 
quarantine was inaugurated : Vessels from New Orleans 
or other infected or suspected places were repelled from 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Quarantine, 
Quassia, 


the Mississippi landings by armed citizens, and trains 
and other overland modes of interstate communication 
were stopped at the State line and denied right of way. 
But under the auspices of the National Board of Health 
these rigorous quarantines were replaced by the system 
of medical inspection ; commerce and travel were not in- 
terrupted, but placed under such a supervision that the 
disease was not propagated on their lines. According 
to the report of a Senate committee of the Forty-seventh 
Congress, the disease ‘‘ was actually stamped out in New 
Orleans and confined to the limits of Memphis ; and in- 
stead of the general disorganization and panic, with sus- 
pension of business, trade, and commerce which pervaded 
the country in 1878, commerce and communication with 
the infected cities were regulated—not stopped, or even re- 
tarded to any considerable extent—and the general busi- 
ness of the country went on in its usual methods and 
through its usual. channels without serious interruption. 
Instead of panic and alarm, confidence and a sense of 
security pervaded the country.” This system proved so 
efficient in restraining the spread of yellow fever, that in 
the following year its continuance was imposed on the 
board by the action of the States that were exposed to 
danger from the presence of the disease in New Orleans. 
As this city had been the starting-point for many wide- 
spread epidemics, its condition was narrowly watched by 
the health authorities of neighboring States, and on the 
acknowledgment of the presence of suspicious cases or- 
dinances were passed prohibiting the landing of freight 
or passengers within their jurisdiction, unless these car- 
ried with them the inspection certificates of the national 
health service. At first the official announcement of the 
resident member of the National Board was accepted by 
the States as authoritative with regard to the condition 
of New Orleans; but as it was found that the city au- 
thorities were disposed to withhold information in sus- 
picious cases, the mere rumor of a case of fever some- 
times precipitated the action of the States in their demand 
for National Health Board inspections as a guarantee of 
safety. New Orleans acknowledged the advantage of 
these inspections in permitting commercial intercourse 
which would otherwise have been stopped during the 
existence of fever, but objected to the imposition of any 
restriction, delay, or inconvenience until the disease was 
acknowledged by its own authorities. The desire to sup- 
press all suspicion of infectious disease in its line of op- 
erations is as old as commerce itself. De Foe, speaking 
of the last and greatest epidemic of plague in London, 
says that, early in May (1665), it ‘‘ had gotten into several 
streets, and several families lay all sick together, and ac- 
cordingly in the next weekly bill the thing began to 


show itself; there was, indeed, but fourteen set down: 


for the plague, but this was all knavery and collusion, 
for St. Giles parish buried forty in all, most of whom it 
was certain died of the plague.” The Mississippi States 
did not have that confidence in the official statements of 
the health authorities of the city of New Orleans that 
they were ready to give to the National Board of Health, 
which represented their interests in the suspected city. 
During the continuance of yellow fever in the city every 
vessel, with its crew, passengers, and cargo was inspected 
before sailing, and similar precautions were taken on the 
lines of rail. Refuge stations were established at points 
on the river below Memphis, Tenn., and Vicksburg, Miss. ; 
at Cairo, [l., and Bayou Sara, La., at which vesseis were 
inspected in passing and their bills of health viséd for 
free admission into their port of destination, or detained 
for appropriate treatment if yellow fever was found to 
have been developed during the voyage. 

The law which imposed on the National Board of 
Health the duty of aiding and co-operating with State 
and local authorities expired at the end of four years 
from its passage. It was tried as an experiment, but al- 
though successful, certain influences were at work to 
prevent its perpetuation. Chief among these was the de- 
sire of the Marine Hospital Service to erect itself into 
a bureau of medical officers.of the Treasury Department 
similar to that of the Army or Navy. The law of 1878, 
repealed in 1879, placed the so-called national quarantine 


in the hands of this service, and from that time it has 
made every effort to recover its lost position and consti- 
tute its members federal quarantine officers, paid from 
the national treasury, instead of hired medical attendants, 
paid for their services to sick sailors from a fund con- 
tributed by the mercantile marine. The board was rep- 
resented as merely a medium by which State and local 
authorities dipped their hands into the federal treasury, 
and the antagonism of the New Orleans board was mag- 
nified into inability to co-operate with the local sanitary 
authorities of the country; while the Marine Hospital 
Service was upheld as having a medical staff, hospitals, 
revenue cutters, etc., all of which could be used for 
quarantine purposes without calling into existence an 
new machinery such as a National Board of Health. 
These arguments, shallow as they were, sufficed to pre- 
vent the re-enactment of the so-called quarantine law, 
yet failed to carry congressional action so far as to make 
the Treasury Department the administrator of a national 
quarantine. The expedient was adopted of placing an 
epidemic fund in the hands of the President, to be used 
in aid of State and local boards of health, or otherwise 
at his discretion, in preventing and suppressing epidemics 
and maintaining quarantine at points of danger. The 
disposition of this fund has been transferred to the Treas- 
ury Department, and of late years the current expenses 
of the refuge stations established by the National Board 
of Health have been paid from it by the Marine Hospital 
Service. 

Other than the law passed at the end of the last century, 
requiring revenue, marine, and custom officials to aid in 
the enforcement of local laws, and an appropriation in 
the sundry civil bill of each successive year, to be used 
in case of an epidemic, there is at present no national 
legislation for the protection of the country from inva- 
sion by exotic disease. Several efforts have been made 
by State and local boards, and such sanitary organizations 
as the American Public Health Association, and the San- 
itary Council of the Mississippi Valley, for the rehabili- 
tation of the National Board of Health; but these have 
failed, and the country is now in no better condition as 
regards national legislation than it was during the epi- 
demic of 1798, which devastated Philadelphia and New 
York, and prevailed even in Boston and other New Eng- 
land towns. 

The need of a central health organization as a bond of 
union between the State authorities, and a means for co- 
ordinating their action and representing their interests on 
the international aspect in the case of a threatened inva- 
sion of cholera or yellow fever, has been so well appre- 
ciated by these authorities, that, having failed through 
the opposition of the Treasury in their efforts to secure the 
re-establishment of the National Board of Health, they 
endeavored to obtain from Congress a central health au- 
thority of some kind, urging at first .a board constituted 
by State representation, and when that was declined on 
the ground of unwieldiness, asking with equally negative 
results for a director-general of health ; yet ready to be 
satisfied with any legislation that would enable them to 
realize the benefits of co-operative action such as were 
obtained under the auspices of the National Board of 
Health. Meanwhile this board continues to have a legal 
existence, as the limitation of four years applied only to 
the so-called quarantine law, not to the constitution of 
the board. It requires merely the financial support of 
Congress to enable it to resume the labor of amalgamating 
into a trustworthy whole the inspection or quarantine 
systems that protect the coast, and the salient points of 
interstate travel and traffic. 

Charles Smart. 


QUASSIA, U. S. Ph.; Quassie Lignum, Br. Ph. ; 
Quassia dé la Jamaique, Codex Med. ; Lignum Quassia, 
Ph. G. (including also wood of Q. amara). The wood 
of Pterena excelsa Lindley; order, Simarubacee. A 
large, fine-looking tree, with erect, thick trunk and 
spreading branches covered with arather smooth brown- 
ish-gray bark. Leaves alternate, odd-pinnate, leaflets 
entire, oblong, pointed, thick, and smooth. Flowers 


127 


Quassia. 
Quinto. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


small, in lateral cymes, polygamous, greenish-yellow. 
The perfect ones have a calyx of five minute teeth, five 
petals, five stamens about as long as the corolla, and two 
or three one-ovuled carpels with their styles 
united. The staminate flowers have more 
spreading petals and longer stamens, no 
pistils. The carpels ripen into purplish- 
black drupes. Jamaica Quassia, also 
called Bitter Wood or Bitter Ash, 
from its resemblance to that tree, 

is a native of some of the West 
India islands, from several of 
which the wood is exported, 
especially from Jamaica. 

Originally the name 
was applied to the 
wood of Quassia ama- 
ra (Bois amer de 
Surinam, Codex 
Med.), a shrub  be- 
longing in the same 
family and _possess- 
ing exactly the same 
qualities, growing in 
Central and South 
America, and first in- 
troduced into Europe 
about the middle of 
the last century. The 
present tree was gen- 
erally substituted for 
Q. amara in the early part of this century, al- 
though the other is still found in European 
pharmacies. Q. amara is rarely to be found 
in American or English shops. 

Quassia is imported in billets or logs several 
feet long, and from two to six inches in diame- 
ter. It has a dark-gray bark, and tough, com- 
pact, yellowish-white, inodorous, but very 
bitter, wood. These logs generally go to turn- 
ers, where the best are cut into drinking-cups 
or goblets, and the pieces are saved for the 
pharmacies. Otherwise the logs must be cut 
or rasped into fine pieces to make them suitable for phar- 
maceutical handling. These shavings are yellow, ino- 
dorous, and intensely and persistently bitter. 

Composition.—The bitterness of Quassia is due toa 
minute quantity 
of a neutral crys- 
talline substance, 
first obtained in 
1835 by Winck- 
ler from the wood 
of Q. amara, and 
afterward from 
that of the Pi- 
crena now used. 
Quassiin is spar- 
ingly soluble in 
water and alco- 
hol, has an ex- 
ceedingly bitter 
taste, and prob- 
ably represents 
the tonic and 
“narcotic” prop- 
erties of the crude 
drug. Quassia 
contains no tan- 
nin. 

ACTION AND 
UsEe.—Quassia is 
generally regard- 
ed as a pure or 
simple bitter 
tonic, like gentian, and is mostly used as such, being 
given, either alone or in combination with aromatics and 
stimulants, as a stomachic and appetizer. In debility, 
in convalescence from fevers, in dyspepsia, it has been 


128 


FiG, 3226.—Flowering 
Branch of Quassia (Pi- 
creena excelsa), (Bail- 
lon.) 


uy) Ole 
DO 
if Oe aA ks 


Ss 
! BePanier| 
NNO eyelet 

oO Gaod 


Y( \ 
Fia. 3227.—Section of Quassia Wood. 


America 


and is still in considerable use. 
more bitter and disagreeable than that of gentian or qui- 
nine, and on this account alone would be less desirable 
as an appetizer than they. Quassia is, in addition, 
poisonous to insects and fishes, and probably in a 
slight degree to other animals. 


sules (Liierssen). 


Its taste is, however, 


The symptoms 
produced by it are stupor, convulsions, paral- 
ysis, etc. It does not appear to be delete- 
rious to man. Another useful employ- 
ment of the drug, depending upon this 
insecticide or vermicide power, is as 
an injection for ascarides, for 
which purpose it is both safe 
and efficient. 
ADMINISTRATION. —Dose : 
One or two grams (gr. 
Xv. ad xxx.) in infu- 
sion. The officinal 
preparations are 
Tincture (Tinctura 
uassi@, U. S. Ph., 
zo), Fluid Extract 

(Eztractum Quassie 

Fiuidum, U.S. Ph., 

+), and Extract (#72- 

tractum Quassiea, 
about **); the latter 
is useful for admin- 
istration as pills. 

The ‘‘ Quassia cups” 

are medical toys of 
no great value. For injection as a vermicide 
from half a pint to a pint of a ten per cent. in- 
fusion may be used. 

ALLIED PLANTs.—Besides three species of 
Picrena, all bitter, the order contains Quassia 
amara, above noted; Q. cedron H. Br., and 
Simaruba officinalis D. C., both of which con- 
tain the same bitter principles and are in the 
Codex. It also contains the Adlanthus glandu- 
losa Desf. 

LLIED DruGs.—For tonics see GENTIAN, 
for anthelmintics see Koosso. W. P. Bolles. 


QUEBRACHO. This name is given in portions of 
Central and South America to several different trees 
whose wood or bark is mostly used in tanning; of these 


that known as 
white or pale 
Quebracho (Que- 
bracho blanco), is 
the only one of 
special medical 
interest. It is As- 
pidosperma Que- 

: bracho Schlecht, 
eS order, Apocyna- 
cee, and is also 
used in tanning. 
It is a large-sized 
tree, with slender, 
drooping twigs ; 
small, opposite, 
or whorled (in 
threes), short- 
petioled or ses- 
sile, elliptic-lan- 
ceolate, pointed, 
leathery, bluish- 
green leaves ; nu- 
merous axillary 
clusters of small 
yellow flowers, 
and large ellipti- 
cal, woody cap- 
of tropical South 


(Baillon,) 


It is an inhabitant 


; the bark is exported from Brazil, where it is 
valued as an antiperiodic. 
Quebracho was first brought to medical notice in Eu- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


rope, about ten years ago, by Dr. Penzoldt, as a cure for 
asthma. The bark, which is the portion employed, comes 
in thick, coarse pieces, of a yellowish-brown color, and 
bitter taste. It containsan abundance of tannin, and six 
alkaloids : Aspidospermine, crystallizing in needles, sol- 
uble in about fifty parts of alcohol, one hundred of ether, 
and six thousand of water—-a weak base of bitter taste ; 
Aspidospermatine, in warty crystals, more soluble ; Asp7- 
dosamine, amorphous or partly crystalline ; Quebrachine, 
colorless crystals becoming yellow in the light ; Hypo- 
quebrachine, yellow albuminoid masses ; Quebrachomine, 
resembling quebrachine. These alkaloids all weaken res- 
piration and circulation, and most of them are general 
paralyzers of motion. All nauseate somewhat ; aspido- 
samine is decidedly emetic ; quebrachine is most efficient 
in its effect upon the breathing ; aspidospermine is simi- 
lar, but weaker. Quebracho, and the two last-named al- 
kaloids, have been employed to reduce the dyspnea of 
asthma, cardiac disease, phthisis, etc., with some reputed 
success ; but although considerably tried and advertised 
several years ago, they are almost never called for at 
present; they appear to have done the most good in 
asthma. Dose, two or three grams (gr. xxx. ad xlv.), in 
form of tincture or infusion ; of the alkaloids quebrachine 
or aspidospermine from two to three centigrams may be 
iven, 

; ALLIED PLANTS.—The genus Aspidosperma contains 
upward of forty species, mostly South American. The 
order is not an important one ; it contains a few, not valu- 
able medicinal, and some poisonous, plants. Alstonia 
scholaris, etc., the Apocynums, Strophanthus, Nerium, 
and Vinca, are examples. . 

ALLIED Drues.—Morphine is probably more reliable 
as a respiratory depressant, and has also a great advan- 
tage over quebracho of stilling pain besides. 

W. P. Bolles. 


QUEEN’S ROOT (Stiliingia, U. S. Ph.). The root of 
Stillingia sylvatica Linn., order, Huphorbdtaceew, a peren- 
nial plant, with a large, woody root, and erect herbaceous 
or slightly woody stem, a foot or so in height; leaves 
large, thick, oval, or lanceolate, finely serrate ; inflores- 
cence a thick terminal spike. Flowers unisexual, the fe- 
male, few at the base of the spike, solitary, each in the 
axil of a thin, broad scale, with a large gland at each 
side, consist of a three-lobed calyx, three-celled ovary, 
and three styles; the staminate flowers are numerous, 
clustered in the axils of similar bracts all the way up 
the axis; they consist of a minute cup, from which 
emerge two partly united stamens. Stillingia grows 
abundantly in the Southern States, and has been used 
there, and a little elsewhere, for about half a century. 

The root is ‘‘ about twelve inches (30 centimetres) long, 
and nearly two inches (5 centimetres) thick, subcylin- 
drical, slightly branched, compact, wrinkled, tough, 
grayish-brown, breaking with a fibrous fracture, show- 
ing a thick bark and porous wood; the inner bark and 
medullary rays with numerous yellowish-brown resin- 
cells; odor peculiar, unpleasant; taste bitter, acrid” 
(U. 8. Ph.) The composition of stillingia is not well 
known ; essential oil and resin appear to be present. It 
is an emeto-cathartic, like many other plants in the order, 
and is also said to be ‘‘alterative.” Uponthis property its 
principal use depends. It is considerably used in ‘‘ scro- 
fula,”’ late syphilis, and other chronic complaints, with 
reputed benefit. Dose, dne or two grams (gr. xv. ad 
Xxx.) two or three times aday. A fluid extract is offi- 
cinal (Hetractum Stillingie FPluidum, U.S. Ph.). 

ALLIED PLANTs.—Another species of Sttlingia yields 
the Chinese ‘‘ vegetable tallow.” For the order see Cas- 
TOR-OIL. 

ALLIED DruaGs.—SARSAPARILLA et 7d omne genus ; 
PokE Root, BrrreR-swEET, etc. W. P. Bolles. 


QUINCE SEED (Oydonium, U. 8. Ph. ; Coing, Co- 
dex Med.). The seed of the garden quince—Cydonia 
vulgaris Persoon—order, Rosacew, an Asiatic shrub culti- 
vated in Europe for many centuries, and now grown in 
most warm, temperate countries. The fruits contain 


Vou. VI.—9 


Quassia. 
Quinto. 


malic acid, pectin, mucilage, etc., and have a peculiar 
flavor, due, perhaps, to pelargonic ether. The seeds are 
valued for their muctlage, and have been long in use in 
Eastern countries. They also contain a trace of hydrocy- 
anic acid. Quince seeds grow eight, ten, or more in each 
cell—they are smaller and more irregular in shape than 
apple seeds—have a dull surface, and are agglutinated to- 
gether. They contain about twenty per cent. of a pe- 


4 
ae 


Fig. 8228.—Garden Quince ; Section of Fruit. 


(Baillon.) 


culiar mucilage, capable of gelatinizing more than one 
hundred parts of water, but of little adhesive power ; 
it consists of a soluble acacia-like portion, and an in- 
soluble part having many of the characteristics of cel- 
lulose. The officinal mucilage is made with two per 
cent. of seeds. Quince seed may be put to the various 
uses of mucilages in general, demulcent drinks, collyria, 
surgical dressings, sizing, etc. 

The principal demand for it, within the past few years, 
has been for toilet purposes (dressing the hair). 

ALLIED PLANTS.—See RosEs. 

ALLIED Drues.—See Gum Arasic. W. P. Bolles. 


QUINTO is a spa in the province of Saragossa, Spain. 
There are two springs, of similar composition, the waters 
of which are employed, as a rule, only internally. The 
two springs are known as the Upper and the Lower. 
The following is the composition of Quinto water, accord- 
ing to the analyses of Moreno and Lletget, quoted by 
Rotureau in the ‘‘ Dictionnaire Encyclopédique des Sci- 
ences Médicales.”’ 

One litre contains : 


Grammes 

Caleiumipsnl platen crate casas eae a cele <> aleicuh Sesion 1.759 
DOCLIMMSELD TAGE a crn ersitictetec oie ae! oecceik's elaehee sore 5,-< 0 Mis 0.498 
Magnesium sulphate. ............ See. Aa OM 0.307 
Magnesium chloride......... Lh oewas eo ateh aes 0.014 
Sodimmachlonide.s. saht< ates aces alee Sib evaltls Sie Sisiesa te alates 0.009 
CaleimTchioride. sici.<ic ae.s1e 66 os dase e sarevo\sh es «is os ocd 0.005 
Silicic acid ...... icc ioe SCI sea RST EHC CRE 0.010 

PD OLBU SAY ie sia a ales eaitiels toda sisted ee 2.602 


These waters enjoy considerable reputation in Spain in 
the treatment of syphilitic affections. They are also em- 
ployed in digestive troubles and for the relief of those 
suffering from uric-acid gravel. The waters are both 
diuretic and laxative. The season extends from the first 
of June to the end of September. bl. 


129 


Rabies. 
Rabies. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


RABIES. 
wuth, Tollwuth ; Fr., Rage, Hydrophobie.) Rabies, or, 
as it is more commonly designated in our language, hy- 
drophobia, is to be classed essentially among the more 
pronounced neuroses. It is thought to be occasioned 
only by the specific poison from rabic animals, and its 
principal phenomena are connected with an exalted reflex 
irritability, chiefly of the respiratory nervous centre, and 
the centre of deglutition ; later, there are increased irrita- 
bility of the motor spinal centres, general hyperezsthe- 
sia, and, finally, psychical exaltation. Lyssa is therefore 
to be regarded, from its symptomatic characteristics, as a 
specific toxic affection, and is essentially a variety of 
tetanus, similar in some degree to that caused by strych- 
nia. It is placed in the list of those diseases which, for 
want of a better classification, may be called ‘‘ tetanici.” 

Rabies, seems to belong to the same class of diseases as 
erysipelas, anthrax, etc., in that it depends for its trans- 
mission upon inoculation into the blood, or at least into 
the subcutaneous tissues of the animal body. It presents 
many points of similarity with many of the bacterial 
forms of disease, in which the infecting agent is known 
to invade the body, and there multiply, and by its in- 
crease to produce the phenomena of the disease. 

True rabies (lyssa vera) arises in all instances from in- 
fection by the specific virus, or that material substance 
which contains or conveys the infecting principle, as 
produced in animals affected with this malady. 

Rabies in man is not known to have ever occurred 
except after penetration of the rabic poison beneath the 
epidermis, or other epithelial covering of~the body. 
There is no known case in which it has been actually 
proved that infection has taken place through the unin- 
jured mucous membrane, although cases have been re- 
ported in which this has been thought to occur. These 
cases are either due to a mistake in diagnosis, or to the 
fact that slight lesions of the mucous membranes are 
easily overlooked, or may be quite healed before the dis- 
ease makes itself evident. 

As a proof of the protection afforded by the mucous 
membrane against the entrance of the rabic virus into the 
animal system, is the fact that the flesh and milk of ani- 
mals affected with this disease have been used as food by 
the human subject without the slightest ill effects. This 
fact accords with the further fact, that the milk and but- 
ter from cows which are the subjects of rabies may be 
taken with impunity. 

The sole avenue of entrance of the rabic poison is, 
therefore, by the path of infection, and this means the 
inoculation of the disease. 

Rabic infection may take place in various ways: First, 
from the teeth or the bite of a diseased animal. This is 
not dangerous unless the teeth have penetrated the epi- 
dermis, or at least have eroded or abraded it, and by this 
means a path of entrance has been made for the saliva 
to reach the subcutaneous tissues, There is reason to 
believe that the virus is dangerous at a period somewhat 
previous to the development of the marked signs of 
rabies in the dog. The danger is proportionally in- 
creased as the teeth of the dog are sharp, and the wound 
is deep and penetrates the flesh to a greater degree. 

The power of communicating the disease is not con- 
fined to the periods of fury, which are a feature of the 
malady in the dog, but the rabic animal is prone to be- 
come suddenly furious from a state of absolute quiet, in 
which the existence of a serious disease could not be sus- 
pected, and may then inflict a fatal bite. 

The clothing, or other covering of the body, affords a 
limited degree of protection from the poison of rabies, as 
the passage of the teeth of an animal through the clothes 
removes the saliva to a more or less perfect degree. 

The claws of any of the carnivorous animals may be 
the bearers of the rabic poison, from the fact that they 
are more or less in contact with the mouth of the animal, 
and are likely to become contaminated with the saliva. 
A slight scratch would be sufficient to afford entrance to 
the infection. The disease may also be communicated 
by the tongue of the rabid animal, in licking any place 
from which the epithelium is absent, which thus allows 


130 


(Gr., Lyssa; Lat., Rabies; Germ., Hunds- | 


the virus to come into contact with the subcutaneous 
tissues. 

Second. Another source of danger is the flesh or 
blood of animals dead from rabies, which constitutes a 
peril to those who may be employed in the disposal of the 
bodies, or in making post-mortem examination, of such 
animals. The smallest excoriation or abrasion is suffi- 
cient for the infection of the system, and thus for the in- 
troduction of a fatal disease. 

Errotoey.—The etiology of rabies (lyssa humana) is 
uniformly and invariably the inoculation of the system 
with the specific poison of the disease, derived from an 
infected animal—dog, cat, fox, wolf, horse, skunk, cay- 
ote, the ruminants, swine; and in one case observed by 
the writer, the disease followed the bite of a rabbit, 
which was not known to be affected. It is not definitely 
known that other species of animals are capable of com- 
municating the infection of rabies. 

Like anthrax and many other infective disorders, the 
inoculation by rabies always takes place through some 
wound or other defect of the skin or mucous membrane ; 
and the disease is communicable only by means of intro- 
duction of the virus into the subcutaneous tissues. The 
virus is contained not only in the saliva of diseased ani- 
mals, but also in other glandular secretions, in the blood, 
in the substance of the nervous structures, and probably 
in all the tissues of the body. 

Rabies is uniformly dependent upon infection from 
without, and in nearly all cases the disease is communi- 
cated by means of the biteofa rabid animal. The period 
of incubation of this disease, 7.¢., the length of time after 
the introduction of the virus into the system before the 
symptoms of rabies make their appearance, is a variable 
one. It has been known to become evident within the 
first day after inoculation, and it is sometimes delayed in 
its appearance for months, or even years. The most fre- 
quent period for the invasion of the disease is at a time 
from three to eight weeks after inoculation. 

There appears to exist in rabies, as in syphilis, a pe- 
riod of latence of the infectious material, during which 
it may be retained within the system, but shows no 
symptoms of its presence. At times the disease appears 
to cause prodromal symptoms in the original seat of the 
infection, such as pain, swelling, etc., with restlessness 
and anxiety on the part of the patient ; but often the mal- 
ady appears suddenly in the form of well-marked dis- 
turbance in swallowing, or the initial symptom may be 
a convulsion of the respiratory apparatus following an 
attempt at swallowing. Death is usually inevitable, 
generally occurring between three and six days after the 
first onset of the symptoms of the disease. The fatal 
result may even occur in so short a time as twelve to 
twenty-four hours. The temperature of the body is ele- 
vated, at times reaching 40° C. (104° F.). Death follows 
from apoplexy, asphyxia, exhaustion, or the patient dies 
suddenly from some unknown interference with the vital 
processes. Not all patients who are bitten by rabid dogs 
are attacked by rabies ; the predisposition of the patient 
to infection of any kind has much to do with the sever- 
ity of the symptoms in many cases. The most important 
features of any case are the location, and still more the 
depth, of the bite. Lacerations by the teeth of the rabid 
animal, which are situated upon unprotected parts, and 
especially those which penetrate deeply, are most dan- 
gerous. 

IncuBATION.—The dreaded character of the rabic dis- 
ease, and the great variability which exists in regard to 
the time of its appearance after the poison has entered the 
system, have led to the more careful obervation of cases 
in which there was supposed to be danger of this mal- 
ady, with the result of obtaining more definite and uni- 
form information as to the time and the manner of the 
symptoms which usher in the rabic development. It 
has been noticed that local sensitiveness, with a gradual 
extension from the extremity toward the trunk, occasion- 
ally precedes the outbreak of the disease, accompanied 
by renewed pain in the scar of the bite, or in the bite it- 
self, if this be not already healed, with redness and swell- 
ing of the neighborhood. Often there is prodromal rest- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


lessness, with physical depression, febrile action, etc., 
though in some cases the spasm in deglutition is the first 
noticeable symptom of the invasion of the disease. Re- 
cently M. Pasteur, of Paris, has made all the known au- 
thentic cases of undoubted rabies which have occurred 
in France, the subject of careful analysis as to the period 
which elapsed after the inoculation of the disease, before. 
the invasion of the symptoms of the fatal malady. He 
collected data concerning 587 cases. Of these, 27 were 
excluded from one cause or another, leaving 510 cases as 
the basis of his deductions. 

These 510 cases show an average period of incubation 
of 72 days, which is divided among the cases in the fol- 
lowing manner: In men the period of incubation was 
found to be 80 days on the average ; in women it was, 
on the contrary, only 65 days. The period of latency 
in men is, therefore, 15 days longer than in women. In 
persons between the ages of two to fourteen years, the 
latent period was 20 days shorter than in persons be- 
tween fifteen and seventy-eight years (women, 57 days; 
men, 76 to 77.5 days, respectively). This apparent dif- 
ference may possibly be accounted for, in some degree, 
by the fact that in children the wounds produced by a 
rabid animal are more likely to be located upon the face 
or other uncovered parts of the body, and thus inocula- 
tion of the patients may take place more easily ; and 
possibly the violence of the succeeding phenomena may 
also be thereby materially augmented. 

It is found that in cases in which the injuries were 
seated upon the head and neck, the period of incubation 
was 55 days; while in those cases in which the wounds 
were situated upon the upper extremity it was 81, and on 
the lower extremity it_was 74 days; while in such cases 
as presented injuries of many parts of the body, among 
which were wounds about the head, the period of incu- 
bation was 55 days. 

Persons who have been bitten by rabid wolves, to the 
number of 49, presented a period of incubation of 39 
days; those bitten by dogs, 293 cases, a period of 73.5 
days ; and those bitten by cats, 31 cases, a period of 80 
days. Pasteur had already called attention to the shorter 
period of incubation in cases of inoculation from the 
bites of rabid wolves. 

The period of incubation is not modified in any way 
by any mode of treatment, neither is the duration of the 
disease, when it is developed, in any material way modi- 
fied by the longer or shorter period of latence of the poi- 
son in the system. It is found that in seventeen per cent. 
of all cases of rabies the period of incubation is three 
months or over. 

Pasteur states that the disease shows itself, in the ma- 
jority of cases, at a period between the fortieth and six- 
tieth days after the reception of the bite. 

Dracnosis.—The most prominent symptoms of rabies 
are referable to the nervous system, and consist of an 
exaltation of the reflex irritability, especially of those 
departments which control the power of deglutition and 
the phenomena of respiration. These symptoms are soon 
followed by the development of an abnormal degree of 
nervous irritability of the spinal motor centres, by gen- 
eral hypereesthesia of the entire body, and finally by pro- 
nounced mental and moral disturbances. 

The classical and only indispensable symptom of hu- 
man rabies consists in the frightful and recurrent spasm 
which is induced by attempts at deglutition, by the pres- 
ence of saliva in the pharynx, by efforts at deep inspira- 
tion, as well as by the slightest irritation of the skin from 
any cause, and also by the movements of the atmosphere, 
in which the slightest breeze is caused, or at feast felt, es- 
pecially if the temperature of the external irritant or of 
the air be much below that of the body of the patient. 

The fact that the attempt to swallow is productive of 
great distress, and that it induces the spasm, causes the 
utmost terror in the mind of the patient at the thought of 
deglutition. This induces the fear of fluids so charac- 
teristic of this disease. It is the pain and distress thus 
occasioned which constitute the real source of the ‘‘ hy- 
drophobia,” the fear of the painful spasm of respiration 
_ and deglutition which the effort of swallowing induces. 


Rabies. 
Rabies. 


The term ‘‘hydrophobia” is the origin of much need- 
less confusion, for not only may a fear of the effort re- 
quired to take liquids be present, without the existence 
of rabies, but the rabic disease may be developed in fatal 
intensity without the occurrence of the spasmodic symp- 
toms usually associated with rabies. Hydrophobia alone 
does not constitute rabies, and rabies may exist without 
‘‘hydrophobia.” In fact, in canine rabies, the hydro- 
phobia is not a prominent or a frequent symptom. We 
should understand by the term ‘‘ hydrophobia” a condi- 
tion which may be thus delineated : First, one in which, 
without apparent motive, the patient finds it impossible 
to swallow liquids, and which may or may not be accom- 
panied by disagreeable or painful sensations to the pa- 
tient ; second, the sensation of fear or terror at the sight 
or sound of fluids, even when the patient may be able to 
overcome this feeling so as to take fluids voluntarily as 
drink. Patients with rabies are. frequently found in a 
state of great excitement from the fact that the fatal char- 
acter of this disease is well known, but the patient can 
always be restored to proper consciousness by kindly and 
calming efforts on the part of those about him, Hydro- 
phobia, therefore, constitutes only a symptom common 
to several distinct diseases. It is the product of an ab- 
normal excitation of the nervous centres, or the nervous 
elements, either of direct or of reflex origin ; or it is due 
to the disturbance of the normal relations existing in the 
tissues, which may be of three varieties: 1, a disturb- 
ance of the nutrition of the member or part ; 2, the effect 
of a direct irritant; and 3, the disturbance of the ner- 
vous supply, or of its distribution in the part affected. 

The ‘‘hydrophobia” (fear of water or other fluid) is 
apparently due to an affection of the general nervous 
system, for the hydrophobic spasm is present before the 
patient attempts to drink ; and it may be provoked by a 
variety of causes, such as a bright light, the view of an 
unexpected or unusual object, a sudden noise, a touch 
from an unfamiliar substance, or even the movements of 
those about the patient or the impression produced by a 
draught of air. 

The last is one of the most important symptoms of 
true rabies (Lyssa vera), as it is never absent in the real 
disease, and is seldom present in any of the other affec- 
tions which are associated with or accompanied by spasm 
of deglutition. It is indicative of communicated rabies. 

The excessive tension or the exalted reflex irritability 
in the nervous centres, or in those nervous centres which 
are concerned in respiration, is the essential character of 
the rabic development in man. The augmentation of the 
excitement by the indispensable requirements of the ani- 
mal (human) organism (air, water, etc.), and the dis- 
charge of nervous force in the way of powerful contrac- 
tion of the muscles controlled by the nerves of respiration 
and of deglutition, constitute the symbols of the disease. 
These pathognomonic conditions constitute the means of 
distinguishing rabies from any other condition of the 
system which may be accompanied by hydrophobia (Jac- 
coud). 

The terror, the maniacal fright, the convulsive cries, 
seem to be provoked by any agitation of external objects 
in a manner to impress any of the special senses. It 
would seem that the entire nervous system, the general 
sensibility, as well as the special senses, the intellectual 
faculties, and the moral nature are in a state of super- 
excitation, so that the least irritation of any part is com- 
municated to the entire system by a kind of special re- 
flex action, and produces the convulsive explosion. 

There seems to exist a special hyperesthesia, which 
does not manifest itself at the seat of contact, as is usual 
in such conditions, but which is reflected to remote cen- 
tres, and there produces an explosion of force in the 
form of painful spasm, cramps, convulsive contortions, 
and delirium of varying intensity, often associated with 
cries, fury, terror, visions, hallucinations of the special 
senses, etc. 

The symptoms of rabies are at times very confusing, 
and have given rise to the two designations, ‘‘ hysterical 
hydrophobia” and ‘‘ hydrophobic hysteria,” both of which 
conditions undoubtedly exist, and render the diagnosis 


131 


Rabies. 
Rabies, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


of the actual state of the patient more or less difficult, and 
frequently prolong the period of uncertainty as to the pre- 
cise nature of the malady. The exalted mental excitabil- 
ity of the patient exaggerates the already existing irrita- 
bility, and the spasm is at length induced by the sight or 
the sound of fluids, and finally is aroused by the simple 
thought of liquids or of drinking. The anxiety of the 
patient is increased by the well-known fatal character of 
the malady, and is too often unnecessarily and cruelly 
augmented by the injudicious and senseless conduct of 
those about the patient ; and in those cases in which the 
fear of the disease leads to the improper or brutal treat- 
ment of the sufferer, which has often occurred, there is 
frequently a condition of absolute mania. Calm and 
gentle measures will, however, always recall the patient 
to a consciousness of himself and his surroundings. 

The diagnosis of rabies in the human subject may be 
rendered difficult or temporarily impossible from simu- 
lation of the disease by Lyssa falsa, seu nervosa. ‘This 
is a condition which is frequently induced by the fear of 
rabies, and usually follows the innocent bite of an ani- 
mal free from the disease. The diagnosis cannot long 
remain the subject of doubt, as an interval of a few days— 
never longer than six—will suffice in all cases to defi- 
nitely establish or to disprove the existence of the dis- 
ease. 

Lyssa falsa may occasionally be followed by a fatal 
termination, owing to the anxiety of the patient, as has 
frequently been observed in neurotic individuals, after 
the bite of a healthy animal, and even after the accidental 
bite of the human subject in cases in which there could 
be no suspicion of rabies, 


These rare cases may, perhaps, be classed as tetanus, or 


as tetanus traumaticus lyssoides, as has been suggested 
by Lorinser. 

The result of rabies is invariably fatal, and usually 
occurs within three days after the appearance of the dis- 
ease. Occasionally the life of the patient is prolonged 
until the fifth or sixth day, but this is exceptional. In 
the human being the first symptoms of the fatal attack 
seem to be a peculiar itching of the old wound, and the 
spread of neuralgic pains from it toward the nerve-cen- 
tres. A general feeling of malaise, and an impending 
dread of something frightful about to happen, a tight- 
ness about the throat, areamong the common complaints 
of the sufferer, and there is difficulty in swallowing ; 
breathing becomes affected, and there is oppression over 
the whole chest. Violent paroxysms follow, showing 
evidently that the whole nervous system is in a fright- 
fully excited state. A ray of light, a breath of wind onan 
exposed part of the body, the sight of water, the constric- 
tion following the attempt at swallowing any fluid, greatly 
craved though it may be, are sometimes sufficient to de- 
termine the spasm. Ropy, viscid mucus is secreted by 
the salivary glands, and vehemently expelled from the 
mouth. Violent convulsions of the muscles of the lar- 
ynx and pharynx take place in many cases, closing the 
windpipe and preventing the access of air. Hallucina- 
tions come on, and sometimes wild delirium. During 
the interval between the attacks the sufferer is often calm 
and rational, and, in many cases, feeling the approaching 
access, he begs to be restrained so that he may do no 
harm. Paralysis finally supervenes, and the sufferer, to- 
tally exhausted, is mercifully relieved by death. The 
fatal result may occur in a short time (from twelve to 
thirty-six hours). In other cases the disease steadily ad- 
vances to a severer form, the temperature rising to 40° 
C. (104° F.). Death usually takes place then from apo- 
plexy, or from asphyxia, or the patient may suddenly 
expire, even when improvement may seemingly have oc- 
curred. 

The following vivid description of the progress of hu- 
man rabies is taken from the Archives de Physiologie, 
February 15, 1887. It is from the pen of M. J. Girode. 
The patient was treated in the Hépital Beaujon, by M. 
Guyot. The case belongs to that form in which the 
symptoms are developed with great rapidity, and is 
classed as ‘‘ presque foudroyante.” ‘The clinical history 
is as follows: 


132 


what to excess. 


Henry B., twenty-eight years of age, Italian, entered 
the hospital April 10, 1886. He has always been well. 
His character is of an impressionable nature, and he 
is decidedly nervous. He has been unfortunate in his 
affairs, and has practised as a musician, an actor, anda 
model in a studio. Has used intoxicating liquors some- 
He had a small slut dog, which was 
of very gentle disposition, but which bit him on the 
right hand, some two months ago, in consequence of a 
slight punishment. He compressed the wounded fin- 
gers in order to encourage bleeding for the time being ; 
but thought no more of the matter. On the same even- 
ing the dog became morose, remained crouched in a 
corner, and died in the space of three days, without hav- 
ing taken either food or drink. These events occurred 
between February 10th and 15th, 1886. 

In spite of their very suspicious character no one 
thought of these symptoms as indicating any dangerous 
condition, either of the dog or of the wound made by 
the bite in the patient’s hand. 

Until April 9th the patient remained perfectly well 
and strong. On this date he awoke with a severe head- 
ache; went, however, to his daily occupation; was 
hardly able to take any food at dinner, but still continued 
his work. Toward two o’clock he began to feel weak 
and feeble. One of his companions offered him some 
drink, but he pushed the glass violently from him, and 
was for afew moments in a state of collapse, without, 
however, wholly losing consciousness. He went to his 
home about three o’clock on April 9th, remained there 
until the 10th, at four o’clock, at which time he presented 
the following symptoms: headache, absolute sleepless- 
ness, with periods of great restlessness, noisy delirium, 
moderate flow of saliva, absolute inability to swallow 
either liquids or solids, an overpowering sensation of 
constriction of the neck, with brief periods of great irrita- 
bility during which he refused to see his friends, who 
were endeavoring to calm him and to restrain him from 
leaving the bed. 

On arrival at the hospital the patient was seen to be 
a remarkably strong and well-built man, tall, with pow- 
erfully developed muscles. The face was pale, the 
features animated, the eyes bright and moist, the eyelids 
widely opened at times, giving the facial picture a 
strange appearance which might almost be called terri- 
fying. He was sitting on the bed, calm, and remained 
quiet while the examination of his condition was being 
made. The patient had entire control of himself, and 
the mind was clear. His replies were correct ; his chief 
anxiety seemed to be that he should be relieved from suf- 
fering ; he spoke frequently of his children and of his 
mother. In spite of his loquacity it was possible for 
him to remain still, and he could assume a reclining 
posture without discomfort. 

The two most striking symptoms at this time were the 
following: While in the middle of a sentence the pa- 
tient would suddenly stop, as if seized by a severe spasm 
of the pharynx. If this occurred in the middle of a word, 
the remainder of the word was prolonged into a harsh 
guttural sound. The patient choked, threw the head 
strongly backward, and pressed his hands upon the 
throat. This condition lasted some minutes, and usually 
ceased with the expectoration of a small quantity of 
white, frothy mucus. The patient at once became talk- 
ative, and insisted that he should be bled, in order to re- 
lieve the pressure about the throat. The pharyngeal 
spasms recurred at intervals of five to ten minutes, and 
were more frequent if the patient talked. 

Although the patient was consuming with thirst, and 
was constantly asking for drink, it was impossible for 
him to swallow anything. He was able to take the glass 
in his hands and look at it; but on the attempt to bring 
it to his lips his head was at once turned away. If the 
effort was made to force him to drink, he was immedi- 
ately seized with a violent spasm. The glass was then 
covered with cloth, so that the patient could not see the 
liquid ; but the result was the same. The repulsion for 
solids was equally marked. The cutaneous sensibility 
was everywhere diminished. In administering a hypo- . 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Rabies. 
Rabies. 


dermic injection of morphia there was no manifestation 
of sensation on the part of the patient, least of all any 
sign of pain when the puncture was made. 

There was no exaltation of the senses, and the patient 
had no hallucinations. He exhibited no tendency to vio- 
lence, either toward himself or toward others. During 
the paroxysms, and in the agony of an attack of cramp, 
he cried out for relief, and called for poison ; but on the 
relaxation of the distress the longing to live returned. 
The skin was moist; temperature, 38.2° C..(100.7° F.); 
pulse, 116, soft and fluttering. There was manifest car- 
diac erethism. The tongue was moist ; there was no ap- 
pearance of vesicles upon it. Bowels constipated, and 
there was no vomiting. Urine was passed naturally ; it 
was little colored, transparent, and contained neither al- 
bumen nor sugar. There was no sign of disturbance in 
relation to the genital apparatus. 

During the night of April 10th to 11th the patient was 
very restless, obtaining absolutely no sleep, even by the 
aid of morphia and chloral. On the following morning 
he was a little more tranquil, but the sight of persons or 
things about him began to terrify him. He was still 
more talkative, pictured his sufferings in frightful colors, 
and demanded to be instantly cured. Were it not for 
the recurrent pharyngeal spasm, which preserved the 
same character and the same frequence, the appearance 
of the patient did not materially differ from that of a ner- 
vous person who is excited on account of some recent ac- 
cident. The skin was still moist ; pulse, 120; tempera- 
ture, 38.4° C. (101.1° F.). Urination was normal, and 
there were no signs referable to the genital organs. 

At eleven o’clock the patient complained that he was 
left alone ; his agitation was more pronounced; his suf- 
ferings were more agonizing. At times he was suffo- 
cating from the severity of the pharyngeal spasm, sprang 
from the bed, and rushed to the window for air. The 
expression of the countenance was much changed. There 
was no tendency to become violent or to bite. On two 
occasions the patient begged his attendants to retire, as 
he felt that he was about to lose control of himself. The 
periods passed without any attempt on his part to bite, 
or to bring anything near the mouth or teeth. Respira- 
tion at this time was jerking and hurried. 

The disposition of the patient was affectionate, and he 
constantly spoke of his family and friends. 

The dysphagia was persistent and complete. The pa- 
tient took the glass filled with water, and made repeated 
efforts to bring the liquid to his mouth by closing the 
eyes and turning the head, but was unable to approach 
the cup to the lips. The attempt was made to introduce 
liquids through a tube. As soon as a few drops had 
passed into the mouth, the whole was suddenly expelled 
by a spasm of suffocation of extreme violence. The 
thirst was most intense, and the patient frequently tried 
to take liquids by bringing a small amount in contact 
with the tongue, but he was unable to do so. The skin 
continued moist. No urine had been passed since early 
morning. Stool absent. 

1.30 p.m.—The. patient was visited for a few mo- 
ments by his family, after which he was in a most 
excited condition. Hallucinations now appeared; he 
thought that his father was by the bedside, and spoke 
to him. He appeared to be searching constantly for 
something, and looked anxiously in all directions. He 
thought that the solution of morphine was colored red. 
The special senses were in a state of exalted function, the 
patient was disturbed by the slightest sound, such as con- 
versation in the adjoining rooms, even in whispers. He 
heard the voice of his father. He did not show agita- 
tion at the sight of bright objects, such as mirrors, 
watches, etc. He could still without difficulty place and 
retain his hands in a vessel filled with water, although 
all efforts to induce him to drink any liquid were fruit- 
less. He could not swallow anything. He tried to take 
a part of an orange, but it was violently rejected. 

The spasm and the salivation were increased. The pa- 
tient was restless, uncovered himself, tried to sit upon 
the bed, etc. At times he was quiet for a few moments ; 
skin dry and burning ; pulse,:150. 


Three o’clock.—Hallucinations of terror. The patient 
attempted to barricade the door of his room by means 
of the chairs. The spasm had become more violent, and 
he cried out in agony, and at times expectorated a mod- 
erate amount of viscid, frothy saliva. There was no ten- 
dency to bite. The intervals of quiet were shorter ; but 
at these times the entire body was relaxed. Tempera- 
ture, 39.6° C. (103.3° F.); pupils punctiform. 

The administration of chloral and injections of mor- 
phine now procured no relief; but, on the contrary, 
furious delirium became rapidly more and more marked, 
so as to require the use of the camisole. The patient re- 
sisted the application of the camisole, saying that he had 
done nothing, and that the room might be locked, but that 
he would not submit to the jacket. With a great effort 
the camisole was applied, when he tore it in shreds, and 
seizing a slat from his bed, he crashed it through the 
window, and.tried to escape. A. stronger jacket was ap- 
plied, and the patient was thus restrained. | 

Four o’clock.—The agitation was now terrific. The 
face had become cyanotic. The spasms were more vio- 
lent, so that respiration was interrupted. The patient 
sweated profusely. Had passed no urine since morning. 
Pulse, bounding, 160. Rigidity of the neck and the 
limbs. 

Five o’clock.—Collapse. 
cyanosis. 

White, frothy saliva flowed from the mouth with each 
expiration. Respiration irregular. Pupils punctiform. 
Subjunctival ecchymosis. Corneal reflex almost absent. 

Six o’clock.—Collapse more pronounced. Eyes large- 
ly opened ; pupils dilated; corneal reflex absent; cor- 
nee dry. Profuse cold sweat. Respiration soft and 
still, but very irregular; the contraction of the dia- 
phragm was still marked, and caused the bed to shake at 
each inspiration. No alvine evacuation. Tympanites. 

Seven o’clock.—Twenty-two respirations per minute ; 
irregular. Cyanosis more pronounced. White and 
abundant froth flowed over the face and neck. Pulse 
thready and tremulous, and could not be counted. Head, 
burning ; extremities, cold. Pupils very large. One 
hour later, dead. 

Control Haperiment.—Immediately after the autopsy 
(made fourteen hours after death), the pons, medulla, 
and cord were transmitted to M. Pasteur, with the his- 
tory of the case. M. Roux made inoculations in rabbits, 
and the animals all died after an interval of fourteen 
days, with the typical symptoms of rabies, thus confirm- 
ing the diagnosis. 

It is important to distinguish rabies from other forms 
of tetanic diseases, or, in other words, from other forms 
of tetanus. The similarity between the rabic spasms 
and those due to other causes is so great that some au- 
thorities deny the existence of two diseases, and consider 
rabies to be one form of traumatic tetanus. Cases are 
recorded in which traumatic tetanus presented the speci- 
fic symptoms of rabies, and were confounded with this 
disease. These doubtful cases are valuable as teaching 
that not all cases of this disease run an exactly similar 
course ; and that not all forms of the disorder are of ser- 
vice in explaining the pathology of the rabic process. 
The horror of liquids is not a common symptom of trau- 
matic tetanus, nor is psychic disturbance a usual accom- 
paniment of this form of tetanus. 

The clinical history of rabies is often obscured or ren- 
dered difficult from the fact that the patient is inclined 
to deny the existence of a bite of inoculation, and the 
original wound is often completely healed at the time 
when the patient applies for treatment. Many cases of 
suspected rabies cannot be traced to the bite of an ani- 
mal known to be diseased. Rabies is sometimes simu- 
lated by the symptoms of acute softening of the brain, 
or by those of acute meningitis; but in these cases the 
most characteristic feature of rabies, the augmented irri- 
tability of the respiratory and of the reflex centres, either 
is not present at all, or is not a prominent symptom. 

After death from rabies, the body is quickly distended 
by gas, which is formed in large quantities, and the post- 
mortem imbibition is usually strongly marked. 


Cessation of the cries, and 


133 


Rabies. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


CLINICAL History.—The study of rabies must be con- 
sidered to begin with the observation of the disease in 
the dog (rabies canina). There are two distinct varieties 
of the disease, the maniacal and the paralytic forms. 
The disease is marked by three stages: the prodromal, 
the irritative,.and the paralytic. During the prodromal 
stage the animal is of variable temper, refuses his favor- 
ite food, passes quickly from excitement to depression 
and vice versa, swallows the most unusual substances, has 
generally a marked degree of sexual excitement, associ- 
ated with a progressive, gradual weakening of the hinder 
extremities, trembling of the limbs, and a faltering gait. 

The dog becomes unruly and obstinate, or sometimes 
timid and suspicious. There is often a marked secretion 
from the nasal passages, some embarrassment in swallow- 
ing, with a tendency toward vomiting. The original 
bite is generally quite sensitive at the time when the 
symptoms of the invasion of the disease begin to become 
evident. After a period varying from a few hours to 
three days, the symptoms belonging to the second stage 
are gradually developed and quickly become distinctly 
marked. ‘The characteristic features of this stage consist 
in an evident tendency to roam, and to wander away 
from home. There is also at this time a marked disposi- 
tion to bite, and there is an unmistakable change in the 
voice, 

These symptoms are accompanied by undoubted indi- 
cations of hallucinations of ‘sight and hearing. The pe- 
culiarity of the voice consists in the prolongation of the 
initial bark into a protracted cry, the latter portion of 
which is raised in pitch to the octave, or nearly that, of 
the tone in which the cry commenced. The sound is 
more to be compared to a prolonged howl] than to ordin- 
ary barking, but the intonation and pitch of the cry are 
unlike anytbing else in the way of canine sounds. There 
is usually at this time no hydrophobia in canine rabies. 
There is, indeed, marked inability to swallow either 
fluids or solids, the efforts to accomplish which often 
lead to vomiting. The loss of strength is therefore 
progressive and rapid. The mucous membrane of the 
mouth is often dry and fissured. Salivation is observed 
only in cases in which there is paralysis of the parts con- 
cerned in deglutition. The tongue, nose, and oftentimes 
the entire head are swollen, the conjunctive reddened, and 
there is usually photophobia. The respiration is gener- 
aily hurried and difficult ; there is frequently tenesmus, 
so that the passage of excrement is not only painful, but 
often impossible. The animal strains, and often the ex- 
creta are tinged with blood. The tenesmus is so fre- 
quently a symptom that some observers have considered 
ee there is an intestinal lesion in the pathology of ra- 

ies. 

A peculiar characteristic in the mad dog is the absence 
of the sense of pain—a red-hot poker will be grasped and 
held in the mouth. Dogs will bite themselves and still 
utter no cry. Periods of calm succeed these accessions 
of excitement, but during them the bite of the animal 
may still communicate the disease. Exhausted by the 
paroxysms, and the fighting and wandering, the dog will 
still continue on in its unsteady gait, with the tail be- 
tween the legs, eyes wandering, the head rolling from 
side to side, and the mouth open with the tongue protrud- 
ing. 

Following the stage just described, and appearing as 
the intervals between the paroxysms of the disease be- 
come shorter, the paralytic stage supervenes, The hinder 
extremities become feeble, the voice hoarse, the respira- 
tion labored, and the heart’s action accelerated. At times 
the convulsions appear early, and, the animal generally 
expires after a longer or shorter period of coma, usually 
in from five to seven days from the onset of the disease. 

Horses, cattle, and sheep, when affected by rabies, usu- 
ally show no disposition to bite. Goats and swine are, 
as a rule, inclined to bite. Rabies is especially danger- 
ous In cats and other carnivorous animals, on account 
of their greater ferocity. Domestic poultry is subject to 
rabies, and occasionally a tendency to bite is observed in 
these animals. True rabies is necessarily fatal in the 
present state of our scientific knowledge. Drugs and 


134 


treatment of every kind, sort, and description, have been 
tried without avail (Mott). 

PaTHOLOGY.—Rabies is eminently an infectious dis- 
ease, and is communicated from one animal organism to 
another by direct inoculation of the infective material. 
The pathology of rabies is not clear, and many observers 
have doubtless added to the existing confusion by record- 
ing the results of mistaken observations. The disease is 
eminently an acute and degenerative malady, and its 
special seat seems to be in the higher nervous structures. 
There can be no doubt that these delicate structures 
might suffer serious pathological changes, from the inten- 
sity of the disease, and undergo a more or less extensive 
process of acute softening, fatty degeneration, colloid de- 
generation, thrombosis, and other serious changes, from 
the presence of such an active febrile disturbance, with 
the added element of recurrent convulsions, evenif rabies 
were not present. Many of the reported pathological 
appearances are unquestionably produced post mortem 
by the wounding of the softened and friable organs in 
making the autopsy. Benedikt, Hammond, Weler, and 
Putz have noticed changes of this character. In a case 
under the observation of the writer, in the Charité in 
Berlin, the autopsy was made by Professor Frerichs with 
his usual great care. The entire cerebro-spinal nervous 
system was examined, but no distinctive lesions were de- 
tected. When one considers the great delicacy of these 
organs, and the accidents to which they are exposed dur- 
ing the process of removal from the body, one can read- 
ily believe that many of the reported lesions, thought to 
be due to rabies, may have been mechanically produced 
at the autopsy. There is no disease in which the oppor- 
tunities for mistaken pathological appearances are more 
abundant or more delusive than in rabies. 

Rabies has practically been a disease of unknown char- 
acter (pathologically) until within the latest years. The 
researches of the most celebrated observers have, how- 
ever, led to the detection of an ever-increasing similarity 
between rabies and the class of diseases, also inoculable, 
which depend upon the. presence of a definite organism 
in the body as the essential element of the disease. 

The symptoms of rabies, in all cases, point to the infec- 
tion of the system with the virus of the disease as the 
first source of the malady. The disease seems to depend 
upon the presence of a foreign element, partaking of the 
nature of the bacterial organism, or of a pathological fer- 
ment, which increases within the system and finally pro- 
duces the explosion of the disease. From the nature of 
the phenomena it is evident that the seat of the active 
lesions is the nervous system, although all the tissues of 
the body are capable of communicating the disease. 

The specific germ of rabies has not thus far been iso- 
lated, as have those of anthrax, tubercle, cholera, etc., 
nor have successful cultures of the infecting principle 
been as yet produced. The reported pathological ap- 
pearances found in rabies are most various, and are often 
exaggerated by the results of accidental injury of the 
nervous structures from violence on the part of those 
making the autopsy. All observers, however, agree that 
there is evidence of molecular changes in the textures of 
the nervous tissues, chiefly of the nature of a granular 
degeneration of the nerve-elements, with the existence of 
granular deposits along the course of the smaller blood- 
vessels and lymph-channels. This material is so abun- 
dant as to occlude to a certain degree the calibre of the 
vascular channels, and to materially interfere with the 
nutrition of the nervous structures, _ The fact must not 
be forgotten that these changes, as well as many others, 
may, to a certain extent, be due to the great loss of 
liquids which the system has sustained ; and it may also 
be in part accounted for by the violent convulsive move- 
ments which are so frequent and so distressing. The 
secretion of the saliva alone is sometimes enormous, and 
the other liquid secretions and excretions are also some- 
times exaggerated during a part of the course of the dis- 
ease, at the same time that the amount of fluid taken by 
the patient is greatly diminished. The nerves of the 
parts in which the original bite or inoculation occurred 
have been observed to present marked pathological ap- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Rabies. 


pearances. The myeline is found in a diffluent condition, 
and in disconnected masses. The structure is softened, 
and the axis-cylinder is at times absent in many of the 
nerve-tubes. The same observation has been recorded in 
relation to the nerves arising from the medulla, the pneu- 
mogastric, the glosso-pharyngeal, and the hypoglossal ; 
also the spinal accessory and the phrenic have been found 
to be the seat of ecchymosis and of localized apoplexies. 
Benedikt thinks the local lesions are sufficient to account 
for the clinical features of the disease. The digestive 
system is the seat of more or less pathological change, as 
might be expected, and there is often congestion of the 
liver and spleen. 

Proenosis.—The termination of rabies under any 

known form of treatment has been universally of a fatal 
character. Indeed, but few recognized diseases have so 
uniform and inevitable a tendency to a fatal issue, under 
all circumstances, as the dreaded malady of which we are 
now treating. Cases of the disease in which recovery has 
occurred are generally conceded to have been the sub- 
jects of mistaken diagnosis, or have been simply one of 
the simulating affections of which mention has already 
been made (Lyssa falsa seu nervosa). 
' Many methods of cure have been advanced in cases of 
rabies, and each recovery has been attributed to some new 
mode of treatment ; but thus far no form of medication 
has proved to be of the slightest avail in the curative treat- 
ment of this dreadful malady. It would seem that any 
medical treatment should be directed to the reduction of 
the exalted susceptibility of the nervous system, and to 
the preservation of the strength of the patient. The ad- 
ministration of nervous sedatives or the employment of 
anesthetics would seem to be indicated, together with 
most careful nursing, in the hope that the disease may run 
its course and at length subside. 

Rabies simulates the class of self-limited diseases in 
many ways, both in its onset and in the character of its 
effects. As yet, however, there is no known method of 
prolonging the life of the patient in this disease. Pro- 
fessor Mott states that ‘‘ true rabies is necessarily fatal 
in the present state of our scientific knowledge.” 

This seems the proper place to allude to the researches 
of M. Pasteur, of Paris, who for many years has labored 
in the department of experimental investigation in rela- 
tion to infectious diseases, and has made many important 
discoveries in the domain of germ-pathology. He has 
succeeded in discovering the means of protective inocu- 
lation in several of the malignant diseases of plants as 
well as of animals. His researches on Anthrax, on the 
Phylloxera, on Rouget, etc., have been universally recog- 
nized. 

The study of rabies by M. Pasteur has extended over 
a period of several years, and has been conducted with a 
degree of care and patience truly remarkable. He has 
found that the infective principle of rabies (which he 
calls a ‘‘ virus,” although the material of inoculation has 
not yet been discovered, either by culture or by any other 
method of procedure), when inoculated directly from the 
dog into animals of other species, is variously affected in 
the degree of its intensity, or, in other words, in its de- 
gree of virulency. Thus, when inoculated into’ the 
monkey, and propagated from one animal to another in 
a continuous series, the virus of canine rabies soon lost 
its virulent character and was no longer fatal to dogs on 
inoculation. If, however, the virus were propagated 
through a series of rabbits in the same manner, it was 
found that the virulency of the rabic poison was rapidly 
increased in intensity, so that the virus taken from a 
successive culture through a series of rabbits was found 
to kill dogs much more quickly than the original virus 
taken directly from rabic dogs (rage de la rue, Pasteur), 
in whom the poisonous principle seems to be possessed of 
a certain definite degree of virulency midway between 
that of the same poison when passed through the system 
of the monkey and that obtained when ig is passed 
through rabbits (see ‘‘ Comptes Rendus”’). 

The specific element of rabies is not yet definitely de- 
termined, though Professor Pol, of Geneva, has an- 
nounced that he has discovered a definite organism which 


Rabies. 
can be isolated and propagated by successive cultures, 
and which possesses the property of inducing the rabic 
disease in dogs or other animals. This assertion is not 
yet verified by the confirmation of other observers, but 
there is reason to hope that the infective material may 
yet be isolated, and may be proved to belong to the same 
general class of organisms as that of anthrax, erysipelas, 
diphtheria, cholera, etc. Pasteur has determined that 
the seat of the rabic disease is the nervous system, espe- 
cially the brain and spinal cord. By suspension of the 
brain or spinal cord in an elevated temperature, the viru- 
lence of the poison was found to be progressively dimin- 
ished, so that by this means an attenuated or enfeebled 
virus may be obtained. The diminution of the rabic 
virulency was found to be regular and uniform in cords 
treated in this way, so that the degree of attenuation can 
be accurately estimated, and a virus of any desired de- 
gree of activity may thus be secured, from that possess- 
ing fatal power to one which provokes only a moderate 
amount of febrile or inflammatory reaction. 

The next step was to test the value of protective inocu- 
lation by these attenuated forms of virus. This was first 
carried out on animals, and later, after numerous trials, 
upon the human subject (Joseph Meister). It was found 
that the animal system became easily tolerant of the rabic 
virus in a state of attenuation, and that more powerful 
forms of virus might then be inoculated without danger, 
until the original virus of the dog (rage de la rue), as 
taken directly from the rabid animal, might be injected 
directly into the. tissues of the animal, on which the at- 
tenuations in increasing strength had been successfully 
employed, without producing the slightest symptoms of 
danger. Here, then, it was proved that the animals thus 
protected were no longer susceptible to the immediate 
effects of rabies, even when bitten by dogs which were 
unquestionably the subjects of this disease ; at the same 
time that other unprotected animals, similarly bitten, 
invariably died of typical rabies. 

There seems reason to believe that the inoculation with 
rabic virus, as thus practised, may protect the individual 
from the rabic disease, though the period of time through 
which the protection lasts is not determined ; and it is yet 
too early in the history of this mode of prophylactic treat- 
ment to allow a settled opinion upon a point of such stu- 
pendous importance. 

As far as a long series of experiments on animals can 
determine (see ‘‘Comptes Rendus”’), the protection, for 
the time at least, seems to be all that can be desired. 
Rabid dogs have been made to bite a series of animals 
which had been protected by inoculation, and also a se- 
ries of animals which were not so protected ; the unpro- 
tected animals, without a solitary exception, died of 
rabies in all its terrible intensity, while not one of the 
protected animals was in the least affected. 

The value of a complete ‘‘ control” in experimental 
pathology, as a means of confirmation, cannot be more 
clearly demonstrated than in the present course of studies. 
In all the inoculations of the human subject there has 
been a control inoculation of a rabbit with the same 
material as was inoculated into the person. 

The material used for inoculation is a portion of the 
spinal cord of a rabbit, which has been simply triturated 
with a small quantity of pure water or other bland and 
sterilized fiuid, so as to reduce the substance of the cord 
to a more or less fluid condition. The matter for inocu- 
lation is not subjected to any further treatment, but the 
portion of water holding in suspension the bruised and 
finely divided substance of the cord is injected directly 
into the tissues of the patient. With each injection the 
tolerance of the system to the rabic virus is increased, and 
at each successive injection a cord may be used which is 
of a greater degree of virulency than those which have 
been previously employed, until, at the expiration of a 
certain number of days, the system of the inoculated in- 
dividual is not susceptible to the poison of the most viru- 
lent form of rabies in the dog or in the rabbit. * 


* During December, 1885, several children were bitten by the same 


supposed rabid dog, in the streets of Newark, N. J., United States. — The 
actual condition of the suspected dog was not satisfactorily ascertained, 


1385 


Rabies. 
Rabies, 


PROPHYLAXIS.—This may be divided into two sections 
—general and protective prophylaxis. — 

I. General Prophylaxis.—Among the most important 
elements of purely prophylactic treatment of rabies must 
be classed that which pertains to the management of 
dogs in large towns, which are not the subjects of rabic 
disease. There is probably no measure of public hy- 
giene which is followed by more certain and positive 
results than those which have been attained by the com- 
pulsory muzzling of all dogs which are allowed to be at 
large, and the prompt destruction of all dogs found in 
the streets without a muzzle. In the city of Berlin, where 
this ordinance has been in force for some years, there 
has not been a case of rabies for many years. 

There can be no doubt that this mode of treatment of 
metropolitan dogs would be the most practical, and at the 
same time the least objectionable method of securing the 
public against the ravages of the rabic disease, so far, at 
least, as city dogs are concerned. It would not, perhaps, 
affect dogs in rural neighborhoods, nor would it materi- 
ally diminish the dangers from rabies derived from other 
animals, such as wolves, foxes, skunks, etc., as the rabic 
disease is rarely communicated to them from dogs, but 
more frequently they are the source of infection of dogs 
or other domestic animals, and at the same time they are 
the cause of the disease in not a few instances in the hu- 
man subject. 

The wearing of a muzzle is not a hardship for the dog, 
as it can be made of metal, and may be so constructed as 
to be at the same time both light and strong, and in no 
material way diminish the comfort or impede the move- 
ments of the animal, except in the one feature of restrain- 
ing him in any attempt to bite either men or other ani- 
mals. The muzzle might be easily removed, and during 
all that portion of the day in which the dog is kept on 
the premises of the owner, he might go about without 
being muzzled ; but when at large the muzzle could be 
easily slipped over the animal’s head, and thus the dan- 
ger of his biting anybody be removed. 

Dogs do not, as a rule, find the muzzle any inconven- 
ience, and appear quite as cheerful when muzzled as when 
unmuzzled. Respiration is not impeded, nor are the 
motions of the dog in any way interfered with. The 
only effect of a proper muzzle is to prevent the dog from 
seizing any article, or taking a grip in any effective way 
with the teeth. 

Another element of prophylactic treatment is the im- 
portant one of the impounding of all suspected dogs, and 
their retention in some secure place, where careful ob- 
servations may be made and their condition be satisfac- 
torily ascertained. If rabies be present in a suspected 
dog, the disease will surely manifest itself in a few hours 
or days, and all doubts in relation to the existence of the 
disease will be dispelled. No suspected dog should be 
killed until such observations have been made, unless 
experimental inoculations are carried out by means of 
the injection of portions of the nervous system, as a con- 
trol of his condition. The foolish idea that immediate 
destruction of the suspected dog is a source of protection 
to any person who may have been bitten by him is still 
extant, and often prevents investigation of the actual 


as the animal was immediately killed. Thechildren were sent at once to 
Paris by public subscription, and there, immediately upon their arrival, 
received the protective inoculations at the laboratory of M. Pasteur. 
The virus was prepared from the spinal cords of rabid animals in the 
manner above described. The first inoculations were with virus which 
had been much attenuated. With each succeeding inoculation the viru- 
lent quality of the inoculation was increased, until the material used 
was the virus taken from an animal newly dead from rabies. As soon 
as this limit was reached the children returned to the United States, 
where they have since that time been under careful observation by com- 
petent medical men, and up to the time of the present writing (twelve 
months) they seem to be free from any tendency to the disease. 

The above reported cases are the first instances in which the protective 
vaccination has thus far been the subject of observation in the United 
States, and are of great interest on that account, though there is some 
uncertainty as to their absolute value, owing to the absence of positive 
knowledge as to the condition of the dog by which these children were 
bitten, Nine other dogs were said to have been bitten by this dog on 
the same day that the children were bitten. These nine dogs were all se- 
cured and impounded, where they were kept under observation during 
the period of three months. At the end of this time none of these dogs 
had showed symptoms of rabies, and they were all set at liberty. 


136 


. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


condition of the dog, by which, in most cases, all fears 
from the bite might be effectually laid at rest. 

II. Protective Prophylaxis.—The extensive researches 
of M. Pasteur into the pathology of rabies have developed 
the important theory, which has now become an estab- 
lished belief, that the inoculation of the system with the 
virus of this disease is the means of securing immunity 
from the attack of this most frightful malady, after the 
introduction of the infective material into the body from 
the bite of a rabid animal. ; 

The present state of this most important question is 
well set forth in an article contained in the Annales 
@’ Hygiéne Publique, December, 1886, which is here re- 
produced almost 77 toto: ‘‘It is now one year (October 
26, 1886) since Pasteur made the announcement of the 
prophylaxis against rabies after a bite from a rabid ani- 
mal, A large number of experiments upon dogs war- 
ranted that the attempt at protection be extended to the 
human subject. This was at length done, and up to 
March ist 350 persons, who had been bitten by dogs 
known to be the victims of rabies, had been treated by 
Dr. Grancher in the laboratories of Pasteur. 

‘At this date, October 31, 1886, the number of per- 
sons who have submitted to the protective inoculations 
in Paris is 2,490. The treatment has been absolutely 
uniform for the great majority of those bitten, notwith- 
standing the diversity of age, sex, the number of wounds, 
the seat of the lacerations, their depth in the tissues, or 
the length of time which has elapsed since the reception 
of the injuries until protective treatment was instituted. 
The period of treatment extended over ten days. Each 
day the person treated received one injection of the spinal 
cord of a rabbit, commencing with acord which had been 
dessicated for fourteen days, and finishing with one of 
five days. 

‘‘The entire number of French patients, being those 
dwelling in France, or French persons coming from Al- 
geria, who have been inoculated during the last year is 
1,700, and we can properly limit our observation to the 
description of the treatment of this quite considerable 
number of French-speaking people, and may form an 
opinion of the effect of the inoculation by a study of 
these cases. ; 

‘‘ Among these 1,700 patients there were ten in whom the 
effects of the inoculations were not productive of immu- 
nity from the occurrence of rabies. These were the follow- 
ing cases: Those of the children Lagut, Peytel, Clediére, 
Moulis, Astier, Videau ; the women Leduc (seventy years 
of age), Marius, Bouvier (thirty years of age), Magneron 
(eighteen years of age). Two cases; those of Louise Pel- 
letier and Moermann, are not included in this category, 
on account of their very late arrival at the laboratory, by 
reason of which the efficiency of the protective inocula- 
tions may have been modified, or the disease may have 
been already developed before their appearance in Paris. 
One case of death in each 170 persons bitten is, then, the 
result of this method, for France and Algeria, during the 
first year of its application as a protective against rabies. 
Taken as a whole these figures demonstrate the efficacy 
of this method, which is equally proved by the relatively 
large number of deaths among those bitten but who were 
not vaccinated. One may feel certain that during the 
year 1885-86, there were comparatively few persons bit- 
ten by mad dogs in France who did not apply for pro- 
tection at the laboratory of Ecole Normale. Even in 
this small minority there were, to my personal knowl- 
edge, 17 cases of death from rabies.” (In a note, M. 
Pasteur gives exact reference to each of these cases, 
none of whom was inoculated for protection. ) 

‘‘ During the last five years sixty persons have died from 
rabies in the hospitals of Paris. That is an average of 
twelve per year. No year of the series was exempt from 
a certain number of deaths. During the last year of the 
series, the number of deaths was twenty-one. Now, since 
November d, 1885, which was the date of the introduc- 
tion of protective inoculation for the human subject into 
practice, in my laboratory, there have been in all the 
hospitals in Paris but two cases of death from rabies, 
neither of whom had received protective inoculation 


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Rabies. 
Rabies, 


(Raffin, at Hoétel-Dieu, and Riffandi, at Hospice Beau- 
jon), and a third who had been inoculated, but not by 
the repeated intensive method, of which I will speak 
later (Clerjot, at Hopital Tenon). 

“Tt will be observed that the larger number of those 
who have succumbed to the disease, in spite of the treat 
ment, are children, and that they were bitten in or about 
the face. These children received only the first simple 
form of treatment. I have since become convinced that 
this form of treatment, particularly in cases in which the 
wounds were of this character, runs the risk of being in- 
sufficient. Unfortunately, this conviction was reached 
only gradually, and after long study, which was necessary 
to establish the fact of an exceptional duration of the 
period of incubation in certain cases of rabies. The his- 
tory of the disease among the Russian patients from 
Smolensk was the first proof of this fact which had come 
to our notice. From these cases we learned that there is 
a vast difference in the results of infection with the rabic 
virus, whether the source of infection be a mad dog or a 
mad wolf. 

‘From reliable sources the following statistics have 
_ been collected in relation to the bite of rabid wolves. 
These are published for the first time. 

“1, On February 27, 1796, eight residents of Saint-Jul- 
lien de Civry, in Bourgogne, were bitten by a mad wolf. 
One died on the same day from the severity of his 
wounds. The other seven died after a period of incuba- 
tion extending from seventeen to sixty-eight days. 

“°2. December 26, 1806, nine persons were bitten by a 
mad wolf in the vicinity of Bourg. Of these eight died 
of rabies. 

“*3. On October 16, 1812, nineteen persons were bitten 
by a mad wolf in the town of Bar-sur-Ornain. All of 
these patients were at once treated by Drs. Champion and 
Moreau, who washed the wounds and cauterized them 
by means of nitrate of antimony. Eleven of those bitten 
died of rabies after a period of incubation of seven to 
seventy days. 

“4. On February 23, 1849, a shepherd in Darbois, 
named Dumont, sixty-four years of age, was bitten by a 
mad wolf. He died, after a period of incubation of thirty- 
two days, of typical rabies. 

‘*5. On January 7, 1866, three inhabitants of the three 
neighboring hamlets of Nant, Alques, and Saint-Jean du 
Bruel were bitten by a mad wolf. A1Jl three died of ra- 
bies on the twenty-second, twenty-third, and thirty-eighth 
days. 

**6. On October 5, 1874, two men were bitten in the 
village of Rochette by a mad wolf, who had just seized a 
little girl and had torn her in pieces. After twenty-five 
and thirty days, respectively, the two men were seized 
with the disease, and died of rabies. The child died on 
the day of the attack, from her injuries. 

““7, In a letter of March 26th, Dr. Nipce, of Eaux de 
Allevard, communicated to Professor Vulpian four cases 
of bites from a mad wolf, occurring in the year 1822. 
The four persons died of rabies, after a period of incuba- 
tion of from nine to nineteen days. 

“©8. On May 11 and 12, 1811, a mad wolf, in the vicin- 
ity of Avallon, bit several persons and many animals. 
All the persons bitten died of rabies. The dates of death 
in the different cases, as taken from the records of the 
hospital, vary from the twenty-fourth to the thirty-first 
day after inoculation. 

“From a comparison of these reports we arrive at the 
ratio of 82 deaths in 100 cases of inoculation from rabid 
wolves. In six of these eight reports there were as many 
deaths as there were persons bitten, hence the ratio 
would be in these cases one hundred per cent. of fatal 
Cases. 

“The above reports prove that, first, the incubation 
of human rabies after the bite of a rabid wolf, is often 
very short, much shorter than is the case after rabies 
from the bite of a mad dog. 

‘Second, that the mortality in consequence of the bite 
of a mad wolf is much greater in comparison than is the 
case after the bite of a mad dog. If we apply these facts 
to the cases of the nineteen Russians from Smolensk, 


whose treatment is finished, and of whom sixteen have 
returned to Russia, we could have reckoned not upon 
three deaths from rabies, but upon fifteen out of sixteen ! 
In Russia it is universally believed that no one who has 
been bitten by a mad wolf can escape death from rabies. 

‘‘When we saw three of those nineteen patients from 
Smolensk die from rabies while under our observation— 
the first being in the course of the former simple treat- 
ment, and the two others having already finished their 
treatment some days before—we were much troubled. 
Would the sixteen others also become victims of rabies ? 
Was the method unavailing against rabies derived from 
the wolf? We then recalled the fact that all the dogs 
which had been vaccinated with success had received, 
as the last preservative inoculation, a preparation from a 
virulent cord removed the same day, and that the first 
person to undergo vaccination, Joseph Meister, had fin- 
ished the treatment by a cord which was removed the 
evening previous to being used. We then at once made 
a second and a third course of inoculations upon the six- 
teen Russians who still remained alive, increasing the in- 
tensity of the inoculations until the cords of the fourth, 
third, and second day were reached. It is very probable 
that to these repeated inoculations is to be attributed the 
cure of these sixteen Russians. A despatch received 
on the day of this report from the Mayor of Beloi, an- 
nounces that these patients are all in the best of health. 

‘‘Encouraged by these results, and by the new facts 
obtained thereby, a new method of treatment has been 
adopted, by making the inoculations more rapidly, and of 
more active quality, in all cases of wounds of the face, 
or in cases of deep wounds and multiple lacerations upon 
other uncovered parts. Three complete treatments are 
therefore made in the space of ten days, and in each 
treatment the last cord used is one of most virulent in- 
tensity.” 

The opinion of the profession upon the discoveries of 
Pasteur is very clearly set forth in an address by Dr. T. 
W. Hime, in the London Lancet, December 11, 1886. 

Dr. Hime says: ‘‘ The success of Pasteur’s treatment 
has been brilliantly demonstrated by statistics as well as 
by experiments. That the disease in the rabbit from 
which Pasteur obtained his material for human inocula- 
tion was true rabies is indubitable. Nerve-matter taken 
from such a rabbit and inoculated in a dog intracranially, 
the only certain method, invariably produces true rabies. 
If nerve-matter be taken from a human being dead 
from an attack of canine rabies, and be inoculated in a 
rabbit, a guinea-pig, a dog, all three will take rabies and 
die. The dog will have rabies according to his kind, 
with symptoms either of the dumb or of the furious kind. 
The guinea-pig will exhibit very characteristic symp- 
toms, and the rabbit will develop symptoms peculiar to 
his kind, such as for convenience may be called the 
‘Pasteuran disease,’ but an interesting and important 
fact may be borne in mind. The virus used for the ex- 
periment, being canine virus, which has passed once 
through the human subject, will retain certain canine 
peculiarities as to period of incubation, date of death, 
etc. If, instead of human nerve-tissues from persons who 
have died from canine rabies, we employ nerve-matter 
direct from a dog which has died from rabies, for inocu- 
lation, the animal will be similarly affected, and the dis- 
ease produced in the rabbit cannot be distinguished from 
that caused by inoculation with nerve-matter taken from: 
a human being who has died from rabies after inocula- 
tion with canine rabies. 

“Tf, again, nerve-matter be used taken from one of the 
rabbits employed by Pasteur for protective inoculation, 
the same result will be obtained, with this difference— 
the course of the disease in the various animals will be 
shortened. Pasteur uses for his protective inoculations 
virus which, originating in ordinary canine rabies, has 
been passed directly from rabbit to rabbit some hundreds 
of series. The result is that the virus has become In- 
tensified, and kills more rapidly than the original canine 
virus. It was actually alleged at one time that the deaths 
following Pasteur’s inoculations were due to them. This 
was triumphantly disproved by the experimental demon- 


137 


i 
Rabies. 
Rabies. 


stration that the virus in the disease was canine virus 
(and was due to the original bite), and not rabbit virus 
inoculated by Pasteur for protection. The opposite re- 
sult is obtained if the virus be passed from monkey to 
monkey through a long series ; the virus becomes weaker 
and weaker. But no doubt, just as the virus of anthrax, 
or fowl cholera, which has been modified by cultivation, 
could be brought back to its primitive virulence, so the 
weakened rabic virus of the ape and the intensified rabic 
virus of the rabbit could be brought back to the original 
degree of virulence. If Pasteuran virus be passed through 
the dog once, and then be inoculated on a rabbit, it will 
be found not to have resumed canine characteristics by 

passing once through the dog. But more frequent pas- 
sages through the dog will probably restore its primitive 
characteristics. 'The symptoms are very special in the 
rabbit inoculated with Pasteuran virus ; the length of the 
incubative period (five to six days), and the date of death 
(nine to ten days), are more invariable than in any other 
known disease of man or animals. Further, the symptoms 
are very characteristic and invariable, notably the slight- 
ness of the general symptoms, even after paralysis has 
become marked. The temperature is also very interest- 
ing, and markedly different from that found after intra- 
cranial injection with other materials than the Pasteuran 
virus or rabic virus from some other source. The fol- 
lowing is a characteristic chart of the temperature of a 
rabbit which died of Pasteuran rabies: First day, 102.6° ; 
second day, 103.0° ; third day, 102.8° ; fourth day, 103.0° ; 
fifth day, 104.2° ; sixth day, 105.6° ; seventh day, 105.8° ; 


eighth day, 106.4° ; ninth day, 104.1° ; tenth day, 97.0°; . 


eleventh day, 86.0°. | 

‘‘The febrile stage may be shorter, and the fall more 
gradual, but the latter is always great. The elevation is 
not always so great as in. this example, but the rhythm is 
characteristic, and the temperature usually gives indica- 
tion before the actual symptoms appear. The course of 
the temperature in the rabid dog is similar. At first 
there is no change ; then the temperature rises gradually 
and may reach 105.0° or 106.0°. The period of acme lasts 
one or two days, and is succeeded by a rapid fall to 
about 84.0°, when.death ensues. The fact that the dis- 
ease is always and invariably transmissible by inocula- 
tion is of great importance as regards its pathology, and 
as distinguishing it from other diseases. With regard to 
post-mortem appearances, there is nothing pathogno- 
monic in the Pasteuran rabbit, any more than in the dog, 
or in the human subject dead from rabies. All the or- 
gans appear free from disease ; some more or less hyper- 
semic ; and sometimes hemorrhages are found ; the brain 
is slightly hyperemic as a rule, the heart contracted, 
and the bladder generally full. The stomach almost in- 
variably contains food ; the cecum is commonly full; 
the remainder of the intestine generally contains but lit- 
tle ; the small intestine nothing. This absence of morbid 
conditions is remarkable, and is certainly not found af- 
ter death from injury to the brain after operation, nor 
after death from intracranial injection of other materials 
—putrid material, etc. In this case, pus would be found 
within the cranium, and other evidence of purulent ab- 
sorption would be detected. 

‘‘ Intracranial injection of sterilized bouillon will not 
produce the symptoms of Pasteuran disease, nor any 
other morbid symptoms, and rabbits so injected will not 
die if skilfully operated upon. Rabbits inoculated ac- 
cording to Pasteur’s methods, with sterilized bouillon 
rubbed up with putrid meat, will die, but with symptoms 
entirely different from those of Pasteuran disease, and 
without the characteristic paralysis. But still more note- 
worthy is the fact that the disease produced by injections 
of putrid material is not transmissible. If fresh nerve- 
matter be taken from a rabbit which has died in conse- 
quence of disease produced by intracranial injection of 
putrid matter, and be injected intracranially, according 
to Pasteur’s method, on another rabbit, the latter will 
not die, and will have no specific disease whatever, nor 
marked symptoms of any kind if skilfully operated 
upon. But the Pasteuran disease is always transmissi- 
ble by intracranial injection. Nerve-matter from dogs 


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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


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which have been suspected of rabies, and have died or 
been killed in consequence, has been frequently injected 
intracranially on rabbits as a diagnostic measure ; if the 
dogs were rabid the Pasteuran disease will be developed 
in the rabbits. If not, the rabbits will survive, without 
showing any symptoms of this disease or any other dis- 
ease. ‘That this crucial method of diagnosis exists is due 
to Pasteur. In fine, the following results are established : 
the virus used by Pasteur for protective inoculation orig- 
inated in the rabid dog, and is the virus of rabies. Pas- 
teur has published results showing that the material used 
for his latest protective inoculations on man, caused ra- 
bies in animals which were unprotected. If virus be 
taken from a rabid dog, and be passed through a series 
of rabbits, it will produce the same disease as is devel- 
oped in the rabbits from which Pasteur takes his matter 
for protective inoculations. If the virus of such inocu- 
lations be inoculated back into the dog or other suscepti- 
ble animal, it will produce true rabies in them, and if 
then passed back to the rabbit it will produce the same 
symptoms ad infinitum. 

‘*Human rabies, if inoculated on the rabbit, will pro- 
duce the same symptoms, with such variations as are due . 
to its origin in the dog, cat, etc. These variations are 
exhibited chiefly in the period of incubation, and the pe- 
riod elapsing before death, the disease invariably termi- 
nating fatally. No other known disease produces the 
same results, nor can the symptoms be caused either by 
surgical brain-lesion or the intracranial injection of inert 
material, such as sterilized bouillon, or with putrid mate- 
rial. The Pasteuran disease is specific, and very dis- 
tinctly characterized by its course and symptoms, which 
are different from those of any other disease ; it invari- 
ably ends fatally, and is indefinitely transmissible by in- 
oculation from animal to animal. The protection af- 
forded to dogs by Pasteur is proved beyond doubt or 
question, and analogy suggests that the same method is 
applicable to man. Dogs can be protected either by in- 
oculation before infection, or after this has occurred. 
Further, they have been protected against the action of 
the rabbit virus, which is much more active than ordi- 
nary canine virus. The reality of this protection estab- 
lishes the truth of Pasteur’s principle. His practice may 
be capable of improvement ; but he has already effected 
a great deal ina short time. It has been objected that 
the inoculated prophylactic virus is inert, because the 
patient shows no specific reaction. It is almost always 
the case that there is a slight though decided reaction. 
Pasteur has established a prophylactic treatment against 
rabies, one of the most formidable, and hitherto intracta- 
ble, diseases. He has thus crowned a glorious career of 
research directed to the benefit of man by a most notable 
discovery, primarily salutary to man himself.” 

The statements of Dr. Hime are corroborated by the 
report of Dr. Grancher upon the cases treated by Pas- 
teur’s method in the laboratories of the institute, which 
is as follows (up to April 22, 1886) : 

‘«' The cases were divided into three classes. The first 
class included those bitten by dogs proved to be mad by 
the inoculation of rabies, or subsequent development. of 
rabies in animals bitten by them. These amounted to 96 
cases, and contained one death. The second class com- 
prised patients bitten by, dogs certified to be rabid by the 
veterinary practitioners of the locality, and numbered 644 
cases, and two deaths. The third class contained those 
bitten by dogs who had run off and had not been seen 
again, 232 cases, with no deaths. 

‘Tn the first two classes, 740 cases, with three deaths, 
not quite one-half of one per cent. of those bitten ; while 
the ordinary statistics of light cases given by M. DeBlanc, 
Veterinary Surgeon of the city of Paris, gives sixteen 
per cent. as the number of deaths. Dr. Brouardel has 
calculated that no less than eighty per cent. of those bit- 
ten by. rabid dogs on exposed parts of the body die. In 
the 84 cases of wolf-bite, not included in the above, 7 
died ; ordinarily sixty-six per cent. of those bitten by 
rabid wolves die, and here the percentage is fourteen.”’ 

Dr. H. C. Ernst, in a recent paper (American Journal 
of the Medical Sciences, April, 1887), describes a series of 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Rabies. 
Rabies. 


experiments performed in the Bacterial Laboratory of 
Harvard University, from which he deduces the follow- 
ing propositions : 

First, is there a specific virus in the brains and cords 
of rabbits inoculated with Pasteur’s materials, and after 
his methods ? 

Second, does the treatment by drying, proposed by him, 
modify the strength of this virus ? and 

Third, does injection with such ‘‘ modified virus” pro- 
duce immunity against inoculation (or bite) with virus 
of full strength ? 

The essay closes with the following :—The conclusions 
which may be drawn from the work here recorded seem 
to be as follows : 

1. There existsin the cordsand brains of animals inoc- 
ulated in Pasteur’s laboratory a specific virus, capable of 
the production of similar symptoms through a long series 
of animals. . 

2. These symptoms are produced with absolute cer- 
tainty when the method of inoculation is by trephining 
the skull, and in injection under the dura mater; with 
less certainty when the inoculation is by subcutaneous 
injection. 

3. The strength of this virus is lessened when the 
cords containing it are removed from the animals and 
placed in a dry atmosphere, at an even temperature. 

4. The symptoms produced by the inoculation of this 
virus appear only after a certain period of incubation, 
distinctly shorter when the inoculation has been done by 
trephining than when done by subcutaneous injection. 

5. The injection of the virus, modified in strength by 
drying, and in the manner prescribed by Pasteur, exerts 
avery marked protective influence against an inocula- 
tion with virus of full strength. 

6. A very moderate degree of heat destroys the power 
of the virus entirely, while prolonged freezing does not 
injure it. 

TREATMENT.—In the actual care of cases of rabies, in 
any form, the treatment is essentially divided into two 
distinct forms: the prophylactic and the clinical. 

The first consists in the destruction or the confinement 
of all suspected animals, and the isolation and careful 
and lengthened observation of all animals which have 
shown indications of rabies, and which have bitten other 
animals or have attacked men. The disease is usually 
developed in the dog within a certain tolerably definite 
period, and if the imprisoned animal demonstrates no 
indications of the disease within these limits, it is fair to 
assume that rabies was not communicated by the same 
dog in biting other animals or men. 

The second part of the prophylactic treatment of this 
disease consists in the early and proper care of the 
wounds caused by the bite of animals thought to be 
rabid, All such wounds should be promptly cauterized 
by means of the ferrum candens, nitrate of silver, caus- 
tic potash, or by some other efficient means. 

After cauterization the wound may be completely ex- 
cised. 

It is considered a wise procedure to maintain suppu- 
ration in the wound fora long time. The safety of the 
patient is increased in proportion to the earliness of the 
treatment of the wound. Sucking of the wound is a 
usual procedure, but it may be a dangerous measure on 
account of unnoticed injuries of the mucous membrane 
of the lips or mouth, by which fatal infection of the sys- 
tem might occur. This mode of treatment requires an 
unusual amount of courage and self-sacrifice. 

The therapeutical measures in this disorder relate to 
the treatment of the disease after it is actually and un- 
mistakably developed. In view of the fact that cases of 
this disease are uniformly and inevitably fatal, and that 
no known method of treatment is able to prevent the 
lethal result, there is little to be hoped from any mode of 
procedure. * 


* In connection with the above statement should be considered the 
lengthy description, on a previous page, in relation to the treatment of 
rabies by protective inoculation or vaccination, as devised and practically 
carried out, in relation both to the lower animals and to man himself, by 
M. Pasteur, of Paris. The value of this new method of treatment is not 


It is important that the care of patients with rabies 
should be entrusted to responsible and skilful nurses, in 
order to avoid the employment of force in restraint, by 
which the patients might be injured, or which might un- 
necessarily increase the excitement and anxiety of the 
patients. The subject with rabies (human) is not danger- 
ous to those about him, nor is he inclined to injure him- 
self.* 

All appearance of forcible restraint or of fear should 
be removed, and the patient should be comforted as 
much as possible. 

The terrors of this fearful malady are greatly intensi- 
fied by the unnecessary fear, and often by the cruelty, of 
those about the patient. 

We know of no method of favorably affecting rabies 
in the way of treatment when the disease has once ap- 
peared. Wedo not even know how to ameliorate the 
agonies of the severer symptoms.t+ 

Among the measures which may be adopted are cer- 
tain influences addressed to the mental and moral condi- 
tion of the patient, by which some degree of relief may 
often be secured. Thus drinks may be taken through an 
opaque tube, or from a dark-colored vessel, so that the 
fluid may not be seen by the patient. + 

Much relief may be secured in some cases from the 
subcutaneous employment of morphine; the application 
of electricity has also at times seemed to be of service. 

The great question, whether there is any other method 
of treatment of rabies than that of protective inoculation 
by means of the attenuated virus, by which the disease 
may be controlled when infection has occurred from the 
bite of a rabid animal, is one of the undecided problems 
of our science. From the stupendous strides which have 
been made in the advancement of therapeutical knowl- 
edge, particularly in relation to the products and effects 
of the large class of synthetic compounds, there is reason 
to hope that we may at length acquire the means of re- 
straining infectious diseases, due to the invasion of the 
system by pathogenic bacterial forms, or to other infec- 
tive agencies, if such other agents of infection exist. 
With the attainment of this increased ability to combat 
the development of the specific germs, we shall possess 
the means of limiting and controlling the ravages of epi- 
demic diseases. The scope and importance of such a 
tremendous addition to our therapeutical resources is 


yet fully and satisfactorily demonstrated in relation to the human sub- 
ject, and therefore it cannot be said to have yet actually taken the posi- 
tion claimed for it as a therapeutical and prophylactic measure, though 
there are strong reasons for the hope that it may prove to be a safe and 
sure preventive of the rabic disease. 

* Benedikt mentions a case in which a dog-fancier was attacked, after 
many years, by rabies, following a new and recent bite by a dog, and on 
experiencing the first symptoms of the disease he hanged himself; but 
the tendency to self-injury is small in this disease. 

+ Kostyleff reports a case of rabies treated by inhalations of oxygen. 
The patient was a railway guard, sixty-three years of age, and intemper- 
ate, who had been bitten by a suspicious dog about four months before 
his admission. The symptoms of rabies consisted of an extraordinary 
sexual excitement, malaise, loss of appetite, and thirst, Three days 
later he was brought to the hospital. There was then hydrophcobia and 
pain in the throat. Respiratory and pharyngeal spasm was frequent, and 
there was frothy expectoration mixed with blood. The patient was ina 
state of intense general excitement, with delirium of persecution, The 
effect of the inhalations of oxygen was most pleasing. After the first 
few inhalations the spasm entirely ceased, the expectoration was dimin- 
ished, the cyanotic lips became rosy, the patient passed into a calmer 
condition, and could eat, drink, and smoke. After one and a half hour’s 
sleep at night there was a return of the spasm with dyspnoea, which was 
again cut short by the oxygen. After an enema of chloral he again slept 
several hours, and then he was able to take two or three glasses of milk, 
On the following day he was able to drink, but soon after this time the 
delirium returned and he became gradually exhausted, and died on the 
fourth day. Kostyleff therefore thinks oxygen to be markedly palliative, 
but not curative. 

¢ A man was admitted into the Massachusetts General Hospital in Sep- 
tember, 1878, who had been bitten, as he claimed, by a rabbit, and had 
developed symptoms of rabies. The patient had no suspicion of the na- 
ture of his disease, and was not informed of the character of the malady 
while in the hospital, and died without knowing that he was affected 
with rabies. The attempt was made in this case to introduce-filuids by 
means of opaque tubes, and by using darkened vessels, but without 
avail. The patient would at once experience the most frightful convul- 
sions if his fingers were dipped into any fluid, even if he could neither 
see nor hear the liquid. The patient’s condition gradually became more 
and more excitable, and he passed into a state of frenzy, in which he 
made his escape from the hospital, and was with difficulty retaken. He 
was brought again to bed, and died a short time afterward from exhaus- 
tion, 


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Railway Medical 


too vast and far-reaching for our present conception. 
The attainment of the result thus hinted at is no chimera, 
but is a warrantable expectation. 

As a contribution to the possible therapeutics of rabies 
may be mentioned a case occurring in the practice of Dr. 
De Capua, of Naples, in which a patient, suffering from 
undoubted rabic symptoms following the bite of a mad 
dog, was treated by subcutaneous injection of mercuric 
bichloride, together with atropine. The case is reported 
in brief in the London Lancet, September 18, 1886. The 
rabic symptoms amended slowly, and the mental phe- 
nomena at the same time subsided in a gradual manner. 
The delirium assumed three distinct forms, and ended 
with a form of mental disturbance related to the occupa- 
tion of the patient as a farmer ; this soon abated, when 
complete physical and mental recovery took place. 

Jagell, Revue Scientifique, August 21, 1886, quoted in 
Medical Record, January 1, 1887, treated eighty-eight cases 
resulting from the bites of rabic wolves and dogs, and all 
were cured by infusion of spirea filipendula ; twenty- 
six of these cases having been found already in the first 
stage of hydrophobia when treatment was commenced. 

Nore.—Since the above article was written, the pro- 
tective inoculation, in cases of threatened rabies from 
the bite of a rabid animal, has been made the subject of 
unceasing study and experimental research by able men 
in every country. The general opinion has been that 
inoculation’ in the way advocated by Pasteur is not only 
an absolute protection to the patient against the outbreak 
of the rabic disease, but that it is itself entirely free from 
serious effects upon the inoculated person. For an in- 
teresting account of Pasteur’s method and its results, as 
seen by Dr. Ullmann, of Vienna, see Wiener Allg. Med. 
Zeitung, 1886, No. 21. Dr. Ullmann allowed himself, as 
did also four other physicians, to be inoculated with the 
rabic virus. All remained well, and with the exception 
of moderate constitutional disturbance, experienced no 
deleterious effects from this courageous experiment. 

For an exhaustive treatise upon this subject, with nu- 
merous references, see article on ‘‘ Hydrophobia,” by 
Bollinger, in ‘‘ Ziemssen’s Cyclopsedia of the Practice of 
Medicine,” American translation, vol. iii., p. 482 e¢ seq. ; 
also Pepper’s ‘‘ System of Medicine,” vol. i., p. 886. 

Albert N. Blodgett. 


RAGAZ-PFAFERS, called also Pfaifers-Ragaz, is a spa 
in Canton St. Gallen, Switzerland. There are really two 
establishments, but both receive their water from the 
same spring. Pfafers is the higher (2,200 feet above sea- 
level) and Ragaz lies below, at an elevation of 1,700 feet. 
The climate is less raw and changeable in Ragaz, though 
in neither place is it very warm; by reason of their 
situation in the valley these stations enjoy the direct sun- 
light for only about six hours out of the twenty-four. 
The following is the composition of the water, according 
to the analysis of Planta. 

One litre contains : 


Grammes 
MAGMIUTMICHLOLIGes ares atte aan eee ee eee 0.002 
POC IIMECHLOrIGGs, cotter nee nis pee eee eee 0.493 
SOGIMOISUIDNALE Risa cr cee oes eee ce hoe eee 0.829 

Galoinmr sulphate were. iec. cas scene eon tc ci coer 0.075 ° 
OCU MU OOVALO I a are rsus diciein sue meteiets cheese ote ete eee nee 0.004 
SOdUTMRCATOON ALC. -c..euw ahccee taco eee aan oe een 0.061 
Magnesium Carbonate s-. cclasis <seece hes cide e feteee ate 0.531 
Calcium "Carbonate sete reek von cclecoeeeren con tete ee 1.806 
DPLrONbIUMMCarVONate s. esti alanis aveiete oaciekat <cclan ote ee 0.015 
BaryoumLCArDONAte -\.1-aieiscletis eisai athe cic cwienies Dae 0.006 
“HETLOUS: CATOONALO a et antes atk Cod cern neat 0.017 
Alnminivnny pHosphate trees ces. ysee emis se chicen: cneee 0.009 
Bilicictacid TERR Aee se ee tees lets Se nae een 0.141 
SL OUML OE Serinctniebeteisteiac ets elec c siacmuieeteme none 2.989 


There are also traces of iodine, bromine, rubidium, 
cesium, and thallium. The temperature of the water 
at Pfafers is 99.5° F., but by the time it has reached 
Ragaz in the pipe-line conduit, it has been cooled to about 
95.5° F. The waters are taken internally and in the 
form of baths, douches, etc. They are recommended 
chiefly in the treatment of excited nervous conditions, 
and of chronic rheumatism and gout. The season in 
Ragaz extends from the beginning of May to the end of 


140 


October ; in Pfafers it is about two months shorter. In 
addition to the use of the thermal waters, there are facil- 
ities for the ‘‘ whey” and “‘ grape” cures. 1S FAP 


RAILWAY MEDICAL SERVICE. In the infancy of 
American railroads, while they were few, short, and no- 
where distant from centres of population, it could not 
have been supposed that the companies would derive 
any advantage from an organized medical department ; 
nor is it likely that such a want was then anticipated, 
any more than an occasion for undertaking the business 
of mining, manufacturing, or the extensive planting of 
forest trees. But, as lines lengthened and business in- 
creased, occasions for surgical relief to passengers and 
employés multiplied, and the advantage of definite and 
permanent engagements with medical men became ap- 
parent. 

It is evident that a strong corporation, well organized 
for a particular purpose, has facilities for undertaking 
new functions ; and medical relief to employés, when 
they became numerous, would seem as natural a want as 
in a military establishment. But the actual outgrowth 
of railway medical service in Great Britain and the 
United States has been governed by the apparent neces- 
sities of companies, to obviate the greater expense of 
employing medical men only when their services were 
indispensable, and at their own prices. In France and 
other countries of continental Europe, where railroads 
have always been more or less under direct governmental 
control, and where a paternal government assumes com- 
plete supervision of the conduct of its subjects, a well- 
organized medical department has long existed on the 
more important roads, 

The first, and for some time the only, occasions for the 
employment of medical men by railway companies were 
in a surgical capacity, for the relief of those injured in 
accidents, when it might be presumed that the companies 
would be held legally responsible for consequences. A 
service once organized for this purpose could be made 
available, without much additional expense, for the relief 
of employés, and even of their families, in ordinary sick- 
ness. The physical examination of employés followed 
later, and, last of all, hygienic measures for the preven- 
tion of disease. These come latest, not because of in- 
ferior importance, but because they are the highest de- 
velopment in the gradual evolution of medical science. 

The medical service of some of the principal railways 
of France and Italy is the most elaborate in the world, 
and will properly serve as a model for general imitation, 
as it has already on the continent of Europe, and to some 
extent in British India, in Australia, and by a few com- 
panies in the United States. The medical department 
of the Paris, Lyons & Mediterranean Railroad has its 
headquarters at Paris, and is administered by a physi- 
cian-in-chief and'a number of district physicians, who 
are practitioners residing at convenient distances along 
the lines. All receive fixed salaries, and their duties are 
defined as follows : 

The district physicians are required : 

1. To attend gratuitously upon sick and injured em- 
ployés, and all other persons accidentally injured upon 
the lines or in the premises of the company. 

2. To ascertain and certify the general health and 
degree of corporeal fitness of applicants for the various 
branches of service, after careful physical examination. 

3. To answer all calls for attendance in case of acci- 
dents upon the lines and in the establishments of the 
company. 

4. To advise the directory in questions of hygiene and 
in the settlement of damages for personal injuries. 

5. To inspect monthly, as far as possible, all estab- 
lishments whose personnel is entrusted to their care, in 
order to certify their sanitary condition, and to inspect 
the relief-chests, medical stores, and apparatus of the 
medical service. 

6. To report monthly to the physician-in-chief the con- 
dition of the sick and wounded, and the results of the 
inspections, adding thereto any necessary observations 
and requisitions. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, 


Rabies. (Service. 
Railway Medical 


7. To certify and countersign bills of hospitals, apoth- 
ecaries, and other purveyors, and those of private physi- 
cians, previous to forwarding the same to the physician- 
_in-chief. 

The duties of the physician-in-chief are : 

1. To supervise the medical service of all the com- 
pany’s lines, and inspect the same as often as he deems 
proper. 

2. To examine and countersign all bills for ordinary 
expenditures (those of hospitals, apothecaries, and other 
purveyors), and to advise superintendents of the operat- 
ing and construction departments concerning extraordi- 
nary expenditures of the medical service (bills of private 
physicians, thermal-water establishments, indemnity for 
personal injuries, etc.), before transmitting them to the 
central bureau of accounts in the department of opera- 
tion. 

3. To consider all matters which are to be submitted 
to the superintendents of operation and construction, such 
as applications for extension of medical relief, for send- 
ing to mineral springs, and for indemnity on account 
of injuries ; investigations and reports upon grave acci- 
dents ; applications for positions in the medical corps. 

4. He also receives the monthly reports of his subor- 
dinates, and consolidates their statements concerning the 
general health of the personnel and sanitary condition of 
the company’s property into a general report, which he 
makes annually to the general manager, and in which he 
includes his own observations upon prevailing diseases 
and upon the medical service in general. 

5. The physician-in-chief is, besides, charged with the 
general superintendence of the medical service ; with re- 
ceiving petitions or claims addressed to him by physi- 
cians, superintendents, or sick persons, in matters which 
concern the medical service ; with the collection of docu- 
ments which may contribute to improving the health of 
employés and the sanitary condition of the company’s 
establishments ; with assisting personally, in case of grave 
accidents, in the organization of relief, and with aiding 
by counsel and influence, in concert with the legal ser- 
vice, the adjustment of indemnities for personal injury ; 
with making several times a year an inspection of the 
medical service and of the company’s establishments ; 
with suggesting any hygienic or medical measures which 
he may deem expedient to the company. 

6. All petitions, documents, letters, etc., relative to 
the medical service, are sent to him through the adminis- 
trative channel. 

Mepicat ExaMINATION.—No individual, except por- 
tresses, female gate-keepers, and sanitary employes, can 
enter the service of the company without previous exam- 
ination by a company’s physician, who gives him a cer- 
tificate declaring the state of his general health and de- 
gree of his corporeal fitness for the particular position 
desired. The system of examination adopted by the 
Northern Railway Company of France is especially com- 
mendable. Any degree whatever of organic heart trouble, 
or any predisposition to tuberculosis, is cause for rejec- 
tion. Particular attention is given to integrity of vision 
(with special reference to color-blindness), to freedom 
from varicose veins and hernia, among all men applying 
for train service—such as conductors, engineers, firemen, 
brakemen, and also switchmen, road-laborers, and shop- 
operatives. The ocular sense is examined by inspection 
of the eyelids, the lachrymal ducts, the conjunctiva, the 
cornea, and the pupil; by comparing the visual field of 
the candidate with that of the examiner ; by determining 
visual acuteness by means of Snellen’s test-types ; by test- 
ing the chromatic sense with colored worsteds. (In the 
last case no one is condemned without re-examination 
by the physician-in-chief.) The sense of hearing is tested 
by the distance at which the ticking of a watch can be 
heard. 

The list of ailments which are made absolute causes 
of rejection, or relative causes of disrating actual em- 
ployés, comprises no less than sixty-eight affections, 
Six are cutaneous, including leprosy, lupus, and syphi- 
litic ulcers. Four are maladies of the nervous system— 
convulsions, delirium tremens, paralysis, and insanity, 


Eye disorders number twelve, among which are myopia, 
color-blindness, and cataract. Well-marked deafness is 
the only ear-trouble specified.. Affections of the neck 
comprise wry-neck, scrofulous and cancerous tumors, 
goitre, chronic laryngeal troubles, etc. Maladies of the 
thoracic walls (four in number) have reference to diseases 
of the bony structure; among those of the respiratory 
organs are included pulmonary consumption, chronic 
catarrh, and asthma ; of the heart, we find organic affec- 
tions of the walls, valves, and pericardium, and aneurism. 
There are six abdominal ailments, and eight of the genito- 
urinary organs, but not all of the last involve total dis- 
ability. Constitutional infirmities include the scrofulous, 
scorbutic, tuberculous, and cancerous taints, and natural 
feebleness. From the above it appears that the examina- 
tion partakes of the nature of that of recruits for the army 
and navy, and of that for life insurance, and on the whole 
is rather more searching than either. Its importance is 
apparent, when it is considered that the company as- 
sumes grave responsibility for the lives and health of its 
servants, while it thereby secures the permanent service 
of picked men, far above the average in efficiency and last- 
ing qualities. The advantages to the men of the medical 
service, after admission to the company’s employ, are so 
manifold (in relief, surgical and medical, in provision for 
the misfortunes of age and disability, and in permanence 
of engagement) that they are correspondingly attached 
to the company, and perform their duties with a fidelity 
not otherwise attainable, and a skill only acquired by 
long practice. At the same time risk of strikes, repri- 
sals, and suits for personal damages is eliminated, as is 
also that of such accidents as are attributable to defects of 
the special senses and to sudden failure of vital organs 
on the part of those concerned in the movement of trains, 

ReLieF.—Every employé, including females not exam- 
ined, is entitled to relief (both attendance and medicines) 
in case of injury or sickness, except under circumstances 
hereafter to be mentioned. Whenever anyone declares 
himself ill, or is reported absent by reason of sickness, his 
foreman gives to him, or sends to the district physician, 
a ticket of attendance, detached from a record-stub, and 
joins to it a pass over the road, in case the patient is not 
near the physician’s station. The physicians receive 
these patients at the station-house or at their own offices. 
They record upon a case-book the names, occupations, 
and residences of the out-patients, the nature and cause 
of their sickness, the remedies prescribed, the expected 
duration, and, after cure, the actual duration of dis- 
ability for work ; adding such observations as they deem 
useful to the patients and to the service. This record is 
examined by the physician-in-chief at every tour of in- 
spection, and facilitates and governs future reference by 
the administration. When an employé, reported sick, is 
unable to leave the house, the ticket of attendance, in- 
scribed ‘‘at domicile,” with its precise location, is de- 
spatched to the physician, who then attends the patient at 
his own residence. In case hospital treatment is thought 
advisable, the patient has the option of home treatment 
at his own expense. On discharge from treatment the 
employé has his condition authenticated by the district 
physician to his foreman, without which the company is 
not responsible for the expense incurred. In a case of 
severe illness or injury, a company’s physician may ask 
the counsel or aid of his colleagues in adjoining districts ; 
or in emergency may call on a private medical man ; but 
an account of the same must be rendered to the physi- 
cian-in-chief. ; 

An employé has the option of attendance by a private 
physician at his own expense. In an emergency Certl- 
fied by the man’s foreman, when the company’s physician 
cannot attend him, the private physician’s bill is to be 
approved by the foreman and the district physician, and 
addressed to the physician-in-chief, who refers it to the 
administration. In any case, all such claim for fees 
ceases from the moment the company’s physician is ready 
to attend the patient. a : 

Medical and pecuniary relief for sickness or injury 1s 
limited to three months. After this the administration 
decides upon extending or discontinuing relief, or fixing 


141 


Railway Med. Serv. 
Railway Spine. 


a time beyond which the employé goes out of the com- 
pany’s service. Every patient who exceeds his leave of 
absence without his physician’s authority, or who un- 
necessarily requires the physician’s attendance at his 
domicile, or is not at home when visited, is regarded as ab- 
sent without leave and subject to penalty. The follow- 
ing are not entitled to medical relief : 1. Employés whose 
annual salary is more than twenty-five hundred francs. 
2. Those who, though not required by the nature of their 
employment, dwell more than two kilometres from the 
establishments to which they are attached, in which case 
they can only require of the company’s physician an au- 
thentication of their illness. 3. Those who, after dis- 
charge from attendance and before resuming work, again 
fall sick. 4. Those who were subjects of a chronic in- 
firmity before entering the company’s service. 5. Those 
whose illness results from their own misconduct (drunk- 
enness, venereal infection, brawls, etc.). 6. Day-laborers 
and those working for contractors. 

ACCIDENTsS.— When an accident occurs upon the line, 
resulting in personal injuries, the physician of that dis- 
trict, and in his absence or in case of need those of the 
neighboring districts, and even private physicians, are 
summoned by telegraph to render aid, and, if necessary, 
organize an ambulance service. The company’s physi- 
cian will attend injured passengers until recovery, if they 
so desire. A circumstantial report of the accident is 
drawn up and transmitted to the physician-in-chief, and 
by him to the general manager. In an urgent. case the 
foremen and employés are to follow the printed instruc- 
tions concerning the first relief to be rendered while wait- 
ing for the doctor. 

Whenever a district physician desires his place to be 
filled by one of his colleagues or by a private physician, 
he is to obtain permission of his chief. Each one is en- 
titled toa free pass over his own and the two adjoining 
sections of the road, and the chief to a pass over the 
whole line. 

Mepicau Stores.—A relief-chest, with an amputation- 
case, a Stretcher, and often a supply of medicines and 
surgical appliances, is deposited at the stations where 
workshops are located or locomotives are changed. Com- 
mon relief-chests are deposited at other stations and es- 
tablishments where they are liable to be needed. Purvey- 
ors of the company, such as apothecaries, druggists, sur- 
gical-instrument-makers, etc., agree to a written tariff of 
prices, and sell to employés of the company by the same 
tariff whatever articles they need for their personal use. 
All bills are presented quarterly to the district physi- 
cians, and after approval are transmitted to the physician- 
in-chief. 

PRINTED INSTRUCTIONS TO EMPLOYES.—These relate : 
1. To the principal hygienic precautions which should 
be observed by individuals to avert preventable diseases 
and accidents. 2. To the chief measures which are to be 
used on the spot while waiting for the doctor, in case of 
the most common accidents and maladies. 3. To the 
mode of employing the contents of the relief-chests and 
of the medicine-chests at the station-houses, especially 
those which are in daily use or can be obtained without a 
physician’s prescription. | 

The Eastern Railway of France has some additional 
provisions, which are worthy of consideration, if not of 
commendation. All trains are provided with relief- 
chests, containing medicines and surgical appliances for 
use in case of accidental injuries to any persons travel- 
ling thereon. Sick employés continue to receive full pay 
during illness not exceeding eight days; from this time 
up to two months of disability for work they are allowed 
. half-pay. Beyond two months the allowance is at the 
discretion of the administration. In case of death the 
company grants to the.widow or orphans a sum equal to 
two months’ pay, and assumes the expense of burial. 
In special cases further pecuniary relief to the family 
may be granted. But these allowances are made only to 
permanent employés. Day-laborers receive medical at- 
tendance and medicines, together with half-pay, during 
two weeks of disability, which may be extended if the 
disability arose strictly in line of duty. 


142 


,their families are provided for. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


A Provident Fund has been established among the peo- 
ple of this company for the purpose of supplementing 
the relief granted through the regular medical service, 
in case of sickness or injury, to employés or to their 
families in case of death. Its benefits accrue only to the 
contributors, and they receive half-pay for two months 
after the company’s allowance has expired. In addition 
the family receive from the fund a sum equal to that al- 
lowed by the company. In case of permanent disabil- 
ity, besides allowances already mentioned, the invalid 
will recover all sums previously contributed by him to 
this relief fund; otherwise the relief is limited to one 
year’s contributions. Relief can be refused when the dis- 
ability has arisen from the person’s own misconduct ; 
and when he leaves the company’s service no claim for 
reimbursement is entertained. Whenever the Provident 
Fund fails to meet all demands, the company advances 
the needed sum, and provides for repayment by increased 
assessment upon contributing members. Any surplus 
goes to the Pension. Fund. 

In France, the Netherlands, and Italy, the families of 
railway employés are not provided with medical relief 
by the railway medical service, but this is generally the 
case in Austro-Hungary, the German Empire, Sweden, 
and Spain.. The regulations usually require employés to 
be contributing members to some association, and deduc- 
tions are made from their monthly wages of one to two 
per cent. to the credit of the medical fund. This is sup- 
plemented by a contribution of a similar amount by the 
company—sometimes equal, and sometimes one-half. 
In the Austro-Hungarian Empire district-physicians in- 
struct the men in the use of instruments, dressings, and 
certain medicines, so that they may know how to act in 
an emergency in the absence of a medical man, and how 
to assist him in case of need.. In the German Empire 
station-agents and train-conductors are provided with 
printed instructions, and are required to familiarize them- 
selves with bandages and simple dressings. In this 
country provision is made by the different companies for 
the care of those permanently disabled by sickness or 
injury while in the discharge of duty. In case of death 
Certain classes of em- 
ployés are also entitled to retire upon a pension, after 
service for a period of not less than ten years. Their 
widows are also entitled to a pension, and their young 
children to an allowance for their rearing. There are 
also regulations for the cleansing and disinfection of cars 
used for the transportation of live animals, as soon as 
emptied. All these regulations in the German Empire 
were drawn up by a government official, and have the 
force of law. 

In the principal railway company of Northern Italy 
there are two associations of the employés which all are 
required to join, except those whose annual pay amounts 
to more than two hundred and forty dollars. One of 
these is for mutual assistance in case of injury or sick- 
ness, to which each member contributes one and a half 
per cent. of his monthly wages ; the other provides retir- 
ing pensions after a fixed term of service, or in case of 


permanent invalidism, and calls for three per cent. of 


the wages. Want of space does not admit going into de- 
tails in these pages. From the former, members receive 
during illness and convalescence, after one month’s con- 
tribution, one-third of their wages; after two months’ 
contribution, one-half ; after three months’ contribution, 
two-thirds of their wages. This relief terminates in 
three months, but may be renewed by decision of the 
committee, provided the state of the funds admits. In 
Sweden similar allowances of pay to sick and injured 
employés is made by the government railways; and 
some provision is made for their families in case of sick- 
ness, injury, and death, both by the companies and by 
their own associations. 

In the United States a railway medical service first be- 
came systematized in 1869, on the Central Pacific Railway, 
and its plan has been imitated by other roads running 
through sparsely inhabited and extensive districts. A 
hospital was erected by the company at Sacramento, to 
the benefits of which all employés are entitled, and for 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ralway Med. Serv. 


Railway Spine. 


the support of which all have to contribute fifty cents a 
month. The Baltimore & Ohio Railroad has an Em- 
ployés’ Relief Association, to which all must contribute 
according to the amount of their pay. For this purpose 
they are divided into five classes; the lowest, receiving 
$35 and under per month, contribute one dollar per 
month, and are entitled to 50 cents a day during disable- 
ment not exceeding six months; while the highest, re- 
ceiving $100 or more, pay five dollars a month, and receive 
$2.50 a day in relief. These figures apply to those em- 
ployed in train service; in other branches the contribu- 
tions and benefits are one-fourth less. After six months 
of disablement the allowance for relief is reduced to one- 
half. In case of death from accident, the legal represen- 
tative is entitled to an allowance of from $500 to $2,500, 
according to the monthly contributions ; in case of death 
from ordinary sickness, the allowance is one-fifth of the 
above. The company has no hospitals of its own, but 
has contracts with hospitals at the principal cities, to 
which its people may be admitted on favorable terms. 
The association pays for surgical attendance at the hos- 
pital, and the member for his board, which is more than 
met by his relief allowance. The company, at the be- 
ginning, appropriated $100,000 as a foundation to the re- 
lief organization, the interest of which is annually avail- 
able. The salaried officers consist of the secretary of the 
association, who is the medical superintendent, and seven 
inspectors, who are assigned to specified districts, which 
they are constantly traversing to investigate cases of dis- 
ability, the sanitary condition of the company’s establish- 
ments, etc. They also attend persons injured by the 
casualties of traffic, both employés and passengers, make 
physical examination of applicants for employment, vac- 
cinate those requiring it, and provide appropriate reme- 
dies for the relief of such disorders as malarial fevers 
and intestinal irregularities, wherever they may be found 
prevalent. There are also pension and building funds, 
to which employés may contribute at option and enjoy 
corresponding privileges. 

Another system in use upon several American railroads 
has reference solely to relief, at the expense of the com- 
pany, to sufferers from accidents, without provision for 
ordinary sickness. The only salaried officer is a chief 
surgeon. Contracts are made with local practitioners, 
at convenient intervals, to attend at fixed rates those 
accidentally injured. The district surgeons have free 
passes over their own territory, which is the most valu- 
able consideration for the appointment. The Denver 
& Rio Grande Railroad, alone of American companies, 
provides relief-boxes for all trains, containing such med- 
ical and surgical supplies as are liable to be needed on 
the route. This company has its own hospitals, and re- 
quires a physical examination of all employed in the 
movement of trains. 

It is evident that railway medical service in this 
country has nowhere attained the degree of efficiency 
and utility found on the continent of Europe. Prob- 
ably the minuteness of details there exercised would be 
here found incompatible with American notions of per- 
sonal liberty. There can be no dispute that an organized 
system of relief to sufferers from the casualties of traffic 
is demanded of all companies of respectable magnitude, 
as a measure of both humanity and economy. It is the 
cheapest mode of exoneration from legal responsibility 
to give all possible relief before it is demanded. When 
once this necessary provision is made, other desirable 
features can be added without great expense, making use 
of the same medical officers. There can be no doubt 
that sure relief to employés in ordinary sickness is a 
great advantage to them, and its appreciation conduces 
to such increase of content and fidelity on their part as 
to warrant a large outlay by a company to furnish a 
foundation for an organized system. The advantage is 
increased when the same privilege is extended to the 
man’s family. It tends to permanence of engagements, 
and forestalls strikes and reprisals. The expense of this 
feature is met by deductions from monthly wages, which 
are cheerfully submitted to when the men find their ad- 
vantage in the system. Physical examination of train- 


men is required for the security of travellers from such 
accidents as are liable to result from defects of sight and 
hearing, and from sudden failure of vital organs; and, 
as a measure of protection to the relief-funds, it must be 
required of all who participate in its benefits. Relief- 
chests will not often be needed ; neither are pocket-pis- 
tols; but, when occasion requires, both are urgently 
wanted. It is indisputable that certain intelligent em- 
ployés ought to know how to use the contents of a relief- 
chest, and that they ought to be instructed by a medical 
man, Attention to the personal hygiene of employés, 
and to the sanitary condition of buildings, grounds, rail- 
way carriages, etc., is also a proper duty of the medical 
staff, and involves no expense comparable to its benefits. 
It is evident that railways are liable, unwittingly, to be- 
come carriers of contagion, both of human beings and of 
animals transported in their cars, and that all reasonable 
means should be used to prevent so undesirable an event. 
Small-pox, cholera, and glanders may be mentioned as 
examples of such transportable diseases. Vigilant medical 
men in the service of a company would generally be able 
to give timely warning, so that the necessary precautions 
might be taken to keep infection at a distance ; or, in case 
of actual admission of choleraic, variolous, or glandered 
subjects, that proper measures of disinfection might be em- 
ployed. The prevention of such diseases is vastly more 
important than their cure, and in general the preventive 
functions of a railway medical service should be regarded 
as the most useful part of its duties. It is time now, near 
the dawn of the twentieth century, to recognize in medi- 
cine, as in an army and navy establishment, that its great- 
est achievements are in forestalling the ills which i®ewas 
formerly expected only to redress. S. 8. Herrick. 


RAILWAY SPINE. This ambiguous and misleading 
term has been for many years applied to the large class 
of cases in which pain and stiffness in the back, and vari- 
ous symptoms referable to the nervous system, follow 
trauma in the form of blows, falls, and collisions. The 
name was given, and has come into general use, because 
railway accidents are among the most common causes, 
especially in those cases which come into prominence on 
account of litigation. The expression is ambiguous in 
that it gives no clew to the seat of the morbid process, as 
to whether the spinal cord, its membranes, its bony and. 
ligamentous coverings, or the overlying parts, are affect- 
ed; misleading in that it directs attention to the spinal 
cord, an organ which has probably far less to do with 
the trouble than has been generally supposed in the past. 
It should be premised that there is still considerable vari- 
ance among those who have written on this subject, as 
well as in the prominent text-books. The views ex- 
pressed in this article far from represent the unanimous 
opinion of authorities. They are, however, practically. 
in conformity with the principles first enunciated by 
Page, to whom, more than to any other, is due the credit 
of rescuing the subject from utter confusion. 

The symptoms under consideration follow accidents 
which cause a jar to the body, whether received from a 
blow on the trunk, head, or elsewhere, or from a fall 
upon the head, back, buttocks, or other part of the body. 
They generally vary in intensity with the violence of the 
jar, but in persons of neuropathic tendency the slightest 
possible shock may be the exciting cause for the most 
marked symptoms—a fact which lets much light on the 
pathology of the affection, in that it points, at least in 
these cases, to traumatic hysteria or neurasthenia, rather 
than injury to the spinal cord. The prevailing theory in 
the past, and perhaps even up to the present, has been 
that concussion of the spinal cord lies at the bottom of 
the trouble—a theory which has done much to perpetuate 
the name. This diagnosis, however, if ever allowable, 
is certainly, in the vast majority of these cases, not ten- 
able. 

Leaving out of consideration the symptoms arising 
from structural injury (hemorrhage, myelitis, meningi- 
tis), which have been falsely attributed to concussion of 
the spine, but which should be sought under their appro- 
priate titles, we find that the patients suffer, asa rule, first, 


143 


Railway Spine. 
Rales. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


from more or less marked symptoms (which need not be 
here enumerated) of shock, and afterward, fora longer or 
shorter period, complain of soreness, pain, and stiffness 
in the back, and of the almost endless variety of nervous 
symptoms, which have been commonly accredited to 
spinal concussion. Included under this title have ap- 
peared not only such symptoms as pains in the back and 
elsewhere, loss of sexual power, general malaise, and 
weakness of the extremities, but also headache, sleepless- 
ness, loss of memory, vertigo, inability to confine the atten- 
tion, and similar symptoms, which would point rather to 
the brain than to the spinal cord, if any one part of the 
central nervous system were to be credited with the en- 
tire pathology of the disturbance. Recent writers (notably 
Page) have expressed great doubt as to the liability of the 
spinal cord to injury, as long as its bony case remains in- 
tact, although not denying that it may occur exception- 
ally. This view seems far more satisfactory than that of 
the writers who favor spinal concussion, when we con- 
sider the fact that the spinal cord, an organ of extremely 
light weight, hangs suspended in a cavity much larger 
than itself, the intervening space being filled out by areo- 
lar tissue, membranes, cerebro-spinal fluid, and a plexus 
of veins, all of which protect it in such a way that no 
ordinary blow is liable to affect it as long as the vertebree 
are uninjured ; furthermore, the automatic centres situ- 
ated in the spinal cord represent a less delicate set of 
functions than those of the brain, and are, therefore, 
probably less liable to be thrown out of balance by a 
moderate jar. The brain itself, moreover, is mechani- 
cally so placed as to be much more susceptible to damage 
from violence than the spinal cord, being heavier and 
less thoroughly protected by its bony covering. On @ 
priort grounds, therefore, we should expect the brain, 
rather than the spinal cord, to be the principal sufferer 
from a jar to the whole body, and the analysis of the 
symptoms, with this fact in mind, shows that the spinal 
cord is not even an essential factor. 

Leaving for a moment the question of strain of mus- 


cles of the back, and of the ligaments of the vertebra, — 


which are frequently present in these cases, and which 
have perhaps been the principal factor in drawing at- 
tention to the spine, we find that most of the symptoms 
of so-called railway spine admit of satisfactory explana- 
tion by disordered function of the cerebral centres, and 
that they are closely allied to, if not identical with, the 
recognized symptoms of the functional nervous disturb- 
ances included under the names hysteria, neurasthenia, 
and hypochondria. Such symptoms as_ hopelessness, 
morbid fears, sleeplessness, mental irritability, and in- 
ability to confine the attention, certainly come under 
this category, as well as asthenopia, amblyopia, nervous 
deafness, and other disturbances of special sense. 
Among the other innumerable symptoms we find pains 
in the back, sensitiveness of the spine to pressure, weak- 
ness in the back, tenderness of the scalp, heaviness of 
the loins and: limbs, flushes and chills, mental and phys- 
ical hyper-sensitiveness, anzsthesia, and impotence. 
These are all recognized symptoms of functional nervous 
disease, and point to weakness and irritability of the en- 
tire nervous system, more especially the brain and the 
sympathetic, and the term spinal concussion, like that of 
spinal irritation, intended, as it undoubtedly often is, to 
convey the idea that disorder of the spinal nerve-cells, or 
of the meninges, furnishes the basis for the trouble, is 
certainly misleading. Sensitiveness of the spine to press- 
ure has probably nothing to do with the cord in the large 
majority of these cases. The tender spots over the spine 
represent simply the ramifications of the sensory nerves 
of the region implicated, and it is a significant fact, in 
this connection, that these sensitive spots are common in 
the lower lumbar, sacral, and coccygeal regions, far be- 
low the termination of the cord. Apart from the sensi- 
tiveness of the tissues from sprain, these regions of hy- 
pereesthesia fall into the same category as the tender 
spots on the scalp, pointing to cerebral irritability. The 
feeling of weakness in the back means, probably, that 
the muscles of the back are wearied in holding up the 
vertebral column, just as any other muscles may tire of 


144 


performing their function, and we have no reason for 
connecting these sensations with the spinal centres. The 
same is true of the sense of heaviness in the loins and 
limbs, of which these patients often complain. Morbid 
fears, vaso-motor irregularities, and extreme sensitive- 
ness to cold, heat, medicines, or other influences, may all 
be classed together as common to hysterical, hypochon- 
driacal, and so-called neurasthenical patients. Such pa- 
tients report the most severe symptoms following di- 
rectly upon the application of cold water or electricity, or 
upon the exhibition of drugs in absurdly minimal doses. 
While these symptoms are by no means to be classed as 
simply imaginary, they are obviously to be explained by 
perversion of cerebral function. One of the most com- 
mon symptoms complained of is loss of sexual power and 
desire, but this is not necessarily connected with the spi- 
nal cord, for the lower centres for erection and ejaculation 
are under the influence of the brain, so that this reflex 
may be started even by a thought or inhibited by a fear. 
Irregularities in micturition are frequently noticed, as 
well as palpitation, precordial distress, and disorders of 
digestion differing in no respect from symptoms of func- 
tional vesical, cardiac, and digestive derangement met 
with in neurasthenia and hysteria. In some cases appear 
paralyses and contractures, anesthesia, hypersesthesia, 
and convulsions ; the motor disorders not being limited, 
as a rule, to any muscle or group of muscles, but affect- 
ing a whole limb or more ; the sensory disturbances being 
generally bounded by a line not representing the distri- 
bution of any particular nerve, and often affecting an en- 
tire half of the body (traumatic hemianesthesia, first ob- 
served by,Putnam). These conditions correspond with 
the typical motor and sensory symptoms of hysteria, the 
special senses being also generally affected in the manner 
characteristic of that disease (see Hysteria). Any or all of 
the symptoms enumerated under hysteria may be present, 
and need not be here recapitulated. It is true that these 
symptoms sometimes persist for along time; this does 
not, however, militate against the diagnosis of hysteria, 
nor does their occurrence in men as well as women, to 
both of which facts Charcot has drawn special atten- 
tion. 

Apart from the neuralgic pains and hyperesthetic 
spots on the back, the majority of the patients complain 


of constant pain and soreness in the back and sensitive- . 


ness to deep pressure over both the vertebral column and 
the muscles of both sides, most frequently over the lum- 
bar regions. The pain is increased on movement, espe- 
cially by bending and twisting the trunk. This symp- 
tom, whether accompanied or not by hypersensitiveness 
of the back to the light touch, points to strain of the 
muscles of the back, and sometimes of the ligaments of 
the vertebral column. It should not, therefore, though 
among the most persistent and troublesome of the symp- 
toms, be attributed in any degree to disorder of the 
spinal cord or its membranes. A similar condition may 
obtain in the muscles of the neck and the ligaments of 
the cervical vertebra, as well as in any part of the body 
which is liable to strain from either direct violence or 
muscular effort. 

PatTuHuoLocy.—As to the exact pathology of those symp- 
toms which are referable to the nervous system, we are 
still in the dark, as we are regarding the pathology of 
hysteria, neurasthenia, and hypochondria. Post-mortem 
examination reveals nothing, and we are forced to adopt 
the term functional disturbance of the central nervous 
system, regarding the brain as the organ most seriously 
implicated, without venturing to theorize as to whether 
the disorder is due to malnutrition, vaso-motor irregu- 
larities, molecular disturbances, or perhaps to reflex irri- 
tation from injury of abdominal or other organs. Cer- 
tain writers (Westphal, Oppenheim) believe that chronic 
structural changes (widely diffused sclerosis) may super- 
vene, and cause the persistence of symptoms sometimes 
seen. This matter must be considered as still under dis- 
cussion. There can be no doubt, however, that atrophy 
of the optic nerve can follow simple concussion. 

DiaGnosis.—The utmost care is necessary to exclude 
organic lesion of the central nervous system, as, for ex- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


ample, hemorrhage into the brain or cord, myelitis, and 
meningitis, as well as injury or disease of the vertebre, 
especially fracture, dislocation, and caries. Before elim- 
inating organic disease we should look carefully for such 
symptoms as local atrophy and coldness, rigidity, altera- 
tion of electrical reactions, ankle clonus, and irregularity 
of the pupils. Bed-sores and cystitis point to organic 
disease, and are practically never present in the class of 
cases here considered. When organic disease is demon- 
strated, the case should be classed and treated accord- 
ingly. Great care must be taken to exclude, as far as 
possible, simulation and exaggeration. The difficulty in 
detecting deceit is especially great on account of the ease 
with which the subjective complaints may be assumed 
and kept up. It must also be remembered that these 
patients may fall into a state of prolonged invalidism 
from simple lack of will-power, and even where no de- 
ceit is definitely planned the prospect of large damages 
naturally places a premium on inertia. We should al- 
ways seek to discover, then, first—are the symptoms real, 
feigned, imagined, or exaggerated ? secondly, if real, are 
they functional or organic? The variety of symptoms 
which may be feigned is so great that the study of their 
detection can hardly be entered upon in this article. 
Cases should be regarded with suspicion in which the 
symptoms have not appeared until the lapse of consider- 
able time after the accident, allowing, however, a certain 
time for the patient to recover from the benumbing ef- 
fects of the shock. Cases which appear to grow worse 
and worse up to the time of settlement of claims for 
damages should be examined with special care, and will 
often be found to improve rapidly after the claim is ad- 
justed. 

TREATMENT.—The treatment differs at the outset in 
no respect from that of shock, and later from that of 
strain, whether of muscles, ligaments, or both, and from 
that of hysteria, neurasthenia, or hypochondria, accord- 
ing as the symptoms of each disorder predominate. The 
treatment of these diseases is considered elsewhere. 

Proenosis.—The prognosis of these traumatic func- 
tional disorders is better than that of similar disorders 
resulting from natural causes, and the tendency of the 
nervous symptoms, as well as that of the strain, is in 
general toward improvement, rapid or gradual, contin- 
uous or intermittent, according to the severity of the 
shock, the surroundings of the patient, and the various 
influences which govern the course of ail functional 
nervous derangements. The previous condition of the 
patient should always be considered in making the prog- 
nosis, inasmuch as rapid and steady improvement is more 
to be expected in the case of a person previously robust, 
than in that of one already of a neurotic temperament 
or broken down by overwork, anxiety, or pre-existing 
disease. The exact period required for recovery can 
never be prognosticated ; while the milder cases may run 
their course in days or weeks, others may last months, or 
even years, and in exceptional instances the symptoms, 
especially those referable to the back, seem to cause an- 
noyance for an almost indefinite period of time, even 
when no question of damages or other inducement to 
invalidism is present. Permanency of the nervous symp- 
toms is, however, of great rarity, excepting in persons 
already suffering from, or on the verge of, hysteria, 
neurasthenia, or hypochondria, where the trauma acts 
merely as an exciting or aggravating cause. It would 
seem that the prognosis which has found its way into 
the text-books, that these cases may grow worse and 
terminate fatally, has arisen from the old confusion be- 
tween organic and functional cases. A prognosis which 
belongs, except in the rarest instances, only to the cases 
of organic lesion of the nervous system, should hardly be 
made to cover all indiscriminately. This prognosis ac- 
cords an undue importance to nervous injuries resulting 
from railway and other accidents, inasmuch as in the vast 
majority of cases we have to do with such functional dis- 
orders as above described, either existing alone or in com- 
bination with strain of the muscles of the back and of 
the ligaments of the vertebre. 

G. L. Walton. 


Vou. VI.—10 


Railway Spine. 
Rales. 


RALES. This term is applied to certain abnormal 
sounds heard in the chest. It is customary with many 
authors to speak of dry and moist rales. Sibilant and 
sonorous breath-sounds are called dry rales, although 
there is no more reason for calling these sounds rales than 


there is for applying the same term to cavernous breath- 


ing. Certain authors also call these forms of breathing 
rhonchi, and use the word rale to designate only the moist 
sounds. Rhonchus, again, by others, is used as exactly 
synonymous with rale. 

The causes of these abnormal sounds vary consider- 
ably. We may have a considerable accumulation of 
exudation in the trachea and larger bronchi, producing 
large bubbles, or the smaller bronchi may be more or 
less filled, giving rise to small bubbles, or perhaps the 
sounds may be produced in the alveoli themselves. Rales 
may also be produced by the rubbing of roughened 
pleural surfaces, by the presence. of fibrinous exudate on 
the pleura, and by the stretching of pleuritic adhesions. 

CoarsE Mucous RALEs are coarse bubbling sounds 
produced in the trachea and larger bronchi. They are 
heard with both inspiration and expiration. They may 
sometimes be made to disappear for a time by causing 
the patient to cough. Sometimes, especially in children, 
they may produce a fremitus easily felt through the 
chest-wall. They are heard most commonly with acute 
bronchitis in its exudative stage, and with broncho-pneu- 
monia, also with chronic bronchitis and phthisis, some 
cases of cedema of the lungs, lobar pneumonia, compres- 
sion of bronchi or trachea due to neoplasm or aneurism, 
some cases of pleurisy with effusion, and empyema, es- 
pecially with perforation of the lung. 

Fine Mucous RAteEs are sounds of the same quality 
as the former, but finer. They are heard under the same 
conditions. 

SUBCREPITANT RAuEs.—These are fine, high-pitched, 
bubbling sounds, heard during both inspiration and ex- 
piration. They may be produced by the bursting of 
small bubbles in the finest bronchioles or air-passages, or 
they may be caused by fibrin‘on the pleura, and by pleu- 
ritic adhesions. The cause of this rale has been a matter 
of considerable dispute. On the one hand, it is held that 
the sound is invariably produced in the finer air-passages; 
on the other, that pleural changes alone can give rise to 
it. The advocates of the former view hold that sounds 
resembling the subcrepitant rale may be produced in thé 
pleura, but that a good ear can distinguish these from 
the true subcrepitant, by a slight difference in quality. 
Believers in the second dictum say that there is not 


enough motion of the air in the finer air-passages to give 


rise to the rale. Both of these views are extreme. There 
are cases in which the subcrepitant rale is heard which 
show, post mortem, nothing but pleurisy as a possible cause, 
and there are cases of oedema of the lungs, with no pleu- 
ritic changes, in which this rale has been clearly heard, 
and in which the serum in the lungs is the only demon- 
strable factor in its production. It cannot be denied that 
the sound may be due to either of these causes. This 
rale may be heard in pleurisy ; bronchitis of the smaller 
tubes ; broncho-pneumonia ; lobar pneumonia during the 
stage of resolution, and occasionally during other stages ; 
phthisis ; and oedema of the lungs. 

CREPITANT RALEs.—These are very fine sounds heard 
only at the end of inspiration, and sounding very near 
the ear. They occur in abrupt explosions. They are 
much finer than the subcrepitant rales, and are usually 
compared to the sound produced by rubbing a lock of 
hair between the fingers. The causes of this rale are 
the rubbing together of inflamed pleurai surfaces, the 
entrance of air into ultimate bronchioles or alveoli, the 
walls of which are partly stuck together by exudate, or 
perhaps the breaking of very fine bubbles. Of these 
three possible causes the first seems most common, and 
it is not unlikely that this is really the only cause. It is 
conceivable that if the pleura be coated with a thin layer 
of sticky exudation, its surfaces will tend to stick to- 
gether until the end of inspiration, and then, in slipping 
over one another, give rise to the sound. This rale is 
often said to be pathognomonic of acute lobar pneumo- 


145 


RaAles. 
Ravenden Springs. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


nia. This is not so. The rale is frequently heard in the 
first stage of this disease, but it is also heard in pleurisy, 
broncho-pneumonia, and phthisis. Taken in connection 
with a rational history of acute lobar pneumonia, the rale 
is of great value as a sign, especially if with it other signs 
be found, but it is not to be called pathognomonic. 

PLEURITIC FRICTION SouNDSs are rales produced in the 
pleura when it is diseased. They may be of a rather 
moist, grazing character, or may be creaking and dry. 
They may be heard in all diseases in which tke pleura is 
involved. As has been mentioned, the pleural surfaces, 
when diseased, may give rise to crepitant and subcrepi- 
tant rales. 

PLEURITIC ADHESION SouNDs.—In some cases of old 
pleurisy, with adhesions, peculiar sounds are heard, which 
may be accurately imitated by applying one end of a rub- 
ber band to the ear and stretching it. The adhesion 
sounds are probably produced by stretching of old adhe- 
sions. 

THe MeETAuuic TINKLE is a sound resembling that 
produced by pouring water in drops into a bottle. It is 
produced either by drops of fluid falling from the roof of 
large cavities in the lung, or the cavity of hydropneumo- 
thorax, or by bubbles breaking in fluid under similar cir- 
cumstances. In different cases one or the other of these 
causes may produce the sound. It is heard over some 
large cavities, and, in some cases.of pneumo-thorax, may 
occur either when the patient speaks or with the breath- 
ing. 

GURGLES are coarse rales which are more liquid than 
mucous rales. They are sometimes heard in bronchitis, 
in some cases of solidified or compressed lung, and in 
some cavities. 

Tae Mucous C1iick is a peculiar dry sound, occasion- 
ally heard at the end of inspiration. Its cause and sig- 
nificance are not clear. 

Dry AND Moist CRACKLES are sometimes mentioned. 
They are difficult to distinguish from subcrepitant rales. 

SIBILANT BREATHING, sometimes called sibilant rhon- 
chus or rale, is a whistling or hissing sound heard in cases 
where a bronchus is narrowed by inflammatory thick- 
ening of its mucous membrane or by other causes. 

SonoRrovs BREATHING is produced in the same man- 
ner as the former. It is of lower pitch and softer qual- 
ity. J. West Roosevelt. 


RANULA, a cystic tumor in the floor of the mouth, 
formed by the dilatation of one or more of the acini of 
the anterior lingual glands (Ward!), known also as the 
‘* Blandin-Nuhn” glands (v. Recklinghausen’), situated 
at the under side of the tongue on either side of the 
frenum lingue, near the apex. 

This definition is founded on the result of a character- 
istically thorough investigation, by the accomplished 
Strassburg pathologist, of a typical ranula accidentally 
found at a necropsy made in his pathological institute. 
The cyst, about the size of a pigeon’s egg, was found on 
the under side of the left half of the tongue, extending to 
a little beyond the median line upon the right side, and 
penetrating into the intermuscular spaces in different di- 
rections. The wall of the cyst was of a nearly uniform 
thickness of from one to three millimetres ; the internal 
surface was nearly smooth, except in the upper part, 
where, anteriorly, toward the apex, there was a promi- 
nence of some five millimetres in height, upon which 
were two furrows; one of these, situated near the top of 
the prominence, allowed the passage of a bristle to the 
depth of two and a half millimetres, while the other, 
situated near the base and away from the apex, was im- 
pervious. The cyst was everywhere colorless and trans- 
lucent, except at the inferior part, where there was an 
opaque spot of about twenty millimetres in diameter, of 
a brownish color, having at its edges two more cysts, 
each about the size of a pin’s head. The ducts of the 
various salivary glands, Wharton’s and Rivinus’, as well 
as Bartolini’s, were all to be traced outside of the cyst, 
having no other relation with it than proximity. The 
microscopic examination showed that the epithelial lin- 
ing of the cyst-wall was in two layers, the inner one of 


146 


ciliated cylindrical epithelium, and beneath this a layer 
of small polygonal cells with large nuclei. The cyst 
contained a clear, somewhat thick, glairy, and viscid 
mucus, faintly yellow in color. The morphological ele- 
ments were cells of an epithelial character in various 
stages of ‘‘ colloid” degeneration, large brownish granu- 
lar bodies, and numerous hyaline corpuscles, among 
which were some quite large, of a diffused, faint green- 
ish-yellow shade, permeated with countless ‘‘ vacuoles.” 
The chemical examination showed a considerable amount 
of mucus, but no evidence either of sulpho-cyanide of 
potassium or of any fermentative material for the saccha- 
rine conversion of starch; therefore the fluid was not 
saliva. This confirmed the investigation of Besanez,* 
made in 1845. 

Ranule, in general, present themselves as translucent 
pink or bluish tumors, generally globular in shape and 
fluctuating, lying either wholly in the mouth or between 
the mouth and chin, according to their size. They pro- 
ject into the floor of the mouth from beneath the tongue, 
at first quite to one side of the freenum lingue ; but as they 
grow to fill the mouth they elevate the tongue, push it 
over to the opposite side, and in time present themselves 
against the tecth in front, and may even prevent their 
closure. They push the frenum toward the opposite 
side, but may project beyond it, giving the appearance 
of two tumors, or of one tumor divided into a larger and 
a smaller portion. With this filling up of the mouth the 
interference with speech and deglutition is very great. 
The elder Cline‘ relates the case of a person who was in 
great danger of immediate suffocation by a large ranula 
which thrust the tongue back into the fauces. When 
not interfered with the tumor will project in the neck 
below the angle of the chin, and fluctuation may be felt 
in this situation. When the tumor is large the deform- 
ity of expression is great, and presents a certain resem- 
blance to the mouth of a frog, the pale bluish, translucent 
hue adding thereto; hence the name, from rana, frog 
(Froschgeschwulsie, Germ.; grenouilletie, Fr.). 

Cysts of other organs than the Blandin-Nuhn glands 
are also found in this situation. Wharton’s duct may be 
dilated by the damming back of the secretion of the sub- 
maxillary gland from the formation of a salivary con- 
cretion in the duct, either at its orifice or in its course, 
and dermoid cysts, often of considerable size, are also 
found. The latter are especially interesting patholog- 
ically, as they undoubtedly represent here the remains of 
a foetal organ which normally entirely disappears. The 
branchial fissures of the foetus are normally obliterated 
early in foetal life, but occasionally a fold of the tegu- 
mentary or epiblastic layer becomes included in the 
deeper tissues in the process of closing in from the sides 
to form the face, and finally becomes entirely separated 
from its attachment to the external skin. It may remain 
quiescent, giving no evidence of its presence, or the cells 
of the epithelial lining may be excited to growth and the 
interior become filled with the products, consisting of 
broken-down epithelium, fat, cholesterin crystals, and 
débris, z.e., the usual contents of cysts developed from 
the dermoid layer. Indeed, hairs, bone, and teeth have 
been found in them.® These dermoid cysts, however, do 
not spring from the same point as do true ranule. They 
are situated either in the median line, between the two 
genio-hyo-glossi muscles, or between one of these and 
the mylo-hyoid; but as they grow they extend upward 
into the floor of the mouth, or downward in the neck, as 
far, perhaps, as the larynx.® 

Draanosis.—These various tumors present points of 
differentiation sufficiently marked, usually, to allow them 
to be recognized, and as the treatment of each is. differ- 
ent, it is important to have them well in mind. The 
positions of true ranula and the dilated Whartonian 
duct are, by the time they have aroused sufficient atten-, 
tion to be brought to the notice of the surgeon, very 
nearly the same; they both lie just under the tongue, 
to one side of the frenum, and filling up the floor of 
the mouth, elevating the tongue above it, and appearing 
as a thin-walled, fluctuating, and translucent tumor. In 
the case of the ranula, this tumor has upon its surface | 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Wharton’s duct, the orifice of which can usually be de- 
tected near the median line, and into which a fine 
probe or bristle may be passed, and seen to glide along 
the surface to the submaxillary gland, external to and 
beyond the cyst. Careful search will often, also, re- 
veal the orifices of the sublingual gland, the ducts of 
Rivinus. Blood-vessels are frequently seen coursing in 
waving lines over the cyst. When Wharton’s duct is 
the seat of the tumor, the entrance of the probe into it 
will be prevented by the obstacle blocking it up, be it 
salivary concretion or inflammatory product, and re- 
moval of the obstacle will usually allow the escape of 
the fluid. In these cases there are usually considerable 
pain and circumjacent swelling, with other evidences of 
inflammatory action in all the parts implicated ; the floor 
of the mouth is hot and tender, the tongue is painful on 
motion, and under the jaw the submaxillary gland is 
swollen and tender. 

The clinical features of the dermoid cyst are different ; 
indeed, there should be no confusion between them, but 
inasmuch as, from their situation and gross appearances, 
they are sometimes described as ranula, it is well to point 
out their differences. The wall is usually thick and 
firm, the contents may be quite thick, even mortar-like, 
sometimes purulent, or the contained fluid may be thin 
or viscid. There may be fluctuation, but it is less dis- 
tinct than in ranula, and the surface often pits on press- 
ure. The tumor is situated more deeply under the mus- 
cles of the mouth, and, when presenting under the jaw, 
is imbedded among those of the neck, and may penetrate 
even as far down as the larynx. In the mouth it arises 
nearer the median line, although as it grows its origin 
becomes obscured, and may not be readily determined at 
the time that the case comes under the observation of the 
surgeon. 

TREATMENT.—No other than operative interference is 
of any avail in the treatment of these cysts, and it is 
usually necessary to do more than simply to evacuate 
their contents. If it be a dilated Whartonian duct, the 
removal of the concretion blocking up the orifice is usu- 
ally sufficient ; but this requires some care, as it is often 
very brittle, and if any fragments remain they set up a 
good deal of irritation in the duct itself, and serve as 
nuclei for further collections. Therefore, an opening 
should be made in the duct sufficiently large to ‘‘ shell 
out” the stone entire. As these are occasionally quite 
long, it may require a considerable incision in the length 
of the duct, but this is preferable to making a small 
opening and endeavoring to drag the stone out; for if 
this is attempted it is liable to break, to the subsequent 
annoyance of both patient and surgeon. It is better, 
when practicable, to remove the dermoid cyst entirely, 
though, when it extends deeply and has very firm attach- 
ments, this will be difficult, and may be impossible with 
' safety to the patient. 

When not large it is usually easiest to make a free in- 
cision through the cyst-wall—whether in the mouth or 
under the chin depends upon its accessibility—and evacu- 
ate the contents. When these are thick and tenacious this 
may be a matter of some difficulty. After this, the cyst- 
wall being tolerably firm, it will bear considerable drag- 
ging upon, and may be enucleated with the handle of the 
scalpel, aided by occasional snips with the blade or with 
scissors. Cases are occasionally met, however, in which 
the operation of entire removal is both difficult and dan- 
gerous. In Mr. Mayo’s® case the tumor extended down 
nearly to the clavicle, passing between the sterno-mastoid 
muscle and the trachea. After scooping out the contents 
and removing a part of the wall, he left the rest to sup- 
purate, first filling the cavity with lint soaked in turpen- 
tine, in order both to arrest the hemorrhage and to hasten 
the suppuration. The patient recovered after a consider- 
able time. 

Sir William Fergusson’s’ case filled the mouth so as 
to threaten suffocation, keeping the teeth forcibly apart 
and projecting prominently under the chin. He feared to 
leave ‘‘a sac so large and thick to the certainty of a vio- 
lent inflammation,” . ,and ‘‘ resolved instead to 
attempt the extraction of the whole cyst.” Incisions 


RAales. 
Ravenden Springs. 


were made both in the mouth and in the neck, but ‘“‘ the 
sac was so amalgamated with the surrounding tissues 
that a free use of the knife was required.” No large 
vessel was cut, but there was much loss of blood both at 
the operation and subsequently ; the ultimate result, 
however, was entirely satisfactory. 

The true thin-walled ranula requires a different treat- 
ment. Simple incision is not sufficient, for the edges of 
the wound usually reunite and the cyst forms again. 
The wall is also too thin to allow its enucleation 77 toto. 
A seton introduced through its walls, and allowed to 
remain a couple of weeks, more or less, will sometimes, 
but not always, cure it, and is to be tried first. This fail- 
ing, some surgeons recommend the removal of a large 
part of the thin wall, in the expectation that the re- 
mainder of the cyst will collapse and the walls unite, 
to the obliteration of its cavity ; but, like the seton, this 
often fails. A sort of plastic cperation has, therefore, 
been tried, and is usually successful. This consists in 
forming a triangular flap by a couple of converging in- 
cisions in the anterior wall, and fastening the apex by 
two or three sutures to the opposite wall ; adhesions are 
thus formed, and the cyst is kept open until the wall 
shrivelsup. Sonnenberg recommends that the remainder 
of the gland be dissected out of its bed in the apex of the 
tongue, thus preventing the development of any other 
cysts afterward. This is occasionally done, with very 
satisfactory results, when milder measures have failed. 

W. H. Carmalt. 


1 Ward, Nathaniel: Article Salivary Glands, in Todd and Bowman’s 
Encyclopedia of Anatomy and Physiology, vol. iv., pt. 1, p. 426. 

2 V. Recklinghausen: Virchow’s Archives, Bd. 84, p. 425. 

3 Besanez, Dr. Goruss: MHeller’s Archiv fur Phys. und Patholog. 
Chemie u. Microscopie, vol. ii., quoted by Dr. Owen Reis in the article 
Saliva, ae Todd and Bowman’s Encycl. of Anat, and Phys., vol. iv., pt. 
1, p. 420. 

4 Chelius’ System of Surgery, vol. iii,, p. 121. 
Philadelphia, 1847. 

5 Butlin, Henry S.: Diseases of the Tongue, p. 2389. Lea Brothers & 
Co,, Philadelphia, 1885. 

6 Mr. Mayo, of Winchester, England: Lancet, 1847, i., p. 667, quoted 
in Druitt’s Surgery, p. 423. Philadelphia, 1860. 

7 Fergusson’s Practical Surgery, p. 445. Philadelphia, 1553. 


Edited by.J. F. South. 


RAPE-SEED, OIL OF. (Olewm Rape, Ph. G.) This 
is a nearly non-drying oil, obtained from several culti- 
vated varieties of Brassica (order, Crucifere), related to 
turnips and cabbages, and extensively raised in Europe 
for their seeds, from which it is extracted by pressure. 

Rape-seed, or colza, oil, is a thick, yellowish liquid of 
no very characteristic odor or taste. It is extensively 
employed as a lubricant, as a salad oil, and as a cheaper 
substitute for olive-oil generally. In this country its 
place is taken by cotton-seed oil. Purified, it is put to 
cheap uses in German pharmacy, such as in making 
liniments, plasters, etc. 

ALLIED PLANTs.—Turnips of various sorts—summer, 
winter, rutabaga, etc. ; cabbages, cauliflower, Brussels 
sprouts, and kohl-rabi ; also mustard and radishes. For 
the order see MUSTARD. 

ALLIED DRuGes.—All the fixed oils ; see OLIVE-OIL. 

W. P. Bolles. 


RASPBERRY. (Rudus Jdeus, U. 8S. Ph.; Framboise, 
Codex Med.) The fruit of the gardenwaspberry. Rubus 
Ideus Linn., order, Rosacew, is a well-known European 
straggling shrub, cultivated both there and here for its 
delicious fruit. It has not the slightest medicinal value, 
and is only used in syrup, ete. (Syrupus Rubi Ide@i, U.S. 
Ph.), as a pleasant vehicle, or a flavor for aérated waters, 
etc. The leaves of raspberry are a household astringent, 
like blackberry root, ete. 

ALLIED PLANTs.—The leaves of R. fruticosus Linn. 
are in the Codex (Ronce Sauvage). They are astringent. 
See RosEs, BLACKBERRY, etc. 

ALLIED Drues.—Fruits and fruit-syrups in general. 

W. P. Botles. 


RAVENDEN SPRINGS. Location, Ravenden Springs, 
Randolph County, Ark. 
. Access.—By the St. Louis, Iron Mountain & Southern 


147 


Ravenden Springs. 
Recto-Vag. Fistula. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


e 
Railway (Missouri Pacific System) to O’Kean, then by 
stage. 
ANALYsISs.—One pint contains : 


Grains 
Carbonate olpmaenesia oo. cee aca ea tadhie enicstace 0.560 
Carbonate of lime yey meer. comin cite canisicis stereo ee ors 0.576 
Carbonate: of lithia Ce ee satnce niece cme & ota kee atne 0.157 
Ghioride, of sodiumyryacw cee sie een ee eee see 0.2738 
Chioride of magneniiim te. awoken tine cattle rieee « «0.3878 
Ohiloriderof lintes AG teenie ee eee cite oe cee 0.155 
Sulphate ol limes, ci: csetetes tectonic alec actece eins trace 
Sulphatejofialuminaan. ccs sch ot tine terse. ace octane 0.295 
SILICA Fe Nec tacte iste tere ue ete ete ET RT bicacre nat 0.103 
Lodine ‘and wron 3... acne concer erie es ce esc ae trace 
Organicimatter ye... ote steer sen aaa eset 0.2382 
WE ObaL gi. SNe, sis atacs ook elo Sema tenele ete aie sieree@ aru ene 2.724 

Cub. in 
Carbonic acid gas. nc cnet enadiaks cece 2.68 
Atmospheric’ air. <i scone meteeioe ] sets canine 1.66 


THERAPEUTIC PROPERTIES.—These are mild alkaline 


waters, sufficiently charged with natural carbonic gas to 
render them very agreeable. 

The springs are situated in the northeastern part of 
Arkansas, in a picturesque country abounding in game 
and fish. Ge Be, 


RAWLEY SPRINGS. Location and Post-office, Rawley 
Springs, Rockingham County, Va. 

AccrEss.—By the Baltimore & Ohio (Harper’s Ferry & 
Valley Branch) Railroad to Harrisonburg; thence by 
stage to the springs, ten miles. 

ANALYsiIs (Professor J. W. Mallet)—One pint con- 
tains : 


Grain 

Carbonate ofvmapnesia sch occa cons eee eae ce eieteen 0.085 
Carbonate Onivon. o.) \ eke cue metccisieteins siete ee ee eae 0.2038 
Garborate ol MANTANCHGL ick cise slocatelonise sce reer 0.002 
Carbonate wl lime. 22.00 Potaceer eck er econ 0.055 
Carbonate or AMMONIA ye ensce eter ee cece trace 
Carbonatesoflithiayani. 2 weeks heen teen trace 
Chioride/ofsodium™. Suseecst serine chee teeter ee 0.005 
Sulphate Of potassas vei. S-1 ciate tee tine 0.014 
Sulphate of Soda yoo e kn 2 ace sacee een een eee 0.068 
Sulphate of lime 
ATU A eee oe cee cic ieee ae f 
Silica Ae se tee Ae tet ante 
Organic Mater... oases clearence are 
TiGSS cE cee s aes ces wteets inavale ee eR ees Cae Cee ens 

EL OVALPS TORK a he pee Solas oie le ae eos ee eee 
Carbonic acid pasMer sso cae. e ts See ee eee 0.47 


THERAPEUTIC PROPERTIES.—This is said to be the 
best chalybeate spring in Virginia. 
Rawley Springs are situated in Northwestern Virginia, 
on the southern side of North Mountain, amid beautiful 
scenery and salubrious air. GED. 


REACTION OF DEGENERATION. When a muscle 
is cut off from its centre of innervation it undergoes 
changes, among which is its susceptibility to the influence 
of electrical excitation. The alterations are known as 
quantitative and qualitative, with reference to the degree 
of contraction, and the variations in it respond to the in- 


terruption or closure of the current. Muscles which are " 


paralyzed, there being total suspension of innervation, at 
the end usually o&two weeks begin to undergo a change, 
when faradic (induced) currents produce no response, 
and the action under the galvanic current is reversed. 
The healthy muscle responds most vigorously to cathodal 
(negative) closure; while in well-established degeneration 
the anodal reactions of both kinds seem to cause the most 
lively contraction. In the unaffected muscle the healthy 
reaction would be as follows: * 


Ua CEG es -AnrUlac 
Ua’ Q C< An O-G) 


* The symbols used in the formule are the following: 


D.R. = Degenerative Reaction. Ca = Cathode. 

An = Anode. Cl (or S) = Closure. 

O = Opening. C = Strong contraction. 

c = Medium contraction. Tc = Tetanic contraction. 
> = greater than, < = less than, 


148 


As the process of degeneration advances we first find 
that the anodal closing contraction is equal to the catho- 
dal closing, and that the anodal opening contraction is 
equal to the cathodal opening, but as the degeneration 
becomes confirmed we find the formula expressed : 


D: Rie An Cl C.> Ca ClCeraAn.O CAGa Oe 


Ultimately it is impossible to get any response what- 
ever, except perhaps a weak anodal closing contraction. 
When such an advanced degree of degeneration exists 
the muscle undergoes atrophic changes, and its essential 
elements, more or less, disappear, while fatty deposit 
takes place. If the abolition of conductivity is not too 
extreme, or does not last too long, we find after a time 
an inverse restoration, the muscle responding feebly at 
first to an interrupted galvanic current of great strength, 
the normal reaction being finally attained, and afterward 
faradic excitability. For the electric diagnosis of the 
reaction of degeneration we should make use of a milli- 
ampere metre, and begin with a minimum current which 
may afterward be increased. If it requires a current of 
several milliamperes to evolve a response, we may meas- 
ure the qualitative improvement by the reduction in the 
required strength and note the same. Small carbon elec- 
trodes covered by absorbent cotton are the best. I have 
of late dispensed with cell selectors, and use simply a 
water rheostat and a milliampére metre. 

Allan McLane Hamilton. 


RECOARO, near Valdagno, in Venetia, is a pleasantly 
situated spa, lying in a sheltered valley at an elevation of 
about 1,500 feet above the sea. The climate is mild. 
There are ten or more springs in the place, the most im- 
portant of which are the Lelia, Amara, Lergna, Giuliana, 
Civillina, and Virgiliana. The first four of these are the 
property of the government. The following is the anal- 
ysis (made by Ragazzini) of two of these springs, com- 
puted in parts per thousand : 


Fonte Lelia. Fonte Giuliana. 


Calchumesuipiate; sae nteat ease sete ee 1.310 trace 
Calcium ‘carbonate’: 2% 5 o's ssc orm 1.016 0.100 
Herrousicarbonates: issue. cence ee oe 0.069 0.063 
Magnesium carbonate................ 0.099 - 0.051 
Sodium eul phate ce ay ovis. es clic 0.045 0.010 
Magnesium sulphate................-- 0.679 0.451 
Macnesitimichloride 2. -4e0s..: essen. 0.004 0.003 
SiliciGiacid 64 eae Avene eee eer 0.017 0.009 
Organic matters) CC. ewes ree 0.022 0.013 

Totaliva hoses thee ie cies 6 Gents 8.261 0.700 


The waters of Recoaro are given chiefly internally, 
though baths are also employed to a certain extent. They 
are recommended in the treatment of ansemia, in con- 
valescence from typhoid fever and other debilitating 
diseases, in catarrhal troubles of the digestive and uri- 
nary systems, and in the visceral congestions following 
rebellious malarial fevers. The season extends from May 
to the middle of September. LeeLee 


RECTO-VAGINAL FISTULA. A communication be- 
tween the rectum and vagina. In rare instances an 
opening is established between the vagina and some 
higher part of the intestine, oftenest the lower part of 
the ileum. A coil lying in the Douglas pouch may be- 
come adherent, and ulcerate or rupture into the vaginal 
cul-de-sac. 

Symproms.—The escape of feeces and intestinal gases 
into the vagina and from the vulva. In some cases, when 
the edges of the fistula are ulcerated or cleanliness is 
neglected, vaginitis and vulvitis result. Then the pa- 
tient suffers from itching, soreness, and offensive dis- 
charge. In sensitive natures this distressing infirmity 
induces depression of spirits, amounting sometimes to 
melancholia. The severity of the symptoms depends, 
however, on the size of the opening and the state of the 
bowels. If the opening be small, the diet properly reg- 
ulated, and the parts kept clean, all the symptoms will 
be greatly mitigated. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


CausEs.—These may be classed under two heads— 


mechanical violence and disease. 

Mechanical Violence.—All forms of difficult or instru- 
mental labor in normal or deformed pelves; the use of 
forceps and the exercise of undue manual force; cepha- 
lotripsy ; slipping of blunt hook, or other instrument 
used in the reduction of the size or extraction of the 
child ; laceration by splinters of the bones of the fcetus. 
Contraction or other deformity of the bony pelvis, as 
from tumors, exostoses, and anchylosis of the coccyx ; 
and a narrow or indistensible condition of the vagina, 
strongly predispose to this injury during labor. Certain 
operations, such as those for the relief of stenosis or atre- 
sia of the vagina; extirpation of tumors of the uterus or 
vaginal walls; excision of cancer of the rectum; and 
perforation of the rectum from rough or unskilful ad- 
ministration of enemata are occasional causes. Pessaries, 
when ill-fitting or neglected, sometimes ulcerate into the 
rectum, though much more rarely than into the bladder. 
Recto-vaginal fistula following labor are usually the re- 
sult of lacerations; more rarely they result from pro- 
longed pressure causing a slough with perforation. . 

Disease. —Cancerous, syphilitic, or other ulceration not 
rarely results in perforation of the recto-vaginal septum. 
Abscesses of the septum, from whatever cause, may rupt- 
ure into both rectum and vagina. Suppuration of an 
adherent pelvic dermoid, or other ovarian tumor, or of 
an extra-uterine gestation-sac, may establish a fistula be- 
tween rectum and vagina. The latter causes lead espe- 
cially to the formation of fistulae communicating with 
the upper part of the vagina. 

Recto-vaginal fistula is very rare except in adults, but 
is not unknown even in infants. Bednar relates a case 
of gangrene of the recto-vaginal septum, resulting in 
fistula, in an infant of four weeks. This child died of 
cellulitis of the right arm. Witter relates another in a 
child of seven months, who had suffered from thrush for 
several months, when suddenly feces began to escape 
from the vagina, and an ulcerated opening was found in 
the recto-vaginal septum. <A healthy wet-nurse was pro- 
cured, and with the addition of local cleanliness and the 
use of carbolized glycerine tampons to the vagina, the 
child recovered perfectly. 

The course and duration depend on the cause and 
mode of origin, and the extent of the opening. A fistula 
from_cancer usually grows larger, and there is no hope 
of cure. Syphilitic or other ulceration may heal and 
cicatrize partially, or even completely, and a spontaneous 
cure result. The latter result is probably rare in syphi- 
‘litic ulceration, but more frequent in the simple forms. 
Perforating lacerations, and sloughing of the septum 
leading to fistula, in many cases get well by attention to 
cleanliness and by securing to the patient influences which 
improve general health. A few weeks may thus suffice 
to close a good-sized opening. Winckel saw an opening 
of the size of a dollar close in a fortnight. Spontaneous 
healing may be retarded or entircly prevented by cica- 
tricial bands, which prevent the edges from coming to- 
gether. Subsequent labors may result in enlargement of 
the opening, or in its closure, or leave it uninfluenced. 

Draenosis.—This is usually a simple matter. Women 
suffering from’ the symptom called by German writers 
garrulitas vulve, in which air entering the vagina in 
certain positions, and escaping, it may be with noise, on 
changing position, or even without, during the move- 
ments of the pelvic floor synchronously with the move- 
ments of the diaphragm, are often in great distress of 
mind from imaginary fistula; but the gas thus escaping 
is odorless, being merely atmospheric air. The symp- 
tom is due to some defect of the forces which maintain 
intra-abdominal pressure. The accessibility of both va- 
gina and rectum to examination by finger and eye 
through the speculum, renders diagnosis an easy mat- 
ter. Except in the case of very small or remote fistule, 
examination by means of one finger in the vagina and 
another in the rectum, assisted it may be by probe or 
sound, at once discovers the opening. If very small, the 
speculum may be necessary. The injection of milk or 
some other colored liquid into the rectum will speedily 


_ 


Ravenden Springs. 
Recto-Vag. Fistula. 


reveal the opening in the vagina as the fluid escapes 
through it. 

TREATMENT.—In cancer thisis hopeless. Inother forms 
of ulceration the first steps must be taken in the direc- 
tion. of securing cicatrization of the ulcer by the neces- 
sary constitutional and local measures. Until these 
measures have been tried operation is inadmissible. Re- 
cent lacerations, if discovered, must be immediately 
stitched, and the prospect of success is as good as in the 
immediate suture of lacerated perineum. If the lesion 
be not discovered in time, or if the primary operation 
fail, the parts on both sides of the opening, rectal and 
vaginal, must be kept clean, and stimulated if necessary, 
in the hope that spontaneous closure may result. This, 
we have seen, is by no means rare. In any case the size 
of the opening will certainly be much reduced. Vaginal 
tampons impregnated with glycerine and carbolic acid 
may assist. The bowels must be regulated, and accumu- 
lations of masses of hardened feeces in the rectum pre- 
vented. For the cure of chronic recto-vaginal, as for all 
other chronic fistulae, two principal methods have been 
resorted to—cauterization, and suture after denudation. 

Cauterization is comparatively easy of application, but 
very uncertain in its results. It is useless for large open- 
ings, and almost so for small ones, if the septum around 
the opening be thin. Most of the strong caustics, as well 
as the actual cautery, have been used. Solid nitrate of 
silver, nitric acid, and the acid pernitrate of mercury 
afford a list from which to choose. The whole extent 
of the fistula, from the vaginal to the rectal opening, must 
be cauterized. Dieffenbach’s method was to cauterize a 
ring around the vaginal opening of the fistula with silver 
nitrate, and a few days later to apply the actual cautery 
to the vaginal opening and whole extent of the fistula. 
The galvano-cautery is better for this purpose than the 
Paquelin cautery, because it need not be heated till it is 
in contact with the surface to be cauterized. If the cau- 
tery fail after a trial or two, it is better not to repeat it, 
as the edges of the opening will be rendered cicatricial, 
and therefore in a less favorable condition for the success 
of the inevitable operation. 

Denudation and Suture.—There are few cases which 
in skilled hands cannot be thus cured, More than one 
operation may be necessary, and in complicated cases 
various modifications of that suitable to simple cases may 
have to be resorted to. For the success of this, as of all 
plastic operations, it is essential that the general health be 
good and that the parts concerned be in a healthy condi- 
tion. Twoor three days immediately before the operation 
will be well spent in dieting and purging, especially with 
calomel and soda aided by salines. The diet had better 
consist. of beef juice, well-boiled wheat flour porridge 
and milk, stale bread or toast, and, once a day, under- 
done tender mutton chops. Immediately before the op- 
eration both vagina and rectum must be thoroughly well 
washed out, and then irrigated with a 1 to 3,000 corrosive 
sublimate solution. The operation may be done through 
either vagina or rectum. ‘The vagina is always selected 
when practicable, and the cases are very few in which 
it isnot. The whole circumference and extent of the 
fistula should be freshened in such a way as to secure as 
broad surfaces as possible for apposition. This is to be 
done by making the opening funnel-shaped, the denuded 
surface at the vaginal opening being of greater extent 
than at the rectal opening. The rectal mucosa is to be 
interfered with as little as possible on account of its 
greater vascularity. The parts will be most effectually 
exposed for operation by placing the patient on her back 
and flexing the thighs on the pelvis, the anterior vaginal 
wall and labia being kept out of the way by retractors 
those known as Simon’s being the best. The direction 
of the line of sutures must be determined by approxi- 
mating the edges with tenacula and observing that in 
which there is the least tension. , Any cicatricial bands 
on the vaginal surface which prevent approximation 
must be freely divided, by knife or scissors, at some dis- 
tance from the edges of the opening. The material of 
the suture may be fine silver or other sufficiently flexible 
metallic wire, carbolized silk, catgut, or silkworm gut. 


149 


Recto-Vag. Fistulas REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Reflex Actions. 


Success may be attained by using any one of these, but 
most operators, probably, prefer silver wire, as it can so 
easily be secured by twisting in a cavity like the vagina. 
A variety of needles have been used, but the simplest ap- 
pears to be Emmet’s—a short, slightly curved needle held 
in the jaws of a needle-holder. It is threaded in such a 
way that a long loop of silk is made to draw the wire sut- 
ures into position. The needle is entered on the right or 
upper side (as the case may be) of the vaginal opening, 
at least half a centimetre (;°; in.) from the denuded edge, 
and made to traverse the tissue of the septum and emerge 
just at the edge of the rectal mucosa. It is then carried 
across the opening to the other side, entered at the rectal 
edge, and brought out on the vaginal surface at the same 
distance from the edge of the freshened surface as on 
the opposite side. Five or six sutures to the inch will 
be necessary. The most exact coaptation possible of 
the raw surfaces must be secured, but the sutures must 
be drawn tightly enough to secure contact only, without 
strangulation. This last is the error most apt to be com- 
mitted by inexperienced operators. The diet for the first 
three days should consist of animal broths, jellies, and 
eruels, with very little milk or other food which leaves a 
solid residue in the intestines. The bowels had better be 
allowed to remain undisturbed for three days, and then 
moved by a five-grain dose of calomel at bedtime, fol- 
lowed next morning by a saline laxative, such as a seidlitz 
powder, a teaspoonful of Epsom salts in a large glass of 
warm water, or a doseof Hunyadi or Friedrichshall min- 
eral water. Soon after the saline is given, an enema of 
from two to four ounces of a warm solution of ox-gall 
must be cautiously thrown into the rectum. This will 
soften any hard masses which may have accumulated, 
and so prevent injury to the line of union during the 
evacuation. The bowels are to be moved every day, for 
at least a fortnight, by salines and the ox-gall enema. 
After the bowels have acted, some tender meat, bread, and 
light pudding may be added to the diet-list, but vegetables 
are to be withheld for a week longer. The sutures are 
to be allowed to remain for eight or tea days. The only 
objection to the method described, so generally success- 
ful, is that, if it fail, tissue has been removed, and this 
may prejudice the chances of success by subsequent 
operation. To obviate this objection various modifica- 
tions have been practised. One is to dissect up a frill of 
vaginal mucosa in the form of a circle around the open- 
ing, and turn it into the rectum. The sutures are to be 
applied to both vaginal and rectal openings, the rectal 
ones being of catgut; or the edges of the fistula may be 
split, rectal and vaginal sutures being employed. When 
the fistula is low and near the sphincter, ani, failure of the 
operation is more common than in the upper part of the 
septum. Thisis due to the disturbing action of the sphinc- 
ter. In such cases success may be more certainly assured 
by dividing the whole of the tissues, sphincter muscle in- 
cluded, from the fistula, through the perineum, freshening 
the edges of the fistula, and then closing the wound as in 
the operation for complete laceration of the perineum. 
In certain other cases in which the recto-vaginal septum 
is very thin, the method of raising a flap of vaginal mu- 
cosa, sliding it over, and attaching it all round to the 
freshened edges of the opening, may be the best opera- 
tion. W. Gardner. 


RECTUM, MANUAL EXPLORATION OF THE. In 
1872 Professor Simon, of Heidelberg, published, in the 
Archiv fir klin. Chir., an article ‘‘On the Artificial 
Dilatation of the Anus and Rectum for Exploration and 
Operation,” in’ which he first described a method of ex- 
ploring the lower bowel by the introduction of the entire 
hand. By this method of examination, he asserted that 
not only was he able to explore all of the pelvie organs, 
and to distinguish any pathological changes they might 
have undergone, but that the greater part of the abdom- 
inal cavity could also be reached. He further asserted 
that this method was so entirely free from danger that 
he had not hesitated to practise it on patients anzesthe- 
tized for other purposes. He thus describes the proced- 
ure: ‘‘ The hand being well oiled, two fingers are at first in- 


150 


troduced through the sphincter, then four, and finally the 
thumb and whole hand. The dilatation must be gradual, 
and assisted by a rotatory motion ; and, if these directions 
be followed, a hand measuring twenty-five centimetres 
(nearly 10 in.) may be introduced absolutely without harm. 

‘«The anus forms, in its greatest dilatation even—which 
is twenty-five centimetres in circumference or more—a 
narrow entrance to the larger cavity of the rectum. This 
cavity is formed by the inferior and middle portion of 
the rectum, the first of which lies outside of the perito- 
neum, and the second is covered only on the anterior por- 
tion by the posterior wall of Douglas’ pouch, and extends 
to the superior third of the rectum, 7.e., to a_ point above 
which the peritoneum encloses the anterior and lateral 
walls of the bowel, and where it is attached to the os 
sacrum, This point lies from twelve to fourteen centi- 
metres above the anus, and corresponds to the third sa- 
cral vertebra. 

‘“‘The greatest width of the rectal cavity is at a point 
from six to seven centimetres above the unus, and its ex- 
panding capacity here is from twenty-five to thirty centi- 
metres. From this point to the superior extremity of the 
middle third it gradually diminishes to from twenty to 
twenty-five centimetres, and from here it rapidly lessens 
until, in the middle of the upper third, it is not more than 
sixteen to eighteen centimetres in circumference, its nar- 
rowest portion being in the sigmoid flexure. The base of 
the thumb is thrust as far as to this point, twelve to four- 
teen centimetres above the anus, and half the hand can 
advance through the upper part of the rectum into the be- 
ginning of the sigmoid flexure. Therewith the abdomen 
can be palpated several centimetres above the umbilicus.” 

Simon thus limits the depth to which the hand should 
penetrate to the upper part of the rectum and lower part 
of the sigmoid flexure, and only claims to be able to pal- 
pate the abdomen somewhat above the umbilicus. Sub- 
sequent experimenters have not been satisfied with these 
limits, and have asserted that the hand could be made to 
enter the descending colon. This can readily be shown, 
on the cadaver, to be a physical impossibility. Nuss- 
baum, in attempting to explore a supposed diaphrag- 
matic hernia, reached the ensiform cartilage. 

Later and more extended experience with this method 
has made it necessary to modify very materially the con- 
clusions reached by its author. Many times disastrous 
consequences have followed its application, and not in- 
frequently diseased conditions which were present have 
entirely escaped detection; we are forced, therefore, to 
the conclusion that it is necessarily attended with dan- 
gers which cannot be foreseen or guarded against, and 
that it is very much less successful as a method of ex- 
ploration than was at first supposed. 

This modification of opinion is manifested in late 
writers, who, like Koenig, admit the dangers and limit 
the method to very exceptional cases, or Follin (‘‘ Pa- 
thologie Externe,” 1883), who speaks with reserve about 
the entire procedure. Furthermore, most of the general 
surgeries, and some of the special works on rectal dis- 
eases, ignore the subject entirely. 

With the increased freedom with which exploratory 
laparotomy is now practised in the diagnosis of doubtful 
abdominal affections, the field for manual exploration by 
the rectum is certainly very materially limited. 

The introduction of the hand into the rectum, even 
where the limits set by Simon were strictly observed, has 
been followed by incontinence of feces, which, however, 
has generally disappeared in a few days. In other cases a 
fatal result has quickly ensued. ‘The writer, some years 
ago, collected five fatal American cases, and the number 
since then has greatly increased. In the fatal cases the 
muscular coat of the bowel has alone been torn in some, 
and in others the peritoneal covering. In a case that 
came under my own observation the rupture of the peri- 
toneal coat was evidently due to abnormal narrowing of 
the bowel from an abscess in the walls. 

In one case an aneurism of the coeliac axis was found 
ruptured on the death of the patient, which occurred on 
the following day. In some cases the patients seem to 
have succumbed to shock, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


In many cases this means of exploration unquestion- 
ably facilitates the exploration of the pelvic, and part of 
the abdominal, cavity. 

Small tumors on the posterior aspect of the uterus 
have been discovered and their relations determined ; the 
ovaries have been fully explored ; the anterior surface 
of the sacrum has been examined and limited caries de- 
tected ; and psoas abscess has been with certainty diag- 
nosticated. The size of stone in the bladder, it is said, 
can be accurately mapped out, and stricture of the rec- 
tum has been explored. 

But with so much success attesting the value of this 
means of exploration, it has not infrequently failed to 
discover stricture, even when as low down as the lower 
part of the sigmoid flexure, and has failed in the detec- 
tion and attempted reduction of inguinal hernia. From 
the recorded experience of manual exploration of the 
rectum we can fairly conclude that its value has been ex- 
aggerated, and the dangers which attend it not duly ap- 
preciated ; so that we feel justified in the conclusion that 
as a means of exploration it is allowable only in very ex- 
ceptional cases. N. P. Dandridge. 


REDRESSEMENT FORCE. A procedure introduced 
by Delore, of Lyons, in 1874, for the immediate correc- 
tion of the deformity of knock-knee. His method is as 
follows: The patient, being anzesthetized, is placed upon 
the side, the deformed member resting with the trochan- 
ter upon the table, and the external malleolus raised 
about four inches above it. The surgeon now makes di- 
rect pressure in a vertical direction upon the affected 
knee, forcing it down by a series of jerks until the ex- 
ternal condyle touches the table. <A peculiar crackling 
is heard during the operation, which is caused by the 
giving way of the bony and. fibrous tissues of the articu- 
lation. The acquired position is maintained by a starch 
bandage. The normal function of the joint is said to be 
restored at the end of about six months. A modification 
of this operation has been proposed by Tillaux, in which 
the limb is placed with the inner condyle resting upon 
- the edge of the table, the thigh is steadied by an assistant, 
while the surgeon seizes the leg and forces it down until 
its axis corresponds with that of the femur. An instru- 
ment has been devised by Collin, similar in construction 
to the osteoclast, which effects the reposition of the de- 
formed member by means of a long lever and the com- 
pound pulley. Redressement forcé is not an operation 
to be commended. It is a dangerous procedure, inflict- 
ing an amount of traumatism upon the joint that is liable 
to excite very intense inflammation, jeopardizing the 
utility of the limb, or even the life of the patient. 

Thomas L. Stedman. 


RED SULPHUR SPRINGS. Location and Post-offce, 
Red Sulphur Springs, Monroe County, W. Va. 

Accrss.—By the Chesapeake & Ohio Railway (New- 
port News & Mississippi Valley Company) to Lowell, 
thence by stage to the springs, twelve miles. From the 
South by Norfolk & Western Railroad to Adairs, thence 
by stage. 

ANALYSISs.—One gallon contains (Hayes) : 


Grains. 

Silicious earthy matter, containing traces of oxide of 

iron and ammonia, probably suspended merely.. 0.70 
Sulphate of soda, in a dry state (which forms with the 

Water SU SF omains ies SA eaeeee te OPN ie ee Fe 3.55 
Sulphaterot liniem eee choy. Cyc. hahettessisicvopaprietey ore 0.47 
Carbonate of lime (lime dissolved in carbonic acid).. 4.50 
Carbonate of magnesia (magnesia dissolved in car- 

bonic acid, and forming the ‘‘ fluid magnesia”)... 4.13 


A peculiar substance, containing sulphur combined 


Wibh Oreanicematveracaaa: a canis cen Pewls isis otaie 7.20 
20.55 

Gaseous contents of a gallon, or 231 cubic inches: 
Carbovic? acids Sate ls sera ubesgeert Se pve gaat bits 5.750 
INDGOGeM ee. nd lo, erat at eth ecaieseicle roiatetemieisis ae Rae 6.916 
OXV GEM Merry cee eee eee taco te aoe te 1.201 
Hydro-sulphuriciacidy fie we asses vent ae eee et on 0.397 
14.264 


THERAPEUTIC PROPERTIES.—This water is remarkable 
as containing an ‘‘azotized base combined with sul- 


stimulus is the cause. 


Recto-Vag. Fistula. 
Reflex Actions, 


phur,” which Dr. Hayes pronounces new and peculiar. 
It is claimed that under this form the sulphur is readily 
absorbed. The reputation of this spring as a ‘‘ cure” 
for pulmonary diseases antedates the recent treatment of 
tuberculosis by enemata of sulphuretted hydrogen, and 
there is good reason for believing that the water has 
often proven efficacious in those affections. 

Red Sulphur Springs is situated in the southeastern 
portion of West Virginia, on Indian Creek. The ride 
from Lowell is through picturesque scenery and forests 
of pine, over an excellent road. The hotel, having ac- 
commodations for four hundred guests, is located in a 
valley thirteen hundred feet above sea-level. The prop- 
erty contains fourteen hundred acres, and possesses every 
variety of mountain scenery. There is excellent hunt- 
ing and fishing in the surrounding forests and streams. 

Geo. B. Fowler. 


¢ s 

REFLEX ACTIONS, or REFLEXES, constitute a 
highly important and fundamental group of the phe- 
nomena displayed by animals, and although they are 
usually executed by muscular or epithelial tissues, and 
are oftenest observed in the form of motion or secretion, 
they are, nevertheless, wholly dependent for their pe- 
culiar characteristics upon the nervous system. Roughly 
speaking, they are distinguished by the fact that the im- 
mediate stimulus to the ‘‘ action” lies outside the central 
nervous system, and yet, in a round-about way, works 
through it so that the nervous impulse or disturbance 
produced by the stimulus upon the periphery of the body, 
or elsewhere outside the central nervous system, travels 
first centripetally into that system, and then centrifu- 
gally out from it to the parts which finally execute the 
‘‘action.” The path described by the nervous impulse 
in its passage in and out resembles so plainly that de- 
scribed by the sound waves in an echo, or by a ray of 
light reflected from a mirror, as to suggest immediately 
the term reflected, or Reflex actions, or Reflexes for phe- 
nomena so peculiar and characteristic. But it cannot 
be too often repeated that this interesting analogy be- 
tween the path of a nervous impulse ina reflex action 
and the path described by light, sound, etc., reflected 
from surfaces, is only an analogy ; for while in the latter 
case the thing reflected is precisely like the thing im- 
pinging, and departs at definite angles, under rigid physi- 
cal laws which are well understood, there is good reason 
to believe that the incoming nervous impulse in a reflex 
action of the animal body is unlike the outgoing impulse, 
which is certaintly not merely a reflected portion of the 
former, but something different from, and often dispro- 
portionate to it, elaborated and sent forth by the central 
nervous system acting under the influence of the incom- 
ing impulse just received—doubtless in accordance with 
rigid physical laws, yet laws which are virtually un- 
known. 

The parts of the mechanism involved are, primarily, 
the stemulus or excitant, which is the cause ; and next, 
the sensitive end-organ (a) upon which the stimulus 
works until it has produced a nervous impulse (0), which 
travels along a nerve or nerve-fibre, the afferent or sen- 
sory nerve (c), by which the impulse is conveyed inward 
to the central nervous system—the brain or spinal cord. 
In a special portion of this central system (and oftenest 
in the spinal cord, which is in great part a special organ 
for this function), the impulse appears to be worked over 
in a reflex centre (d), from which after a time a new ner- 
vous impulse (e) is forwarded along another nerve or 
nerve-fibre, the efferent or motor nerve (f), which con- 
ducts the impulse to a nerve-ending or end-organ (9), 
which thereupon so stimulates the humbler muscular or 
epithelial tissues with which it is connected that these 
(h) execute the visible acts called reflexes. The whole 
group of events, from (a) to(g)inclusive, must, therefore, 
be regarded as in some sense the effect, of which the 
Yet it should not be forgotten 
that this ‘‘ effect” is largely influenced by other condi- 
tions, some of which will be mentioned hereafter. ‘The 
ordinary observer, of course, witnesses only the beginning 
and the end of the action, although he may generally 


151 


Reflex Actions, 
Reflex Actions, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


perceive that considerable time has elapsed between the 
application of the stimulus and the reaction. This is 
known as the reaction-time, and that portion of it which 
is spent in the reflex centre (d) is known as the reflea- 
time. 

Examples of reflex actions are abundant and familiar, 
as, for instance, the movements and laughter produced 
by tickling ; coughing due to an irritated throat ; vomit- 
ing from an irritant (stimulus) in the stomach, or a for- 
eign body in the fauces. Light falling on the retina is 
the stimulus which leads to reflex movements of the iris, 
and (in many persons) to sudden sneezing. A finger un- 
wittingly brought against a hot object, such as a stove, 
is almost instantly withdrawn, even without the help of 
volition. The legs of a decapitated frog, provided the 
spinal cord be still intact, are drawn away from acid or 
mechanical stimuli, and perform movements, almost 
purposeful in appearance, to wipe off bits of acidulated 
paper laid upon the flanks. The act of winking is a re- 
flex mechanism, as are also the secretion of the digestive 
juices, some of the movements of the different portions 
of the digestive apparatus which convey the food to the 
rectum, the secretion of saliva, known as the ‘‘ watering ” 
of the mouth at the sight or smell of appetizing food, 
the flow of tears, the secretion of sweat from fear, etc. 

Over against these REFLEX, or “‘ reflected,” actions must 
be put the AUTOMATIC actions of the animal body (such 
as volition, the beat of the heart, etc.), whose source is 
not immediately discoverable outside the central nervous 
system, or which arise within it. This division of ner- 
vous actions into the two great groups of ‘‘ reflex’ and 
“automatic” actions is the modern one. Before it was 
adopted physiologists maintained that many actions, 
such as eating ‘and drinking, walking, talking, and, the 
like, were purely voluntary ; others, such as the beat of 
the heart, the peristaltic movement of the intestine, the 
flow of saliva and the other juices, the motions of the 
iris, etc., being purely involuntary ; while still others, 
such as the respiratory movements (ordinarily done in- 
voluntarily, but capable of control to some extent, as 
when we sit with ‘‘ bated breath”), winking, coughing} 
sneezing, etc., seemed to be of a mixed nature, being or- 
dinarily free from the help or hindrance of the will, yet 
sometimes subject to its influence. This view was the 
one generally held in the last century, as, for example, 
by Dr. Robert Whytt, F.R.S., who, in the Introduction 
to his essay upon ‘‘ The Vital and other Involuntary 
Motions of Animals” (1751), says: ‘‘ Physiological writ- 
ers have divided the motions of animals into voluntary, 
involuntary, and mixed. The voluntary motions are such 
as proceed from an immediate exertion of the active 
power of the will. The involuntary and mixed motions 
(which last, though subject.to the power of the will, yet 
are not ordinarily directed by it) may be aptly enough 
comprehended under the general denomination of spon- 
taneous ; since they are performed by the several organs, 
as it were, of their own accord, and without any attention 
of the mind, or consciousness of an exertion of its power. 
Such are the motions of the heart, organs of respiration, 
stomach, intestines, etc., which have been also distin- 
guished by the term automatic; though perhaps there is 
an impropriety in the word, as it may seem to convey 
the idea of a mere inanimate machine, producing such 
motions purely by virtue of its mechanical construction ; 
a notion of the animal frame which ill agrees with the 
inertia and other known properties of matter.” 

As is foreshadowed in the latter portion of this quota- 
tion, the view stated in the former part has been some- 
what changed since that time. The study of reflexes, 
which has been greatly extended along lines begun in 
part by Whytt, together with more exact studies of biol- 
ogy in general, and, especially, of the animal organism 
as an isolated mechanism acted upon by an environment 
external to itself, and by it reacted upon in its turn, 
have led to most interesting and fruitful conceptions of 
the physiology of the nervous system. Instead of vol- 
untary, involuntary, and mixed actions, physiologists 
for the most part now agree to consider every action as 
aroused by some definite cause or stimulus. Stimuli 


152 


proceeding directly from the environment, and provoking 
reactions upon it, plainly produce reflex actions. Stimuli 
arising within nerve-centres, and acting directly upon and 
through the centres in which they arise, produce auto- 
matic actions. Stimuli arising within the organism (it 
may be in nerve-centres), and acting upon nerve-centres 
other than their own, must clearly produce reflex ac- 
tions, since the event differs essentially in nowise from 
an ordinary reflex action. If, for example, it could be 
shown that the heart-beat depends directly upon the 
pressure of blood upon the endocardium, or upon the 
quality of that blood, or upon any other stimulus affect- 
ing the cardiac ganglia from without, we should be 
forced to regard the heart-beat as a reflex act, But un- 
til some such evidence is forthcoming we are obliged to 
consider it automatic, self-regulating, spontaneous. In 
the same fashion, whenever it is proved beyond doubt 
that the activity of the respiratory centre depends wholly 
upon the oxygenation of the blood, we shall be obliged 
to regard it as a reflex centre ; and there is a very consid- 
erable amount of evidence already pointing in that direc- 
tion. Finally, it must not be overlooked that modern 
physiology, in using the word ‘‘ automatic,” or self-regu- 
lating, applied to a nerve-centre, does not regard auto- 
matic powers as either the result of chance, or as having 
arisen, by a kind of spontaneous generation, de novo. The 
powers and properties in any automatic centre to-day 
were either inherited (after having been acquired more 
or less remotely), or were acquired, being repeated until 
they became fixed in what we call habit. In the infant, 
talking is at first chiefly echo, imitation, and ‘‘ reflexion,” 
more or less perfect. Judgments, also, of distance, time, 
position, and the like, are chiefly the resultants of childish 
experience often repeated and blending with an inherited 
background, in which they grow and become more easily 
fixed or transformed into habits; and even actions ap- 
parently the most automatic or spontaneous, viz., those 
of the kind called voluntary, not seldom have their origin 
in rernote impressions, or are directly modified by sensory 
impulses. Thus the acts of walking, talking, eating, etc., 
usually go on without the direct supervision of the will ; 
and even the orator’s words, chosen it may be beforehand, 
are delivered in a modified manner according to impulses 
arising from the picture of his audience upon his retina. 
Even the most characteristic beliefs, ideas, and desires of 
the most original minds are largely, if not almost wholly, 
the delayed or postponed resultants of earlier impressions 
acquired and inherited—reflexes infinitely elaborated and 
modified in the reflex or automatic centres, or having a 
very long ‘‘ reaction-time.” 

Thus it appears that in comparison with complex 
automatic actions, ordinary reflex actions, which in their 
simplest forms are merely reactions upon an acting en- 
vironment, are the simplest of all—the units, from the 
addition and multiplication of which we have reason to 
believe that the higher forms of action—automatic actions 
and even volition—are in great part compounded. That 
classification, therefore, of nervous actions into reflex 
and automatic, which is now almost universally adopted 
and to which we shall adhere, is evidently warranted 
more by convenience than by any marked fundamental 
differences between them. 

GROWTH OF OUR KNOWLEDGE OF REFLEX ACTIONS.— 
The great body of facts relating to reflexes forbids an 
enumeration of all of them, but the more important prin- 
ciples thus far established and underlying their physiol- 
ogy, may be easily apprehended by reviewing the histori- 
cal development of the subject. Here we are fortunate 
in being able to refer, even for the smallest details, to the 
work of Eckhard, whose extensive and laborious history 
of reflexes appeared in 1881. From this the following 
historical data have been chiefly, and often literally, 
taken (C. Eckhard: ‘‘ Geschichte der Lehre der Refiex- 
erscheinungen,” Bettrdge zur Anatomie und Physiologie, 
Band ix., Giessen, 1881). 

Many reflexes had been observed, of course, long before 
any of them were understood. Sneezing, tickling, and 
coughing must have been always familiar to everybody. 
Moreover, it had not escaped notice that stimuli often 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Reflex Actions, 
Reflex Actions, 


produce effects in parts remote from the point of applica- 
tion. Thus, ‘‘ Hippocrates has observed that the unex- 
pected sight of a serpent will make the countenance pale. 
The sight of grateful food occasions an uncommon flux 
of the saliva in an hungry person. When one eye is 
affected with an inflammation or a cataract, the other is 
often soon after attacked with the same disease. A bright 
light coming suddenly on the eyes sometimes occasions 
sneezing. We shut both eyelids, whether we will or no, 
as often as anything threatens to hurt cither eye. The 
contraction of the pupil is not owing to light acting as a 
stimulus on the iris, but solely to the sympathy between 
this membrane and the retina.” This quotation from 
the ‘‘ Works of Robert Whytt, M.D.,” Edinburgh, 1768, 
p. 495, indicates well some of the reflex actions which 
were then familiar, and also (in the last sentence) intro- 
duces us to the then prevailing theory of physzological 
sympathy, which was the forerunner of the modern doc- 
trine of reflex actions. To Whytt belongs in large meas- 
ure the honor of showing that ‘‘sympathies” are effected 
through the central nervous system; and that he held 
very advanced views appears, é.g., from the following: 
‘Cold water thrown on any part of the body that is 
warm produces a sudden contraction of the whole ves- 
sels and pores of the skin. By doleful stories 
or shocking sights delicate people have been often af- 
fected with fainting, etc., and, although in these cases the 
changes produced in the body are owing to the passions 
of the mind; yet, as the mind is only affected through 
the intervention of the optic and auditory nerves, they 
seem proper enough instances of the general sympathy 
that extends through the whole nervous system” (Joc. 
cit.). Much, however, had been learned long before the 
time of Whytt. Hippocrates has been quoted already, 
as having noted the blanching of the face from fear, etc. 
Galen was aware that closure of one eye causes the pupil 
of the other to dilate, although he did not know of any 
other motions of the pupil, and attributed this ‘‘ dilata- 
tion of the pupil of the open eye to its having the spirits 
which used to be bestowed on both eyes now determined 
into it alone” (Joc..czt.). Explanations like this were to 
be expected before the discovery of the circulation of 
the blood, or the establishment of the fact that the ar- 
teries are not air-tubes. In fact, we learn from Whytt 
that at the beginning of the sixteenth century ‘‘ Achil- 
linus makes particular mention of the motion of the pu- 
pil from different degrees of light ; which, however, was 
so little attended to that its first discovery has been gen- 
erally ascribed to Father Paul, who lived about a hun- 
dred years after him. However, neither Father Paul nor 
Fabricius ab Aquapendente seems to have known how 
these motions are performed” (‘‘ Whytt’s Works,” p. 61). 

‘With the seventeenth century a change began, although 
theories and arguments rather than proofs still held the 
day. Among the authors of that time Descartes comes 
first. He dwells upon the subject in two separate pa- 
pers, viz., ‘‘ Les Passions de ’4me”’ (1649), and ‘‘ Tracta- 
tus de Homine” (1677). In the former he points out 
that involuntary movements may be evoked, without af- 
fecting consciousness, by the most unlike sensory nerves 
and the brain ; this, too, in some groups of muscles rather 
than in others. As an example, he cites the involuntary 
shutting of the eyelids, and other movements which we 
unconsciously and involuntarily make for defence from 
threatened danger. It is interesting to learn, moreover, 
that he considers as the central organ, or seat of transfer 
of sensory to motor impulses—not the brain or spinal 
cord, but—the pineal gland, long regarded as the seat of 
the soul, but now known to be non-nervous in nature, 
made up of a mesh of blood-vessels, and probably repre- 
senting the rudiment of a third, unpaired, and median 
eye. In this connection Descartes spoke of the impulse 
as ‘‘reflected.” The second paper is interesting chiefly 
because it shows Descartes’ clear comprehension that 
these events occur without the participation of the 
‘* soul.” 

Swammerdam, in his ‘‘ Bibel der Natur” (1652), refers 
to the involuntary movements which men and the lower 
animals, especially when sleeping, exhibit whenever their 


skins are gently irritated ; and says that they occur with- 
out any great participation of the will, yet attempts no 
explanations. Willis, on the other hand, in 1664, was 
not only familiar with many genuine reflex phenomena, 
but gave of them explanations similar to those given to- 
day. -He mentions the involuntary placing of the ears, 
the involuntary cries, etc., of animals to which auditory 
impulses come, and compares the whole event in each 
case to an ‘‘echo.” Willis regarded the brain as the 
‘‘centre” of such physiological echoes, although he be- 
lieved that the transfer of the impulse from the sensory to 
the motor nerves takes place also through peripheral 
anastomoses. | 

In the seventeenth century experiments upon decap- 
itated animals were also known, and although explained 
otherwise than they are to-day, and not brought into line 
with the observations just recorded, they are of great in- 
terest as being the earliest examples in experimental 
physiology which prove that in brainless animals move- 
ments can be evoked by stimuli. Toward the end of the 
century physiologists generally seem to have been famil- 
iar with such observation as that of Boyle, described by 
himself as follows: ‘‘ The body of vipers may be some- 
times, two or three days after the skin, heart, and head, 
and all the entrails are separated from it, seen to move in 
a twining or wriggling manner, nay, may appear to be 
manifestly sensible of punctures, being put into a fresh 
and vivid motion when it lay still upon being pricked, 
especially on the spine or marrow, with a pin or needle.” 
Yet it was only in the next century that physiologists 
pushed the analysis further. At this time they had, how- 
ever, established the important fact that beyond the do- 
main of a will conditioned by the presence of the brain, 
there must exist somewhere in the body a source of or- 
derly muscular movement. 

The question whether or not these movements are 
accompanied by consciousness does not seem to have at- 
tracted much attention as yet, although, as we shall see, 
it afterward assumed great prominence. Some, indeed, 
like Boyle, recognized the two possibilities, viz.: first, 
that the sensorium reaches down into the spinal cord, 
so that the latter is conscious by itself alone, as well as 
when joined normally to the brain; or, second, that 
all parts of the body may be potentially conscious or 
‘‘independently perceptive,” consciousness being dif- 
fused throughout the body, and not confined strictly to 
the brain, or brain and spinal cord. An experiment 
which we now know to be misleading, seemed to point 
to the first explanation. It was observed that decapi- 
tated frogs do not merely pull back their legs on being 
irritated, but also crawl and leap in a manner closely re- 
sembling the normal. This is indeed true in some cases, 
especially if the decapitation is done by scissors, one 
blade of which is put in the back of the mouth—in 
which case the optic lobes are generally only partially, 
if at all, removed—or if any large portion of the me- 
dulla be left connected with the cord. But if the whole 
brain, including the medulla oblongata (which was then 
usually reckoned as a part of the spinal cord), be taken 
away, the crawling or leaping movements never appear. 
The frog squats flat upon the belly, and is unable to do 
other than simple, purely reflex, movements. 

In the eighteenth century more rapid progress was 
made. The chief place of ‘‘ transfer” (Uebertragung) of 
the sensory to the motor nerve, or, as we will henceforth 
designate it, ‘‘the central reflex organ,” was finally set- 
tled, after much debate and experimentation, which con- 
stantly brought new facts to light. Regarding the cen- 
tral reflex organ (which, as has been insisted above, is not 
a mere shunt or reflecting organ (p. 151), two hypotheses 
had arisen, viz.: first, the suggestion of Willis, that the 
peripheral anastomoses and sporadic ganglia are such re- 
flex centres ; and, second, that the brain and spinal cord 
(central nervous system, often called the sensorzwm com- 
mune) are the great central reflex organ—an idea held 
earlier by Descartes, etc. Of the first theory Vieussens 
was the principal supporter, although around him were 
grouped H. Boerhaave, Comparetti, Bergen, Walther, 
Vater, Buchner, Meckel, Gasser, Camper, and others, 


153 


Refiex Actions. 
Reflex Actions, 


chiefly anatomists. The only ground for this theory of 
the peripheral anastomoses lay in the argument (post hoc 
ergo propter hoc) that in the parts which stand in sym- 
pathy peripheral anastomoses occur in the nerves there 
distributed. Tissot (‘‘ Traité des nerfs et de leurs mala- 
dies,” tome ii., pt. ii, Paris, 1780) has given a. num- 
ber of examples of this kind. The theory that the cen- 
tral nervous system is also the central reflex organ was 
defended by Perrault, Astruc, K. Boerhaave, Haller, 
Van Swieten, Monro, Marherr, Thaer, La Roche, Whytt, 
Tissot, and others ; of whom Astruc, K. Boerhaave, and 
Whytt brought forward the most effective evidence for 
the theory and against that of the peripheral anastomo- 
ses. Astruc and K. Boerhaave affirmed (1) that there 
are sympathies where no anastomoses exist to regulate 
them ; and (2) that even where there are anastomoses 
there is no genuine fusion of the nerve-fibres, which run 
parallel to one another into the central nervous system, 
and do not unite in the anastomoses, thus making ‘‘sym- 
pathy ” in the latter impossible. It is not clear whether 
these bold (and certainly prophetic) statements were 
mere guesses, or based upon actual observation. Both 
these authors employ the word ‘“ reflexion,” but not, as 
Cayrade would have it, for the first time. It had been 
used already by Descartes and Willis. 

Most significant and fruitful of all was the work of 
Robert Whytt, to whom reference has been made above. 
Of him Eckhard well says: ‘‘ R. Whytt is, in manifold 
ways, noteworthy in the history of reflex actions. We 
may grant that his conceptions of them were not exactly 
like our own, and yet find in his works a wealth of ex- 
perimental discovery to which his predecessors did not 
approach in the remotest degree ; containing in their in- 
fancy many principles of the physiology of reflexes 
which have only lately become the subjects of extensive 
research ; besides a much more fundamental refutation of 
the ‘ peripheral anastomosis’ theory than had been given 
by Astruc or anyone else ; and finally, and perhaps most 
important of all, the first experimental evidence that the 
reflex movements of decapitated frogs are governed and 
elaborated by the spinal cord.” 

The more important discoveries of Whytt (‘‘ The Works 
of Robert Whytt, M.D.,” etc. Published by his son. 
Edinburgh, 1768) may be summarized as follows: 1. It 
was known that decapitated animals exhibit movements 
upon being duly stimulated ; it was suspected, urged, be- 
lieved, and denied that the spinal cord is the central reflex 
organ, the seat of transfer of the impulse from the sensory 
to the motor nerve. Whytt proved that the spinal cord is 
the essential centre in.such cases, by the simple but con- 
clusive experiment of destroying it and then observing 
that movements afterward never ensue. Moreover, he 
frankly owns that the experiment was not wholly origi- 
nal with him, but done after the method of Dr. Stephen 
Hales, who, it will be remembered, was the first to take the 
blood-pressure by the manometer, and whose works on 
‘‘Staticks”” abundantly prove his ingenuity. ‘‘ The late 
reverend and learned Dr. Hales informed me that, having 
many years since tied a ligature about the neck of a frog 
to prevent an effusion of blood, he cut off its head, and, 
thirty hours after, observed the blood circulating freely 
in the web of the foot ; the frog also at this time moved 
its body when stimulated ; but that, on thrusting a needle 
down the spinal marrow, the animal was strongly con- 
vulsed and immediately after became motionless” (J. c., 
p. 290. See, also, pp. 284, 510). 

2. Whytt was the first to point out that after decapi- 
tation the movements which are afterward easily evoked 
in such animals cannot be obtained till after the lapse of 
afew minutes. This is probably the first scientific ob- 
servation of inhibition, and to it he added others (pp. 308, 
501-502). 

3. Whytt distinguished more clearly than had been 
done before him certain actions as reflex, the clear ex- 
planation of which was novel. We have mentioned 
above his reference to the ‘‘ watering” of the mouth at 
- the sight of ‘‘ grateful food.” This, of course, opened up 
the whole subject of reflex secretions. His theory of the 
reflex dilatation and contraction of the pupil is also note- 


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worthy. ‘‘ The pupil is contracted more or less in pro- 
portion to the quantity of light admitted into the eye, not 
on account of ‘any immediate action of this subtile fluid 
on the fibres of the iris, as some have imagined, but in 
consequence of its affecting the tender retina with an 
uneasy sensation ” (p. 62). ‘‘ The contraction of the pu- 
pil when light offends the eyes, and of the eyelids when 
grosser bodies threaten to hurt them ; the co- 
pious secretion of tears and the saliva when stimulating 
substances are applied to the eyes or taken into the 
mouth. These motions cannot, in my opinion, 
be referred to any connection or communication among 
the nerves, but to the brain itself” (‘‘ On the Sympathy 
of the Nerves,” U. c., p. 519). 

It has been vigorously urged that Prochaska (1749- 
1820) is entitled to be regarded as the principal founder 
of the modern doctrines of reflex actions; but, in spite 
of the conflicting testimony, if we observe carefully-the 
ideas, knowledge, and discoveries of Robert Whytt, we 
shall not greatly err, if we hold with Eckhard ‘that, 
aside from some few observations, Prochaska has neither 
discovered new facts or explained old ones, nor to any 
great extent advanced the theories of reflex actions” (¢/.’ 
‘‘Unzer and Prochaska on the Nervous System,” Syden- 
ham Society, London, 1851, esp. pp. 429-488). 

Herbert Mayow showed, in 1823, more clearly than 
had been shown hitherto, that the reflex movements of 
the pupil depend primarily on stimulation of the optic 
nerve, and that the experiments succeed (in pigeons, 
with which he worked) even after decapitation, provided 
that the forepart of the crura cerebri, corpora qua- 
drigemina, and the second and third pairs of cranial 
nerves are unharmed. This was perhaps the first ex- 
perimental evidence of reflexes in heads separated from 
the rest of the body, and in the brain alone (cf. Herbert 
Mayow’s ‘‘ Commentaries on Physiology,” ii., London, 
1823). 

The most prolific writer upon, and vigorous exponent 
of, the doctrine of reflexes that the nineteenth century 
has produced is undoubtedly Marshall Hall; and yet a 
comparison of his labors with those of his predecessors 
and followers, inclines us to agree with Eckhard, that it 
is very likely true that Marshall Hall made his first dis- 
coveries, and formed his earlier theories independently, 
and in ignorance of the work already done. Finding 
himself thereafter with a reputation to sustain, and dif- 
fering somewhat from the older authors, he published 
copiously (perhaps rather than wisely), and without al- 
ways giving full credit to his predecessors. Neverthe- 
less, his services are very great and conspicuous, and his 
publications, reaching from 1882 to 1847, drew general 
attention to, and aroused great interest in, the whole 
subject. Hall was the first (unless Johannes Miller be 
excepted) to observe the rise of reflex irritability under 
opium and strychnine, and the fall under prussic acid ; 
the first to observe the interesting fact that reflexes are 
more easily evoked through nerve-endings than nerve- 
trunks ; the dependence of tonus upon the spinal cord, 
etc. He also proposed the hypothesis of a special 
‘“‘excito-motor system” distinct from the sensory-motor ; 
the former to account for reflexes free from conscious- 
ness, and concerned chiefly with the spinal cord ; the 
latter to explain the ordinary actions consequent upon 
sensation and volition. The hypothesis called for a 
double set of nerve-fibres going to all parts of the skin, 
but ending centrally, the one in the cord, the other in the 
brain. 

Grainger sought to find an anatomical basis for this , 
theory of Hall, and in his ‘‘ Observations on the Struct- 
ure and Functions of the Spinal Cord ” (London, 1837), 
he claimed to have observed that, from the anterior and 
posterior roots of the nerves certain small threads pro- 
ceed to the gray substance, while others enter the white 
substance of the cord, and then pass upward ; according- 
ly, he assumed the former to be the ‘‘ excito-motor ; ” 
the latter, those of sensation, perception, and voluntary 
movement. From the present standpoint of physiology 
it is interesting to perceive that, even so early as this, 
Grainger was led to conceive the gray substance of the 


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Reflex Actions. 
Reflex Actions. 


cord. to be, in the last analysis, the principal central re- 
flex organ within which the exchange from afferent to 
efferent impulses is effected. Grainger appears also to 
have been the first to formulate definitely the theory of 
the reflex function of the submaxillary ganglion in the 
act of salivary secretion ; in which the afferent twigs are 
supposed to belong to the lingual, and the efferent to be 
branches (chiefly of the chorda tympani) from the gan- 
glion. It was not new to regard the sporadic ganglia 
as reflex centres, however, for that was involved in the 
‘‘anastomosis”” theory. Indeed, Prochaska regarded the 
sympathetic ganglia as important reflex centres, and Le 
Gros Clark, a year earlier than Grainger, had done like- 
wise. It is interesting to remark here that, as we shall 
see hereafter (p. 156), Claude Bernard, more than a 
score of years after Grainger, and, apparently, quite in- 
dependently, took almost exactly the same ground re- 
garding the function of the submaxillary ganglion, and 
adduced important experimental evidence which led to 
fresh researches, and to one of the most animated and 
fruitful debates in the history of experimental physio- 
logy. 

Johannes Miller was working upon reflex actions at 
the same time as Marshall Hall, and in the first edition of 
his ‘‘ Text-book of Physiology ” (1833), gives the princi- 
pal results of his labors. Unlike Hall, he was well ac- 
quainted with the history of the subject, although he 
seems to have overlooked the fact that the Hales-Whytt 
fundamental experiment had been repeatedly done al- 
ready, and, like Hall, ‘‘ discovered” it once more, appar- 
ently quite independently. He makes the usual state- 
ments about reflexes, gives the usual examples, and 
discusses thoroughly the sporadic ganglion question. In 
this he inclines to the belief that sporadic ganglia do not 
behave as reflex centres, but pronounces the question un- 
settled. ' 

In 1838 Ehrenberg first published an account of the 
ganglion cells (in the sympathetic ganglia, and possibly in 
the cortex of the brain), (Pogg. Ann., Bd. xxviii., 1833, 
p. 449). In 1837 Purkinje described them more clearly, 
in the brain and spinal cord, noting their processes or 
‘* poles,” but not observing any connection of these with 
the nerve-fibres. Valentin, in 1839, proposed the hypoth- 
esis that these ganglion cells effect the transfer ( Ueber- 
tragung) of the impulses in reflex actions, and are there- 
fore the ultimate reflex centres. In 1846 R. Wagner and 
Robin (Wagner’s Physiologie, Bd. iii., 2, 361) saw the 
ganglionic processes in direct connection with nerve- 
tibres, and Wagner suggested that the transfer is by a 
virtually continuous path—the three principal elements 
being the afferent nerve, the centre, and the efferent 
nerve. 

From the time of Marshall Hall up to the present day 
so many workers have been engaged upon the physiology 
of reflex actions, that it is here impossible to do more 
than, with Eckhard, to follow out some of the lines of 
inquiry which seem most interesting, viz.: 

1. The Methods of Study. 

2. The Nervous Mechanism of Reflexes. 

3. Inhibition of Reflexes. 

4. The Time-Element. 

5. The Effects of Drugs, Temperature, etc., upon Re- 
flex Actions. 

6. Laws of the Propagation of Reflexes. 

7. Reflex Centres. 

Meruops or Strupy.—In passing from qualitative to 
quantitative studies of reflexes, it becomes necessary to 
measure and compare stimuli as causes, and actions as 
effects. The stimulus remaining the same, it has been 
found that the excitability of the reflex-apparatus varies 
with different circumstances, such as temperature, 
moisture, drugs, and, above all, the condition of the 
spinal cord. Or the apparatus being the same, different 
stimuli produce-different effects. 

The first successful attempt to secure precise results 
was by means of chemical stimulation, in a way since 
known as ‘‘ Tiirck’s Method” (Ludwig Tiirck, ‘‘ Ueber 
den Zustand der Sensibilitaét nach theilweiser Trennung 
des Riickenmarks,” Zevtschrift der k. k. Geselischaft der 


Aerzte zu Wien, vii. (1851), 189). Tiirck’s method con- 
sists in allowing the toes of a suspended frog to dip to 
a fixed depth in very dilute sulphuric acid. The time 
which elapses between the immersion of the toes and the 
pulling of them out by the animal—the veaction-time—is 
then taken as the measure of the excitability of the reflex 
apparatus. Tiirck used acid of one-fifth to four-fifths 
per cent., and found that in any one animal, the conditions 
remaining the same, the reaction-times are equal, espe- 
cially if care be taken to wash off the acid promptly after 
the dipping of the foot. Setschenow added a useful 
feature to the method by introducing the metronome as 
a simple and convenient chronograph, and he, besides 
others, has employed the method without questioning its 


‘accuracy. Some, however, have alleged that with very 


great dilution of the acid frogs react only after longer 
and longer intervals. Still others maintain that the first 
reaction follows later (¢.e., after a greater interval) than in 
the succeeding trials. These and other disputed points 
in Tiirck’s method have been carefully investigated by 
W. Baxt (Berichte der Konig. Sdchs. Gleselischaft d. Wiss., 
1874, pp. 309-814). 

According to Eckhard (Bettrdge, etc., ix.), who has 
thoroughly reviewed the literature of the subject, three 
important considerations must be borne in mind, not 
only in this method of chemical stimulation, but in ther- 
mal and other methods described further on, viz. : 

1. Very gradual increments of strength in an ineffec- 
tive irritant will not always suffice to produce a reaction, 
even though they be continued until a greater strength 
has been reached than—otherwise applied—would prove 
to be a powerful stimulus; for it has been shown, espe- 
cially by C. Fratscher (Jenatsche Zeitschrift, N. F., ii., 
1875, 30), that if we begin to stimulate by a solution of 
acid, alkali, etc., so dilute that no reaction follows, we 
may gradually increase its strength up to a point where 
actual destruction of tissue ensues, without once evoking 
areaction. With hot water equally astonishing results 
were obtained, for Fratscher found it possible to heat 
slowly, not only decapitated, but even normal, frogs from 
the ordinary temperature until they passed into calorés 
rigor, without any reflex actions ensuing at any point of 
the process. 

2. The reaction-time varies with the strength of the 
stimulus. In general, acids of the strength of the acids 
of the body, such as that of the gastric juice, are inef- 
fective. Above this point, according to Baxt, while the 
concentration increases arithmetically, the reaction-times 
diminish geometrically. 

3. For each individual there is a point where stimuli 
of a certain weakness will evoke (though barely) a reflex 
action. These stimuli are called minimal stimuli ; and 
the point itself is called the Reflerschwelle or reflex thresh- 
old. If we overstep this threshold by still greater dilu- 
tion of the irritant, no reaction follows ; if we have been 
using ineffective stimuli, this marks the lowest point at 
which reaction begins. 

Mechanical stimulation is probably the oldest, and yet 
the least trustworthy, method of evoking reflexes. The 
difficulty of making quantitative measurements by its 
means is, however, so great as to make other methods 
preferable. Here, also, increments of stimulation must 
be sudden and considerable, for it has been found possi- 
ble even to crush a limb without ever provoking action, 
provided care be taken to make the increments of press- 
ure small and gradual. 

Thermal Stimulation.—Here too, as has been shown 
above, gradual increments are ineffective to evoke reac- 
tion. Heinzmann (Pfliiger’s Archiv, vi., 1872, 222 found 
that the increments, when a whole leg was immersed, 
must exceed 34> to 345° C. per second, otherwise the an- 
imal might pass motionless into rigor caloris. Foster 
(Journal of Anat. and Physiology, vol. viii., p. 45) found 
that if only the toes were immersed, it was impossible to 
pass, however slowly, above 35° C. without reaction ; 
and explained the fact of easier reaction following the 
immersion of a smaller area by comparing it to the easier 
stimulation of a nerve through a bit of skin than through 
the whole nerve-trunk. Fratscher, however, finds it 


155 


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Reflex Actions, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


_ possible to go higher than 35°; indeed, as high as is de- 
sired even with the smaller area. It has been suggested 
by Sedgwick (Studies from Biol. Lab. Johns Hopkins 
Univ., ii., 885) that the greater difficulty of arousing 
reflexes by thermal stimuli, when larger areas are im- 
mersed, is due not so much to the stimulation of a large 
area as to the heating of the whole animal by the circu- 
lating blood to such an extent that the contrast between 
the part in the water and that out of it never amounts to 
enough to constitute a stimulus. That this is very likely 
true is shown by stopping the circulation at the begin- 
ning of an experiment ; after which it is found that com- 
paratively low temperatures produce movements, even 
when large areas are immersed. 

The question has been raised whether the reflexes pro- 
duced by various stimuli are produced through the same 
end-organs. Tiirck, who first introduced the subject, 
takes the affirmative. Setschenow (Setschenow und Pas- 
chutin, ‘‘ Neue Versuche,” etc. Berlin, 1865), and Dani- 
lewsky (Archiv fir Anat. und Physiologie, 1866, p. 677) 
take the negative, the latter holding that a difference ex- 
ists between ‘‘ tactile” and ‘‘ pathic” reflexes. The sub- 
ject cannot be further treated here, but it may suffice to 
say that the present tendency appears to be toward the 
idea of a (limited) number of end-organs, rather than of 
one kind susceptible to all sorts of stimuli. 

Hlectrical Stimulation.—The same general statements 
may be made here as in the other cases of stimulation. 
The constant current is effective only when of a certain 
strength ; but summation may occur and give rise to 
stimulation, in the use of streams so weak as to be ineffec- 
tive, by making thecurrent interrupted. Induced currents 
at rather long intervals may be of considerable strength, 
and yet produce no reactions ; while weaker but more 
frequent currents may be ‘‘summated” and produce re- 
actions. This whole subject has been accurately studied 
by Stirling (‘‘ Berichte der Konigl. Sachs. Gesellschaft 
der Wissenschaften,” 1874, p. 372), who carried out his 
investigations in Ludwig’s laboratory, and employed 
novel and exact apparatus. Reference must be made 
to his complete paper for the details. 

THE Nervous MECHANISM OF REFLEXES.—Since the 
time of Mayow, Hall, Miller, and Grainger (vide supra), 
there has never been any doubt that the brain acts as a 
central reflex organ. It does not appear to act as a 
whole, but the cerebrum and cerebellum seem rather 
each to include many centres. The spinal cord, how- 
ever, is the central reflex organ par excellence, not so 
much from the great number of reflex centres located 
in it (for it must be remembered that the extreme hind- 
brain—the medulla oblongata—is very rich in reflex cen- 
tres), as from the fact that this is probably its most im- 
portant function, while the brain, including the medulla, 
is much devoted to other important functions. It must 
not be forgotten, however, that the hindmost portion of 
the spinal cord does not act as a central reflex organ, as 
was first shown by Volkmann (Miiller’s Archiv, 1888, p. 
15; 1841, p. 354), and has since been confirmed. Thus 
Sanders-Ezn (1867) affirms that no reflexes can be obtained 
from the cord of a frog behind the level of the eighth 
pair of spinal nerves. Koschewnikoff states that all re- 
flexes cease upon removal of the cord as far back as the 
middle of the fifth vertebra. Eckhard finds that even 
strychnized frogs showed no reflexes with the hindmost 
portions only of the spinal cord intact. 

It is no longer held by anyone that reflexes occur ac- 
cording to the old doctrine of the peripheral anastomoses. 
‘When, however, we turn to the question whether or not 
the sporadic ganglia can serve as reflex centres, we find 
amass of conflicting testimony, and great difference of 
opinion. It may be said, meanwhile, that although the 
possibility that they may so act is granted, no sufficient 
proof has yet been given that they do or do not. At the 
same time it cannot be denied that if they do act as reflex 
centres some evidence of the fact ought to be easily ob- 
tained ; and, on the other hand, it is not difficult to see 
the advantages which must accrue to that organism 
- whose central government is instantly and directly in- 
formed of changes occurring in its periphery. It is much 


156 


easier on @ prior? grounds to suppose internal, and, so to 
speak, domestic affairs, such as the heart-beat, vaso-motor 
actions, and the like, to be partially self-controlled, auto- 
matic, or even purely reflex, than more external affairs, 
such as locomotion, motion, secretion, etc., which are 
far more irregular and unequal. In the latter the ad- 
vantage of a central co-ordinating apparatus in direct 
communication with every part of the body is too evident 
for debate. That this central system should reserve di- 
rect reflex authority over the periphery, and surrender 
to internal machinery the general control of vaso-motor 
actions, etc., is also quite within the limits of possibility. 

Studies of the reflex powers of sporadic ganglia have 
been made upon the cardiac ganglia, the inferior mesen- 
teric, and the submaxillary ganglion, all of which are 
macroscopic, besides the microscopic ganglia of the 
blood-vessels, etc., either known or supposed to exist. 
Most famous of all is the controversy of which the reflex 
functions of the submaxillary ganglion form the subject. 
This ganglion, from its size, its accessibility upon the 
living animal, and from the ease with which its effects 
upon salivary secretion can be estimated, is well adapted 
for use as a ‘‘test case.” It is connected with the sub- — 
maxillary gland by the chorda tympani, with the tongue 
by the lingual, and with the brain by both. 

The debate was begun by Claude Bernard (Comptes 
Rendus, 1862, ii., 341), who seems to have overlooked 
the earlier experiments of Grainger (see above), and was 
taken up by Kiihne (Lehrbuch der Physiol. Chem., 1868, 
p. 8) and Vulpian (Lecons sur Vapp. vaso-moteur, i., 311, 
1875), who supported Bernard, and by Eckhard (Zezt- 
schrift fiir ration, Med., xxix., 74), Heidenhain (Breslau 
Studien, 1868), Bidder (Archiv fir Anat. und Physiol., 
1867, 1), and Schiff (Moleschoit’s Untersuchungen, x., 1870, 
p. 423), who opposed him in the theory that the submax- 
illary ganglion acts as a reflex centre for salivary secre- 
tion. This celebrated discussion, so important to the 
student of the physiology of reflex actions, has been ad- 
mirably reviewed and summed up by Dr. Michael Foster 
in his well-known ‘‘ Text-book of Physiology,” where he 
treats of the physiology of secretion in general, and then 
proceeds as follows : 

‘‘In the angle between the lingual and the chorda 
tympani, where the latter leaves the former to pass to the 
gland, lies the small submaxillary ganglion, from which 
branches pass to the lingual on the one hand, and to the 
chorda on the other; branches may also be traced toward 
the ducts and glands, and toward the tongue, It has 
been much debated whether this ganglion can act as a 
centre of reflex action. 

‘‘Bernard found that after he had divided the con- 
joined lingual and chorda at about one centimetre above 
the place where the chorda diverges to the gland, stimu- 
lation of the lingual at about three or four centimetres 
distance below the ganglion still caused a flow of saliva ; 
this effect, however, was no longer seen when the branches 
passing from the ganglion to the lingual had been pre- 
viously divided. He explained the result by supposing 
that the impulses generated by the stimulus were con- 
veyed by afferent fibres in the lingual, along the lingual 
roots of the ganglion, to the ganglion, and were thence 
reflected by efferent fibres along the branches from the 
ganglion to the chorda, and so to the gland. The gan- 
glion, in fact, acted as a reflex centre. ‘The same appar- 
ent reflex secretion could also be induced, but less read- 
ily, by pinching the peripheral branches of the lingual 
near the tongue, or by dipping them into concentrated 
salt solution. In this case also the secretion failed to 
appear if the lingual roots of the ganglion were divided. 
Such a reflex secretion was very difficult to obtain by 
stimulating the mucous membrane of the tongue ; but 
Bernard was successful when he stimulated the tongue 
directly with a galvanic current, or drew the tongue out 
and placed ether on its surface. The secretion in all 
these cases was accompanied by a dilatation of the blood- 
vessels of the gland, and the effect on the gland was in- 
deed wholly similar to that of directly stimulating the 
chorda. Bernard further insisted that in these experi- 
ments no anesthetics were to be used, and observed that 


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Reflex Actions. 
Reflex Actions. 


the reflex act was no longer visible when two or three 
days had elapsed after section of the conjoined lingual 
and chorda trunks. Both these facts rather militate 
against his view, since it seems improbable that a spo- 
radic ganglion should be so susceptible of anesthetics, or 
that degeneration and functional incapacity of the gan- 
glion should follow upon section of the conjoined lingual 
and chorda, so long as the afferent and efferent connec- 
tions of the ganglion with the gland and tongue were 
kept up. 

‘Eckhard, in repeating Bernard’s experiments, failed 
to obtain any effect from dipping the endings of the lin- 
- gual nerve in salt solution, or from placing ether upon 
the tongue, and he very naturally argued (being support- 
ed in this by Heidenhain) that the effects seen when gal- 
vanic stimulation was employed were due to an escape 
of the current upon the chorda fibres. Schiff did obtain 
reflex secretion, after section of the conjoined lingual and 
chorda, by direct galvanic stimulation of the tongue, 
and by pouring ether on the surface of that organ; but 
the currents necessary in the first case to produce any 
effect were so strong that escape must have taken place, 
and in the second case the secretion appeared even though 
the lingual was divided close under the tongue, and 
when, therefore, this nerve could not have been the 
channel for conveying impulses to the submaxillary 
ganglion. He further pointed out that in large dogs, 
at all events, certain fibres of the chorda, after running 
along the conjoined lingual and chorda, do not leave the 
lingual with the rest of the fibres going straight to the 
gland, but continue in the lingual close up to the tongue, 
then bend round, and, as recurrent fibres, run back and 
eventually join the nerve going to the gland. He in con- 
sequence argued that Bernard, in stimulating the lingual 
below the divergence of the chorda, was in reality stim- 
ulating not afferent but efferent fibres. But in sucha 
case these recurrent fibres must pass to the chorda through 
the ganglion, if Bernard’s result be true that the reflex 
effect ceases when the lingual roots of the ganglion are 
divided. Schiff further states that these recurrent fibres 
degenerate in the retrograde portion of their course when 
the lingual is divided near the tongue, and that no effect 
follows upon stimulation of the lingual if the lingual 
have, some five or six days previously, been divided close 
to the tongue, so as to cause degeneration of the recurrent 
fibres; provided that the stimulation be not so strong as 
to lead to an escape of the current to the main chorda 
fibres. In small dogs Schiff could not so readily demon- 
strate these recurrent fibres, and though he says the ap- 
parent reflex secretion is more easily obtained in large 
dogs, such as Bernard probably used, than in smaller 
ones, it is improbable that mere size should make such a 
difference in nervous distribution ; and if an escape of 
current can explain the results in the one case, it can also, 
probably, in the other. 

** Bidder’s account of the nerves of the ganglion at 
first sight offers support to Bernard’s views. In the 
dog he finds, passing from the ganglion direct to the 
tongue, medullated nerve-fibres which do not degenerate 
when the chorda is divided at its exit from the skull. 
These fibres, accordingly, would seem to take their ori- 
gin in the ganglion, and to be the afferent nerves required 
for Bernard’s views. When Bidder divided the con- 
joined lingual and chorda he found fibres, the chorda 
fibres, after about three weeks, completely degenerated ; 
not only those forming the nerve going to the gland, but 
also those constituting the branches going to the gan- 
glion, 7.¢., the chorda roots of the ganglion. In the gan- 
glion and in the branches going from the ganglion to 
the gland were seen numerous degenerated fibres in the 
midst of undegenerated (but non-medullated) fibres 
which seemed to have their origin in the ganglion itself. 
Thus, after complete degeneration of the true chorda 
fibres, there still remained intact (1) the ganglion, (2) 
fibres from the ganglion to the tongue, and (8) fibres 
from the ganglion to.the gland; in fact, exactly the ner- 
vous mechanism demanded by Bernard’s view. But 
Bidder, like Eckhard, failed to obtain a reflex secretion 
by pouring ether on the tongue after division of the con- 


joined lingual and chorda, and he found that galvanic 
stimulation of the nerves going from the ganglion to the 
tongue was of no effect, provided that errors due to es- 
cape of current on to the main chorda fibres were avoided 
by previously inducing, through section, degeneration of 
the chorda fibres, including the chorda roots of the gan- 
glion. So that Bidder’s results in the end oppose the 
view that the ganglion can act as a centre of reflex ac- 
tion. In fact, such a view must be regarded at present 
as not proven.” 

For the discussion of cardiac and other vaso-motor 
ganglia, etc., as reflex centres, the discussion of which 
belongs rather to the physiology of automatic actions, 
reference must be made to the original paper of Eckhard 
(Bettrage zur Anat. und Physiol., ix.), where, also, the 
literature may be found 7n extenso. 

INHIBITION OF REFLEXES.—The actions of the animal 
body may be physiologically interrupted, postponed, or 
otherwise modified. Such interruption or postponement 
is called tnhibition, of which the most striking example, 
perhaps, is the slowing or total stoppage of the automa- 
tic heart-beat by stimulation of the pneumogastric nerve. 
More familiar examples are the voluntary refusal to be 
tickled, or to sneeze, or to cough when only a strong 
effort of the will forbids what would otherwise hap- 
pen; the frequent insensibility to pain when greater 
pain is being suffered ; and the unsusceptibility to many 
stimuli, ordinarily effective (absent-mindedness or pre- 
occupation), induced by ‘‘absorbing” pursuits of work 
or play. All these phenomena, and more, were well 
known when, in 1868, Dr. J. Setschenow, professor of 
physiology in St. Petersburg, published a work upon in- 
hibition (‘‘ Physiologische Studien iiber die Hemmungs- 
mechanismen fiir die Reflexthatigkeit,” etc., Berlin, 1863) 
which immediately drew general attention to the subject. 
It had been observed already that the reaction-time of a 
frog is greater before than after decapitation, or, in other 
words, that reflex actions are more quickly performed in 
the absence of the brain. Setschenow states, at the be- 
ginning of his monograph, that there were at that time 
two possible explanations of this increase of reflex-exci- 
tability consequent upon decapitation, viz. : first, that since 
the spread of sensory (afferent) impulses must tend to 
weaken them according to the area over which they are 
extended, those which cover the smaller area should give 
rise to stronger reflexes. Hence, when the head is cut 
off, because the sensory impulses are more confined the 
reflex of any given impulse is more intense. Or, second, 
that the brain normally exerts an inhibitory action-upon 
the reflex excitability of the spinal cord. This latter the- 
ory Setschenow accepts and proceeds to verify, regarding 
it the more worthy of support since ‘‘ Ed. Weber, speak- 
ing with a certain authority (on account of his celebrated 
discovery of the inhibitory influence of the vagus upon 
the heart), had first suggested that the will, whose seat is 
commonly supposed to be in the brain, is in a position to 
exert an inhibitory influence upon the reflex functions of 
the spinal cord” (loc. cit., p. 1). This hypothesis seemed 
to presuppose the existence of “inhibitory mechanisms,” 
and to find these Setschenow set to work. By cutting 
away the hemispheres no marked effect was produced ; 
but whenever the optic lobes or optic thalami were re- 
moved, the excitability of the cord rose; whenever they 
were irritated it was depressed. Setschenow concludes 
as follows (loc. cét., p. 35): 

1. The inhibitory mechanisms for the reflex activity of 
the spinal cord have their seat, in the frog, in the optic 
lobes and corpora quadrigemina, and in the medulla ob- 
longata. 

2. These mechanisms must be regarded as nerve-centres 
in the broadest sense. 

3. The afferent nerve-fibres form one (and probably the 
only) way for the excitation of these inhibitory mechan- 
isms. ; 

In the twenty-five years which have gone by since Set- 
schenow propounded his theory of the existence of special 
centres for reflex inhibition, it has found numerous ad- 
herents and opponents. The former have added little 
enough to the evidence upon which Setschenow’s theory 


157 


Reflex Actions. 
Registration. 


is based, while the latter have made it clear that the hypo- 
thesis is probably gratuitous, the facts involved being 
more easily explained otherwise. To give the whole 
history of this debate would carry us too far into details, 
and for these we must refer again to Eckhard (Beitrdge 
zur Anat, und Physiol., ix.). The tendency of physiolo- 
gists to-day is to look upon the inhibition of reflexes, not 
as a peculiar function of a special inhibitory centre or 
centres, but as one phase of inhibition in general, some- 
what as follows: The central nervous system is a system 
of centres—automatic as well as reflex—closely bound to- 
gether by nerve-fibres. The separate centres are to a 
great extent independent, but by no means entirely so, 
each being more or less influenced in its activity by others. 
Into this central system (brain and spinal cord) impulses, 
recognized or unrecognized by consciousness, are con- 
tinually flowing from the eye, the ear, the heart, the vis- 
cera—in short, through every afferent nerve. Within the 
system itself impulses are started by the automatic cen- 
tres and sent along its length as well as outward. Each 
centre, therefore, is always affected more or less by every 
other, and by afferent impulses arising in the peripheral 
sensory end-organs. To remove a quantity of these in- 
ward-bouna impulses is to alter materially the conditions 
affecting the centres. But to remove the hemispheres of 
the frog is probably to remove only a very limited and 
(in the frog) uninfluential group of automatic centres. 
To take away the optic thalami, optic lobes, and medulla, 
however, is to remove the most important of all the in- 
coming impulses, viz., those from the eyes, the ears, and 
the great pneumogastric, which of all the nerves probably 
modify most the more purely mechanical functions of 
the cord. It is not surprising, therefore, that after de- 
capitation the cord, freed from the interference ordinarily 
produced by these impulses, should work, from a mechan- 
ical point of view, more perfectly, passing into an abnor- 
mally sensitive condition analogous to hyperesthesia. 
Or, again, to remove the cerebral hemispheres and then 
stimulate the mid- and hind-brain with salt, after the man- 
ner of Setschenow, thus producing a depression of reflex 
activity, is plainly to intensify the impulses passing down 
into the cord, and to increase interference. That salt does 
not so readily do this when applied to the cut end of the 
cord after the brain has been all removed, is probably be- 
cause in the former case the salt-produced impulses were 
added to the ordinary impulses going from the hind- 
brain, while now they are alone; previously they acted 
upon a cord already normally ‘‘ depressed,” while now 
they act upon a cord abnormally exalted. On the other 
hand, stimulation of one sciatic inhibits more or less*per- 
fectly the reflexes performed by the other; and yet sec- 
tion of one is said to depress the reflex powers of the 
other. The fact is, we are not yet in a position to dogma- 
tize upon the subject of reflex inhibition, and the whole 
subject urgently demands further elucidation. 

THE TIME ELEMENT IN REFLEX AcTIons.—Exner has 
estimated the time required for a stimulus applied to one 
eyelid to make the other blink. <A sharp electric shock 
was applied, for example, to the eyelid of one eye, and 
the interval elapsing before the other eyelid blinked was 
noted, and found to be 0.0662 to 0.0578 second, being less 
for the stronger stimulus. If these figures be taken to 
represent the reaction-time, it is possible, by measuring 
the nerves traversed and knowing the latent period of 
muscular contraction, to estimate roughly the time spent 
in the reflex centre, which is given as 0.0555 to 0.0471 sec- 
ond. Without placing too much confidence upon these 
figures, which are probably wide of the mark owing to 
the numerous sources of error involved, we may still be- 
lieve that much the larger portion of the time is spent in 
the reflex centre. Helmholtz, so long ago as 1854, came 
to the same conclusion, estimating the reflex-time as 
twelve to fourteen times greater than the rest of the re- 
action-time. These results form one basis of the now 
general belief, that the passage of the impulse through 
the centre is not a mere transit but an actual change, in 
which considerable time is consumed. 

Rosenthal (Monatsbericht d. Berlin. Acad., 1873, 104) 
asserts that the reaction-time depends on the strength of 


158 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the stimulus ; the stronger the stimulus the shorter the 
time ; and that it is greater when cross-conduction is 
necessary than when the reflex occurs on the same side 
as that where the stimulus is applied. The condition of © 
the cord is also highly influential—fatigue delaying the 
reflex- and increasing the reaction-time. Wundt has 
confirmed Rosenthal in the statement that cross-conduc- 
tion is slow, but denies that the reaction-time is depend- 
ent upon the strength of the stimulus. 

Tue EFrects oF DruGs, TEMPERATURE, ETC., UPON 
REFLEX Actions.—The detailed treatment of the effects 
of different drugs upon reflexes belongs to pharmacology. 
It will suffice here to mention only strychnine, the effects 
of which are peculiar and have a direct and important 
bearing upon the theories of reflex action. 

Magendie, even as early as 1809, found that certain 
vegetal matters, from which strychnine was afterward 
extracted by Pelletier and Caventou, produced peculiar 
cramps, the seat of which appeared to be the spinal cord. 
The same fact was more securely fixed, by the use of the 
alkaloid in a pure state, by Marshall Hall, in 1838, and 
the spinal cord has ever since been regarded as peculiarly 
affected by this poison, the remarkable effects of which . 
have caused it to be widely studied. 

Stannius (Miiller’s Archiv, 1837, 223) proved that when 
the strychnized blood does not reach the cord no spasms 
ensue. H. Meyer (Zetischrifit fir rat. Med., v., 257) 
found that direct application of the drug to the motor 
nerves is ineffective. Bernstein (Moleschott’s Untersuch., 
x., 280, 298) showed that it does not act indirectly by poi- 
soning the blood, but directly upon the cord, by intro- 
ducing it into the circulation of a frog from which the 
blood had been washed out by salt solution, and noticing 
that the spasms occurred as usual. brit 

Meihuizen (Pfliger’s Archiv, vii., 201) made the inter- 
esting observation that the motor nerve and the energy of 
the muscle in a nerve-muscle preparation is not affected. 
The evidence against heightened excitability in the sen- 
sory nerves is less conclusive, but points in the same di- 
rection. Apnoea prevents or does away with the spasms 
of strychnine-poisoning, but the explanation of the fact 
is not clear. Of chief interest, however, are considera- 
tions relating to the changes produced by strychnine in 
the cord itself ; and here two theories have been pro- 
posed. The first supposes that the excitability of the 
cord is enormously increased, so that the smallest stim- 
ulus produces comparatively great results in the centres. 
The second looks upon the spasms as due to a dimin- 
ished resistance in the cord, which allows the incoming 
impulses to roam unrestrained, as it were, up and down 
among the centres. At first sight the two views do not 
seem very unlike; but the former presupposes a change 
in the protoplasm of the centres themselves, making 
them more ‘‘explosive ” and thus overcoming the normal 
barriers in the cord; the latter regards these barriers as 
broken down by the strychnine, thus allowing the nor- 
mal operations of the centre to work results unusually 
extensive. 

Concerning the effects of temperature as a stimulus, 
enough has already been said above, but as to the influ- 
ence of temperature upon the condition of the reflex ap- 
paratus it may be remarked, in general, that there is a 
certain temperature at which the reflex mechanism is 
most active, and above and below which reactions occur 
less readily. It depends, therefore, upon circumstances 
whether a rise or fall of temperature shall give better 
or worse results (ef. Eckard, Bettrdge, ete., p. 185, and 
Sedgwick, ‘‘ On Variations of Reflex-excitability in the 
Frog, induced by Changes of Temperature,” Studies 
from Biol. Lab, Johns Hopkins Univ., ii., 385). 

LAWS OF THE PROPAGATION OF REFLEXES.—One of 
the earliest observations of ‘‘ sympathy” and reflex ac- 
tion was, that it is not a matter of chance or indifference 
what action follows a particular stimulus applied to a 
particular spot. The most commonplace observation 
shows that weak stimulation of a special spot produces a 
certain result in certain muscles or glands, while a more 
powerful stimulus affects a more extensive set of mus- 
cles, etc, The earlier observers—Volkmann, Grainger, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


—— 


Valentin, and others—contented themselves with stating 
that movements stand in a pretty definite relation to the 
spot of skin stimulated. But with strong stimuli, and es- 
pecially with stimulation of nerve-trunks, other phenom- 
ena occur which cannot be'so simply formulated. Thus 
salivary secretion and movements of the pupil may fol- 


low stimulation of the sciatic, of purely sensory cutaneous | 


nerves, or even of membranes like the dura mater. 

Accordingly, Pfliiger (‘‘ Die sensor. Functionen des 
Riickenmarks d. Wirbelth., nebst einer neuen Lehre 
iiber die Leitungsgesetze der Reflexionen,” Berlin, 18538) 
has laid down for the human subject a series of laws cal- 
culated to define the paths of propagation of reflexes, and 
called by him General Laws of Reflex Actions. 

1. Law of the Propagation of Unilateral Reflexes.— 
Whenever muscular movements follow upon the appli- 
cation of a stimulus to a peripheral sensory nerve of one 
side of the body only, and occur upon only one side, they 
are invariably found upon the same side as the stimulus. 

2. Law of the Bilateral Symmetry of Reflexes.—W hen- 
ever a stimulus has affected a reflex-centre so that move- 
ments occur not only upon the same, but also on the op- 
posite, side, it invariably happens that only those motor 
nerves of the opposite side are affected which correspond 
to the motor nerves already affected upon the same side 
as the stimulus, z.é., the muscular movements produced 
are bilaterally symmetrical. 


3. Law of the Unequal Strength of Bilateral Reflexes.— | 


Whenever the irritation of a sensory nerve produces bi- 
lateral reflexes of unequal strength, the stronger is always 
upon the side to which the stimulus is applied. 

4, Law of Irradiation.—Whenever an afferent cranial 
nerve evokes reflexes, the impulses travel among the 
centres from before backward ; but whenever an afferent 
spinal nerve has produced reflexes through its centre in 
the cord, the impulses spread from behind forward. 

Other laws have been given, both by Pfliiger and others, 
but all, including some of the foregoing, have been called 
in question by different observers, especially by Luch- 
singer (Pfliiger’s Archiv, xxii., 178, etc.). The whole sub- 
ject needs further investigation. 

REFLEX CENTRES.—Besides the great automatic nerve- 
centres, such as those of the cortex, the cerebral hemi- 
spheres, the respiratory centre, the vaso-motor centres, 


the cardio-inhibitory, etc., we must suppose that the - 


brain, and especially the spinal cord, is the seat of nu- 
merous, more purely reflex, centres. But when we are 
asked to prepare a map showing precisely where these 
different centres lie, it is evident that in only a few cases 
can positive statements be made. The method of search- 
ing for such centres consists in tracing the afferent and 
efferent nerves (when this is possible), and removing por- 
tions of the cord (or brain) successively until the ordinary 
function is stopped or interfered with. The difficulties 
met with in special cases may be illustrated by referring 
to the search for the centre (or centres) of reflex contrac- 
tion of the pupil. Flourens was the first to locate a re- 
gion in the brain the destruction of which would do 
away with contraction of the pupil, and he placed the 
‘‘centre ” for this function in the corpora bigemina and 
quadrigemina. Longet confirmed this statement and as- 
serted that the hemispheres, cerebellum, corpora striata, 
and optic thalami, could be removed without interfering 
with reflex contraction of the pupil. Budge located the 
centre on the inner side of the two anterior of the corpora 
quadrigemina; but Vincent (1877) asserts that it lies at 
the upper end of the spinal cord. 

It would lead us into too many details to follow up the 
history of the discovery of the numerous reflex centres 
now known or supposed to exist. Suffice it to say, that 

while many are assumed, few are very definitely located. 
- The question, which is as old as the subject itself, 
whether consciousness extends into these centres or into 
the spinal cord at all, has been much debated, and is still 
unsettled. There is a certain amount of evidence which 
seems to some to make it likely, but to others is incon- 
clusive. If a decapitated frog be hung up and have a 
bit of filter paper, soaked in acid, laid upon the skin near 
the anus, one leg will generally be lifted and a brushing 


Reflex Actions, 
Registration. 


or sweeping movement will be made, as if with a purpose 
to wipe the paper off. Still more purposeful appears the 
movement which is made, oftentimes, if the leg ordina- 
rily used to make the movement be gently held and 
prevented from moving ; in. which case the other leg 
(commonly not used for the movement) is called into re- 
quisition and makes wiping movements. This certainly 
seems to indicate intelligence, though intelligence of this 
sort is not necessarily accompanied by consciousness. It 
seems possible, in cases like this, to suppose merely a com- 
plicated and very perfect reflex action going on without 
the existence of consciousness. Moreover, the experi- 
ments of Fratscher (see p. 155), in which normal frogs sat 
motionless in water gradually heated from the normal to 
a fatal temperature, lead us to rate the normal conscious- 
os of the intact frog as certainly not very high, at the 
est. 

IN CONCLUSION, it must not be overlooked that the 
practical importance of reflexes is very great, not only 
to the individual, most of whose ‘‘ experience” is hardly 
more than the resultants of repeated reflexes, but also to 
the practitioner of medicine, both as regards diagnosis 
and treatment. The digestive and other disorders due 
to teething in infants, the headaches resulting from de- 
cayed teeth or from defective vision, the vomiting in 
pregnancy, the coughing from chronic laryngeal irrita- 
tion, and the like, are well understood. Less clear are 
the effects of over-exertion, the reactions from the stim- 
uli—infinite in number and variety—of city life, of 
changes in environment, climate, food, and dress; but 
that these are real and produce their own peculiar re- 
flexes cannot for a moment be doubted. The science of 
hygiene—if not the science of medicine—must, undoubt- 
edly, in the future give greater heed to these multifarious 
stimuli, for the sake of their effects. 

Therapeutics—consciously or unconsciously—has long 
made use of reflex actions. The use of the blister, the 
sinapism, and the hot iron reaches back to a very early 
time. Applications of heat and cold are often indispen- 
sable; and rest, z.e., freedom from the usual stimuli; 
and sport, ¢.e., the application of agreeable stimuli—are 
universally and justly recognized as the chief instru- 
ments of recreation and refreshment. Yet it is not so 
well recognized as it ought to be that the skin, and hence 
the whole nervous system, may be as truly “‘ scourged ” 
by sudden changes of temperature in a “‘ trying” climate, 
or by clothing, as by the blister or the hot iron; and 
that the sensitive retina or inner ear, may be ‘‘ scourged ” 
as certainly as the skin with which it is homologous. 
The practical value of reflexes lies principally in the fact 
that in their- use or disuse we have a means of reaching 
or resting the central nervous system, and hence of in- 
fluencing more or less nearly every action or condition 
of the whole organism. W. T. Sedgwick. 


REGISTRATION OF DISEASES. That knowledge 
which tends most directly to preserve life is the knowl- 
edge of the most common causes and conditions which 
lead to death. As, according to Herbert Spencer, that 
knowledge which tends directly to preserve life is “‘ of 
most worth,” so, to the human race in general, the most 
important questions to be settled are the causes and con- 
ditions which lead to most deaths. That the registration 
of deaths and their causes would be attempted by many 
governments was therefore to be expected. 

At first sight, however, it seems strange that in this 
most important work so little progress has been made. 
One of the principal reasons seems to be, that for success 
in gathering such statistics there is needed the co-opera- 
tion, not only of many individuals, but of many classes 
of people; and the importance of the subject has not 
been so clearly impressed upon the average person as to 
secure that co-operation. In this country it has been al- 
most impossible to obtain reliable statistics of deaths or 
their causes, except in limited areas, such as in cities 
where burial permits are required for the purpose of se- 
curing such statistics. And when reliable statistics of 
the causes of deaths are secured, the compilation of such 
statistics, in ways to teach valuable general truths, 1s ex- 


159 


Registration. 
Registration. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


tremely difficult. Expert ability of a high order is re- 
quired, and much experience in such work. The com- 
mon way, however, is to entrust this work to a new man 
each time. In some of the States the compilation of the 
vital statistics is entrusted to an ordinary clerk in the 
State Department. Even the general government at 
Washington has as yet no permanent office or officer for 
census work, but nearly every United States Census is 
managed by new men, who are obliged to learn anew 
this most difficult of all scientific work. There is hope 
in the fact that people are coming to appreciate the value 
of statistics relating to labor, and bureaux of statistics 
are being demanded and created, which in time will un- 
doubtedly do something to teach all classes of people the 
value of statistics, the importance of continuous system- 
atic work for their collection, and the necessity for their 
compilation by skilled and experienced men. 

Much has been learned from the registration of deaths ; 
it has shown us’ the relative importance of the various 
diseases, the relative danger from each to persons of the 
two sexes at the different ages, and many other useful 
facts. When, however, we come to study the real causes 
of deaths, we find that we need to know a great many 
facts which no ordinary statistics of deaths supply. We 
need statistics of the meteorological and other conditions 
antecedent to, and coincident with, the deaths; and since, 
in most cases, the fatal sickness (the name of which only 
is given as the ‘‘ cause of death’’) was incurred some time 
previous to death, the date of the death is not sufficient— 
we need to know the average duration of each of the dis- 
eases, in order to know how far back in time to look for 
the real cause of the disease. It may be thought that, as 
regards many of the ordinary diseases, we already know 
the causes, and that concerning those diseases there is no 
need for further research. Thus small-pox, scarlet fe- 
ver, consumption, and some other diseases are known to 
be caused by special contagia, which are conveyed from 
the sick to those who become sick. But it has recently 
been shown by statistics! that the rise and fall of these 
diseases are apparently controlled by meteorological con- 
ditions ; so it appears that, under some meteorological 
conditions, either there is very much less susceptibility to 
the disease, or the contagia are much more readily de- 
stroyed, or both; and it becomes important to gain fur- 
ther information which may teach us how to favor the 
destruction of the contagia, or to promote the insuscepti- 
bility of the people. 

REGISTRATION OF SICKNESS.—For gaining a knowl- 
edge of the causes of diseases, the registration of sickness 
is on some accounts more important than the registration 
of deaths ; and in various ways efforts have been made 
to secure records of sickness ; medical college professors 
have recommended to students that they record their 
cases ; medical societies have appointed committees on 
prevalent diseases ; the British Medical Association has 
inaugurated the ‘‘ Collective Investigation of Disease,” 
and in many ways the profession has shown its high ap- 
preciation of such records for the advancement of the 
medical sciences. 

In recent times, extensive registration of disease has 
occurred in some of the great hospitals, in the marine 
hospital services, in the navies, and especially in the 
great armies of the world; and, in this country, the 
medical and surgical histories and records of the War of 
the Rebellion are a vast mine of valuable data, which 
may be made to yield knowledge of the causes and con- 
ditions of sickness from many of the most important 
diseases, which should go far toward teaching mankind 
how to avoid and prevent them. But there are difficul- 
ties in the way of inducing people to utilize these valu- 
able records, which it may take many years to overcome. 
As it is not profitable for any class of persons, unless it 
be the insurance companies, to engage in such work, the 
people—that is to say national or state governments—must 
provide the means. The publication of the mere statis- 
tical tables is only supplying the raw material, for the 
utilizing of which expert ability is required, and graphic 
illustrations of results are essential to its proper and for- 
cible expression ; and then, on the part of those gener- 


160 


ally who are to receive it, knowledge of statistical meth- 
ods, of the theory of probabilities, and how to use graphic 
representations, is required for its correct appreciation. 

It would seem that a government can have no better 
function and no higher duty than the supplying of such 
information and knowledge, for saving the life and pre- 
serving the health of the people for whom the government 
exists. 

The army and navy records have one advantage over 
other registrations of disease—namely, that of a statement 
of the population in which the sickness occurred—the 
‘mean strength” of the army supplying this factor for 
that service. On the other hand, the registrations by 
civil governments give us the sickness among both sexes, 
at all ages, and under all ordinary conditions of living. 

Outside of army and navy records, the earliest system- 
atic effort to secure a continuous record of sickness by 
many observers, was that of Benjamin Ward Richardson, 
of London, England. Dr. Richardson says that the idea 
of making a registration of disease originated with him 
in 1852, and in 1854 he began to carry it out in his new 
journal of public health—the Sanitary Review—then a 


novelty in the literature of Great Britain. His registra- . 


tion tables were published quarterly for four years, at the 
end of which time observations were being taken from 
sixty stations, extending from St. Mary’s, Scilly, in the 
extreme south, to Lerwick, almost in the extreme north 
of those islands. 

Unable to continue the inquiry in consequence of the 
increasing expense, which multiplied with the success of 
the experiment, he tried, through Sir Benjamin Hall, 
then President of the Board of Health, to transfer the 
labor to the government without asking anything for 
himself in the matter. The suggestion was kindly re- 
ceived, but declined. 

Dr. Richardson read a paper on this subject to the So- 
cial Science Association, at its meeting in Dublin, the 
meeting being presided over by the late Lord Brougham. 
This paper is published in the transactions of the Asso- 
ciation for 1861, pp. 5385-546. . 

In this country the honor of pioneer effort to have such 
registration of sickness done by the government, appar- 
ently belongs to the State Board of Health of Massachu- 
setts, which, on November 1, 1874, issued a circular to 
‘‘a large and select number of physicians in full general 
practice, in various parts of the State.”? The plan was 
for each physician to send each week to Dr. F. W. Dra- 
per, in Boston, ‘‘the registrar of this new Bureau of 
Health correspondence,” a postal card ‘‘report of dis- 
eases prevalent during the week ending Saturday, ... . 
1875.” From these reports a weekly bulletin was pub- 
lished, showing, for each of seven districts in Massachu- 
setts, the prevalent diseases and facts of interest relative 
to the rise and decline of contagious diseases. At the 
close of the year asummary of the results was published, 
containing two charts showing by weeks the rise and fall 
of fourteen important diseases. Being for only one year, 
and compiled by weeks, the curves in those charts are 
not steady, but the fluctuations would undoubtedly dis- 
appear, in accordance with well-known laws, with more 
numerous occasions and a greater number of reports. 


These curves are very instructive, indicating as they do 


the strong influence which the season of year has upon 
sickness from each of these fourteen important diseases. 
In his report Dr. Draper says: ‘‘ The sensitiveness of the 
public health to weather variations has been shown re- 
peatedly by means of the weekly returns. A sudden 
change in temperature or in humidity has again and 
again indicated its effect upon the amount and gravity of 
the prevailing diseases. A single instance, which many 
persons in Massachusetts will recall, may be cited as an 
example of this. The fourth week in April, the week in 
which the centennial celebrations at Concord and Lex- 
ington occurred, was marked by a severe cold snap after 
an interval of mild weather. The sickness returns for 
the week represented a very decided increase of acute 
diseases ; bronchitis, influenza, rheumatism, pneumonia, 
whooping-cough, measles, scarlatina, and sore throat 
were returned as being much more prevalent. 


—— 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Hegistration. 
HRegistration, 


‘Tt isone of the advantages of suchasystem of sickness- 


registration that it shows at any time, and without delay, 
the effect of the weather changes, making a far more 
prompt and satisfactory exhibition of the influence of 
such changes upon the public health than is possible 
with the mortality table which gathers the more distant, 
indirect, and partial results of the same phenomena. ”? 
No attempt was made, however, to bring together with 
these data similar exact data relative to meteorological 
conditions, and by this comparison to learn the causes 
or conditions of the rise and fall of the several diseases. 

It is much to be regretted that after a single year’s 
trial with reports of sickness, this work was discontinued 

by the Massachusetts Board of Health. 

‘ On July 11, 1876, the Michigan State Board of Health in- 
augurated a system of weekly reports of sickness by prom- 
inent physicians in active general practice in different 
parts of the State.* At first it followed somewhat closely 
the form and methods employed in Massachusetts, but as 
time and experience suggested changes, the methods and 
forms have been amended. One of the first and difficult 
changes made was from the term ‘‘ prevalent”’ applied to 
disease, because there could be no scientific exactness so 
long as it was employed. Now, each observer reports 
the cases of each disease wnder his own observation in his 
locality ; or, if he does not like to report the number of 
cases, he may state the ‘‘ order of prevalence” of each 
disease, but it is confined to cases under his own observa- 
tion. 

Not Necessary that all Sickness shall be Recorded.—Many 
persons at first find difficulty in understanding how it is 
possible to use statistics unless the statistics include all 
of the phenomena to which they relate, and most phy- 
sicians at first lean toward an effort to learn and report 
all of the sickness in their locality. To do this is entirely 
impracticable, and will probably remain so for genera- 
tions to come ; and it is not necessary, because statisticians 
now know how to use statistics which do not include all 
the cases. The theory of probabilities, the law of averages, 
and the disappearance of minor errors through the mul- 
tiplication of instances and observations, supply the prin- 
cipal foundations for the work of statistics. But this is 
not the place to more than refer to that part of the work. 

Essentials for the Registration of Sickness.—The essen- 
tials for a good registration of the sickness from the most 
common diseases (the most important diseases to be stud- 
ied, because they cause the most sickness) are, 1, a suffici- 
ent number of reliable physicians in active general prac- 
tice ; 2, the distribution of these observers so as fairly to 
represent the area to be studied; 3, accurate reports 
showing for each disease its presence or absence (under 
the reporter’s own observation), and preferably the num- 
ber of cases ; 4, reports, or at least records, of these facts 
to be made so soon after their occurrence that none of 
them shall be forgotten ; 5, the compilation of these re- 
ports by an expert statistician who must be honest, and 
should also be a physician well grounded in the physical 
and biological sciences; 6, the union of the data thus 
obtained with similar data of meteorological conditions 
recorded by competent meteorological observers, using 
standard instruments, self-registering so far as practi- 
cable, and the records to be made tri-daily. 

Not Essential that the Population be Known.—One hin- 
derance to progress in the registration of diseases is the 
idea that no use can be made of records of sickness with- 
out a knowledge of the population in which the sickness 
occurs. If the number of inhabitants is not known, it is 
not possible to learn the proportion sick from any given 
disease ; but that is not the most important knowledge to 
be gained in searching for the causes of diseases ; and it 
is quite possible to compare one week, or other specified 
time, with another with reference to the sickness from a 
given disease, without any exact statement of the number 
of inhabitants. It has been found that in Michigan the 
distribution of sickness /ocally follows about the same 
law that it does generally throughout the State—that is to 
say, the ‘‘ order of prevalence” of a given disease in lo- 
calities ‘‘ where present,” is found to be practically about 
the same as the ‘‘per cent. of all reports received which 


Vou. VI.—11 


stated the presence of the disease.” It follows that, in 
order to learn the rise and fall of the disease over a con- 
siderable area, it is not even necessary to know the num- 
ber of cases of each disease, but only to know the fact 
whether each observer did or did not, during the given 
short time, observe a case of the given disease ; then a 
comparison of the per cent. of reports, stating the pres- 
ence of the disease in the several weeks or months, will 
show the comparative area of prevalence of the disease 
in each specified period of time. It-is advisable, how- 
ever, that the number of cases be reported, because this 
gives opportunity for the study of the subject locally ; 
and this leads to the remark that, after the meteorological 
conditions coincident with the rise and fall of each dis- 
ease shall have been learned for all localities, there will 
remain other conditions which must be studied in order 
to learn why the sickness is not always associated with 
the ea meteorological conditions in every part of the 
world. 

Graphic Comparisons are Essential.—No ordinary per- 
son can, with reasonable effort, so master an ordinary 
table of mortality or sickness from, a single disease by 
months in a single year, as to secure a correct and com- 
plete mental picture of the relations of the several months 
each to every other month in the year, and at the same 
time compare the same with a similar table relating to a 
condition such as temperature, which may be supposed 
to have relation to the sickness or mortality. If any 
person doubts this statement let him try it, as the writer 
has many times done, and afterward compare his effort 
with a good diagram accurately drawn to scale. As the 
carpenter needs his square to measure his work, and his 
try-square to test the angles, so it is true, and should be 
generally understood, that some sort of graphic represen- 
tation is essential for any degree of accuracy in a statistical 
comparison. 

Even in this discussion, diagrammatic representation is 
almost essential to a clear understanding of the subject. 

Inasmuch as there can be no progress in utilizing the 
results of the registration of disease without a proper use 
of diagrams, every one interested in the medical sciences 
should be able to read easily those which are correctly 
constructed, and to reject those which are not correct. 

The Essentials for Graphic Comparison.—The making 
of diagrams is very easy when one knows how; but 
when two or more curves are to be compared with refer- 
ence to a law of causation, there are a few essential con- 
ditions which do not seem to be generally known, and 
which are seldom complied with by those who publish 
such diagrams. One of the most important principles 
to be observed is to insure that the fluctuations, in two or 
more curves to be compared, shall be measured by the 
same measuring rule. Noone would think of comparing 
one piece of timber measured in feet with another meas- 
ured in yards without first converting one measurement 
into its equivalent in the other ; yet, substantially, this 
error is quite frequently found in published diagrams. 
One difficulty seems to be to firmly grasp the idea of 
what is to be measured and compared, and another, the 
idea of how to compare such dissimilar statements as de- 
grees of temperature with per cent. of sickness. 

In each such curve representing dissimilars the varia- 
tion is to be measured and compared, and whether stated 
in inches or pounds, by number or by per cent., these 
variations may easily be brought to a ‘‘common de- 
nominator,” so to speak, by planning the diagram so that 
the greatest variation, or extreme range, in each curve 
shall be the same as it is for every other curve with which 
it is to be compared. This is simply done by making 
the range of the diagram the range for each curve—the 
highest and lowest. parts of each curve reaching the 
highest and lowest parts of the diagram. 

This insures that the extreme range shall be the same 
for each of the curves. If then the variations in one 
curve are quantitatively related to the variations in an- 
other curve, the two curves will sustain the same rela- 
tions to each other throughout their extent; otherwise 
they will not do so, and their lack of parallelism will be 
apparent. 


161 


Registration. 
Reinerz. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


TABLE 1.—Evhibiting by Months, for a Period of Hight Ye ears, 1877-1884, the Relation of Sickness in Michigan from 
Pneumonia, to the Average Atmospheric Temperature. 


Jan. | Feb. |. Mar. | Apr. | May. June, | July. | Aug. | Sept. | Oct. | Nov. Dec. 


Av *pemberauires i bepress Far. ee 21.43 | 25.60 | 31.04 | 44.48 | 56.60 | 65.54 | 70.68 68.85 | 62.05 | 51,34 | 35,99 | 27.25 


Av. Per Cent. of Reports stating Presence of Pneumonia....... 62 


62 | Beal. 49° 087 P18 35 | 48 


To find the scale of value of numbers applicable to a 
curve representing a line in a table, subtract the lowest 
from the highest statement to be represented ; this will 
give the extreme range (which equals the entire distance 
of the diagram), and that sum may be divided into such 


lower line tn Table 1. 
mospheric temperature, upper line in Table 1. 


u* 
SQ 
oo 
0 0 
a, 
o» 
RR 


Fie, 3229, 


parts that the numbers may be conveniently stated, and 
the entire distance occupied may be divided into parts 
proportionally. For instance, for a full-page (octavo) 
diagram, leaving room for the head and foot-notes, 6.375 
inches may be occupied by the curves (see Fig. 3229).* 
Suppose the highest number to be represented (stating 
per cent., degrees, or cases) is 66, as it is in the lower 
line in Table 1, and the lowest number 14, the difference 
(52) is to be distributed over the 6.3875 inches, one (per 


* The engraver has reduced the size of this diagram, so that instead 
of the curves occupying 6.375 inches vertically they occupy only 4.675 
inches ; but the principle of subdividing this space remains the same as 
described. 


162 


The line —— represents sickness from pneumonia, 
The line — — — represents at- 


cent. or case, etc.) then equals 0.122 inch, ten equals 1.22 
inch. The nearest convenient number above 14 is 20, 
and lines so placed that they will be opposite the value 
of 20, 30, 40, 50, and 60 may conveniently be used, 
because they are even numbers which can be easily di- 
vided. There being the value of 10 (cases, etc.) 
between them, these lines will be 1.22 inch 
apart. * 

To make a scale to use in dividing such a dis- 
tance as 1.22 inch into ten equal parts,+ draw 
along a slip of stiff paper two lines 1.22 inch 
apart, then place across one end of these lines a 
rule having ten divisions, covering a space a lit- 
tle more than the space between the two lines; 
move the rule until it crosses the space diago- 
nally, in such a way that the nine lines on the 
rule will divide the space equally, and make a 
diagonal row of dots opposite the nine lines ; 
move the rule along the slip a few inches and 
repeat the dots; then rule a short line on the 
end of the paper slip exactly in line with each 
two corresponding dots; the spaces between 
these lines will then all be 0.122 inch, and in 
this assumed case (Fig. 3230) will be the space 
which will represent one.{ The ruled end of 
the slip of paper is then a scale which will en- 
able a person to measure exactly the space to be 
allotted to any number from one to ten. But 
this measuring-scale is only applicable to curves 
representing what may be measured by the 
same scale and stated in precisely the same 
manner. It may, for instance, apply to many 
curves representing sickness, to many repre- 
senting deaths, to many representing tempera- 
ture, or even to one curve representing sick- 
ness and one representing deaths, provided both 
are stated by numbers of cases; but it cannot 
apply both to sickness and to temperature, be- 
cause the values must be differently stated, and 
it is not usual that both values are such as to 
be conveniently stated together ; therefore it is 
usually necessary to make such a scale and a 
set of marginal figures for each dissimilar curve 
in a diagram. For instance, in the diagram 
shown in Fig. 3229, the entire range of tem- 
perature, which, according to my rule, must 
equal the entire range of the diagram, amounts 
to 49.25 degrees, and is between 21.48° and 
70.68°. In order that the variations in the tem- 
perature may be compared with the variations 
in the sickness, this 49.25 degrees must be pro- 
portionately distributed over the same space as 
that occupied by the curve of sickness. This is 
done, in the manner described for the sickness 
curve, by dividing the 6.375 inches by 49.25, 
when it is found that ten degrees of tempera- 
ture should occupy 1.29 inch.t 

This 1.29 is subdivided by means of a rule 
placed diagonally, as previously described, and marginal 
figures are placed opposite values convenient for use— 
such as 30°, 40°, 50°, 60°, and 70°. When this is done 


* The illustrative diagram (Fig. 38229) having been reduced in size, 
these horizontal lines are shown only .90 inch apart, instead of 1.22. 

+ These directions for making a scale to use in constructing or reading 
such a line as is the continuous one in Fig. 3229 (representing per 
cent. of reports showing sickness from pneumonia) were written before 
that diagram was reduced, and are retained because they apply to a size 
believed to be especially useful. For the continuous line in this diagram 
as reduced and here printed, the subdivision should be of .90 inch in- 
stead of 1.22, and the scale would be like that given on page 163—each 
subdivision representing one per cent. of reports. 

+ This was written with reference to the diagram (shown in Fig. 38229) 
as drawn, not as reduced in size by the engraver. 


-annual reports of the Michigan Board of Health. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


and the curves have been made, both curves have what, 
for lack of a better term, may be called a ‘‘common de- 
nominator,” that common denominator being the total 
variation during the entire period of time. The curves 
have this in common—that the entire range of each oc- 
cupies precisely the same space as does that of the other, 
and each curve as a whole, has the same space-value. 
Referring to Fig. 8229, if the entire range (fifty-two 
per cent. of reports) of sickness from pneumonia is 


Fre. 3230. : 
caused by, or is quantitatively related to, the entire range 
(49.25°) of atmospheric temperature, then it seems reason- 
able to suppose that the sickness from that disease may 
be directly proportional to the temperature in every 
month of the year, in which case the curves for sickness 
and for temperature would be parallel throughout. The 
amount of parallelism in this particular case may be 
seen in the diagram. 

It is well to have the perpendicular lines (ordinates), 
not the spaces between them, represent the months or 
other specified periods of time, then the exact crossing 
of the line (ordinate) by the curve is easily seen, and the 
degree or value of the intersection may be learned by re- 
ferring to the figures in the margin ; and each curve, the 
values for which have to be differently stated, requires 
its own scale and set of marginal figures, which for com- 
parison may all be on one side of the diagram, but for 
distinctness and ease of reading may well be separated 
(as in the diagram above referred to). 

When it is practicable, it seems most logical to have 
the degree or value of the meteorological or other con- 
dition increase from below upward, so that, as the curve 
representing a disease rises or falls, the fact whether the 
condition rises or falls will be apparent; but another 


_ fact seems to be of even greater importance to be learned, 


which is, just how closely, quantitatively, the two curves 
are related to each other, and this cannot be accurately 
estimated when the curves run in opposite directions ; 
therefore the curves should accompany each other, wheth- 
er or not both marginal scales read in the same direction. 

Results of Registration of Sickness.—The publication of 
the results of the registration of sickness in England, in 
1854-58, has already been mentioned. 

The work in Massachusetts showed that for a single 
year (1875), in that State, the sickness from diarrhcea, dys- 
entery, cholera-morbus, and cholera-infantum was great- 
est in August and September; from typhoid fever, in 
September and October ; from influenza, bronchitis, and 
pneumonia, in the cold months. The published results 
contain no tables, but the charts, accurately drawn to 
scale, are valuable, and will undoubtedly yield much use- 


_ ful material to anyone who will mine it. 


Some of the results of the registration of sickness in 
Michigan since 1876, have been published in the ie 

n the 
earlier reports little more is recorded than the data, but 
their elaboration is commenced in ways which may sug- 
gest uses to be made of the statistics. Curves represent- 
ing the sickness from each of several important diseases 
illustrate the report each year, and similar curves, repre- 
senting the principal meteorological conditions, permit of 
comparison therewith. The work has now been in prog- 
ress long enough to make it possible to state just what 
relations exist (in Michigan at least) between each disease 
and each important meteorological condition ; and in the 


, Sort: 


Registration. 
Reinerz. 


later reports this part of the work is commenced,’ not, 
however, by presenting all of those relations, but by se- 
lecting for presentation such as seem to have causal re- 
lations to diseases of most importance. Briefly, it may 
be stated that the evidence seems to show quantitative 
(and presumably direct or indirect causal) relations be- 
tween temperature of the atmosphere and all important 
diseases of the lungs and air-passages, including pulmo- 
nary consumption, the number of cases of these diseases 
rising after the temperature falls and falling 
after the temperature rises. The rise and fall 
of a few diseases known to be communicable 
are also apparently controlled by the atmospher- 
ic temperature.! Intermittent fever appears to 
be quantitatively related to the average daily 
range of atmospheric temperature.* The curve 
for remittent fever appears to follow more or 
less closely the reversed curve for atmospheric 
ozone. The relations of atmospheric tempera- 
ture to sickness from diarrheea, dysentery, 
cholera infantum, and cholera morbus are 
graphically shown. 

Such knowledge as that intestinal diseases 
prevail in hot weather, and that diseases of the 
alr-passages prevail in cold weather, has been possessed 
by the medical profession since the time of Hippocrates, 
but it has had no accurately recorded, scientific .basis, 
and no great progress can be made in eliminating the ac- 
cidental, and in isolating the causal relations until re- 
cords of each important meteorological and other condi- 
tion shall have been passed in review, interrogated, and 
cross-questioned. 

It would seem that a beginning has now been made in 
the scientific registration of diseases, by the method 
known as the ‘‘ Collective Investigation of Disease,” 
which, started by the British Medical Association, is 
spreading through this and other countries; by such 
governmental works as are recorded in the ‘‘ Medical 
and Surgical History of the War of the Rebellion ” in 
this country ; by the systematic registration of vital sta- 
tistics by State and other governments, and the periodi- 
cal collection of such statistics by means of censuses ; 
and finally, by the systematic and continuous registration 
of sickness, such as was started in England under the 
leadership of Dr. Benjamin Ward Richardson, was taken 
up for a time by the Massachusetts Board of Health 
and by the Provincial Board of Heaith of Ontario, and 
has been, since 1876, continuously maintained by the 
Michigan State Board of Health. Henry B. Baker. 


1 Some of the Cold Weather Communicable Diseases. 
Mich, State Med. Soc., 1587, pp. 56-66. 

2 Report Massachusetts State Board of Health, January, 1876, p. 482. 

3 Ibid., p. 491. 

4 Annual Report Michigan Board of Health, 1876, pp. 26, 27, 47. ' 

5 Typhoid Fever and Low Water in Wells, in the Report for 1884, and 
Causation of Pneumonia, in the Report for 1886, Mich. Bd. of Health, 

6 Relations of Certain Meteorological Conditions to Diseases of the 
Lungs and Air-passages. Paper read before a Section of the Interna- 
tional Medical Congress, in Washington, September, 1887. 

7 Some of the Cold-weather Communicable Diseases, Trans. Mich. 
Med. Soc., 1887. 

8 Report Mich. Board of Health, 1879, pp. 504, 505; Report for 1880, 
pp. 3818 and 467, 468. 


Trans. of 


REICHENHALL, in Bavaria, distant four hours by rail 
from Munich, is a popular watering-place, visited chiefly 
by those suffering from obstinate catarrhal affections 
of the respiratory organs. The waters are also recom- 
mended in the treatment of rickets, gout, anemia, and 
scrofulous adenopathies. There are about twenty saline 
springs at Reichenhall, the most important of which are 
the Edelquelle and the Carl-Theodorquelle. The waters, 
mixed with a strong brine, are used chiefly for bathing, 
though they are also drank in small quantities. The 
climate is mild and agreeable. The season extends from 
the first of May to the end of October, the last month 


being for those who wish to take the ‘ ea ‘ Z 
. ~ KY. 


REINERZ is a pleasantly situated Prussian health-re- 


It lies at an elevation of about 1,800 feet above the 
sea. The air is pure and fresh, free from sudden changes 


163 


Heinerz. 
Reptiles. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


of temperature, but not very mild. The following is the 
analysis of the three springs used for drinking purposes, 
as given by Kisch in Eulenburg’s ‘‘ Real-Encyclopadie.” 
One litre contains of : 


Kalte- Laue- Ulriken- 
quelle. quelle. quelle. 
Bicarbonate of iron........... 0.017 0.051 0.051 
Bicarbonate of manganese..... 0.001 0.004 0.001 
Bicarbonate of sodium......... 0.319 0.786 0.622 
Bicarbonate of calcium........ 0.655 1.180 1.024 
Bicarbonate of magnesium..... 0.206 0.3856 0.832 
Chioride:of sodium :es. me ecice 0.006 0.015 Boe 
Chloride of potassium ......... 0.011 ahs 0.008 
Sulphate of sodium............ 0.022 Ae Nahe 
Sulpnate of potassium......... 0.127 0.084 0.958 
Bilicic acid|¥ "be cmo Se tae ace: 0.056 0.065 0.016 
EDOtALT. Goto Naree eae aeteets 1.400 2.541 3.012 


There is a large proportion of free carbonic acid gas. 


There are several other springs, the waters of which 
are used for bathing. Besides these, therapeutic use is 
made largely of milk and whey from cows, goats, sheep, 
and asses. 

Reinerz is visited chietly by sufferers from laryngeal 
and bronchial catarrh, pulmonary phthisis, and chronic 
catarrhal diseases of the digestive organs. It is also 
much frequented by those run down by overwork or 
from other causes. The season extends from May to 
October. ILS Bee: 


REMEDIES, ANTAGONISM OF. Under this head 
will be considered only the physiological antagonism 
between certain drugs. Physiological antagonism be- 
tween two drugs may be so extensive as to practically 
include almost their entire range of action, or it may be 
limited to one or more of their actions. We have many 
examples of the latter, but few indeed of the former. In 
fact, it is difficult to mention any two drugs the antago- 
nism between which is complete. 

Very numercus experiments have been performed on 
the lower animals with the view of establishing the prin- 
ciples which underlie the antagonistic effects between 
certain drugs, and also with the view of endeavoring to 
extend our practical knowledge in the treatment of cases 
of poisoning, especially of alkaloidal poisoning. Unfor- 
tunately, the results are not at all commensurate with 
the time and labor spent in the study of this subject. 
The results, however, are extremely interesting in a 
pharmacological sense, and have done much to extend 
our knowledge of therapeutics in general. 

It would serve no useful purpose, even if space admit- 
ted of it, to give in detail the numerous drugs whose an- 
tagonistic effects to those of others have been carefully 
worked out. After all, the practical outcome of our 
knowledge of this subject is not so much that we can 
make use of it in the treatment of cases of poisoning, but 
rather that it saves us from prescribing drugs together 
that have marked antagonistic effects. It is exceedingly 
common to find in the one prescription drugs having di- 
rectly antagonistic effects. We might instance the fol- 
lowing, which have come directly under our own ob- 
servation: The administration of digitalis and aconite 
in a case of loss of compensation in mitral insufficiency ; 
the combining together of bromide of potassium, calabar 
bean, and strychnine in a case diagnosed as subacute 
transverse spinal myelitis. No doubt, these prescriptions 
were put together on the ‘‘ gunshot” principle. Still, if the 
writers had had clear and distinct views of the physiolog- 
ical antagonism existing between the different agents in 
their prescriptions, they would never have been written. 

The physiological antagonism between the following 
drugs only will be considered : 

Chloral and strychnine. 

Digitalis and aconite. 

Muscarine and atropine. 4 

Atropine and pilocarpine, 

Atropine and morphine. 

. Chloral and Strychnine. Both of these agents act 
principally on the respiratory centre and the spinal cord. 

Chloral is a powerful respiratory depressor, while 
strychnine, on the other hand, has a powerful stimulating 


‘ 


Sti eee 


164 


effect on the respiratory centre. It has been conclu- 
sively proved that after the administration of a fatal dose 
of chloral to one of the lower animals, life may be saved 
by injecting strychnine ; but I have been unable to find 
a single case of chloral-poisoning, in man, where there is 
clear'evidence that life has been saved by strychnine. 
Numerous cases are recorded where it has been used, 
but in conjunction with other agents. As chloral causes 
death by depressing the respiratory centre, it certainly is 
reasonable to expect that this effect will be antagonized 
by an agent which has a powerfully stimulating effect 
on the same centre. , 

Chloral is, however, more of an antagonist to the ef- 
fects of strychnine, than strychnine is to those of chloral. 
A large dose of chloral may kill before the action of 
strychnine is manifest. Strychnine kills by producing 
asphyxia, from spasmodic arrest of the respiratory mus- 
cles. It brings about greatly increased excitability of 
the motor centres in the spinal cord. The respiratory 
muscles share in the spasms with the other muscles, and 
death is due to the fact that they are contracted in inspi- 
ration. There are a few cases on record in which the 
lethal effects of strychnine in man have certainly been 
antagonized by chloral. In treating a case of strychnine- 
poisoning by chloral, the latter should be pushed until 
the spasms are allayed; the amount required to effect 
this purpose varies greatly. 

Judging from the often beneficial action of choral in 
tetanus, we would expect a similar effect from chloral in 
strychnine-poisoning, which is practically an artificial 
tetanus. On the motor centres of the spinal cord the 
antagonism between chloral and strychnine is very com- 
plete, chloral being one of the most powerful motor 
depressants, while strychnine is the most powerful 
motor stimulant, that we have. Chloral being a more 
powerful motor depressant than strychnine is a respira- 
tory stimulant, it naturally follows that chloral is more 
effective as a physiological antidote to strychnine than 
the latter is to chloral. 

2. Digitalis and Aconite. 'There is a striking difference 
between the action of digitalis and that of aconite on the 
heart. This difference is more marked on the hearts of 
cold-blooded animals than on the hearts of warm-blooded 
animals. On applying a small quantity of aconite to the 
exposed heart of the frog it rapidly comes to a standstill 
in dilatation ; if now we apply digitalis, the distended 
ventricle soon recovers itself and returns to its normal 
condition. If more digitalis be injected, the systole be- 
comes longer and longer and the diastole less complete, 
especially at the apex, which remains white and firmly 
contracted. This gradually extends over the whole ven- 
tricle, the heart finally coming to a standstill in firm con- 
traction. 

When either digitalis or aconite is given in such doses 
as to produce standstill of the heart, the pulse becomes 
quick, and the blood-pressure falls. ‘‘ In aconite-poison- 
ing the aortic pressure falls because the over-distended 
ventricle is unable to contract on its contents. Each 
contraction only sends a small quantity of blood from 
the upper portion of the ventricle. In digitalis poison- 
ing the aortic pressure falls, because the over-contracted 
ventricle permits but little blood to get into it, and can, 
consequently, send but little forward. The result is sim- 
ilar in both cases, but the cause in one case is just the 
reverse of that in the other” (Balfour). 

Owing to the slowness of the action of digitalis on the 
heart, even when administered hypodermically, it is doubt- 
ful whether it is able to antagonize the effects of a large 
dose of aconite. So far, I have been unable to find in 
the literature any case of aconite-poisoning treated simp- 
ly by digitalis. In fact, from our present knowledge it 
would be very unsafe to trust to digitalis alone in such 
cases. The antagonism existing between these two agents 
is more interesting from a pharmacological than from a 
toxicological point of view. 

3. Muscarine and Atropine. Muscarine, an alkaloid 
obtained from the fly agaric (Agaricus muscarius), has 
marked antagonistic effects on all the peripheral organs 
paralyzed by atropine, The antagonism existing between 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Reinerz. 
Reptiles. 


these two agents is probably the most extensive known. 
Muscarine is a powerful cardiac depressant. It causes 
salivation, lachrymation, as well as an increase in other 
glandular secretions, violent contractions of the gastric 
and intestinal muscles, with consequent vomiting and di- 
arrhoea, contraction of the bladder, spleen, and uterus. 
It produces contraction of the pupil, and spasm of the 
accommodation. All these effects of muscarine rapidly 
disappear under the influence of atropine, and, further, 
they do not appear at all in an animal that is completely 
atropinized. 

Muscarine causes death by cardiac paralysis. 
fatal issue can be averted by the use of atropine. 

4, Atropine and Pilocarpine. The antagonism exist- 
ing between atropine and pilocarpine is very extensive, 
including almost the entire actions of these two agents. 
Pilocarpine causes an increase in all the secretions, espe- 
cially of the secretion of the sweat and saliva. The sali- 
vation is due to irritation to the terminal filaments of the 
-chorda tympani in the glands. It is rapidly arrested by 
atropine, and it can be prevented entirely by giving atro- 
pine previously. 

The perspiration which is due to stimulation of the 
sudoriparous nerves and the sweat centres can also be 
prevented and arrested by the use of atropine. The other 
secretions are stimulated by pilocarpine, and arrested by 
atropine. 

Pilocarpine contracts the pupil and gives rise to spasm 
of accommodation. Atropine dilates the pupil and causes 
paralysis of accommodation. 

Pilocarpine slows and weakens the pulse, and lowers 
the blood-pressure. Atropine quickens and ‘strengthens 
the pulse, and raises the blood-pressure. Atropine stim- 
ulates the respiratory centre. Pilocarpine has no definite 
effect on it.” 

Cases are recorded where pilocarpine has been used 
successfully in cases of poisoning by atropine, but it is 
doubtful whether the success was really dependent or 
not on the treatment. The power that pilocarpine has in 
antagonizing the effects of atropine is much less than the 
power of atropine over pilocarpine. When, further, we 
remember that in many cases of atropine-poisoning death 
results from a paralysis of the respiratory centre succeed- 
ing the over-stimulation first induced, it is not to be ex- 
pected that much good will result from pilocarpine. 

5. Atropine and Morphine. The antagonistic action 
between atropine and morphine is, in a practical point of 
view, the most important that we have to deal with. 
Cases of poisoning by opium and its alkaloid are very 
numerous, and owing to the alleged powerful antagonis- 
tic effects between it and atropine, numerous cases are on 
record in which this alleged power has been tested. 

Atropine and morphine are antagonistic in their action 
on the pupil, the former causing dilatation, the latter 
contraction. In cases of poisoning by opium we do not 
always find the pupils contracted. 

Morphine diminishes or arrests the peristaltic move- 
ments of the intestines, while atropine has a contrary 
effect. The functions of the heart are not greatly influ- 
enced by morphine; atropine, however, causes a marked 
increase in the number of beats. The effects on the re- 
spiratory centre are antagonistic. This is the important 
antagonistic action of these two agents. Morphine causes 
death by paralyzing the respiratory movements, while 
atropine stimulates the respiratory centre. In over-doses, 
however, this stimulating action may be followed by a 
depressing one, There is a genera] consensus of opinion 
in the profession that atropine is very efficient as a phy- 
siological antidote to opium-poisoning. Numerous cases 
are recorded where, apparently, death from an over-dose 
of opium or its alkaloid has been averted by the admin- 
istration of atropine. The literature of this subject is now 
a very extensive one, lLeukartz (Deut. Arch. fiir klin. 
Med., Band 40, p. 574) gives a very complete réswmé of 
the cases of opium treated by atropine. In all he has 
collected fifty-nine cases of opium-poisoning where atro- 
pine was used. In by far the greater number of these cases 
other measures were employed also. Artificial respira- 
tion, strong coffee, emetics, ammonia, alcohol, etc., were 


The 


the principal adjuvants to the atropine treatment. Sev- 
enteen of the fifty-mine cases died, being a mortality of 
28.8 per cent. 

Leukartz believes that the essential effect of the opium 
—the coma—is increased rather than made less by the ac- 
tion of atropine ; and further, that atropine is powerless 
in combating the great danger in opium-poisoning—the 
paralysis of the respiratory muscles. He has collected 
73 cases of opium-poisoning in which atropine was not 
used in the treatment, and there were only 11 deaths, a 
mortality of fifteen per cent. We thus have a mortality 
of 28.8 per cent. in the cases where atropine was em- 
ployed, and a mortality of fifteen per cent. where it was 
not used. Leukartz from his researches comes to the fol- 
lowing conclusions: 

1. That the alleged physiological antagonism between 
morphine and atropine has not one single certain observa- 
tion for its foundation. 

2. That in the treatment of morphine-poisoning by 
atropine no certain improvement is to be expected. 

3. That the treatment of morphine-poisoning should 
be carried out rationally (artificial respiration, etc.), and 
not by the exhibition of an alleged physiological antago- 
nist. 

4, That statistics show that the former method is much 
to be preferred to the latter. 

Leukartz’s conclusions may appear rather startling to 
the many who have an unbounded faith in the value of 
atropine in opium-poisoning. Upon a close examination 
of them, however, they appear to be well grounded, being 
founded on facts. James Stewart. 


RENNES-LES-BAINS is a spain the Département de 
VY Aude, France, lying on the Salz River, at an elevation of 
1,045 feet above the sea. There are five springs, the 
waters of which are administered both internally and 
externally. The springs are known respectively as the 
Bain Fort, Bain Doux, Bain de la Reine, Source du Pont, 
and Source du Cercle. The water of the Salz River, 
which contains the chlorides of sodium and magnesium, 
and the sulphates of sodium, calcium, and magnesium, 
is also used for drinking mixed with the spring waters. 
The following is the analysis of two of the springs, ac- 
cording to Ossian Henry (Dechambre’s ‘‘ Dictionnaire 
Encyclopédique’’). In 1,000 parts there are of : 


Bain Fort. Bain Doux. 

Calcium carbonatens. 8.4.5.6 os6 «lee 0.250 0.140 
Magnesium carbonate ............... 0.070 0.030 
Sodium Chiorid Gime ects cle ciate ae 0.071 0.181 
Macnesium chloride (20 02.20... 6cec0. « 0.280 0.244 
Potassium chloride ..0. 0... 0s. ees trace trace 
Sodiumisnll phate sen css mo she Aetere vere 0.090 0.120 
@alciumisilphatern awe curds arerteeis eles 0.162 0.180 
Perroys Cavvonaveiga..ssa cece ws secede 0.031 0.002 
Silicic acid, organic matters, etc...... 0,089 0.057 

ANG Mle wv Ae gil Se ee ae Mace eel a3 1.043 0.954 


The temperature of the different springs varies from 
53.6° to 124° F. 

A course at Rennes-les-Bains is recommended to those 
suffering from rheumatism, irritable nervous conditions, 
so-called scrofulous bone and joint affections, and en- 
larged glands, and also certain forms of cutaneous dis- 
eases. FAG. 8: 


REPTILES, POISONOUS. The popular mind, from 
the earliest period of historic time, has always turned 
with awe and wonder toward those mysterious gliding 
forms which hold in their economy the power of a swift 
and terrible death, a power which seems in no degree 
commensurate with the size of the destroyer; and this 
being the case, it is not to be wondered at that reptiles, 
particularly serpents, should have been objects of venera- 
tion and worshipped as gods, as they are even to the 
present day. 

It would be foreign to the purpose of this paper to at- 
tempt a history of the serpent cult of all ages, its object 
being to call attention to certain poisonous forms, and to 
point out such remedial methods as may possibly mitigate 
the human suffering which they cause, or save the lives 
which they imperil. 


165 


HReptiles. 
Reptiles, 


In the subject matter which follows, no extended ac- 
count of all the poisonous reptiles of the known world 
will be given, as this would require more space than 
could be- allowed, but a list of our own species is fur- 
nished, with brief description of their appearance, char- 
acteristics, and the manner in which they destroy life by 
their bite. The physiological action of the different 
venoms will also be mentioned. Supplementary to this 
will be found brief notices of some of the more important 
forms of the old world. 

For present convenient purposes the reptilian fauna of 
the United States may be considered as occupying an 
area bounded upon the north by the line of the Northern 
Boundary Survey, upon the east by the Atlantic Ocean, 


upon the west by the Pacific Ocean, and south by an | 


imaginary line drawn from the southern extremity of 
the peninsula of California, extending eastward to the 
point of the Floridian peninsula. 


In this vast extent of country naturalists have dis- . 


covered no less than twenty-seven well-marked species 
of poisonous serpents, in four genera, and one poisonous 
lizard, the latter being the only one so far found upon 
the habitable globe. The first genus, Crotalus, contains 
fourteen species; the second, Caudisona, four species ; 
the third, Ancistrodon, four species; the fourth, Hlaps, 
five species ; the lizard belonging to the genus Heloderma. 
The names of the serpents belonging to the genus Crota- 
lus (the true rattlers) are as follows: 

Crotalus lepidus Kennicott, Kennicott’s Rattlesnake. 

Crotalus pyrrhus Cope., Red Rattlesnake. 

Crotalus Mitchelli Cope., Mitchell’s Rattlesnake. 

Crotalus cerastes Hallowell, Horned Rattlesnake, 
‘« Side-winder.”’ 

Crotalus tigris Kennicott, Tiger Rattlesnake. 

Crotalus enyo Cope., St. Lucas Rattlesnake. 

Crotalus horridus Linn., Banded Rattlesnake. 

Crotalus adamanteus Beauvois, Diamond Rattlesnake. 

Crotalus atrox Cope., Arizona Diamond Rattlesnake. 

Crotalus scutulatus Cope., Scutulated Rattlesnake. 

Crotalus lucifer Baird and Girard, California Rattle- 
snake. 

Crotalus polystictus Cope., Spotted Rattlesnake. 

Crotalus confluentus Say, Confluent Rattlesnake. 

Crotalus molossus Baird and Girard, Black-tail Rattle- 
snake, 

Belonging to the genus Caudisona are the following : 

Caudisona rava Cope., Mexican Ground Rattlesnake. 

Caudisona miliaria Linn., Southern Ground Rattle- 
snake. 

Caudisona Edwardsi Baird and Girard, Sonora Ground 
Rattlesnake. 

Caudisona tergemina Say, Black Rattlesnake, Prairie 
Rattlesnake, Massasauga. 

The genus Ancistrodon (Moccasin and Copperheads) 
contains the following : 

Ancistrodon piscivorus Lacépéde, Water Moccasin. 

Ancistrodon pugnax Lacépéde, Texas Moccasin. 

Ancistrodon contortrix Linn., Copperhead, Moccasin, 
Cottonmouth, Red-eye. 

Ancistrodon atrofuscus Troost, Troost’s Moccasin. 

The genus Hlaps (Vipers) contains : 

Elaps fulvius Linn., Harlequin Snake, Viper. 

Elaps tener Linn., Texas Harlequin Snake. 

Elaps euryxanthus Kennicott, Sonora Harlequin 
Snake.. 

Elaps distans Kennicott, Florida Harlequin Snake. 

Elaps tristis Baird and Girard, Tawny Harlequin Snake. 

The poisonous lizard is known to science as: 

Heloderma suspectum Cope., Gila Monster. 

It should be stated that this list is in accordance with 
the ‘‘ Check-list of North American Reptilia and Ba- 
trachia,” Bulletin No. 24 of the National Museum, and is 
adopted, provisionally, by the authorities of that institu- 
tion. 

In view of the very general ignorance regarding the 
appearance of the venomous reptiles of this country, it 
seems desirable to give a brief account of their generic 
differences, as well as an account of the specific peculiar- 
ities of some of the well-known forms of the genera 


166 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


mentioned. Crotalus, Caudisona, and Ancistrodon belong 
to the family Crotalide, the remaining genus, Hlaps, be- 
ing a Colubrine serpent. The family characteristics of 
the Crotalidz may be 
broadly stated as hav- 
ing erectable poison- 
fangs in front, few 
or no teeth in the up- 
per jaw, a deep pit 
between the eye and 
the nostril ; the gen- 
eral characteristics 
being as follows— 
the upper surface of 
the head is covered 
with small plates, 
scale-like in appear- 
ance, with a few 
larger ones in front ; 
the tail terminates 
in a well-developed rattle ; there is a deep pit between 
the eyes and the nostrils; the shields of the temporal 
and labial region are 
small and convex. 
Figs. 8231 and 3232, 
representing the head 
of Crotalus atroa, 
show very plainly the 
peculiarities named. 
In Caudisona the 
upper surface of the 
head is covered with nine large plates, as is seen in the 
Colubrine snakes, and the tail terminates in a rattle, gen- 
erally smaller than that of 
Crotalus. Figs. 3233 and 3234 
represent the appearance of 
the head of Caudisona ter- 
gemina, and by comparing 
these figures with those of 
Crotalus, the difference in the 
head plates will be plainly 
seen. The pits anterior to 
the eye are also discernible. 
In the genus Aneistrodon, 
the fangs are similar to those of Caudisona, and the 
ante-orbital pit is also present. There is no rattle on the 
tail, and the head is covered 
by either nine or eleven 
scales. Of the different 
species of this genus, one, 
A. contortriz, the Copper- 
head, is terrestrial, the others 
aquatic in their habits. Figs. 
3235 and 8236 represent the 
head of Ancistrodon contortriz, the common Copperhead. 
Eiaps, the only venomous Colubrine serpent of North 
America, differs so materially 
from the other venomous ser- 
pents that a careful description 
seems necessary. The body, 
instead of being thick and 
stumpy, is slender and cylindri- 
QE cal, never exceeding four feet 
Skabehs tite i inlength. The headis continu- 
ott: ; Wien athe eae ous with the body , not ee arated 
above! by a narrow neck as in Crota- 
lus ; it is subelliptical in shape, 
tapering forward, and is covered with plates. There is 
no ante-orbital pit. The mouth is not dilatable, and the 
upper jaw is furnished on each 


SS 


Fig. 3231.—Crotalus Atrox. 
from above. 


Fig. 3232.—The same, as seen in side view. 


Fig. 3233.—Candisona T'ergemina. 
View of head from above. 


Fig. 3234.—The same, as seen in 
side view. 


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side with a small permanently = >a 
erect fang, which is situated OES 
farther. back than that of the i OOS s=— 
Crotalids. The tail is slender eS es=sse 


and continuous with the body, * 
and has norattle. All the culee TR parame age ae a 
of the body are smooth, not ; 

keeled as in Crotalus, Figs. 3237 and 3238 represent the 
head of Hlaps fulvius, the Harlequin Snake. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


The colors of the different species of this genus are 
generally red for the body tint, with black, red, or yel- 
low annulations, and their similarity 
to certain non-venomous snakes makes _ 
them particularly dangerous, as in- { 
stances are on record of individuals 
having suffered in consequence of 
handling what were supposed to be 
innocuous serpents, but which really 
belonged to the genus Hlaps. 

The genus Heloderma contains but 
one species, viz., Heloderma suspectum, the ‘‘ Gila Mon- 
ster,” which may be described as a large stumpy lizard 
with a short tail, the whole reptile sel- 


Fie@. 3237.—Elaps Ful- 
vius. View of head 
from above. 


SOFAS dom exceeding eight inches i 
f WA g eighteen inches in 
eee length. The head, sub-triangular in 
ruieene at a .__ Shape, is separated from the body by 
1G tho same,  & Constricted neck, and the whole of 


its upper surface is covered with ovoid 
-tuberculated scales. The color is brownish-black, inter- 
spersed with yellowish spots. (See Plate XXVIII.) It 
is of interest because of the peculiar character of the teeth, 
which somewhat resemble those of poisonous serpents. 
Dr. Jacob Wortman, who has made a careful study of 
the dentition of this curious reptile, states as follows: 


Fie, 3239.—Heloderma Suspectum, as seen from above. 


“The form of the crown is that of a long, slender, sharp- 


pointed cone, curved inward and backward. The ante- 


rior outer surface of each tooth is marked by a well-de- 
fined groove, extending from the base to the apex. It is 
somewhat deeper at the base than at the summit, and is 
most distinct in the teeth of the lower jaw. The intervals 
between the bases of the teeth allow abundant room for 
the accommodation of poison-glands, the secretion of 


which is conveyed down the grooves and thus injected . 


into the wound which the teeth inflict upon a prey.” 


Fia. 3240.—The same; side view. 


Whether true poison-glands actually do exist, has not 
yet been accurately determined. 
will convey an excellent idea of the appearance of the 
head of the Heloderma, seen from above and in profile ; 
the black line running vertically through the snout, hav- 
Ing a hook at its lower end, is intended to show the lip 
drawn up, as under ordinary circumstances the teeth are 
concealed by the lips. 

Having thus briefly considered the characteristics of 
the venomous reptiles, it may be proper to give a de- 
scription of the mechanism which controls and operates 
the poison-fang apparatus of all our venomous serpents 


Figs. 8239 and 38240 : 


Reptiles. 
Reptiles, 


with the exception of Hlaps, the account being substan- 
tially the same as was published by Dr. Elliot Coues and 
the writer as a result of their herpetological studies, a few 
years since, more modern researches having in no wise 
induced an alteration of the opinions then expressed. 

In the production of the bite the active instruments 
are a pair of deciduous fangs, one on each side of the 
upper jaw, rooted in the maxillary bones, which bear few, 
if any, other teeth ; but it should be mentioned as a mat- 
ter of interest that, while in Crotalus confluentus the 
fangs are generally shed or pushed out of place at vari- 
able periods of time (probably in twelve months), in Cro- 
talus atrox, a species common in the Sonoran region, 
this shedding or loss frequently fails to take place, and 
it is common to find, generally in the right side of the 
jaw of this species, two or more fangs in position. In one 
specimen, in possession of the National Museum, three 
are to be seen in position, and behind them are others 
well advanced in growth. The fangs vary in size, being 
sometimes three-fourths of an inch in length. They are 
somewhat conical and scythe-shaped, with an extremely 
fine point ; the convexity looks forward, the point down- 
ward and backward. The fang is hollow for the trans- 
mission of the venom, but the construction of the tube is 
not as if a hole had been bored through a solid tooth. It 
is in effect a flat tooth, with the edges rolled over to- 
gether till they meet, converting an exterior surface, first 
into a groove, finally into a tube. This is shown, on mi- 
croscopic examination of a section of the tooth, by the 
arrangement of the dentine. Unlike an ordinary tooth, 
the fang is movable, and was formerly supposed to be 
hinged in its socket, since it is susceptible of erection 
and depression. But the tooth is firmly socketed, and 


‘the source of this movement is the maxillary bone itself, 


which rocks to and fro by a singular contrivance. The 
maxillary is a small, stout, triangular bone, movably ar- 
ticulated above with a smaller one, the lachrymal, which 
is itself hinged upon the frontal. Behind, the maxillary 
articulates with the palatal and pterygoid, both of which 
are of rod-like shape, and are acted upon by the spheno- 
pterygoid muscle, the contraction of which pushes them 
forward. This forward impulse of the palatal and ptery- 
goid is communicated to the maxillary, against which 
they abut, causing the latter to rotate upon the lachry- 
mal. In this rocking forward of the maxillary, the 
socket of the fang, and with it the tooth itself, rotates in 
such manner that the apex of the tooth describes the arc 
of a circle, and finally points downward instead of back-- 
ward. This protrusion of the fang is not an automatic 
motion, consequent upon mere opening of the mouth, as 
formerly supposed, but a volitional act, as the reverse 
motion, namely, the folding back of the tooth, also is ; 
so that, in simply feeding, the fangs are not erected. 
The folding back is accomplished by the ecto-pterygoid 
and spheno-palatine muscles, which, arising from the 
skull behind as a fixed point of action, in contracting 
draw upon the jaw-bones in such a way that the maxil- 
lary, and with it of course the fang, are retracted, when 
the tooth is folded back with an action comparable to 
the shutting of the blade of a pocket-knife. All the mo- 
tions of the fangs are controlled by these two sets of an- 
tagonistic muscles, one of which prepares the fangs for 
action, while the other stows them away when not 
wanted. 

The fangs, when not in use, are further protected by a 
contrivance for sheathing them, so that they rest like a 
sword in its scabbard. This is a fold of mucous mem- 
brane, the vagina dentis, which envelops the tooth like 
a hood, enwrapping its base, and slipping down over its 
length, partly as a consequence of its elastic texture, 
partly on account of its connections. Erection of the 
fang causes the sheath to slip off, like the finger of a 
glove, and gather in folds around the base of the tooth. 
This arrangement can readily be examined without dis- 
section. 

The poison-fluid is secreted in a gland which lies 
against the side of the skull, below and behind the eye, 
of a flattened oval shape, obtuse behind, tapering in front 
to a duct that runs to the base of the tooth. Without 


167 


Reptiles. 
Reptiles. 


going into the minute anatomy of the gland, it may be 
described as a sac, or reservoir, in the walls of which the 
numerous secretory follicles are imbedded , it is invested 
with two layers of dense, white, fibrous tissue, the outer 
of which gives off three strong ligaments that hold it in 
place. Ina large snake, the entire gland may be nearly 


an inch long and one-fourth. as wide, weighing, empty, . 


ten or twelve grains, and having a capacity of ten or fif- 
teen drops of fluid. There is no special reservoir for the 
venom, other than the central cavity of the gland. A 
certain dilatation of one portion of the duct, formerly 
supposed to be such a store-house, is due to thick- 
ening of its walls, without corresponding increase 
of capacity, resulting from muscular fibres which 
serve as a sphincter to compress the canal and pre- 
vent wasteful flow of the contents. There is fur- 
ther provision to this same end. When the tooth 
is folded back, the duct attached to its root is sub- 
mitted to some strain, which pushes it against a 
shoulder of the maxillary bone, and tends to shut 
off the communication. 

The injection of the venom, though to all ap- 
pearance instantaneous, is a complicated process of several 
rapidly consecutive steps. Forcible voluntary closure of 
the jaws may always be, if desired, accompanied by a gush 
of the venom, owing to the arrangement of the muscles 
which effect such movement of the jaw. These are the 
temporales, one of the three of which is situated in such 
relation to the poison-sac that its swelling in contraction 
presses upon the receptacle and squeezes out the fluid. 
The force of ejection is seen when the serpent, striking 
wildly, misses its aim; under such circumstances, the 
stream has been seen to spirt five or six feet. A blow 
given in anger is always accompanied by the spirt-of 
venom, even when the fang fails to engage, from what- 
ever cause. But since this result does not follow upon 
mere closure of the mouth, it is probable that the two 
posterior temporals ordinarily effect this end, the more 


a (64 


© pn 2\ 


\" 
Zp 


z. 


Fie. 3241.—Head of Crotalus. a, a, Anterior temporal muscle; b, point 
of insertion in the lower jaw ; c, venom-gland; d, fang, partly erected. 


powerful action of the anterior temporal (the one which 
presses upon the poison-sac) being reserved for its special 
purpose. There is one curious piece of mechanism to be 
noted here. Since the serpent snaps its jaws together in 
delivering a blow, the points of the fangs would pene- 
trate the under jaw itself in case they failed to engage 
with the object aimed at, were there no contrivance for 
preventing such disaster to the snake. But there is a 
certain movement among the loose bones of the skull, 
perhaps not well made out, the result of which is to 
spread the points of the fangs apart in closure of the 
mouth, so that they clear the sides of the under jaw, in- 
stead of impinging upon it. 

The complicated mechanism of the act of striking may 
be thus described: The snake prepares for action by 
throwing itself into a number of superimposed coils, 
upon the mass of which the neck and a few inches more 
lie loosely curved, the head elevated, the tail projecting 
and rapidly vibrating. At the approach of the intended 
victim, the serpent, by sudden contraction of. the mus- 
cles upon the convexity of the curves, straightens out 
the anterior portion of the body, and thus darts forward 


the head. At this instant the jaws are widely separated, | 


and the back of the head fixed firmly upon the neck. 
With the opening of the mouth the spheno-palatines 
contract, and the fangs spring into position, throwing off 


168 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the sheath as they leap forward. With delivery of the 
blow and penetration of the fangs, the lower jaw closes 
forcibly, the muscle that executes this movement causing 
simultaneously a gush of venom through the tubular 
tooth into the wound. There are also some secondary 
actions, though all occur at the same moment. The 
mouth fixed at the wound drags upon it with the whole 
weight of the snake’s body. This dragging motion is 
accompanied by contraction of the ecto-pterygoid and 
the spheno-palatine muscles, which ordinarily fold back 


Fre. 3242.—Naja Tripudians. 
the digastric ; c, c, the posterior temporal; d, d, the anterior temporal ; 
e, e, the masseter; 7, the poison-gland covered by masseter and fascia : 
g, poison-duct; , maxillary bone; 7, neuro-mandibular muscle; J, 
costo-mandibular muscle. 


a, Is the trachelo-mastoid muscle ; 0, b, 


the tooth ; but the fang being at this moment engaged in 
the flesh, the action of the muscles only causes it to bury 
itself deeper, and thus enlarge the puncture. The train 
of action seems to be, the reaching of the object, the 
blow, the penetration, the injection of the poison, and the 
enlargement of the wound, These actions completed, 
the serpent loosens its hold by opening the jaws, and dis- ~ 
engages itself, sometimes not without difficulty, espe- 
cially when the bitten part is small and the numerous 
small teeth have caught. The head is withdrawn, the 
fangs folded, the mouth closed, and the former coiled at- 
titude of passive defence is assumed. 

Fig. 3241, after Mitchell, represents the head of Crota- 
lus, and shows the relation of the temporal muscles to 
the venom-gland, and the mode in which the pressure is 
exerted upon the poison-gland at the proper moment. 

Fig. 3242, copied from Sir Joseph Fayrer’s admirable 
work on the Thanatophidia of India, represents the head 
of Naja tripudians, the Cobra, the cifferent’ muscles in- 
volved in the movements of the jaws and fangs being 
carefully delineated. By comparing this cut with Fig. 
3241, it will be noticed that the fangs are fixed more an- 
teriorly in the upper jaw than those of Crotalus, and 
the arrangement of the temporal muscles differs some- 
what. 

The mechanism of the jaw of Hlaps resembles some- 
what that of the Cobra, both reptiles belonging to the 
same class of poisonous colubrine serpents, the Elapide ; 
but in Hlaps the fang is permanently erect, the jaws be- 


Sr 


SS 
nea. 


Fig, 8243.—Head of Naja Tripudians, as seen from above. 


ing less dilatable than in most venomous species. This 
fact explains why it is that the death-dealing power of 
Hilaps is more restricted than in other species. 

Figs. 8248 and 3244 represent the head of Naja tripu- 
dians seen from above and in profile, and shows the 
characteristic appearance of the heads of the venomous 
colubrine serpents. 


GE HANDBOOK 
ewan” Be J Plate XXVII 
MEDIGAL SCIENCES. / oNT py . 


sf a ad gun teyy det. : LINDNER, EDDY & CLAUSS,LITH. N.Y 


DIAMOND RATTLE-SNAKE./Georacus abaranrevs./ 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


It is acurious fact, that notwithstanding the knowledge 
possessed for ages regarding the poisonous effect of ser- 
pent venom, until within the last three centuries no at- 
tempt was made to study its peculiar physiological 


Fia. 8244.—The same, as seen in side view. 


effects, the first writer on the subject being Francisco 
Redi, an Italian, who in 1664 published, at Florence, a 
paper upon the venom of the viper, entitled ‘‘ Osserva- 
zione intorno alle Vipera,” and this was followed, in 1767, 
by a work which may be considered classic, written by 
Felix Fontana, entitled ‘‘ Richerche filosofiche sopra il 
veneno della Vipera,” published in Lucca. In 1845, the 
naturalist, Prince Lucien Bonaparte, published a paper 
on the results of his analyses of viper venom, which was 
really the first scientific chemical study made. A num- 
ber of other papers appeared from time to time subse- 
quent to this, but it was not until 1860 that the most im- 
portant work on serpent venom appeared. This was thre 
‘«Study of the Venom of Rattlesnakes,” by Dr. S. Weir 
Mitchell, of Philadelphia, and appeared as a volume of 
one hundred and seventeen quarto pages in the Smith- 
sonian Contributions to Knowledge. In 1868, this dis- 
tinguished physician supplemented his first paper by one 
in the New York Medical Journal, and in 1886, in collab- 
oration with Dr. Edward T. Reichert, the great work 
entitled, ‘‘ Researches upon the Venoms of Poisonous 
Serpents,” appeared as No, 647 of the Smithsonian Con- 
tributions to Knowledge. It should not be forgotten 
that while our own countrymen were seeking to diffuse 
knowledge among mankind, the subject of serpent ven- 
om was being investigated by scientists abroad. In 1872 
Sir Joseph Fayrer published a work on the venomous 
serpents of India; Dr. Lauder Brunton and himself pub- 
lished in the same year an admirable physiological study 
of venoms. In 1883, appeared a comparative study of 
the venoms of the colubrine and viperine snakes of India, 
by Dr. A. J. Wall; nor should the work on antidotes, by 
Vincent Richards, be forgotten. 

The physical appearances of all serpent venom are near- 
ly alike, varying in color from pale amber to deep yellow 
when fresh, although it has been stated that occasionally 
the Cobra venom is colorless ; and this finds its analogy in 
the venom of our own laps, which has been seen.on one 
occasion to lack color. In the desiccated condition venom 
appears as yellow particles, semi-transparent, and remains 
unchanged for long periods of time. It is equally viru- 
lent whether dry or preserved in alcohol or glycerine, 
Dr. Mitchell having in his possession a glycerine solution 
which was poisonous after twenty years’ preservation. 
For a full description of the microscopic appearance and 
the changes which venom undergoes the reader is referred 
to the admirable study by Mitchell and Reichert already 
mentioned. So far as the chemistry of venom is con- 
cerned, the presence of alkaloids and ptomaines has long 
been suspected, but up to the present time they have been 
sought for in vain; but Mitchell and Reichert have suc- 
ceeded in isolating certain principles belonging to two 
classes, the former termed globulins, the other peptones. 
To the first belong complex substances which they call 
water-venom-globuline, copper-venom-globuline, and dialysis- 
venom-globuline, these names indicating the chemical pro- 
cesses by which they have been separated. The venom 
peptone is found in a solution of the poison after boiling, 
which coagulates the albuminous principles, or it may be 
prepared by dialysis. In the cobra venom Drs. Mitchell 
and Reichert have been able to isolate two proteids which 
are similar in character to those found in the venoms of 
Crotalus and Ancistrodon, which are a globulin and pep- 
tone-like principle. From a careful series of analyses it 


Reptiles. 
Reptiles. 


has been found that the venom of Crotalus adamanteus 
contains 24.6 per cent. of globulins, that of Anctstrodon 
7.8 per cent., and that of the cobra 1.75 per cent. Ser- 
pent venom has been subjected to the action of various 
agents with a view to determine the effects in reducing 
its toxic power. Dry and moist heat have little if any 
effect, but prolonged boiling seems to reduce the poison- 
ous quality, owing to the fact that the peptone is con- 
verted into a coagulable albuminoid which is not destruc- 
tive to life. The addition of a sufficient quantity of 
caustic potassa to a solution of venom, absolutely de- 
stroys the toxic power, and caustic soda appears to have 
the same effect. A number of other substances have 
been employed, but space will not admit of a further 
consideration of the results attained ; but it may be stated 
as a matter of interest that a solution of the permanganate 
of potassa is said to be an absolute chemical antidote to 
serpent venom. i 

Much might be said of the effects of venom, but a brief 
notice seems all that is necessary, as the subject has been 
most elaborately discussed by the authors already quoted. 
Crotalus poison, if swallowed, is harmless, as it is not ab- 
sorbed by the healthy mucous membrane, or because it 
undergoes some change in the progress of digestion which 
makes it harmless ; but Fayrer has found that the inges- 
tion of cobra poison by mammals does produce death. 
When venom is applied to serous surfaces absorption 
takes place most rapidly, and hemorrhagic patches occur 
with surprising celerity. According to Mitchell, after 
the hypodermic injection of venom, the following patho- 
logical appearances may be noticed: ‘‘'There appears a 
swelling at the point of injection, with intense violet- 
black discoloration of the skin which gradually extends 
over an area of several square inches. On making an in- 
cision into the tissues in the immediate neighborhood of 
the injection, they are found to be soaked with extrava- 
sated blood. This is often all that is visible if death has 
occurred soon, but if it has been postponed for a short 
time, then, in tissues distant from the place of injection, ° 
extravasations to a smaller extent are always found. 
Most pronounced and most frequent are the ecchymoses 
below serous membranes (subpleural, subperitoneal, and 
subpericardial) ; in fact the whole organism is deeply af- 
fected, the tissues being congested and presenting a much 
darker appearance than normal. The blood does not 
seem to coagulate readily within cavities or interstices of 
the body unless death follows almost instantaneously. 
In cases which live longer the blood remains constantly 
in a liquid state, or coagulates imperfectly, and then only 
after being exposed to the air, resembling in this particu- 
lar the state of that fluid observed in conditions of as- 
phyxia.” 

As the valuable work of Mitchell and Reichert is not 
generally available to the public or practitioners of med- 
icine, it may be proper to give in their own words a sum- 
mary of the conclusions arrived at, as a result of their 
most valuable and careful studies : 

‘1, Venoms bear in some respects a strong resem- 
blance to the saliva of other vertebrates. 

‘¢2, The active principles of venom are contained in 
its liquid. parts only. The solid constituents, such as we 
observed suspended in the poison, consist of epithelium 
cells, some minute rod-like animal organisms and micro- 
cocci, etc., which, when separated from the liquid, fresh 
venom by means of filtration and well washed by water, 
are harmless. Micrococci are constantly present in fresh 
venom, but have nothing to do with its virulence. 

‘©3, Venoms may be dried and preserved indefinitely 
in this condition, with but very slight impairment of their 
toxicity. In solution in glycerine they will also probably 
keep for any length of time. 

‘‘4, There probably exist in all venoms representatives 
of two classes of proteids, globulins and peptones, which 
constitute their toxic elements; the former may be rep- 
resented by one or more distinct principles. 

‘©5,. When venom is taken into the stomach in the in- 
tervals of digestion, enough of the poison may be ab- 
sorbed to produce death, especially in the case of those 
venoms which contain a larger proportion of the more 


169 


Reptiles, 
Reptiles, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


dialysable peptone ; but during active digestion the ven- 
om undergoes alteration, and is rendered harmless. 

‘6. Potassic permanganate, ferric chloride in the form 
of the liquor or tincture, and tincture of iodine seem 
to be the most active and promising of the generally 
available local antidotes. 

‘“7, Venom exerts a powerful local effect upon the liv- 
ing tissues, and induces more rapid necrotic changes 
than any known organic substance. It causes cedema, 
swelling, attended with darkening of the parts by in- 
filtration of incoagulable blood, breaking down of the 
tissues, putrefaction, and sloughing. 

“8. It renders the blood incoagulable. 

‘‘9. When brought in contact with a vascular tissue 
of a warm-blooded animal, it produces such a change 
in the capillary blood-vessels that their walls are un- 
able to resist the normal blood-pressure, thus allowing 
the blood-corpuscles to escape into the tissues. These 
lesions are, however, not analogous to those of inflam- 
mation, since in the latter process it is principally the 
white blood-corpuscles which emigrate from the ves- 
sels, and the blood is highly coagulable, while here the 
blood exudes en masse, and coagulates with difficulty, 
if at all. Free access of air (probably of oxygen) ap- 
pears to lessen the virulent effects. The mesentery ex- 
posed to air, and on which the venom is merely brushed, 
endures the venom ionger and in much larger quantities 
than when the poison is injected into the unopened and 
uninjured peritoneal cavity, or when directly thrown 
into the blood. There may be here, also, a question of 
temperature and other conditions. 

‘The following facts, as elicited in these investiga- 
tions, seem to be sufficient to explain the mechanism of 
the hemorrhages: The blood-pressure has been shown 
to play a most important part ; a watery salt solution sub- 
stituted for the blood does not extravasate, hence blood 
seems to be necessary ; there always occur molecular 
changes in the blood-vessel walls from the effect of 
venom. That blood-pressure is an important factor has 
been established by the observation that the hemor- 
rhages, as a rule, occur first in the capillaries which 
are immediately next to, or nearest, the large blood-ves- 
sels. The hemorrhages take place soonest where the 
force of the blood-current is first felt and cannot be 
sufficiently resisted, and in no case do hemorrhages 
seem to originate from vessels with strong walls, like 
the arterioles or veins. Cutting off the circulation of a 
part, as, for instance, by ligation of the vessel of the 
mesentery, destroys the blood-pressure, and, as a con- 
sequence, the hemorrhages are so slight as scarcely 
to be seen by the naked eye, though venom was 
freely applied. Finally, the colloid, softened, diffluent 
condition of the red corpuscles must inevitably facili- 
tate extravasation. It is impossible to have seen nu- 
merous cases of venom-poisoning without noting a va- 
riety of symptoms often abrupt or unexpected. These 
often are due, as Dr. Mitchell long since pointed out, 
to accidental hemorrhages into the brain, kidney, and 
heart tissues. They explain much which might other- 
wise seem inscrutable, and serve sometimes to give a 
marked individuality of symptoms to cases which sur- 
vive long. 

‘“10. Among the most remarkable effects of venom is 
that upon the red blood-corpuscles. These bodies un- 
dergo substantial modifications, 7.e., they lose their bi- 
concave shape, become spherical and softened, and fuse 
together into irregular masses, acting like soft, elastic, 
colloid material. This jelly-like condition of the cor- 
puscles is, no doubt, doubly important: in connection 
with the extravasation of the blood, and in its probable 
interference with the normal respiratory functions of the 
blood-cells. 

“11. The direct action of venom upon the nervous sys- 
tem, Save as concerns the paralysis of the respiratory 
centres, is of but little importance. 

‘12. The alterations in the pulse-rate are dependent 
chiefly upon two antagonistic factors which are active at 
the same time, the one tending to increase the rate, and 
the other to diminish it. The former is found in the 


170 


increased activity of the accelerator centres, and the 
other in a direct action on the heart. When we have 
the action of the accelerator centres removed by isolation 
of the heart from any centric influence, we almost inva- 
riably find a diminution of the heart-beats. Occasionally 
after this operation the pulsations are increased, but this 
alteration is attended, as in the case of the diminution of 
the pulse, by feeble heart-beats, and, accordingly, is but 
a manifestation in another way of a depressed condition 
of the heart. 

‘13, The variations in arterial pressure are due chiefly 
to three causes—depression of the vaso-motor centres, 
depression of the heart, and irritation, and consequent 
constriction or blocking up, of the capillaries. It seems 
not improbable that all of these are consentaneously ac- 
tive, and it therefore follows that such alterations are de- 
pendent upon the relative degree of power exerted by 
any one of these factors. Our results indicate that the 
profound primary fall of arterial pressure is chiefly due 
to depression of the vaso-motor centres, and is in part 
cardiac, that the subsequent recovery is capillary, while 
the final fall is cardiac. The initial fall does not con- 
tinue, because the constriction of the capillaries is, for a 
time at least, capable of compensating the depressed ac- 
tion of the central organ of circulation. 3 

‘14, The respirations are primarily increased and sec- 
ondarily diminished. Here again we have two antago- 
nistic factors at work together, one tending to increase 
and the other to diminish the rate. The former is an 
irritation of the peripheries of the vagi nerves, and the 
latter a depression of the respiratory centres ; whether 
we have an increase followed by a decrease, or a decrease 
from the first, will depend upon the relative intensity of 
the action of the venom on these two parts. When the 
action of the Yenom is sufficient to profoundly depress 
the centres the excitation of the peripheries may prove 
futile. 

‘15. Death in venom-poisoning may occur through par- 
alysis of the respiratory centres, paralysis of the heart, 
hemorrhages in the medulla, or possibly through the in- 
ability of the profoundly altered red corpuscles to per- 
form their functions. There can be no question, how- 
ever, that the respiratory centres are the parts of the 
system most vulnerable to venom, and that death is com- 
monly due to their paralysis. 

‘‘A general survey of the chief physiological actions of 
venoms leads us to believe that the most important effects 
are upon the respiratory and circulatory apparatuses, and 
that in the production of these results antagonistic fac- 
tors are at work, so that we sometimes have observations 
which seem directly contradictory. When it is remem- 
bered that there are two classes of poisons in venoms, 
that each class possesses certain distinguishing physical, 
chemical, and physiological differences, although closely 
related, it is easy to conceive of the cause of the exist- 
ence of antagonistic actions and the necessarily varying 
results. 

‘‘ A comparative study of the actions of the globulins 
and peptones indicates that the globulins produce swell- 
ing and blackening of the parts by infiltration of inco- 
agulable blood; they are the more potent in producing | 
ecchymoses, in destroying the coagulability of the blood, 
in modifying the red corpuscles, and in the production 
of molecular changes in the capillary walls; their action 
on the accelerator centres of the heart is more notable 
than that of the peptones, hence they are more active in 
causing the increased pulse-rate ; they exert, too, a more 
marked action on the vaso-motor centres in producing 


_ the primary fall of pressure, and are the greater depres- 


sants of the heart ; they also act more powerfully upon 
the respiratory centres to paralyze them. The peptones 
are more active in the production of cedema, in the break- 
ing down of the tissues, in the production of putrefac- 
tion and sloughing; they have little power to produce 
ecchymoses, to prevent coagulation, or modify the capil- 
lary walls or the blood-corpuscles ; they have less ten- 
dency to accelerate the pulse ; they tend to increase the 
blood-pressure by irritating the capillaries, and are the 
principal factors in exciting the peripheries of the vagi 


ae 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Reptiles. 
Reptiles. 


nerves in the production of the increased respiration- 
rate. 

‘© A knowledge of these peculiarities in the actions of 
globulins and peptones, coupled with the fact that the two 
classes exist in different proportions in the various species 
of venoms is of great importance in explaining the di- 
verse pathological appearances in cases of poisoning in 
different kinds of snake-bite, and suggests immediately 
the cause of the frightful local changes which are seen 
after the bite of the Crotalide, but scarcely at all in 
cobra-poisoning. It must not, however, be supposed 
that the peptones or globulins, for instance, are abso- 
lutely identical physiologically in every venom, as they 
are probably modified physiologically as well as chemi- 
cally, although we do not doubt that on the whole the 
type of action is carried throughout all species. Cobra 
venom does not produce the marked lesions of crotalus- 
poisoning because it is so lacking in globulins ; it is weak 
in the production of the local swelling and blackening of 
the parts, of the ecchymoses, of the altered corpuscles, 
and of the non-coagulability of the blood ; but the effects 
of cobra venom are closely in accord with the actions 
peculiar to peptones. The peptone of cobra seems to 
have a more decided power in producing convulsions 
than that of the rattlesnake. 

“The fact that the active principles of venom are pro- 
teids, and closely related, chemically, to elements nor- 
mally existing in the blood, renders almost hopeless the 
search for a chemical antidote which can prove avail- 
able after the poison has reached the circulation, since it 
is obvious that we cannot expect to discover any sub- 
stance which, when placed in the blood, will destroy the 
principles of venom without inducing a similar destruc- 
tion of vital components in the circulating fluid. The 
outlook, then, for an antidote for venom which may be 
available after the absorption of the poison, lies clearly in 
the direction of a physiological antagonist, or, in other 
words, of a substance which will oppose the actions of 
venom upon the most vulnerable parts of the system. 
The activities of venoms are, however, manifested in 
such diverse ways, and so profoundly and rapidly, that it 
does not seem probable that we shall ever discover an 
agent which will be capable at the same time of acting 
efficiently in counteracting all the terrible energies of 
these poisons.” 

With regard to the poisonous effects produced by the 
venom of the Ancistrodons (Moccasins and Copperheads), 
the reader is referred to an article by the writer which 
appeared in the American Journal of the Medical Sciences, 
Philadelphia, April, 1884, in which special attention is 
called to the recurrence of symptoms of poisoning after 
snake-bite ; this recurrence seems to be confined to cases 
in which individuals were bitten by the serpents of the 
genus named. In the Medical News, Philadelphia, 1887, 
i., p. 628, the writer, after carefully watching the two 
cases mentioned in the former paper during a period of 
nearly three years, published a short paper upon the 
‘Recurrence of Symptoms of Poisoning after Snake- 
bite,” in which the results of the examination of the 
patients and the recurrent symptoms are fully set 
forth. : 

With regard to the poisonous lizard, Heloderma suspec- 
tum (Gila Monster), there is a mass of conflicting evi- 
dence as to its toxic power. The Mexicans have long 
looked upon it as dangerous, but other perfectly harm- 
less lizards also share in this evil reputation. Surgeon 
B. J. D. Irwin, U.S. A., experimented many years since, 
while on duty in New Mexico, with the Gila Monster, 
and concluded that it‘ was harmless, and a number of 
persons have been bitten, within the writer’s knowledge, 
without evil results. In fact, in New Mexico and Ari- 
zona the reptile is kept. as a domestic pet, and handled 
with great carelessness. Opposed to the view of its non- 
dangerous nature are the facts that persons have un- 
doubtedly perished from its bite, the writer having in 
his possession the affidavits of two respectable indivi- 
duals who witnessed a death, and the experiments of 
Mitchell and Reichert, which conclusively show that the 
saliva-like fluid from the mouth of the Heloderma, when 


injected beneath the skin of an animal, produces fatal re- 
sults with great rapidity. 

These investigators obtained the fluid by provoking 
the animal to bite on a saucer edge, and after it had held 
on for a few moments a thin fluid like saliva was ob- 
served to issue from the lower jaw. This fluid was dis- 
tinctly alkaline, differing in this respect from the venom 
of all serpents, which is acid. The first experiment 
made by these gentlemen was as follows: ‘‘ About four 
minims were diluted with one-half cubic centimetre of 
water, and thrown into the breast-muscles of a large, 
strong pigeon at 4.23 p.m. In three minutes the pigeon 
was rocking on its feet and walking unsteadily. At the 
same time the respiration became rapid and short, and at 
the fifth minute feeble. At the sixth minute the bird fell 
in convulsions, with dilated pupils, and was dead before 
the end of the seventh minute. The first contrast to the 
effects of venom was shown when the wound made by 
the hypodermic needle was examined. There was not 
the least trace of local action, such as is so characteristic 
of the bites of serpents, and especially the Crotalide. 
The muscles and nerves responded perfectly to weak in- 
duced currents, and to mechanical stimuli. The heart 
was arrested in the fullest diastole, and was full of firm, 
black clots. The intestines looked congested. The spine 
was not examined.” 

Subsequent experiments with rabbits and frogs pro- 
duced like results, the conclusions of the authors being, 
‘“That the poison of Heloderma causes no local injury. 
That it arrests the heart in diastole, and that the organ 
afterward contracts slowly—possibly in rapid rigor mor- 
tis. 

‘“That the cardiac muscle loses its irritability to stim- 
uli at the time it ceases to beat. 

‘‘That the other muscles and the nerves respond read- 
ily to irritants. 

‘“That the spinal cord has its power annihilated ab- 
ruptly, and refuses to respond to the most powerful 
electrical currents.” 

It should not be forgotten, however, that Dr. Stern- 
berg and Professor Gautier have proved that human sa- 
liva may produce death in rabbits and pigeons, the latter 
observer considering the venomous properties due to nor- 
mal ptomaines or animal alkaloids.! 

It is by no means uncertain that in the near future it 
may be shown that the saliva of other reptiles possesses 
poisonous qualities, especially in such genera as Siren, 
Pseudobranchus, Necturus, Amphiuma, Murenopsis, and 
Menopoma, which in the Southern States are popularly 
supposed to be able to destroy life by their bite. 

The symptoms produced in man by the bites of poi- 
sonous serpents possess a certain degree of similarity, 
their gravity depending largely upon the size of the rep- 
tile and the amount of venom injected into the wound. 
In case the serpent had repeatedly used its fangs and 
exhausted the supply of venom, dangerous symptoms 
would be less pronounced. Briefly, they may be stated 
as follows: After the puncture, at first the pain is slight 
in the part ; this gradually increases along the line of the 
lymphatics, with nausea; bleeding takes place, with 
rapid tumefaction and discoloration in the vicinity of the 
wound. The pulse is feeble and fluttering, and in some 
cases, when an overwhelming dose of the venom has 
been received, the action of the heart is almost paralyzed. 
If remedial means are not employed there is exaggera- 
tion of all the symptoms mentioned, with incontinence 
of urine and involuntary passage of feces, delirium, 
coma, and death, which may occur within a few hours. 

These symptoms may be immediate or delayed, as in 
the case of the photographer bitten by a copperhead, and 
reported by the writer, as in this individual several days 
elapsed before any real suffering commenced, the entire 
duration of the poisonous symptoms lasting from May 
30th until late in August. 

Regarding the treatment of poisoning by serpent 
venom, many plans have been suggested, and hundreds 
of remedies employed with varying success ; but to an in- 
telligent observer of such an accident the indication 
would doubtless be to prevent the entrance of the poison 


171 


Reptiles. 
Reptiles, 


into the general circulation by means of a ligature or 
bandage, which should not be narrow, but quite broad, 
and applied above the bite or between it and the heart, it 
being, of course, understood that these remarks, so far 
as ligatures are concerned, apply to wounds of limbs. The 
bite or bites should then be laid open by crucial incision, 
care being taken not to injure blood-vessels, and suc- 
tion should be made, either by the mouth (in case no 
abrasions of the mucous surface exist), or by cupping ; 
this latter procedure may be made by means of sur- 
gical cups if available, by a small tumbler or wineglass 
from which the air has been exhausted by burning a 
small quantity of alcohol or spirits. therein, or by 
means of an ordinary wide-mouthed bottle or can, in 
which boiling-hot water should be poured and quickly 
emptied. Alcoholic stimulants or digitalis should be 
given by the mouth, or hypodermatically if nausea ex- 
ists, to keep up the flagging heart, and the band should 
be loosened fora few moments at atime in order that 
only a small quantity of the venom shall enter the circu- 
lation. This process should be repeated, and the pulse 
- will indicate when the proper amount of stimulation has 
been reached. It is not necessary to produce drunken- 
ness, aS it is believed that in some cases, especially of 
children, death has resulted not from the snake venom, 
but from lethal doses of alcohol. The mountaineers of 
the West attach much virtue to the flashing of a quantity 
of gunpowder over the bite, this, with cataplasms of to- 
bacco and unlimited whiskey, constituting almost their 
entire pharmacopceia. 

Within a few years, however, the attention of those in- 
terested in the subject of serpent-bite has been called to 
the elaborate experiments of Dr. J. B. de Lacerda, Di- 
rector of the Physiological Laboratory of the National 
Museum of Rio Janeiro—a study followed with most con- 
scientious care, and one which seems to show that there 
exists a most potent chemical antidote to serpent venom. 
His researches commenced in 1872, and in 1881 he an- 
nounced to the French Academy of Sciences that he had 
made a valuable discovery. Alluding to the inefficiency 
of the various so-called antidotes, he stated that he found 
that a solution of potassium permanganate was an absolute 
antidote. The venom used was from the Bothrox, a very 
well known and venomous serpent of Brazil, and it was 
obtained by forcing the reptile to bite upon cotton-wool. 
The quantity thus procured was dissolved in eight or ten 
grammes of distilled water, and a certain amount of the 
solution was injected into the leg of adog. In afew min- 
utes after, the same quantity of a filtered one per cent. 
solution of potassium permanganate was injected into the 
wound. Next day the animal was perfectly well, with 
the exception of a slight local irritation. The poison in- 
jected in other animals, without the subsequent use of the 
permanganate, produced grave and dangerous symptoms. 
The venom was also injected into a vein, and the perman- 
ganate proved equally efficacious in preventing poisonous 
symptoms ; and in some cases, before using the antidote, 
the symptoms of poisoning were allowed to continue for 
quite a lengthy period ; and out of thirty experiments all 
were successful with but two exceptions. It is proper 
to add that many of Lacerda’s experiments were per- 
formed in the presence of the Emperor of Brazil, and 
other scientific individuals. Lacerda’s experiments with 
the permanganate of potassa have been repeated by a 
number of observers with varying results, but in view of 
the very positive statements made by him it would appear 
that the permanganate should be given a trial. It should 
be used in the form of a one per cent. solution in water, 
and injected into the bites made by the teeth of the ser- 
pent. 

The writer, while sojourning among the Moqui Indi- 
ans of Arizona, at the time of their celebrated ‘‘ snake- 
dance,” was shown the so-called antidote which they em- 
ploy in case a dancer is bitten; it is a pale, dirty-green 
fluid, without odor, and slightly bitter taste, but its com- 
position could not be ascertained, only two individuals in 
the tribe knowing how to prepare it. This preparation 
is used, mixed with saliva and the charcoal of pifion 
nuts, to smear the bodies of those Indians who are to par- 


172 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


ticipate in the dance, and after it is finished copious 
draughts of it are swallowed, which produce prompt 
emesis. In case one is bitten, which happens occasion- 
ally, the wound is immiediately sucked, some of the an- 
tidote rubbed into the wound, and a large quantity swal- 
lowed. During the last ten years, in which period five 
dances have occurred, but one individual has perished from 
snake-bite; and this is the more surprising when the fact 
is made known that the salient feature of the dance con- 
sists in the dancer holding one or two rattlesnakes in the 
mouth. The writer saw two individuals bitten, both by 
harmless snakes. Unfortunately for science, no oppor- 
tunity was afforded to test the permanganate solution, 
which had been prepared and was on hand for use should 
occasion offer. 

After the subsidence of acute symptoms of snake-bite, 
the others would have to be treated according to the gen- 
eral indications. 

Considering the number and wide distribution of ven- 
omous serpents in the United States, and in view of the 
fact that no absolutely reliable plan of treatment is known, 
it is surprising that so few individuals lose their lives 
from snake-bite. That the rattler is still numerous in cer- 
tain portions of our country, the following statement will 
show : In 1876, Lieutenant Morrison, U.S. A., encountered 
in New Mexico acolony of Crotalus confluentus, of which . 
not less than from three to five hundred were seen during 
the occupation of a hill as a topographical station, and 
of which seventy-nine were killed in less than one hour ; 
and Professor J. A. Allen reports that during the Yellow- 
stone Expedition of 1872, not less than two thousand 
were killed. 

With reference to the subject of antidotes, mention may 
be made of a remarkable work, published by Boericke 
& Tafel in 1872, in which the author endeavors to 
prove that the galls of serpents are antidotal to their bite. 
In preparing the gall for use, one drop is added to ten 
drops of pure alcohol, and the mixture is allowed to 
stand for a few days, at the expiration of which period 
the supernatant liquid is poured off and carefully pre- 
served in a well-corked vial. In ordinary cases of bite, 
five or ten drops of this tincture are added to half a 
tumbler of water, and a tablespoonful of the mixture is 
administered every five, ten, fifteen, or twenty minutes, 
according to the violence of the symptoms. In addition 
to the internal use of the gall, a cruciform incision is 
made over the wound, and a few drops of the prepara- 
tion are dropped in. Unfortunately the value of this so- 
called antidote depends entirely upon the statement of 
its discoverer, and it is believed little credence can be at- 
tached to his published results, as Sir Joseph Fayrer, 
following instructions received from the author, failed 
utterly to neutralize the poisonous effects of the venom 
of Cobra and Bungarus, using the gall as directed. 

The popular mind has ascribed to certain serpents 
properties, venomous and otherwise, which they really 
do not possess, and it is thought a correction of these er- 
rors may perhaps serve a useful purpose. 

In some parts of the United States is found a snake be- 
longing to the genus Heterodon, which inspires as much 
fear as the rattlesnake ; in fact, the species known as Hete- 
rodon niger is called in Virginia the ‘‘ black rattlesnake,” 
although the want of a rattle should prove the name a 
misnomer. This reptile has a broad, flat head, with a 
somewhat constricted neck, a stout body, and a short 
stumpy tail, and when captured it hisses. fiercely, ex- 
pands the cervical ribs, and presents a very pugnacious 
appearance. The coloration of one species is somewhat 
like Crotalus confluentus, and, if the mouth is examined, 
in the upper jaw will be found fang-like teeth, which 
have given origin to the generic name, which means “‘ dif- 
ferent or dissimilar teeth.”” These teeth are not grooved, 
and are not connected with anything resembling a poi- 
son-sac. Notwithstanding its dangerous appearance it is 
absolutely harmless, and can scarcely be provoked to 
bite. -Not long since, the writer had forwarded to him, 
by an intelligent gentleman living in the South, one of 
these snakes, which was declared to be one of the most 
poisonous known to the region; it proved to be Hetero- 


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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


don platyrhinus. The common names for this serpent 
are ‘‘ puff-adder,” ‘‘ hog-nosed snake,” ‘‘ sand-viper,” 
etc. 

Next to the almost universal belief regarding Hetero- 
don, is a Similar opinion about the so-called water moc- 
casin, Tropidonotus sipedon, and oneof the old writers, in 
a history of Virginia, describes this serpent so that no 
doubt as to its identity can exist, and then gravely states 
that an Indian was severely bitten by one, but by the ap- 
plication of proper remedies finally recovered. This 
serpent, as is well known to naturalists, resembles the 
poisonous species Ancistrodon piscivorus, and as both are 
found in and about watery places, it is not surprising 
that their properties should have been confounded. In 
addition, Tropidonotusis a very pugnacious individual, 
and will bite fiercely if opportunity offers, especially if 
it has not been handled—in fact, even then, if roughly 
seized. Some time since, the writer had occasion to re- 
move a small sebaceous tumor from below the angle of 
the jaw of a fine female Tropidonotus belonging to the 
National Museum, and after the operation, as it had lost 
a considerable amount of blood, and seemed very weak, 
it was placed in the pond of water in the rotunda of the 
Museum. Desiring to exhibit it toa friend, it was re- 
moved from the water, when it struck fiercely at the 
hand, throwing its upper jaw back as the venomous ser- 
pents are in the habit of doing, and at the third stroke 
succeeded in fixing its teeth near the base of the thumb. 
The pain was trifling, and had it not been for the some- 
what free bleeding, an injury would hardly have been 
suspected ; no evil consequences resulted, nor have any 
ever occurred, as the writer has been bitten several times 
by this species. . 

The difference in the appearance of the head between 
the true moccasins and the so-called water moccasin is 
very marked. In the former the plane surface of the 
head may be said to roughly resemble a triangle, the 
snout representing the apex, the angle of the jaws’ the 
base, the neck being narrow behind. In this species 
the pit between the eye and nostril is well marked. In 
the harmless species the head is hardly separated from the 
body by a constricted neck ; it is rounded, and the ex- 
panse of the angles of the jaw not so well marked. It 
has, however, when coiled up, a very vicious appearance, 
and resembles greatly a venomous snake. 

One of the most curious myths in regard to serpents is 
that of the ‘‘hoop-snake”’ or horn-snake, which is thus 
described by a recent writer: ‘‘ The horned snake is the 
last of the poisonous serpents, and is a great curiosity. 
Instead of in the head, it carries its weapon in its tail, 
which has a horny appearance, is shaped like a cock’s 
spur, and is from an inch to an inch and a half in length. 
This tail has a cavity, inclosed in which is a sharp needle- 
like sting, growing from the extreme point of the tail. 
The snake puts the end of the tail in the mouth, thus 
forming a hoop, and rolls forward until within striking 
distance, when it slips the tail from the mouth and 
strikes with considerable force ‘tail foremost. The sting 
produces about the same effect as the sting of the adder. 
The horned snake is about three feet long when full 
grown, rather dark in color, and is oviparous. They are 
very scarce and seldom seen.” 

What is known as the horned snake in the West and 
Southwest is the Farancia abacura, of which the head 
and back are bluish-black above, and which has sub- 
quadrate red spots on the flanks. Its abdomen is rosy- 
red, with transverse or alternating bluish-black irregular 
spots. How or why it should have acquired the unen- 
viable reputation it possesses, at present is unknown, for 
it is one of the most harmless and gentle of all snakes. 
That its tail ends in a horny tip is true, but the ‘“ bull- 
snake” of California, Pityophis bellona, has a similar 
horny tip, but neither the one nor the other ever uses it 
for defensive or offensive purposes. In some of the 
Southern States the grass lizard, Opheosaurus ventralis, is 
also called the horn snake. 

Another serpent about which a curious superstition 
prevails is the ‘‘coach-whip snake,” and lying at full 
length in the road it seems worthy of its popular name, 


Reptiles. 
Reptiles, 


To naturalists it is known as Bascanium flagelliforme. 
The anterior fourth of the body is a deep brownish-black 
color, which gradually becomes lighter until near the 
posterior part, where it is of a yellowish-gray. This col- 
oration, in connection with a peculiar arrangement of the 
scales, gives it a very whip-like appearance, the dark part 
of the body being the handle, the lighter the lash. This 
reptile, in the South, has long been a terror to the col- 
ored population, and many are the stories related of how 
drunken and belated negroes have been found dead in 
the road, whipped to death by the coach-whip snake. 
Perhaps it would not be unfair to say that it is probable 
that this tradition was encouraged during ante-bellum 
days as a wholesome corrective to the night-prowling 
propensities of the slaves. This serpent is very graceful, 
and it may be imagined that if held, provoked, or irri- 
tated, it might, in its efforts to escape, switch fiercely 
with its long tail and body; but as for its being able 
to seize a person and whip him to death, the tradition 
must be consigned to limbo, with others of similar nat- 
ure. From the somewhat fragile nature of the liga- 
mentous attachments of the spinal vertebre of the rep- 
tile, it is more likely that the snake would stand a 
better chance of breaking its back than of inflicting 
serious injury. 

Of all the habitable regions of the globe, the empire of 
India is without doubt the one in which the greatest de- 
struction of human life takes place from the bites of 
venomous serpents, and it may be interesting to briefly 
consider some of the well-known species which con- 
tribute to the fearful result. Sir Joseph Fayrer states 
that the average mortality from serpent-bite is fully 
twenty thousand annually, and in 1869, care was taken 
to obtain, officially, returns of cases, which showed that 
out of a population of 121,000,000, in an area embracing 
only one-half of the peninsula of Hindostan, the deaths 
were 11,416, or nearly one in ten thousand. These deaths 
were caused, as nearly as could be ascertained, as follows : 
Cobra, 2,690; Krait (Bungarus ceruleus), 359; other 
snakes 889; unknown snakes, 6,922; no details, 606; 
total, 11,416. The British government recognizing the im- 
portance of destroying venomous snakes,-paid a bounty, 
in 1880, for the enormous number of 212,776, and in 1881, 
for 254,968. 

Superior in venomous properties are the Hlapida, of 
which several genera are common in India; Najzde, or 
snakes with hoods, or dilatable hoods, or dilatable necks ; 
and the Hlapide, without hoods. Najid@ contains two 
genera, Vaja and Ophiophagus, and in Hlapide are Bun- 
garus, Xenurelaps, and Callophis. The characteristics of 
the family are a cylindrical body, a rather short and 
tapering tail, and a lateral nostril. The poison-fang has 
a mark in its convexity indicating the groove, differing in 
this respect from the poisonous water-snakes, Hydrophide, 
in which it is quite open. At the head of the list should 
be placed the Cobra, or Cobra di capelio, Naja tripu- 
dians, of which there are a number of well-recognized 
varieties, all of them possessing most deadly properties. 
The largest Cobra seen by Fayrer had attained a length 
of five feet eight inches, and measured six and one-fourth 
inches in circumference, and a fowl bitten by it perished 
in one minute. The color of the Cobra varies from dark 
olive or black, to pale chocolate or yellow, and the mark- 
ings on the hood vary greatly in the different varieties. 
All of them possess the hood, and never bite without ex- 
panding it, and, unlike the rattlesnake, the body is not 
coiled, the lower two-thirds remaining upon the ground 
while the anterior third is raised, the head oscillating 
from side to side with wary caution in preparing to at- 
tack. They are good climbers and take readily to water, 
although essentially terrestrial in habits. Ophiophagus 
elaps is the only representation of its genus, and is prob- 
ably even more formidable than the Codra, as it attains a 
length of from twelve to fourteen feet. It has no hood 
and is exceedingly aggressive. The coloration varies 
greatly, but the general tint may be described as olive- 
green above, the scales edged with black, the trunk hav- 
ing on it numerous alternate black and white bands con- 
verging toward the head. To the Bengalese it is known 


173 


Reptiles. 
Resection. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


as the “shell. breaker,” and its habits are largely arboreal, 
although it takes to the water. Dr. Carter relates the 
following anecdote regarding its fierceness: ‘‘ An intel- 
ligent Burman told me that a friend of his one day 
stumbled upon a nest of these serpents and immediately 
retreated, but the old female gave chase. The man fled 
with all speed over hill and dale, dingle and glade, and 
terror seemed to add wings to his flight, till reaching a 
small river he plunged in, hoping he had then escaped his 
fiery enemy ; but lo! .on reaching the opposite bank up 
reared the furious Hamadryad, its dilated eyes glistening 
with rage, ready to bury its fangs in his trembling body, 
In utter despair he bethought himself of his turban, and 
in a moment dashed it upon the serpent, which darted 
upon it like lightning, and for some moments wreaked 
its vengeance in furious bites; after which it returned 
quietly to its former haunts.”” This serpent, as its name 
implies, devours other snakes, but it doubtless also feeds 
upon birds and small animals. 

The genus Bungarus contains two Indian species, B. 
fasciatus and B, ceruleus, known to the natives as Kraits, 
and these serpents, next to the Cobra, are probably the 
most destructive to human life in India. The coloration 
of Bungarus is uniform blackish-brown,. the head being 
white in young individuals, although as in the other ser- 
pents there is some variation of tint. In B. fasciatus the 
triangular shape of the body and sharp dorsal ridge are 
especially noticeable. Xenurelaps bungarotdes, the only 
known representative of its genus, resembles greatly the 
Bungarus ; but little is known as to its habits. 

The genus Callophis contains a number of species, but 
from their small size and diminutive fangs they are prob- 
ably not so dangerous to human life as the other venom- 
ous serpents. 

Belonging to the viperine serpents is the terribly venom- 
ous Daboia russelli, which is of a light chocolate color, 
with black white-edged rings, and which also shows many 
variations of tints. It is most justly dreaded, for with 
its long, movable fangs it produces deep mortal wounds. 
It is terrestrial in its habits, and lives upon smal] animals. 
Dr. Imlach states that it is not uncommon to find two 
fangs.on both sides of the upper jaw. 

There are a number of other genera of poisonous ser- 
pents in India, such as Hehis, Trimeresurus, Peliopelor, 


Halys, and Hypnale, which resemble the North American | 


Crotalide in having the ante-orbital pit, and are without 
rattles; but space will not admit of a consideration of 
their peculiarities. 

The most interesting of all venomous serpents are 
probably the sea-snakes, which inhabit the estuaries and 
tidal streams, and are known to naturalists as the Hydro- 
phide. They have a wide geographical distribution, 
being found in the Indian and Pacific Oceans from Mad- 
agascar to the Isthmus of Panama; Ginther says they 
are most numerous in the Eastern Archipelago and in 
the seas between Southern China and North Australia. 
The sea-snakes vary greatly in form, some of them at- 
taining a length of five feet; the body is elongated, and 
in some instances is short and thick, while in others 
it is very thick toward the tail and much attenuated near 
the neck, the head being minute in proportion to the 
size of the individual. The posterior part of the body 
and the tail are flattened and compressed vertically, like 
the tail of a fish, and with it they swim with extreme 
grace. The fangs and jaws of the sea-snakes are gener- 
ally smaller than those of land-serpents, the venomous 
teeth having open grooves. That they are venomous is 
without doubt, as several instances are on record of per- 
sons losing their lives, and Fayrer found by actual ex- 
periment the dangerous nature of their venom. Be- 
longing to this family are seven genera: Platurus, 
Aipysurus, Disteira, Acalyptus, Hydrophis, Enhydrina, 
and Pelamis, and of these the latter only is known -to 
be found occasionally near the Isthmus of Panama. 
Platurus contains two species ; Hydrophis, twenty-seven ; 
Enhydrina, two; and Pelamis, one. The coloration of 
the sea-snakes varies greatly, one of the most beautiful 
being Pelamis bicolor, the back of which is slaty black, 
the belly orange. Another very beautiful species is 


174 


Hydrophis nigrocincta, in which the ground color is fawn, 
the entire body being partly surrounded with lake-brown 
circles. 

In the experiments reported by Fayrer as having 
been made by Dr. W. P. Stewart, at Pooree, British 
India, the virulence of the venom of the sea-snakes is 
abundantly proved. 

Fayrer’s experiments, which were made upon different 
sorts of animals, using different: kinds of serpent-venom, 
led him to the following conclusions. 

Snake-poison acts with most vigor or the warm-blooded 
animals ; birds succumb very rapidly ; a vigorous snake 
can destroy a fowl in a few seconds. The power of 
resistance is generally in relation to the size of the ani- 
mal, though not altogether so; cats, for example, resist 
the influence of the poison almost as long as dogs three 
or four times their size. Cold-blooded animals also 
succumb to the poison, but less rapidly. Fish, non-ven- 
omous snakes, mollusca, all die. After death from co- 
bra-poison the blood coagulates, but generally remains 
fluid after the bite of a viperine serpent. 

With regard to treatment of snake-bites, Fayrer tried 
every reputed antidote and every plan of treatment, but 
without success, although he believes that ligature, exci- 
sion, and general treatment seem to afford some chance. 
Much, however, needs still to be done in the way of. ex- 
perimentation.® 

It would be foreign to the purpose of this article to 
give an account of all the venomous serpents of the world, 
but the names of a few may be added to swell the al- 
ready formidable list. 

In Europe the most dreaded serpent is the Pelias berus, 
common viper; in Australia the Hoplocephalus curtus, 
tiger-snake ; in Africa the different species of Clotho, 
Megera, etc.; in South America the different species of 
Craspedocephalus, the Jaracacas and Fer de lance ; while 
in Costa Rica particularly is found a genus of venomous 
serpents known as Telewraspis, which are allied to the Cro- 
talid@, but have no rattles. These snakes are arboreal in 
habit, and present no less than five color variations, the 
most beautiful of all being of a golden-yellow color. A 
peculiarity of the genus is the presence of a series of 
scales above the eye resembling small horns. It is said 
that these serpents, which are very venomous, lie at full 
length along the branches of trees, striking at the faces 
of passers-by. In Mexico a large Hiaps and the various 
Crotalide are most justly feared. 

The illustrations which accompany this article have 
been drawn with great care by Mr. John Ridgway, of 
the Bureau of Ethnology, United States National Mu- 
seum, from certain cuts already shown in the various 
works on Serpents; in other instances they have been 
copied from life, and leave nothing to be desired in 
the way of drawings. The large colored plate of Cro- 
talus adamanteus has been drawn from a fine specimen 
owned by the National Museum, and that of Heloderma — 
suspectum is by Mr. A. Zeno Schindler, copied from a 
living reptile in the same institution. Acknowledgment 
is also made to the published works of many authors, the 
most prominent being those by Mitchell and Reichert, 
Fletcher, Cope, Garman, Fayrer, Halford, and others. 


1 With regard to the very poisonous qualities of the Heloderma saliva 
recent experiments by the writer would seem to indicate an extremely 
feeble toxic effect, at least so far as rabbits and fowls are concerned, 

2 It is to be regretted that a repetition of Lacerda’s experiments with 
the permanganate by the writer has not given the resuJts claimed by the 
distinguished Brazilian. 

3 A series of experiments are now being tried to verify what appears 
to be decided antidotal effects of Jaborandi to Crotalus venom, the writer 
having succeeded in saving rabbits which had received fourfold lethal 
doses of the poison. It has no antidotal effect, however, upon fowls. 


Henry Crécy Yarrow. 


RESECTION OF JOINTS.—In the strictest sense, the 
terms resection and excision as,applied to joints are not 
synonymous. The former involves the primary idea of 
the removal of a section of a bone, especially of its shaft ; 
the latter refers more particularly to the removal of the 
joint as such. As a joint is excised by the resection 
of the ends of the bones that compose it, the terms in 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Reptiles, 
Resection, 


practice become synonyms, and are so found in standard 
works. It may be noticed that in French and German 
works the term resection is commonly employed ; in Eng- 
lish and American writings excision is more in use. In 
this article they will be used as practically synonymous. 
The term exsection is also used in the same sense. 
Resections have been divided into complete and partial, 
the former meaning operations in which all the compo- 
nent bony surfaces are removed, the latter op- 
erations in which the articulating surface of one 
bone, or of more, in some complex joints, is left. 
Here again the nomenclature is not always 4 
strictly adhered to—as applied to the shoulder J 
or hip for instance,—and writers seem to be not a 
at all agreed as to what constitutes a complete a 
5 
& 
S 


excision of some joints, notably the wrist. 

The term osteoplastic is applied to resection 
in the performance of which a bone or bony 
prominence (¢.g., the trochanter major, the ole- 
cranon, or the patella) is divided and the parts 
temporarily separated, in order to expose the 
diseased tissues, and subsequently replaced more 
or less perfectly in situ. The same term has 
been applied to operations analogous to those 
of plastic surgery in which the sawn surfaces of 
bones not normally in apposition have been 
brought together after the removal of the inter- 
vening parts; for example, Mikulicz’s osteo- 
plastic resection of the tarsus. It is not easy to rl 
see why such operations are more osteoplastic F!6- 4. 
than many others in which anchylosis is sought for, ordi- 
nary resection of the knee, for instance. 

It is unnecessary to enter upon the history of resec- 
tions. Scattered through surgical literature are allusions 
to operations, made to meet emergencies, more or less 
resembling modern resections. But it is little more than 
acentury since Henry Park (1783) first formally proposed 
the removal of the elbow and knee joints for the cure of 
disease, and Moreau soon after (1786) made the first com- 
plete operation and became the advocate of it as a defi- 
nite surgical procedure. Nevertheless resections gained 
footing with such slowness that their real history belongs 
to the present century, and chiefly to its second half. 
Excision of the shoulder, by reason of the ease of the 
operation and the disabling mutilation it promised to 
prevent, became an accepted operation earlier than the 
removal of other joints. The labors of Syme, beginning 

‘ about 1831, made the profession acquainted with 
| the value of elbow-resection, and the authority 
and teaching of Ferguson in the decade follow- 
ing 1845 fairly put excisions of the hip, knee, 
and wrist among recognized procedures, how- 
ever much surgeons differed as to their real 
value and applicability. Continental surgeons 
were also engaged in working out the problems 
of excision, but the influence of the two British 
surgeons named was especially powerful. 

Resection was primarily an attempt to escape 
the disaster of an amputation. Hodges, in his 
classical monograph, says: ‘‘ It is only as a sub- 
stitute for amputation in traumatic lesions, and 
in certain organic ones, that the proposition of 
excising joints has been entertained, excepting 
in those comparatively few cases in which the 
operation has been undertaken for the cure of 
deformities or in disease of the hip-joint where 
it is the sole operative alternative.” It was in 
the spirit of conservatism that Ferguson in par- 
ticular urged the resort to excision. To sur- 
geons of the present day, at least in America— 
excision seems a radical procedure, and they 
have difficulty in appreciating the condition of 
affairs existing thirty or forty years ago. To-day, ina 
case of joint disease, we choose between resection and 
a highly perfected plan of treatment by joint-rest and 
expectancy in its best sense. Then the choice was be- 
tween amputation, on the one hand, and probable death, 
or, at least, painful and disabling disease of indefinite 
duration, on the other. Under such circumstances a pro- 


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Fig. 3246. 


cedure which gave better chances as to life or function 
was a boon, and truly conservative, even if hidden under 


~ the guise of a somewhat complicated surgical operation. 


To establish the true value of resections, it is necessary 
to determine, first, whether they are really conservative 
of life as compared with either amputation or expectant 


3S 
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SSSSSS OSS SSS 
SSIS OS 
PODS AOS 


Fig. 8247.—Sands’ Periosteotome. 


treatment, and, second, whether the limb saved is really 
a useful member and worth the suffering and the risk. 
With regard to some joints these points are entirely settled ; 
as to others, there is not yet entire unanimity of opinion. 
Before the introduction of aseptic surgery, the question 
of vital conservatism was kept open by the considerable 
death-rate of excisions, dependent upon prolonged sup- 
puration and its results. Since the change in surgical 


Fic, 3248.—Sayre’s ‘*‘ Oyster Knife.” 


methods has reduced the operation-death-rate in civil 
practice of both amputations and resections to a much 
lower figure, the question is no longer very important, 
except as to the results of operative interference of any 
kind when compared with those of purely conservative 
treatment. And it should be noted that asepsis has had 
its influence not on the greater operations alone, but upon 
the minor substitutes for them, such as incision and 


Fie. 38249.—Parker’s Retractor. 


drainage, as well as upon conservatism pure and simple. 
The vital prognosis being a matter of less urgent con- 
sideration, the functional prognosis has taken a propor- 
tionally more prominent place. 

There is no doubt that the different estimates at present 
set upon resection in different countries depend upon 
the value of its alternatives. In America and in Great 
Britain, certainly, even before the prevalence of aseptic 
surgery, resections were almost confined to 
those classes whose circumstances did not al- 
low them the best kind of conservative treat- 
ment. .The same, we think, is at least meas- 
urably true of other countries, and wherever 
joint-diseases are very common among the very 
poor, then operative procedures are not only 
much more frequently resorted to but are also 
much more necessary than they would be un- 
der more fortunate circumstances, 

The znstruments necessary for resections of 
joints are essentially the same as those for 
other operations on bone. 

For the division of the soft parts and the 
denudation of the bone are required knives, 
periosteotomes, and retractors. The knife 
should be strong and broad-bladed, the handle 
roughened to assure firmness of grasp (Fig. 
3245). It is sometimes convenient to have the 
handle terminate in a periosteotome (Fig. 3246), 
but in operative surgery, as in other mechani- 


cal arts, combination-tools are usually annoy- yy. 3950. 
ances, and perform no one office really well. 
Periosteotomes are of very various patterns. The es- 


sentials of a good one are that it shall be strong enough 
for its work, its handle sufficiently large and rough, its 
edge sharp enough to avoid any contusion of tissues, and 


175 


Resection. 
Resection, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


to easily and completely remove the periosteum, while it 
shall not be so sharp as that of a knife or any instrument 


intended for cutting the soft parts. Figs. 3247 
and 3248 represent tyo patterns much used in 


DORADA OOOO 
JU REVMOERS & OL 
Fie. 3251. 


this country. The latter is Sayre’s “ oyster-knife,” and 


when the edge has just the right degree of sharpness, it 
is a very efficient instrument. Ollier’s periosteotomes re- 


semble dull chisels and flattened gouges. 
Retractors may be of thin German silver (Fig. 3249) or 


Fig, 3252. 


of steel (Fig. 8250), the latter being made of various pat- 
terns with sharp or blunt points. Those which give the 
most certain control of, while doing the least injury to, 
the parts, are the best. 

For the removal of the bony parts various forms of 
saws and of cutting and holding forceps are required. 


Fie. 3253. 


The ordinary amputating saw (Fig. 3251) is quite suffi- 
cient for most operations on the larger joints. Occasion- 
ally other forms of saw are convenient. The chain-saw 
(Fig. 3252) is useful where it is desired to sever the bone 
without raising it from its bed in the tissues ; as, for in- 
stance, the neck of the femur in excision of the hip. In 


~.2 oa 


WOE Seer ce AM aol 
LEO THN, 


<-->? 2. 


Fia. 3254. 


some situations the small saw with movable back (Fig. 
3258) is very convenient, as is the key-hole saw (Fig. 3254). 
Butcher’s saw, with its thin rotating blade, or the sim- 
ilar instrument of Szymanowski (Fig. 3255) is rarely de- 
manded, although useful where cuts of curved or varied 
For the division of small 


directions are to be made. 


Fra. 3255. 


bones the cutting forceps, either straight (Fig. 3256) or 
bent (Fig. 3257), are often handier than any saw. Cut- 


tant vessels and nerves, and wherever possi- 


gnawing, or rongeur, forceps (Fig. 3260) are necessary 
for the removal of the edges of bone and of diseased 
ee Parts not otherwise acces- 
tie sible. For this last object 
gouges, to be used by hand 
(Fig. 3261) or driven by 
the mallet (Figs. 38262, 
. 3263, and 3264), are 
am very useful. Se, too, 
Sy are bone-scoops (Figs. 
Sey 3265 and 3266), and 
occasionally the chis- 
el (Fig. 3267). For 
removing detached pieces of bone, and 
for steadying the parts, the holding for- 
ceps (Figs. 3268 and 8269) are needed. 
For the last-named purpose the “‘ lion- 
jaw” forceps of Ferguson (Fig. 3270), 
or that of Farabeuf, are preferable. 
When the bony parts are to be 
fastened by gut or wire, drills (Fig. 
3271) are necessary to the introduc- 
tion of the suture, 
and if nails are to 
be used for the pur- 
pose, it is better to 
make with the drill 
a preliminary chan- 
nel to guide them. 
The elaborately 
planned and care- 
fully executed resections of to-day 
could scarcely have existed previous 
to the use of anesthetics ; the facil- 
ity and certainty of their performance have 
been immensely increased by the Esmarch 
bandage; and their danger 
reduced to a minimum by ~ 
aseptic methods. It is as- 
’ sumed in what follows that, 
wherever necessary, these \ 
adjuvants to success will be 
employed. Whatever asep- 
tic precautions and dressing 
are used, they should be 
those in which the operator 
has faith and with the de- 
tails of which he is familiar. 
In the hospitals of this city (New York), in 
bone-surgery, the favorite method seems to 
be the bichloride of mercury 
for douching; iodoform and iodoeform 
gauze for the wound-application, and iodo- 
form or bichloride gauze for the envelopes. 
i It is convenient and efficient. 
ie | The general law of surgery, to do the least 
: possible damage to the parts consistent with 
the full accomplishment of the end sought, 
emphatically applies to joint-resections. 
To extirpate the disease or to remove the 
sources of danger is the surgeon’s first care, 
to impair the functions of the part as little 
as possible his next. To the 
A ied accomplishment of these ends /{ 
-esov. —_ certain general rules of proced- |) } 
ure hold good, whatever joint is the seat of | 
operation. It may save needless repetitions 
if some of 
theseare con- 
a sidered in 
M\, this place. 
Incisions. 
—Al1l inci- , 
sions should be so made as to avoid impor- 


Fie. 3256. 


Fia@. 3257. 


Fie. 8258. 


LY 


ble they should avoid muscles and tendons. *%* eat 
The latter requirement can usually be accomplished by 
using the intermuscular spaces as avenues of approach to 


ting forceps of various shapes (Figs, 3258, 3259), andthe | the bone. When a muscle must be cut, let the incision 


176 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Resection, 
Resection, 


as far as possible follow the direction of the fibres of that 
muscle, avoiding its nerve. The situation of an incision 
is often determined by pre-existing wounds or sinuses. 
Simple incisions are preferable, but should not be adhered 
to to the embarrassment of the operator ; broken incisions 


SS — 
= =< 


Fie. 3261. 


or transverse cuts may sometimes be demanded for con- 
venience. All incisions should be ample, without being 
excessive ; if the previous rules are observed a long inci- 
sion is of no harm. Two or more independent incisions 
are often convenient. It is often possible to make an in- 
cision, in a sense exploratory, which will be sufficient for 
arthrotomy, resection, or amputation, as the 
condition of the explored parts may demand. 
Usually the same incision that traverses the 
overlying parts divides the capsule also. The 
same rule as regards extent of incision, 7.¢., 
ample but not excessive, applies to the capsule 
as to other soft: parts, if it is intended to pre- 
serve the mobility of the joint. 

Tendons should be preserved in their entirety, 
and if possible remain undisturbed in their 
sheaths, and their insertions carefully dissected 
away from the bone if the latter is to be re- 
moved. Or, what in many places is preferable, 
_asmall piece of bone may be chipped or pried 
off attached to the tendon. If by accident or 
through necessity a tendon is divided, suture of 
it with catgut is desirable; but the fact that sut- 
ure of tendons is often successful should not be 
made a ground for unnecessary injury to them. 
The occasional surprising restoration of a de- 
stroyed or lacerated tendon, and the success 
following the interposition of a leash of catgut 
or a piece of animal’s tendon in the interval 
when the divided ends could not be approxi- 
mated, should encourage the surgeon to every 
endeavor to preserve the functions of tendons. 
The management of the soft parts during the 
operation deserves a word. One often sees during an 
excision the operator or his assistants, intent upon denud- 
ing and removing the bone, maltreat the soft parts, for- 
getful of the processes of repair. The tissues are over- 
strained to make room which could have been more easily 
obtained by a more generous incision ; they are torn with 


C.T/EMANN &CO0. 


Fie. 3262, 


As sharp retrac- 
= a | or or ped 
G.TIEMANN &CO. WW ee, 

ones, some- 


Fie. 3263, : 

times lacerat- 

ed by the violence with which the bone to be sawn is 

thrust out, and lastly they are teased and nicked by care- 

less sawing. Such errors only need to be pointed out to 
be corrected. 

How the periostewm shall be dealt with is still an open 

question among surgeons, Many operators ignore it, or 


6. TIEMANN &C 


Fria. '8264. 


pay little attention toit. The bone having been reached 
in an operation, it is neatly cleared of the soft tissues 
by sharp or blunt dissection, with no especial care to 
save the periosteum. The advocates of the sub-periosteal 
method, on the other hand, insist upon the careful preser- 
vation of this membrane. Against the method it has 
been urged that it is difficult and tedious in execution, 


Vou. VI.—12 


and that it has not given better results than the other 
plans (which Ollier styles the parosteal). Further, it has 

been accused of favoring anchylo- as 
sis of the excised joint. It is ad- 
mittedly a slow method, but exci- ° 
sions are'rarely undertaken upon 
patients whose condition demands 
speed in operation. 

Ollier is perhaps the most ar- 
dent advocate of the preservation 
of the periosteum intact, although 
he has the support of other emi- 
nent surgeons, prominent among 
whom are Langenbeck in Ger- 
many, and Sayre in America. 
The former claims? for his method 
that, by going directly to and 
through the capsule, and then 
carefully turning back the perios- 
teum with all its overlying tissues 
undisturbed, the traumatism is re- 
duced to a minimum ; that the en- 
velope left after the removal of the 
bones, which he styles the perios- 
teo-capsular sheath, ig at once a 
a protection to the soft parts and a 
fa Support to the bones, retaining the 

# latter in more normal relations 
@ during the reparative process ; and 
that the reparative process is itself 
y much more efficient, and that the 
f functional results are much better 
than can be obtained by the other es 
maintains Fie. 3266. 


ae 


¥ OXVZVH ‘ay 


_ AN GYOS -1'M‘09 


L/ method. He further 
Fie. 3265, that the method, if time is allowed, = Hebra's 


is not difficult. Making all allow- 
ance for enthusiasm, it would seem that these claims are 
mainly sound. The chief point, namely, that better 
functional results are obtained, is the very one that is 
difficult of proof. Excellent results have been obtained 


G.TIEMANN & CQ 
Fig. 3267. 


by both methods. One man’s results can with difficulty 
be compared with another’s ; the conditions under which 
they are obtained may also vary exceedingly. It is, 
however, fair to say, in estimating the value of the sub- 


periosteal method, that many 
operations done under that name 
are so imperfect as to be worth- 
less as such. The method as 
employed by Ollier is most care- 
ful in details, and the after-care 
is prolonged and remarkably at- ff 
tentive and painstaking, so that @ 
one is left in doubt whether the X 
excellent success in some cases ‘ 
is due to the operative procedure or the after-treatment. 
Ollier detaches the periosteum by means of instru- 
ments (rugines) much sharper than the periosteal eleva- 
tors ordinarily in use. They are comparable in this 


Big 


Fie. 3271. 


Resection. 
Resection. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


respect to dull chisels, but are made of various shapes. 
He maintains that the periosteum should be lifted in its 
entirety by very careful to-and-fro motions of the tool, 
and that this can only be accomplished by a rather 
sharp instrument; a blunt one usually tearing the mem- 
brane, bringing away its fibrous part more or less lacer- 
ated and shredded, and often leaving behind the bulk of 
the osteogenetic layer, which alone is valuable for repro- 
duction of bone. To make sure of the removal of this 
layer, the elevator must be sufficiently sharp and strong 
to chip the bone when necessary, and whenever he en- 
counters a small prominence or a dimpled surface which 
is very difficult to enucleate, he slices off a bit of bone 
with the periosteum, and later on detaches it from within 
if desirable. Asa rule, however, such pieces of bone, if 
sound and firmly attached, may be well left as aids in 
the restorative process. <A corollary of this last detail 
is the practice, already alluded to, of leaving a small 
piece of bone, if sound, at the point of insertion of a 
tendon. Every pains is taken to avoid tearing the per- 
iosteum or detaching it from its overlying tissues. The 
same care is exercised in detaching fragments of bone 
which must be removed in.a resection for injury. The 
whole technique of denudation may be expressed in one 
; phrase: When the elevator has reached the 
? bone, it should never leave it until its work is 
: done. This, in brief, is the sub-periosteal 


eocen---- 


mies 
' 
' 
' 
ee 


an operator, it will be readily distinguished 
from the manceuvres so named in which the 
periosteum is left behind asa mass of half- 
connected shreds. In practice it is worth the 
operator’s consideration, to be employed if he 
thinks he is able in the given case to properly 
carry it out. 

The bone to be removed having been de- 
nuded by whichever method is selected, it is 
to be sawn. The slice removed should be, as 


DA tlle 
. 

-_—--—e 
- ee eee 


‘\ 
s 


plissar s 


i] 
I 
I 
I 
1 
t 
! 
' 
an | 
inv 
i\t 
{Ab 


Fig. 3272. 


a rule, as thin as possible. In most joints the 

end of the bone may be made to protrude 
through the incision, and the saw is applied outside. If 
more than one bone is to be sawn, that which is more 
easily thrust out is sawn first. Great care is to be exer- 
cised against unintentional stripping of the soft parts 
‘from the bone, although periosteum will generally re- 
unite if kept aseptic. Whatever form of saw is used the 
soft parts should be perfectly guarded, and metal retrac- 
tors are usually most convenient and efficient. The saw- 
cut, especially in places where important vessels or nerves 
lie near, and more particularly when the bone is not pro- 
truded, should not be carried absolutely through the 
bone, but when it is nearly done the sawing should be 
slowed, and the fragment be broken off with a pair of 
forceps or the fingers, or by simply raising it by tilting 
the blade of the saw. The edge is subsequently trimmed 
with the cutting forceps or chisel. If the chain-saw be 
used this last precaution is not so necessary, as the cut 
comes toward the operator and away from the parts en- 
dangered. The chain-saw can easily be introduced by 
tying the free end to an eyed probe, or to a curved nee- 
dle, which is then carried beneath the bone. ‘Before be- 
ginning to saw, the chain should be carefully straightened, 
as any kink pretty certainly causes it to break. A com- 
mon error in its use is the bringing of the two handles too 
near together, making too short a turn around the bone, 


178 


method, and whether it is preferred or not by | 


which also favors breaking. The hands should be widely 
separated, so as to make but a slight angle in the chain as 
it cuts the bone. It is drawn to and fro very steadily, 
the chain being always kept taut between the hands. 
While convenient in certain cases, it is a far less perfect 
tool than the common amputating saw. <A very conven- 
ient instrument for sawing bone 77 sztu is the ‘‘ Exsector”’ 
(Fig. 3272), devised by Gowan, and modified in this coun- 
try by Wyeth. It combines a powerful grasping forceps 
with asaw. The latter is at the end of an instrument 
shaped somewhat like an ordinary screw-driver ; it passes 
through a guide, which again turns on a pivot. The 
bone-end to be sawed is tightly grasped by the forceps, 
the saw pushed through the guide until it touches the 
bone, the handle is moved forward and backward, and 
the saw-end rapidly cuts the bone cleanly and safely. 

In the removal of some joints various devices of co- 
aptation, by sawing the bones into particular shapes— 
notches, mortise and tenon, etc.—have been employed. 
They have their advantages, but should not be employed 
at the expense of sound tissue, and the operator must 
be prepared to make his decision after he has seen the - 
parts to be removed. 

The bones having been sawed, the surfaces are critically 
examined by eye and touch, to ascertain if the entire 
amount necessary has been removed. If the resection 
has been made for disease, this examination reveals any 
point of bone actually or probably diseased. If found, 
they are removed by the gouge, chisel, or scoop. If very 
extensive, a second slice may need to be removed by the 
saw. All suspected bone, at least in cases of tubercular 
disease, should be extirpated. It should, however, be 
borne in mind that the artificial anzemia produced by the 
elastic bandage may give to the bony surface such a pale 
or grayish color as to lead to an unduly wide condemna- 
tion of bone ; in case of real doubt, the elastic band may 
be loosened. The edges of the bone being made smooth, 
if, asin the knee, anchylosis is to be sought, the sawed 
surfaces are approximated, 
in order to ascertain if the 
resulting limb will have the 
right position. If motion is 
expected, a similar but less 
close adjustment is generally 
made, to judge of the prob-. 
able suitability of the new 
articulation. This latter pre- 
caution is chiefly of value 
when the excision is for the 
relief of anchylosis. Any er- 
rors in the adjustment of the sawed surfaces are then cor- 
rected by the saw or cutting instrument. 

The bones being satisfactorily arranged, the synovial 
membrane is next attended to. All fungous parts are 
cut away with scissors or scraped with the sharp scoop. 
As these fungosities are believed to be usually tubercular 
in their nature, the extirpation cannot be too thorough. 
If anchylosis is expected, the whole membrane may as well 
be dissected away, and in any case of doubt it is safer to 
err on the side of thoroughness. The actual cautery and 
some cauterants have been used, but their proper place, 
as applied to synovial membrane, seems to be where the 
spoon or scissors cannot be employed. As to how far 
this extirpation should be pushed beyond the synovial 
membrane—that is to say, to what extent the capsule and 
ligaments should be sacrificed—authorities are not agreed. 
Although assent has been given above to the doctrine of 
thorough extirpation, it cannot be denied that it has 
sometimes been applied toorigorously. In each step com- 
plete examination should precede destruction. 

Extirpation completed, the vessels are to be looked 
after. Some may have been recognized as exposed or 
cut, and twisted or tied at the time. The removal of the 
Esmarch bandage will reveal any other bleeding points, 
which will be secured in the usual way, and a hot anti- 
septic solution will check the oozing. Some operators, 
when sure that no considerable vessel has been hurt, do 
not remove (from some joints, at least) the Esmarch band- 
age until the wound is entirely dressed and the limb has 


REFERENCE HANDBOOK OF 


been placed upon its temporary splint. By so doing the 
pressure diminishes the amount of oozing, and the de- 
mand for drainage is less. 

But in all cases the drainage must be thorough and 
complete. The position of the drains should be in such 
places as to drain the wound whatever position the pa- 
tient may occupy. Bone-drains are much used for the 
purpose. It often occurs that after a few days no tubes 
are needed, and they may be withdrawn and the joint 
enveloped in its permanent antiseptic dressing. Ollier, 


whose technique is characterized by the most anxious 


carefulness, prefers to make his drainage-incisions at the 
start, because the relations of parts are then undisturbed, 
and less risk of damage is incurred by making them 
from without inward thus early. Few operators, how- 
ever, can tell in advance the extent of the operative cav- 
ity that will require drainage with sufficient accuracy to 
thus early place the drains, and the usual method of wait- 
ing till they are needed is, on the whole, probably prefer- 
able. 

When anchylosis is sought it is more certainly gained, 
both as to solidity and as to position, if the parts are se- 
curely fastened together. As will be shown later, such 
fivation is not absolutely necessary, but is of great con- 
venience. Ordinary suturing materials—silk, catgut, 
and the like—will serve in case of need; but usually 
pretty stout wires, either iron, silver, copper, or silvered 
copper, are employed. ‘To introduce them, bone-drills 
are necessary. In using the drill it should be carefully 
passed through one of the bones from its outer surface, 
beginning an inch (more or less according to the size of 
the bone) from the sawed surface, in a diagonal direc- 
tion, so that it perforates the sawed surface sufficiently 
far from the edge to insure a strong hold. The bones 
are then placed together in the desired position, so that 
the point of the drill may show where the other bone 
must be drilled, and a hole carried from this point out to 
the surface of the second bone. In this way channels for 
two or more sutures in the best positions for insuring 
firmness are made, and the wire, carefully straightened, 
is carried through.. When all are in place the surfaces 
of the bones are approximated and the wires tightened, 
and when the former are in the desired position the wires 
are made as tight as possible and twisted. To avoid diffi- 
culty in removal, it is usual to adapt a fixed way of twist- 
ing, say from left to right, and to make a certain number 
of twists, of which a memorandum is kept. This renders 
the untwisting at the time of removal certain, and no 
doubt remains in the mind of the operator as to whether 
he has completely untwisted the wire, or has overdone it 
and begun to retwist it in the opposite direction. It is 
now well known, however, that an aseptic wire may be 
safely left in the tissues, and the precautions above de- 
scribed to get rid of an irritant which tended to prolong 
the suppuration always attending a resection are now no 
longer really necessary. 

A still further improvement is the use of nails instead of 
wire to fasten the bones together. They are easier to intro- 
duce, and much easiertoremove. Nails for the purpose 
are made by the instrument-makers, and are sometimes 
plated, an unnecessary refinement. It is an advantage 
that they should be of steel rather than of iron, as strength 
and rigidity can be thus had without undue thickness. 
They may be of round or square wire, and should be very 
smooth, in order that they may be the more readily made 
aseptic. ‘They should be of good length, in order that 
after the necessary penetration for security is had some 
part of the nail may project through the soft parts to 
render its removal easy. Preparatory channels are made 
with the bone-drills, starting from various points on the 
outer surface of one bone and carried straight on into the 
other, the two being held in juxtaposition meanwhile. 
The directions of the nails must not be parallel, in order 
to prevent the bones drawing apart. This may be as- 
sured by introducing the nails diagonally from two or 
three different aspects of the bone. The nails, which 
should be very slightly thicker than the drills, are driven 
into the prepared holes. 

Still more convenient are the drills (Fig, 8273) of Dr, 


Resection. 
Resection. 


THE MEDICAL SCIENCES. 


Wyeth. They are set ina movable handle. The long, 
slender shaft is readily introduced, and the handle is then 
detached, and the drill serves as a nail until the time for 
its removal arrives. 

Howard Marsh® recommends the use of bone-pins— 
bone knitting needles will serve very well—for fastening 
the bones. It is not necessary to withdraw them if it is 
not perfectly convenient to do so. 

Whatever method of fixation is employed, great pains 
should be taken to exclude everything from between the 
sawed surfaces of the bone, whether it be folds of tissue, 
drainage-tube, or anything else. 

In closing the operation-wound, if there be fair reason 
to expect prompt union, it should be neatly closed except 
at the drainage-apertures. If, after the extirpation of the 
disease, the capsule of the joint has been left behind its 
cut edges may be sewed together with catgut before the 
outer parts are sutured. If anchy- 
losisand consolidation are looked for, 
the superabundant tissues may be 
brought together both by deep and 
superficial continuous sutures. 

Indications.—The indications for 
resection vary somewhat with dif- 
ferent joints, but the general rules 
are the same for all. For chronic 
fungous disease excision is indicated 
when expectant treatment has failed, 
and no less extensive operation is 
sufficient to arrest the progress of 
the disease. Just what condition of 
the joint justifies the opinion that 
expectancy has failed will vary ac- 
cording to circumstances presently 
to be referred to. But excision 
should not be considered as a sub- 
stitute for, or alternative of, expec- 
tation ; it may be its sequel in case 
of failure. This cannot be too 
strongly insisted on, in view of the 
tendency of some surgeons to look 
upon excision as a short road to the 
cure of chronic joint disease. Nor 
should the opposite error be adopt- 
ed, of believing that because among 
the well-to-do excision is of the 
greatest rarity such operations are 
uncalled for elsewhere. In America 
an intelligent and efficient expectant 
treatment of joint diseases by rest, 
fixation, and traction has been so 
long established that it may seem 
idle to discuss this point.. Not only 
among the prosperous or comfort- 
able classes is the expectant plan 
successful, but the result of work 
done among the poor by the special 
dispensaries and at clinics is on the 
whole very satisfactory. But there 
is, and probably always will be, a 
certain proportion of cases that cannot or do not get 
good expectant treatment, or in which it fails. In con- 
sidering the indication in these cases it is quite irrelevant 
to urge the success that has attended expectancy in more 
fortunate ones; they must be considered by themselves. 
If there is necrosis with a sequestrum of such size as will 
not readily pass through a fistula, some operative pro- 
cedure is imperative. But the existence of neither sup- 
puration nor caries, nor the lapse of any particular 
amount of time, is of itself an indication for resection. 
safe rule is this: If, in spite of the best hygiene and the 
best care that the patient can command, either at home or 
in charitable institutions, suppuration exists and persists ,; 
if there is with it fever, or if the condition of the patient 
is deteriorating, operative interference of some kind is 
indicated—either resection or some of its substitutes. It 
is evident that the decision will be often determined really 
by what are called the extra-medical indications—that 1s 
to say, by the social status of the patient, by what com- 


179 


WAFORDNY, 


* HAZARD, HAZARDS co. 


Fie. 3273. 


Resection. 
Resection. 


forts he can command during prolonged expectant treat- 
ment, and by the necessity of the use of the affected joint 
in earning his living. 

As against amputation, excision is always to be pre- 
ferred in civil practice, unless the extent of disease threat- 
ens that the saved limb will be more useless than a stump 
would be. As against arthrotomy, with the removal of 
diseased tissue in an informal manner, no certain rule can 
be given. Such operations frequently succeed, but re- 
lapses demanding excision are also not rare. If the bones 
be diseased, the removal of the affected parts piecemeal 
may make a practical resection under another name. The 
indications for such procedures are very different for dif- 
ferent joints, and will be alluded to under those head- 
ings. The general rule, however, is that in children, and 
especially young children, informal resections are to be 
preferred, the shoulder and hip, perhaps, making excep- 
tions to this rule. 

There have been for some time, particularly among 
German surgeons, many advocates of early excisions. 
The failures after operations have been considered as 
largely influenced by delay in operating, and in recent 
years theories as to the tubercular nature of joint dis- 
eases and the success attending aseptic surgery have 
tended in the same direction. It is held that since fun- 
gous joint disease is tuberculous, extirpation is the readi- 
est if not the only certain way of curing it, and at the 
same time is a safeguard against the generalization of 
tuberculosis. So that by a single operation the danger 
to life is diminished and time saved. The tuberculous 
nature of most fungous joint disease may be conceded, 
but it is impossible to set inferences regarding the results 
of tubercular disease against general clinical experience. 
The latter shows us that, taking one country with an- 
other, such joint diseases in the majority of cases do re- 
cover without serious operative interference. The vital 
indication for early excisions therefore fails, unless it 
can be shown that a larger proportion of cases are cured 
with excision than without. This has not been shown. 
Further, it has not been shown that excision, even with 
antiseptic precautions, has diminished the tendency to 
other tuberculous diseases. The most considerable con- 
tribution to this question is Konig’s.* Of 117 excisions 
of all sorts, made during three and one-half years, 25 
died ; 18 from tuberculosis, while 9 others still alive were 
hopelessly tuberculous. Other less extended lists give 
similar results. The tubercular infection of the opera- 
tion-wound is common, although such affections very 
often yield to secondary extirpation. The operative 
procedure not rarely explodes some remote tubercular 
trouble—meningitis, pleurisy, etc.—following within a 
few days of operation. In respect to tubercular infection 
of remote parts, the results gained by aseptic surgery 
have been little, if any, better.than were had before. 

The existence of pulmonary tuberculosis is generally 
held to be a contraindication of any resection, but the 
rule is not absolute. When the pulmonary lesion 
seems to be secondary to the joint trouble, quiescence of 
the former occasionally follows the removal of the latter. 
If the pulmonary tuberculosis is primary, resection is 
only mischievous. 

In acute suppurative arthritis, the success of antiseptic 
arthrotomy bas been such as to make it preferable to ex- 
cision of the joint. It should, at least, be tried in ordi- 
nary cases before resorting to the latter operation. 

The results of resection for gunshot fractures of joints 
are so different in military surgery from those done in 
civil practice, and vary so much with different joints, 
that the indications must be given under each head. The 
same will be done for resections for deformity. 

Aseptic methods have diminished the objections, for- 
merly valid, to partial resections, and in gunshot resec- 
tions the informal, or untypical, methods are usually 
preferable. 

Trophic disturbances of the limb, as distinguished 
from simple atrophy of inactivity, seem to be more com- 
mon after gunshot resections than after operations for 
pathological causes. 

RESECTION OF THE SHOULDER-JOINT has been long 


180 


‘ 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


established as a standard operation of surgery. Extrac- 
tion of fragments of the head of the humerus after gun- 
shot injury had been done for some years, when Charles 
White,’ of Manchester, England, in 1768, removed, as 
he believed, the head and part of the shaft for disease. 
James Bent, of Newcastle, England, published, in 1774 ° 
an account of a true excision of the head of the humerus 
for disease. He pointed out the fact that Mr. White had 
not removed the head, and that the bone removed at the 
first operation ended at the epiphyseal line. White’s re- 
port and plate seem to justify this criticism, although his 
claim was made in good faith. Bent (1771) or Lentin 
(1771), probably, should have the credit of priority. The 
first complete excision of the shoulder is attributed to the 
elder Moreau (1786). Larrey seems to have first introduced 
excision of the shoulder into military surgery in the Egyp- 
tian campaign (1798). Thereafter the operation gained 
in professional esteem, and on the Continent its value 
may be said to have been established by the experience 
of the Schleswig-Holstein campaign of 1848, the Crimean. 
war (1855), and in this country by our own war (1861-65). 

Owing to the relative infrequency of disease of the 
shoulder,* as compared with other joints, operations for 
disease are far less numerous than for gunshot wounds. 
Culbertson collected: 855 cases of excision for gunshot 
wounds, 12 for other injuries, and 116 for disease. 

The mortality of resection for gunshot injury of the 
shoulder-joint is not relatively high, being, according to 
Culbertson, for all operations, complete and partial, 31.44 
per cent., most of the observations belonging to the pre- 
aseptic period. Operations for disease give a still smaller 
mortality. The same author gives (omitting cases of 
malignant disease) 101 cases, with 16 deaths, or 15.84 per 
cent. Otis’ gives the comparative mortality for gunshot 
injuries of the shoulder thus: ‘‘Of 2,369 determined 
cases, 577 were treated by expectancy, with a mortality of 
25.1 per cent.; 951 by excision, with a mortality of 36.6 
per cent.; 841 by amputation, with a mortality of 29.1 per 
cent.—in all, 738 cases terminating fatally, or 31.1 per 
cent.” The statistics of more recent wars, as far as at- 
tainable, seem to show no great variation from the above. 

In civil practice, under modern methods, resection un- 
doubtedly gives a smaller death-rate, but no extended 
statistics can be given. 

Results.—While it appears that the immediate mortal- 
ity of resection of the shoulder-joint is somewhat greater 
than that of amputation for gunshot injury, the incom- 
parably better result—the saving of an arm—in case of 
success, has made resection of the shoulder one of the tri- 
umphs of military surgery. 'To escape amputation is to 
save a hand and elbow, even if the functions of the shoul- 
der-joint are seriously impaired. Gurlt® gives the func- 
tional results of resections made in German wars between 
1848 and 1871. He divides them into five classes: I., 
‘“very good,” those which are perfect or as perfect as is 
possible ; II., ‘‘ good ” results, not perfect, but members 
very useful; III., ‘‘ middling,” members of some use, but 
perhaps needing artificial support; IV., ‘‘ bad,” members 
not useful; V., ‘‘ very bad,” not only not useful, but bur- 
densome. Of 213 cases of shoulder resection, the per- 
centage of results is: L, 1.87; IT., 42.25; IIL, 47.88: 
IV., 7.98; V., 0; or, roughly, good, 44 per cent. ; mid- 
dling, 48 per cent. ; bad, 8 per cent. Remarkably useful 
shoulders are sometimes obtained, as witness cases figured 
by Langenbeck,® or the case reported by MacCormac”® of 
a Chasseur d’Afrique injured at Sedan from whom, 
twelve days later, he removed the shoulder and elbow 
joints of the right arm. The strength and utility of the 
arm were remarkable (see Fig. 3274, showing limb pas- 
sive and active). 

A common imperfection of result, both at the shoulder 
and elbow, is preternatural mobility, or ‘‘flail-joint.” In 
spite of this want of firmness at the shoulder, the arm is 
often very useful. Gurlt found, in the cases before al- 


* The writer has added the lists of several hospitals, American and 
foreign. Of 1,368 cases of joint diseases, 22 only were of the shoulder— 
less than two per cent. In one hospital, for one year, there were,10 out 
of 320 cases; in another, only 5 out of 540—that is, about three per cent. 
of all cases for the highest, one per cent for the lowest, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Resection, 
Resection, 


luded to: Closely knit joints, 45.07 per cent.; flail-joints, 
35.68 per cent. ; anchylosed joints, 9.86 per cent.; un- 
known but not anchylosed, 9.39 per cent. There is little 
doubt that the careful sub-periosteal resections urged by 
Langenbeck and Ollier give much better results as to 
flail-joint, as well as in other respects, than the older meth- 
ods. Not only is the muscular structure less damaged, 
but the reproduced bone gives a better point d’appui, the 


Fic. 3274. 


loss of which has been considered a main reason for the 
difficulty in raising the arm above the horizontal. 

Indications.—The experience of the war of the Rebel- 
lion and of the German wars between 1848 and 1871, as 
analyzed by Otis! and Von Langenbeck,!? goes far to settle 
the indications in gunshot injury of the shoulder. If the 
injury is slight, expectant treatment is justifiable, even if 
a secondary resection becomes subsequently necessary. 
In cases in which a part only of the head has been broken 
off by the shot, partial excisions, 7¢.e., removal of the in- 
jured part only, have succeeded. If extensive (commi- 
nuted) fracture of the head exists, or the ball is impacted, 
the main vessels and nerves being sound, primary resection 
is indicated. 
of the clavicle, or of the neck, or processes of the scapula, 
or of the upper third of the humerus, do not necessarily 
contraindicate excisions at the shoulder” (Otis). Nor, ac- 
cording to Langenbeck, does shattering of the shoulder- 
joint with laceration of the soft parts necessarily indicate 
exarticulation, but rather a secondary resection. ‘‘ Inter- 
mediary resections should seldom or never be practised ” 
(Otis). Injury of the axillary nerves and vessels compli- 
cating shot-wound of the shoulder usually calls for exar- 
ticulation. 

Resection has also been held as indicated in compound 
dislocation, in compound fracture with protrusion of 
fragments, and in some forms of laceration of joint-struct- 
ure. The success of aseptic dressings, however, has 
made these indications less distinct than formerly, and 
if reduction can be accomplished and asepsis insured, 
the surgeon may decide between resection, or the aseptic 
expectant treatment and subsequent osteotomy in case of 

too rigid anchylosis resulting. 

* For fungous arthritis resection is demanded when ex- 
pectant treatment has not succeeded and the strength of 
the patient is failing. There is then a vital indication 
for interference. If on the joint being opened the bony 
parts are found to be not involved to any extent, gouging 
and scraping may suffice, but the relative advantages of 
informal operations over the formal are not so great at 
the shoulder as in some other articulations. The great 


“* Concomitant fractures of the acromial end — 


success of resection justifies its use in any case in which 
there exists much risk to life from exhaustion or from the 
sequels or complications of prolonged suppuration. Func- 
tionally, the results of resection are not so much superior 
to those of cure by anchylosis, more or less complete, as 
might be at first thought. Owing to the mobility of the 
scapula, a great deal of motion is permitted to the arm, 
even if no motion takes place at the shoulder proper, and 
in some excellent results with motion after resec- 
tion the portion of the mobility furnished by the 
sliding scapula has been found to far exceed that 
in the joint itself. This is, however, not always 
true, but the facts stated have led some surgeons 
to advocate the securing of cure by anchylosis if 
practicable, rather than by resection, and to make 
subsequent osteotomy, if necessary, as before men- 
tioned. This supplementary mobility being great- 
est in the very young, the age of the patient may 
determine the surgeon’s choice of procedure. 
Methods,—Very many forms of incision have 
been employed for the removal of the head of the 
humerus, such as the V, the U, the T, the 7, single 
or double and inverted, and others, but practically, 
when the surgeon has a choice, all have now given 
place to the anterior longitudinal incision. The 
injury, particularly if a gunshot wound, for which 
the resection is performed, may have determined 
site of the operative wound, orif the muscular the 
cap of the shoulder is already badly torn, little ad- 
ditional damage will be done by making use of the 
same opening for the removal of the bone. But 
in the operation for disease, or whenever the sur- 
geon may choose, the straight anterior cut is to be 
preferred because of the less injury it inflicts upon 
the muscles. The two varieties of this incision 
are Langenbeck’s and Ollier’s. Langenbeck’s orig- 
inal procedure has been modified by him so as to 
become a sub-periosteal method. The first is as 
follows:!? The patient lies upon his back, with the 
shoulder raised upon a pillow ; the arm is held so that 
the external condyle of the humerus is directed forward. 
An incision, beginning at the anterior border of the acro- 
mion, quite close to its articulation with the clavicle, and 
running for six to ten centimetres (24 to 4 inches) vertical- 
ly downward, divides the deltoid muscle and reaches the 
capsule of the joint and the periosteum (Fig. 3275). The 
muscle is retracted on both sides 
of the incision ; the tendon of the 
long head of the biceps is seen ly- 
ing within its sheath. An incision 
along the outer side of the tendon 
opens its sheath ; the knife is di- 
rected upward with the back of 
the blade in the bicipital groove, 
and divides the whole length of 
the sheath, together with the cap- 
sular ligament up to the acromion. 
The tendon of the biceps is lifted 
out of its groove and drawn out- 
ward with the blunt retractor. 
While the assistant rotates the arm 
outward, a curved incision, with a 
strong knife placed at right angles 
upon the bone, is carried around 
from the opening in the joint over 
the lesser tuberosity, dividing the 
capsular ligament and subscapu- 
laris muscle. The arm being again 
rotated inward, the tendon of the 
biceps is also drawn inward over the head of the bone. 
The knife is again carried around in a larger circle over 
the greater tuberosity and divides the capsule together 
with the insertions of the supra-spinatus, infra-spinatus, 
and teres minor. The head of the humerus is forced out 
of the wound by pressure from below, seized with the 
forceps, and after the posterior insertion of the capsule 
has been divided, removed with the keyhole saw. When 
the head of the humerus is separated from the diaphysis by 
the bullet, it must be drawn forward, and fixed by a sharp 


181 


Fia. 38275. 


Resection. 
Resection. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


bone-hook or bullet-screw. If shattered in many pieces, 
the fragments are removed separately. 

Better results, however, are obtained by the use of the 
sub-periosteal method. The incision, described in the 
paragraph but one above, having been made, the perios- 
teum is divided with the bone-knife along the inner 
border of the bicipital groove, and carefully raised with 
a narrow elevator from the lesser tuberosity... The tendon 
of the subscapularis is pulled from the bone with the 
knife and toothed forceps, without separating the fibrous 
capsular ligament from the liberated periosteum. Dur- 
ing this part of the operation the humerus must be slowly 
rotated outward, and as it becomes more and more liber- 
ated, the knife is frequently changed for the elevator. 
The arm is rotated inward again, the tendon of the bi- 
ceps lifted from its groove, and slipped over the head of 
the bone to its inner side. The periosteum on the outer 
surface of the neck of the humerus, together with the 
insertion of the supra-spinatus, infra-spinatus, and teres 
minor into the great tuberosity, are detached in the same 
manner as before. This preservation of the periosteum 
is rather difficult in primary excisions for gun-shot in- 
jury, because it is usually normally so thin. The head 
of the humerus is forced out of the wound and sawn off 
as in the preceding operation. If only the head above the 
tuberosities is to be excised (which always. gives the best 
result), there can be no question about detaching the 
periosteum. Beginning from the interior of the joint the 
muscular attachments are peeled off from the bone as far 
as is requisite ; care is taken that they are not divided 
transversely, but that their connection with the bone be- 
low is preserved. The head must be removed in sdtu 
with the keyhole, or chain-saw. 

Ollier’s '* method differs somewhat from the preceding, 
and is as follows: The elbow is abducted nearly to a 
right angle. The incision is made in the interspace be- 
tween the pectoralis major and the 
deltoid, or, if this is not easily recog- 
nized, from the point of the coracoid 
process downward and outward in the 
direction of the fibres of the deltoid. 
If the border of the del- 
toid is recognized the in- 
cision should slightly en- 
croach upon the muscle 
in order to avoid the 
cephalic vein, which last 
should be left in the in- 
ner lip of the wound. 
The edges being retract- 
ed, the head of the hu- 
merus is exposed. The 
capsule is opened by 
Fig. 3276.—Ollier's Incision. A, the carrying the incision 

principal incision ; B, cross incision if throu gh it outside of and 

ot. for excision of glenoid cav- p arallel to the tendon of 
cee the biceps (long head). 
The same incision divides the periosteum as far as re- 
quired. The outer lip of the wound is raised, the perios- 
teum detached by the sharp periosteotome, the bone being 
inverted by an assistant. All the attached muscles are 
raised with the periosteum, The arm is then everted and 
the bone denuded on the inner side. The head of the 
bone is then luxated, the posterior part of the capsule de- 
tached, the neck denuded. The bone is then sawn with 
any saw preferred. 

Afler-treatment.—No splint is really necessary, the asep- 
tic dressing and shoulder spica being sufficient, while the 
patient is recumbent. The arm should preferably be ab- 
ducted at first. If it is found desirable that the patient 
sit or walk, an axillary cushion and sling, or a plaster 
bandage will be needed for support. Passive motion 
must be begun early, as soon as the tissues are well con- 
solidated. Persistent care is essential to the best re- 
sults. 

RESECTION OF THE ELBOW appears to have been one 
of the earliest of resections, Wainman having, in 1759, 
resected the lower end of the humerus for a compound 
luxation of the elbow, and Filkin having excised this 


182 


joint for disease three years later. But like other excis- 
lons it came slowly into general use. Symes’ advocacy 
of the operation had considerable influence among British 
and American surgeons, and during the following twenty 
or thirty years it became established in civil practice ; 
while the wars on both continents from 1848 to 1871 
gave large opportunities for testing its merits in military 
surgery. 

Resulis,—Culbertson gives the following percentages of 
mortality as the result of his table of cases, mainly from 
the pre-antiseptic period. For gunshot wounds, ‘‘partial” 
excision, 27.02 per cent.; for ‘‘ complete,” 25.30 per cent. 
For injury, ‘‘ partial,” 7.40 per cent.; ‘‘ complete,” 21.05 
per cent. For disease, ‘‘ partial,” 11.11 per cent.; ‘‘ com- 
plete,” 9.94 per cent. In this classification only those 
resections are considered ‘‘ complete” in which the lower 
end of the humerus with the upper ends of the radius and 
ulna, or of the ulnaalone, are removed. Removal of head 
of the radius with the lower end of the humerus is con- 
sidered a ‘‘ partial” operation. These figures as regards 


resections for gunshot injuries are not much different © 


from those of Gurlt, who gives 27.41 per cent. for all 
operations by German operators in the war of 1870-71, 
and 26.64 per cent. for the German wars 1848-71. ‘These 
percentages with that of our own war (23.70) give a total 
percentage of mortality for all operations of 25.10; the 
complete operations giving 25.40 per cent.; partial, 23.07 
per cent.; operations of unknown extent, 30.60 per cent. 
Partial operations were much more frequent during our 
own war than in the German wars. Otis’s tables show 
that the time of operation in our war very much modi- 
fied the death-rate ; it being for determined cases only, 
primary operations, 21.38 per cent. ; intermediary, 35.2 
per cent.; secondary, 9.2 per cent.; time unknown, 8.3 
per cent. The total mortality of elbow resection in our 
war, 23.7 per cent., may be compared with that of am- 
putation in the upper arm, which was 238.6 per cent.* 
The comparatively low death-rate of operations for dis- 
ease (10.4 per cent.) for all of Culbertson’s cases will be 
noted, but no extended statistics are at hand to show how 
great the purely operative mortality is, and how much is 
to be attributed to the progress of the disease. That 
under favorable circumstances the mortality is very 
slight is shown by the fact that Culbertson gives no 
deaths for excision for deformity, and Salzman (quoted 
by Ollier) puts the mortality of resection for anchylosis 
at 1.47 per cent.t Age affects mortality, the death-rate 
being for disease least between ten and twenty years 
of age; for gunshot injury least between twenty and 
twenty-five years of age. The relative fewness of sol- 
diers under twenty, and the inability of the immature to 
bear the hardship of campaigning, account probably for 
the greater percentage of mortality between fifteen and 
twenty. ; 

The functional results of resection of the elbow are, in 
civil practice, in general, very good. The joint is not in- 
frequently nearly perfect in function, and strong enough 
for ordinary occupations, and sometimes even for labo- 
rious work. The precise degree of success cannot cer- 
tainly be made out from statistics, as in some groups the 
ultimate result is wanting in a large proportion of cases 
(e.g., Culbertson, excision for gunshot injury, 62.86 per 
cent., ‘‘not stated”). Culbertson gives 40 cases of re- 
covery from ‘‘ partial” resections for disease, with 6 
‘‘ perfect” and 82 ‘‘ useful” joints, together 80 per cent. 
Of 290 recovered ‘‘ complete” resections, 32 were “‘ per- 
fect,” 196 ‘‘ useful,” together 78.6 per cent. The pen- 
sion inspections have given opportunities for critically 
observing the remote results of resected joints, and Gurlt 
gives the following for the resections of the elbows made 
in the German wars from’ 1848 to 1871, the classification 
being the same as for shoulder resections given above ? 
Very good, 5.63 per cent.; good, 23.66 per cent.; mid- 


* For the lower third of the arm only, 35.2 per cent. 

+ Ollier (Revue de Chirurgie, 1882, p. 717) says that in a series of fifty 
cases since 1876 he has had no death attributable to the operation. Pre- 
vious to 1876 he had twelve deaths in sixty-three operations. The im- 
provement he attributes to asepsis and earlier operations, which render 
the operation less extensive in patients less exhausted, 


REFERENCE HANDBOOK OF 


‘Resection. 
Resection. 


THE MEDICAL SCIENCES. 


dling, 53.24 per cent.; bad, 14.387 per cent.; very bad, 
3.09 per cent. 

The restoration of the resected parts is often quite ex- 
tensive, and many autopsies have been made upon such 
restored joints. Nepveu” has collected some twenty-one 
observations. The commonest peculiarities are forked 
or malleoli-like developments of the condyles, or instead 
an olecranon-like prolongation of the humerus. The 
olecranon is sometimes absent, and its place supplied by 
a radial or humeral prolongation. The coronoid process 
is often absent. There is usually some restoration of 
cartilage. The general form of the new joint is similar 
to that of the ankle. 

Indications.—Resection was formerly held to be indi- 
cated whenever in a gunshot wound of the elbow the 
bones were found to be implicated, while the extent of 
the injury did not make amputation the preferable opera- 
tion. More recent experience has made the indication 
less absolute. Otis!* expresses the result of the latest 
extensive military experience when he says: ‘‘1. That 
in shot wounds in young healthy subjects, attended with 
slight injury of the articular extremities of the bones of 
the elbow, such as fractures of the olecranon, of the 
outer condyle, or of the trochlea, without much splinter- 
ing and without lesion of important vessels and nerves, 
it is justifiable, in many instances, to attempt an expect- 
ant conservative treatment, keeping the injured extremity 
in entire rest, after removing any detached fragments or 
foreign bodies, in a semi-prone and very slightly flexed 
position, employing ice or other cold applications.” If 
inflammation occurs it should be met by drainage and 
appropriate treatment, and if necessary secondary opera- 
tions resorted to. ‘‘ Unless all the favorable conditions 
mentioned are present at the outset, it would be safer to 
resort to primary excision or amputation. 2. In grave 
shot comminutions with lesion of the principal vessels 
or nerves, amputation should be practised immediately 
after the reception of the injury. 3. In severe shot 
fracture without extensive lesions of the soft parts, the 
joint should be freely exposed by a longitudinal posterior 
incision, and the full extent of the fracture ascertained. 
Unless there is extraordinary fissuring, the injured joint 
ends should then be sawn off as close to the limits of the 
injury as possible, save that the bones of the forearm 
should be shortened to the same level. If the splintering 
extends very far, or if there is reason to believe that the 
humeral vessels are injured though not wounded, the 
incisions should be so modified as to convert the opera- 
tion into an amputation.” If by reason of the success of 
aseptic dressing the above needs modification, it is only 
in enlarging somewhat the range of cases amenable to 
expectant treatment and in diminishing the weight that 
splintering of bones gives to the indication for amputa- 
tion. 

For disease, after infancy has passed, resection is indi- 
cated, as in other joints, whenever it is clear that expect- 
ancy has failed or will fail; that is to say, whenever the 
best treatment and hygiene at the command of the 
patient has not arrested the advance of the disease, or if 
after prolonged trial no material improvement has oc- 
curred. While not absolutely indicated, resection is also 
worth considering if, although the case is progressing 
toward cure by anchylosis, the position in which anchy- 
losis must occur will be a disadvantageous one. An- 
chylosis at the shoulder is palliated by the mobility of 
the scapula, at the wrist, the tendons being free, by the 
mobility of the fingers. At the elbow there is no con- 
siderable compensation, and the very complex function 
of this joint makes anchylosis of it often very embarrass- 
ing. 

For anchylosis actually existing resection seems to be 
indicated in the young, that is to say, until the age of 
twenty or twenty-five years, if the position of the joint 
is decidedly disabling, as, for instance, that of total ex- 
tension. The indication is increased in strength by the 
existence of double anchylosis, especially if symmetrical 
as to position. If the two joints be flexed at different 
angles, the sufferer may be able to perform many of his 
duties ; but a symmetrical anchylosis usually materially 


° 


disables him.* In such a case excision might be indicated 
even if anchylosis in a better position were the only gain. 
It should be borne in mind that the lower epiphysis of 
the humerus and the upper epiphyses of the radius and 
ulna contribute but a small part of the growth of the arm. 
Ollier thinks about one-tenth of the total growth, so 
that resection of the elbow in early life does not greatly 
shorten the limb. In adult life excision for anchylosis 
gives less satisfactory results. In every case of anchy- 
losis the condition of the muscles as to vitality and possible 
redevelopment must be considered before resection is de- 
termined upon. 

For gunshot wounds total resections have been con- 
sidered indicated. The experience of our own war and, 
to a certain extent, that of the Franco-German war has 
shown, however, that under favorable circumstances par- 
tial operations may do well. For disease the rule is the 
same, although partial resections of late years are found 
to be less disadvantageous than formerly supposed. In 
childhood informal resections have grown in favor; 
many German operators urging them in place of typi- 
cal resections. 

For anchylosis the resection must be total. But as the 
age increases the power of reproducing bone diminishes, 
and consequently in adult life the bone cannot be so 
freely removed as in youth without endangering flail- 
joint. 

Methods.—Many forms of incision have been employed, 
and as far as can be judged from Culbertson’s statistics 
no marked difference in results follows the different 
incisions. The incision of Liston (F, the longitudinal 
part being along the inner border of the olecranon and 
the transverse portion across the back of that process to 
the lower border of the external condyle) has been much 
employed, but at present single lon- 
gitudinal incisions are deemed to 
be in ordinary cases sufficient. If 
the form of the existing wound or 
other reasons make it. preferable 
some other incision should be em- 
ployed. Of the longitudinal inci- 
sions Langenbeck’s subperiosteal 
method is probably the most fre- 
quently resorted to.. It is as fol- 
lows :!7 An incision eight or ten 
centimetres in length is made over 
the extensor surface of the joint, 
somewhat to the inner side of the 
middle of the olecranon, the tip of 
the olecranon being above the cen- 
tre of the cut. (See Fig. 3277 in 
which the incision is placed too 
high.) This cut goes down to the 
bone throughout its course. The 
periosteum is first elevated toward 
the inner side and the inner half of 
the tenden of the triceps, together pyg. 3977.— Langenbeck’s 
with the periosteum, is divided by Incision. 
short parallel longitudinal incisions 
directed against the bone. The soft parts, covering the 
internal condyle and inclosing the ulnar nerve, are drawn 
by the left thumb-nail toward the tip of the epicondyle, 
and liberated by curved incisions close together and 
against the bone until the epicondyle is completely ex- 
posed. The last incisions are carried around this promi- 
nence and separate the origins of the flexor muscles as 
well as the internal lateral ligament from the humerus, 
without however disturbing their connection with the 
periosteum. The tissues are replaced and the outer part 
of the tendon of the triceps and the anconeus are de- 
tached with the periosteum, and in the same careful way 
described the capsule is raised and the external condyle 
reached and cleared, the external lateral ligament and 
the extensor muscles being raised with the periosteum of 
the humerus. Both condyles being free, the joint 1s 


* Double anchylosis appears to be most common as a sequel to small- 
pox. Such cases are frequently referred to in continental articles, and 
the writer has met with two cases from this cause. 


183 


Resection. 
Resection. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


forcibly flexed, the articular surfaces forced out of the 
wound. The humerus is steadied with the forceps and 
the articular surface sawn off. ‘The ulna and the radius 
are then sawn. If it be necessary to go below the coro- 
noid process, the upper fibres of the brachialis anticus 
must be divided, without destroy- 
ing the connection of the tendon 
with the periosteum of the ulna. 
Ollier employs the ‘‘ bayonet” 
incision (Fig. 3278) as calculated to 
do the least injury to the soft parts. 
It is made thus:?8 Commence the 
incision on the external border of 
the arm six centimetres above the 
line of the articulations ; carry it 
down to the level of the promi- 
nence of the epicondyle; thence 
turn it downward and inward to 
the olecranon. The direction of 
the knife is again changed and fol- 
lows the posterior border of the 
ulna for four or five centimetres 
according to the amount of bone to 
be removed. This last part may 


Above the aponeurosis should be 
divided and the incision carried be- 
tween the triceps on the one side 
and the supinator longus and the 
extensor carpi radialis longior on 
the other. The division of the 
capsule follows the external incision. The oblique part 
_of the latter corresponds nearly to the interval between 
the triceps and anconeus. The internal lip of the wound 
with the triceps is detached, the connection of the tendon 
with the periosteum being carefully preserved. The 
external condyle is then cleared, the humerus luxated 
backward, the denudation completed, and the bone saw 
off. The bones of the forearm are then denuded and 
divided with saw or cutting forceps. It is usually better 
to begin with the radius. 

When the operation is done for anchylosis Ollier some- 
times finds it necessary to make a long radial incision and 
a small oneonthe ulnar side. The 
bone is sawn from behind forward 
nearly through and broken. This 
procedure somewhat resembles that 
of Hueter given below. 

Nélaton used a radial incision : 
with a transverse cut across the 
olecranon (Fig. 3279). The head 
of the radius is first exposed and ' 
sawn off. The olecranon is then 
denuded and the triceps tendon de- 
tached. The forearm is bent in- 
ward, the ulna protruded and sawn. EE 
The humerus is then easily pro- 
truded, denuded and sawn. i 

Hueter,!? to avoid the division of ‘ 
the triceps tendon and facilitate the i 
enucleation of the olecranon with- 
out disturbing the relations of the 
tendon to the periosteum and fas- Og 
cia, used the following method. A ee 
preliminary longitudinal incision : 
(Fig. 3280), about half an inch in LAY 
length, is made over the promi- ale 
nence of the internal epicondyle, or gaa 
rather jai in feyik to more cer- \ 
tainly avoid the ulnar nerve. A “9 __N . 
reed te cut around the base of the 3 ae ‘ay 
epicondyle detaches the muscles 
and divides the internal lateral ligament. The principal 
incision is made on the radial side. The knife is entered 
above the external epicondyle and carried straight down 
over that prominence, opening the joint and exposing 
the head of the radius, the lateral ligament being divided 
longitudinally and the annular ligament transversely. 
The head of the radius is easily freed and sawn off with 


Fra. 3278.—Ollier’s Inci- 
sion. 


184 


be carried at once to the bone. . 


Fra. 8280.—Hueter’s Inci- of the operation, 


the keyhole-saw and extracted. The left forefinger is then 
passed into the joint and the anterior part of the capsule 
made tense while it is detached from 

aah the bone with the knife or elevator. 

| ae The finger is then passed behind, 
stretching the triceps tendon, which 

is detached in the same manner. 

It is not easy to clear the inner bor- 

i der of the humerus in this way, but 
‘ Sy by forced abduction of the forearm 

ee the ulna is dislocated inward and the 
i humerus thrown out of the wound, 
ee ‘where it is easily denuded as far as 

necessary and sawn off. The ulna 
is then brought into the centre of 
H the incision, examined, and the tri- 
Lee ceps separated from above down- 
vaeyae ward by short firm strokes of the 
Pe. Sr ae knife or elevator, and the olecranon 
fee ook shelled out of its fibrous envelope 
See NEY until the necessary amount is denu- 
ae ded, when the bone is sawn. 
oe ap ae Von Bruns, as early as 1858, pro- 
ee posed osteoplastic resection of the 
elbow, by making use of temporary 
rama division of the olecranon, the sawn 
He surfaces being reunited at the close 
Originally this 
device was directed to the manage- 
ment of ancient dislocations or to 
compound dislocations. Other German operators have 
extended the use of the osteoplastic method to resection 
for foreign bodies in the joint, and 
have even employed it in opera- 
tions for disease. This last appli- 
cation has been, by some surgeons, 
held to be unwise, owing to the 
frequency of disease of the ole- 
cranon, but there seems to be no 
impropriety in making section of 
the olecranon in doubtful cases, 
and removing the diseased bone 
entirely, if, after inspection, this 
course seems to be_ preferable. 
The methods employed for osteo- 
plastic resection have been various, 
but the two given are as simple 
and apparently as successful as : 
any. Fig. 3281 shows the incision his: 
of Von Mosetig-Moorhof.?° The Pais Sar 
elbow being slightly bent the inci- Le Need 
sion is carried from the lowest 
point of the external condyle across 
the base of the olecranon to its in- 
ner margin. From the end of this 
cut another runs at first parallel to the inner margin of 
the olecranon, and then curves slightly inward to a point 

. about a finger breadth above the tip 

of the bone. The ulnar nerve is 

i dissected out and drawn aside, the 

\ olecranon divided and turned up in 

US the flap. The humerus is cleared 

\ \ and sawn off below the epicondyles, 
\._/ \ the head of the radius taken off, the 
: olecranon scraped to sound tissue, 
and its sawn surfaces reunited with 
silver wire. 

Stimson”! avoids meddling with 
the ulnar nerve by combining the 
lower two-thirds of Ollier’s incision 
with a transverse one across the base 
of the olecranon (Fig. 3282), and 
sawing the latter somewhat ob- 
liquely, from below upward, into 
the joint. The joint is then further 
opened through the lateral incision, 
the external condyle denuded and 
the flap, including the upper part of the olecranon, turned 
upward and inward. The humerus is then denuded and 


1 
‘ 
‘ 
' 
! 
t 
1 
' 
, 


sions. 


= 
Se amen arene 


Fig. 8281.—Von Mosetig- 
Moorhof’s Incision. 


Fie. 8282.—Stimson’s In- 
cision. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Resection. 
BResection, 


sawn off through the epicondyles, the radius protruded 
and sawn through the neck, the diseased part of the ulna 
scraped, the capsule dissected out, and the parts of the 
olecranon reunited by silver suture. 

It will be noticed that while many of the older opera- 
tions, Liston’s, for instance, were upon the ulnar side, 
and Langenbeck’s is central, that the majority of the 
more recent operations, if not bilateral, are mainly upon 
the radial side. 

In operating for anchylosis, if the union can be broken 
up, and frequently where it cannot be, the single incisions 
will usually suffice. Occasionally bilateral incisions are 
called for. Many operations have been devised, and 
methods for meeting the indications of special cases, but 
space forbids detailing such. 

The after-treatment is important. The position pre- 
ferable is that of very slight flexion, or perhaps, as Roser 


_ urges, for some time in extension, as giving more compact 


restoration of the soft parts. No splint is more generally 
acceptable than a well-applied gypsum bandage, brack- 
eted or not, as the condition of the wound may render 
desirable. At first a very firm antiseptic dressing may 
suffice in place of splint. In the very young early motion 
is advisable, but in adults there is much less danger of 
anchylosis than of flail-joint, and passive motion may be 
delayed until a moderate degree of firmness in the tissues 
has been reached. 
RESECTION OF THE WRist.—The earliest operation of 
this kind known was for injury, Mr. Cooper, of Bungay, 
having, in 1750,* removed the lower ends of the radius 
and ulna for acompound dislocation. In 1762 Bagieu ex- 
cised the joint for gunshot wound, The first resection for 
disease was in 1794, when the elder Moreau performed it. 
Operations were few until about 1840, since which time 


they have been more frequent. Nothing has ever done 


so much to establish the operation as the paper of Mr. 


Lister,*? published in 1865, detailing an improved proced-. 


ure, and giving the encouraging results of fifteen cases 
in which he had employed it. Resection of the wrist, 
however, has never enjoyed the popularity among sur- 
geons that has been accorded to similar operations on 
some other joints. No one to-day would endorse Mal- 


gaigne’s wholesale condemnation, but many grant the op-, 


eration but limited approval. This is not due to a high 
death-rate, for, according to Culbertson,?? the mortality 
proper to the operation for all causes is but 1.73 per 
cent. The failure of the resection in many cases to ar- 
rest the local process, or to hinder the development of 
kindred maladies, and the frequent worthlessness of the 
hand when saved, are responsible for this distrust. A 
glance at the anatomy of the wrist will show that the 
complex synovial sacs, and their relations to the many 
small bones, and the proximity of the numerous tendin- 
ous sheaths, favor the spread of disease and hinder its 
extirpation, except by an extensive and careful operation ; 
while prolonged suppuration would very probably set up 
such adhesions of tendons as to permanently destroy the 
usefulness of the remains of the hand. Until a compara- 
tively recent time, surgeons had not the technical resources 
to satisfactorily deal with the problem. Itseems, too, that 
the operation has not been quite fairly dealt with, in that 
a tendency is shown to compare the functional results ob- 
tained with the perfect hand, and not, as should be done, 
with those of other operations, such as scooping or ampu- 
tation. 

There has been an unusual want of agreement among 
writers as to what constitutes a complete, and what a par- 
tial, resection of the wrist. Strictly speaking, the wrist 
means the radio-carpal articulation, but by extension it 
has come to include in this connection both the medio- 
carpal and the carpo-meto-carpal articulations as well. 


: The most reasonable definition seems to be that a com- 


plete resection of the wrist must include the removal of 
the lower articular extremities of the bones of the fore- 
arm, or at least of the radius on the one side, and of the 
first row of carpal bones, except perhaps the pisiform, 


* This date is given in some books; Gooch, in 1767, alluded to the 
operation as occurring ‘“‘ many years ago.” 


on the other. More may be removed in a complete re- 
section, but less would make it partial, 7.e., to be com- 
plete both members of the radio-carpal joint must be re- 
moved. . 

Results.—The functional results of wrist exsection are 
very often very vaguely stated by reporters. So far as 
they can be separated, they may be divided into bad, in- 
different, and satisfactory. By ‘‘bad” is intended that 
the limb is worthless and was subsequently amputated ; 
by ‘‘ indifferent,” a hand of limited usefulness, the im- 
paired mobility of the fingers preventing any work de- 
manding delicacy or strength; by ‘‘satisfactory ” is meant 
that there is mobility of all the fingers, that the opposition 
of the thumb is preserved, and that the person can write, 
sew, and do similar things requiring dexterity, and that, 
in some cases at least, the hand has sufficient strength for 
more laborious work, such as driving, the use of moder- 
ately heavy tools, or for the support of several pounds 
weight. In Culbertson’s extensive tables of 58 excisions 
for gunshot wounds, 1 gave ‘‘ perfect” result ; 16 “‘ use- 
ful” hand; 8 ‘‘ not useful;” 2 ‘‘ amputated ;” 31 ‘‘ not 
stated.”” Of 14 operations for injury, 4 are ‘‘ perfect ;”’ 8 
‘‘useful ;” 2 ‘‘not stated.” Of 79 operations for disease, 
6 are ‘“‘ perfect ;” 86 ‘‘useful;” 11 ‘‘not useful;” 10 
‘‘amputated ;”” 16 ‘‘not stated.” These were all, or 
nearly, done without aseptic precautions. 

Nepveu”! has collated the final results in 86 cases, some 
of which are more recent than those in Culbertson’s table. 
In 8 cases the result was absolutely bad, in 18 indifferent, 
in 15 really satisfactory. 

Ollier * thinks that even better results than those usually 
considered ‘‘ satisfactory ” should be looked for. One of 
his patients, from whom he removed all the carpal bones 
but the pisiform, the articular surface and styloid pro- 
cess of the ulna, lower extremity of the second, fourth, 
and fifth metacarpal bones, and the whole of the third 
with its finger, two years after the operation could hold 
out at arm’s length, for some seconds, a weight of ten kilo- 
grammes—about twenty pounds. A second traumatic 
case, after eleven years, held out eleven kilos and was 
skilful on the trapeze, played the cornet, and was em- 
ployed as a notary’s clerk, writing all day without fa- 
tigue. In the latter case the operation was done for gun- 
shot injury, the shot passing transversely through the 
wrist and severing the radial artery.” 

Experience in the field has not been very encouraging, 
but nearly all of the records are based upon experience 
previous to 1865, before which date the status of the op- 
eration, as to technique and in other respects, was un- 
favorable to success. Inthe War ofthe Rebellion, of six 
complete excisions of the wrist, one proved fatal after re- 
course had been had to amputation in the forearm. The 
five others recovered with functions of the hand much 
impaired, but, all things taken into consideration, in a 
better condition than if they had been subjected to ampu- 
tation.°7 

Gurlt’s tables show that, of recovered cases of resection 
of the wrist in military surgery, none belong to his class 
of ‘‘ very good ;”” 6.25 per cent. were ‘‘ good,” 50 per cent. 
‘‘medium,” 87.50 per cent. ‘‘ bad,” 6.25 per cent. ‘‘ very 
bad.” The same authority gives the mortality of pri- 
mary resection as 10,25 per cent.; intermediary, 30 per 
cent. ; secondary, 22.22 per cent.; total mortality in,126 
cases, 16 per cent. . 

Partial excision, and mixed operation in which portions 
of the hand were removed, gave but indifferent results on 
the whole ; but even these imperfect members, especially 
with proper supports, were usually more useful than the 
stump of amputation could be made to be. 

Resection for anchylosis of wrist has been done. The 
one case (Langenbeck’s) of which this writer knows the 
result was not successful, the anchylosis recurring.”*® 

In general, anchylosis is frequent and flail-joint rare. 
The hand in many cases is distorted toward the radial 
side. ‘Both the anchylosis and distortion are probably 
largely due to incomplete after-treatment. Dorsal flex- 
ion is naturally usually imperfect, owing to the normal 
predominance of the flexors over the extensors. It is as- 
serted by some German authorities that soldiers some- 


185 


Resection. 
Resection. 


times wilfully neglect after-treatment, lest their pension 
should be diminished. 

Indications.—For injury, as compared with amputation, 
resection is always to be preferred, unless hopeless dam- 


age has been done to the tissues, especially to vessels and ° 


nerves. In civil practice the prognosis is excellent as to 
life, and as to function, it should always be remembered 
that a very indifferent hand is much better than none. 
There is good reason to believe that, with the simplifica- 
tion of aseptic dressings, very much better results can 
now be expected in military practice than heretofore. 

In military surgery informal resections are now thought 
to be preferable. But nowhere is great attention to de- 
tail, the removal of hopelessly detached fragments, cleans- 
ing, tendon suture, etc., more necessary than in these 
operations. 

In compound fractures and in compound dislocations 
the same careful informal operations are to be pre- 
ferred. 

For disease (caries) resection is indicated if expectant 
treatment has failed, but the rule is to be applied here 
with more limitation than to some other joints. Prac- 
tically, resection is never called for during the first five 
years of life, and rarely before puberty, as less formal or 
less extensive operations take its place. In very young 
children the actual cautery, used through fistulee or car- 
ried down knife-wise into the boggy and fungous tissues, 
is often followed by a marked improvement, with retro- 
gression of the fungoid changes. Still later, ¢.e., until 
about the age of puberty, the excavation of diseased 
parts by the scoop or periosteotome (conjoined with the 
actual cautery in parts which cannot be easily reached, 
or which the operator prefers to leave untouched by the 
instrument), and free drainage and compression, are fol- 
lowed by the happiest results and, probably, by more 
useful hands than could have been gained by formal re- 
section. This last method, however, should not be made 
to include too niggardly openings. Sufficient room 
should be allowed for proper inspection of the parts, etc. 
After puberty, and during the first half of life, resection 
in form has its best results. The excavation may still 
succeed, but its special province is during the growing 
period of bone, while it still has great reparative vitality. 
After thirty-five or forty years resection is not forbidden, 
but its functional results are less brilliant.* The exist- 
ence of caries of the carpus in adult life is often associ- 
ated with tuberculosis elsewhere. This-is generally con- 
sidered as a contra-indication of resection, but in young 
adults resection is not rarely followed by a recession of 
pulmonary signs, and the operator must critically ex- 
amine the history of the case as to the probable depend- 
ence of the general condition upon the local one, before 
deciding between resection or amputation. The existence 
of fungosities in the sheath of the tendons in adult cases 
is generally considered a strong contra-indication of re- 
section, owing to the small chance of good functional 
results. 

Operative Methods.—The back and sides of the wrist 
contain no important vessels or nerves, and the skin and 
tendons only overlie the joint structures. All operations 
on the joint are therefore preferably begun from these as- 
pects. The radial artery winds into the dorsal aspect, 
but can be usually managed without damage. The in- 
jury done, in the older methods of excision, to the exten- 
sor tendons both by the operation itself and the pro- 
longed suppuration, is largely accountable for the poor 
results obtained. At present the longitudinal incisions, 
single or double, have practically displaced all others ; 
and the admirable method of Mr. Lister is by far that 
most frequently employed, at least by English-speaking 
surgeons. Although the case which seems first to have 
fixed Mr. Lister’s attention upon the subject was a trau- 
matic one, his paper is confined to the consideration of 
excision for caries. The description below is slightly 


* Gangolphe, De la Résection du Poignet, Revue de Chirurgie, 1884, 
p. 340, relates among others three successful cases at the ages of forty- 
six, fifty, and sixty-six years; one of whom was operated on after having 
refused amputation. Other cases of success, in spite of forbidding com- 
plications, are detailed, 


186 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


abbreviated from this paper.’® The operation elaborated 
by this great surgeon avoids most dexterously the chief 
difficulties of wrist-joint excision. 

Before the operation is commenced, any adhesions of 
the tendons are thoroughly broken down by freely moy- 
ing all the articulations of the hand. The radial incision 
is then made in the situation indicated by the thick line 
(LL) in Fig. 8288. This in- 
cision is planned so as to 
avoid the radial artery, and 
also the tendons of the ex- 
tensor secundi internodii pol- 
licis and indicator. It com- 
mences above, at the middle 


| of the dorsal aspect of the 
ig, radius, on a level with the 
\ styloid process, this being as 
. close to the angle 
where the tendons 
meet as it is safe 


is at first directed 
toward the inner 
side of the meta- 
\ carpo- phalangeal 
\ articulation of the 
*" thumb, running 
parallel in this 
, course to the ex- 
Sn ee tensor secundi in- 
Fra. 8283.—A, Radial artery; B, tendon of the ternodii; but on 
extensor secundi internodii pollicis; C, indica- pegehin g the line 
tor; D, extensor communis digitorum; E, ex- f tl ais 
tensor minimi digiti; F, extensor primi inter- © the radial bor- 
nodii pollicis; G, extensor ossis metacarpi der of the second 
pollicis; H, extensor carpi radialis longior ; I, metacarpal bone 
extensor carpi radialis brevior; K, extensor iti ied d zs 
carpi ulnaris; L L, line of the radial incision, 218 Carried GoWn- 
ward longitudi- 
nally for half the length of the bone. The soft parts at 
the radial side of the incision are next detached from the 
bones with the knife guided by the thumb-nail, so as to 
divide the tendon of the extensor carpi radialis longior at 
its insertion into the base of the second metacarpal bone, 


and raise it, along with that of the extensor carpi radialis. 


brevior previously cut across, and the extensor secundi 
internodii, while the radial artery is thrust somewhat out- 
ward. This prepares the way for the next step, which is 
the separation of the trapezium from the rest of the car- 
pus, by means of cutting forceps applied in a line with the 
longitudinal part of the incision—a 
procedure which, as experience 
shows, does not endanger the 
radial artery. The removal of 
the trapezium is reserved till the 

rest of the carpus has been 
taken away, when it can be 
dissected out without any 
considerable difficulty ; 
whereas its intimate re- 
lations with the radial 
artery and its secure 
connections with the 
neighboring parts, 
would cause a 
great deal of 
trouble at an ear- 
lier stage of the 
operation. The soft parts onthe 
ulnar side of the incision are now 
dissected up from the carpus as 
far as is convenient, the hand 
being bent back to relax the ex- f 
tensor tendons of the fingers. The separation of these is, 
however, best effected from the ulnar incision, which 
must be made very free. The knife is entered at least 
two inches above the end of the ulna, immediately ante- 
terior to the bone, and is carried downward between it 
and the flexor carpi ulnaris, and on in a straight line as 
far as to the middle of the fifth metacarpal bone at its 
palmar aspect. (Fig. 3284.) The dorsal lip of this inci- 


Fia. 8284. 


to go. Thenceit - 


ae 


— 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


sion is then raised, and the tendon of the extensor carpi 
ulnaris is cut at its insertion into the fifth metacarpal 
bone, and is dissected up from its groove in the ulna, care 
being taken to avoid isolating it from the integuments, 


which would endanger its vitality. The extensors of the 
‘fingers are then readily separated from the carpus, and 


the dorsal and internal lateral ligaments of the wrist- 
joint are divided; but the connections of the tendons 
with the radius are purposely left undisturbed. Atten- 
tion is now directed to the palmar side of the incision. 
The anterior surface of the ulna is cleared by cutting to- 
ward the bone so as to avoid the artery and nerve ; ‘the 
articulation of the pisiform bone is opened, if that has 
not been already done in making the incision, and the 
flexor tendons are separated from the carpus, the hand 
being depressed to relax them. While this is being done, 
the knife is arrested by the process of the unciform bone, 
which is clipped through ‘at its base with pliers. Care is 
taken to avoid carrying the knife further down the hand 
than the bases of the metacarpal bones; for this, besides 
inflicting unnecessary injury, would involve risk of cut- 
ting the deep palmar arch, the position of which is 
shown in Fig. 8285. The anterior ligament of the wrist- 
joint is also divided, after which the junction between 
the carpus and the metacarpus 
is severed with cutting pliers, 
and the carpus is extracted by 
seizing it from the ulnar incision 
with a serviceable pair of se- 
questrum forceps, and touching 
with the knife any ligamentous 
connections that may remain 
undivided. The hand being 
now forcibly everted, 
the articular ends of 
the radius and ulna 
will protrude at the 
ulnar incision, and are 
carefully examined 
and treated according 
_ totheircondition. If 
* they appear sound or 
very superficially af- 
fected, the articular surfaces 
only are removed. The ulna 
is divided obliquely with a 
mar small saw, so as to take away 
acon, waperinm® C. articn- the cartilage-covered rounded 
which the fadius moves. part over which the radius 
sweeps, while the base of the 

styloid process is retained. The end of the radius is 
then cleared sufficiently to permit a thin slice to be sawn 
off parallel to the general direction of the inferior articu- 
lar surface. For this purpose it is scarcely needful to 
disturb the tendons in their grooves on the back of the 


bone, the bevelled ungrooved part being enough to re- 


move, and thus the extensor secundi internodii pollicis 
may never appear at all. The articular facet on the ul- 
nar side of the bone is then clipped away with bone for- 
ceps applied longitudinally. If, on the other hand, the 
bones prove to be deeply carious, the pliers or gouge 
must be used with the greatest freedom. The metacar- 
pal bones of the fingers are next dealt with on the same 
principle. If they seem sound, the articular surfaces 
only are clipped off, the little facets by which they articu- 
late with one another being removed by the longitudinal 
application of the pliers. 

The trapezium is next seized with a strong efficient 
pair of forceps, and dissected out so as to avoid cutting 
the tendon of the flexor carpi radialis, which is firmly 
bound into the groove on its palmar aspect, the knife 
being also kept close to the bone elsewhere to preserve 
the radial artery. The thumb being then pushed up 
longitudinally by an assistant, the articular end of its 
metacarpal bone is cleared and removed. Lastly, the ar- 
ticular surface of the pisiform bone is clipped off, the 
rest of the bone being left, if sound, as it gives insertion 
to the flexor carpi ulnaris, and affords attachment to the 
anterior annular ligament, and may serve other useful 


Resection. 
Resection, 


purposes in the palm. But if there is any suspicion of 
its unsoundness, it must be dissected out completely. 
The same applies to the processof the unciform., — It may 
be observed that the extensors of the carpus are the only 
tendons divided ; for the flexor carpi radialis is con- 
nected with the second metacarpal bone below its base 
and so escapes. 
_ The long single dorsal incision seems to have been used 
independently by several operators, but its use was made 
general through the influence of Langenbeck, and gen- 
erally bears hisname. His method is as follows : * 

_ The hand is back upward and slightly bent toward the 
inner side. The cutaneous incision, beginning at the cen- 
tre of the ulnar border of the metacarpal bone of the 
index-finger, is carried upward about four inches (nine 
centimetres), to the middle of the dorsal surface of the 
radial epiphysis (Fig. 3286). The 
incision is carried deeply on the 
radial side of the extensor indicis 
and without injuring its sheath, 
passing upward to the ulnar 
border of the extensor carpi 
radialis brevior (just at its 
insertion into the base of 
the third metacarpal 
bone). Here it divides 
the posterior annular 
ligament between the . 
tendons of the ex- AB Peet! 
tensor secundi in- Ae 
ternodii pollicis 
and the extensor ary i 
indicis as far as Big a 
the epiphyseal border of the St Leg ek 
radius. The incision being | i / , ey ,\ ? 
carried down to the bone, the | !; /\ el /\ ‘ 
soft parts, including the fibrous | ji / / i'¢ 1! 
sheaths of the tendons, are 
lifted with the elevator and Biga0 
knife, together with the periosteum, the sheaths being 
unopened, first to the radial and then to the ulnar side of 
the incision. The hand is flexed so that the articular sur- 
faces of the upper row of carpal bones are exposed. The 
scaphoid is liberated from the trapezium and trapezoid, 
and the semi-lunar and cuneiform from the os magnum 
and unciform by dividing the intercarpal ligaments, and 
gently lifted out with a narrow elevator. The trapezium 
and pisiform can be left behind [if sound]. The bones of 
the anterior carpal row are then taken out, the globular 
articular head of the os magnum is seized with the fin- 
gers of the left hand or a pair of vulsellum forceps, and 
while an assistant abducts the thumb the ligaments unit- 
ing the trapezium with the trapezoid are divided. The 
operator then tries to penetrate from here in a direction 
toward the ulna, into the carpo-metacarpal joints, by di- 
viding the ligaments on the extensor side of the bases of 
the metacarpal bones, while an assistant forcibly flexes 
the latter. The trapezoid, magnum, and unciform ‘can 
thus be lifted out together. The ends of the radius and 
ulna are carefully denuded, protruded, and sawn through 
in the usual manner. 

Ollier urges the subperiosteal method. Although ad- 
mitting that the wrist is not so good a field for this 
method as some other joints, he believes that the estab- 
lishment of the ‘‘ periosteo-capsular sheath” is useful in 
the repair. It hinders the changing of the relations of 
parts, and helps the forming of osseous or fibro-osseous 
masses which, although smaller than normal, are of value. 
They are irregular, and are bony grains ‘‘ disseminated 
in an osseous gangue” which make the wrist firm but 
flexible. In one of his later articles,*! Ollier claims 
that his opinion is based on the results of twenty-two 
personal cases of radio-carpal resection for osteo-arthritis, 
not counting partial ablations of the carpus and articular 
cauterizations in children. In addition he has had two 
primitive traumatic resections. After all the doubt arises 
whether the results, which in some cases were remark- 
ably good, were due as much to the method of operation 
as to the very patient and pains-taking after-treatment. 


187 


s 
‘ 
‘ 


1 
‘ 


oe? 


Resection. 
Resection. 


The incision he formerly advocated ® was on the radial 
side (see Fig. 8287). More recently * he has employed 
an incision much like that of Langenbeck, as follows :_ 
The guides are an imaginary line connecting the styloid 
processes, the tendon of the extensor indicis, if recog- 
nizable, and the head of the second 
metacarpal bone. The patient lies 
upon his back, the hand extended 
and prone. An incision four or 
five inches long, commencing 
above the head of the second 
metacarpal, is made on the 
radial side of the tendon of 
the extensor indicis, and 
follows its direction un- 
til the bi-styloid line is 
reached near its mid- ff 
dle. The cut di- Ce et 
vides the skin and cote 
subcutaneous tis- 
sue, a branch of 
the radial being 
drawn aside and 
the veins cut between two liga- 
tures. Over the wrist the cut 
goes down to the periosteum 
and dorsal ;ligament, between 
the tendon of the extensor in- 
dicis and that of the extensor whey 
carpi radialis brevior. The annular ligament is divided 
and the tendons drawn widely apart. The articulation 
being open, all attachments on the dorsal surface of the 
carpus are separated by the sharp periosteotome (détache- 
tendon), the carpus is dislocated backward by a move- 
ment of forced flexion, and the denudation of bone is 
continued on the palmar side until one of the bones can 
be extracted. Then, by the aid of the forceps and the 
periosteotome, the bones, one after another, are denuded 
and removed. The articular surfaces of the bones of the 
forearm are then examined, and if they must be resected, 
the incision is continued upward in the axis of the fore- 
arm, and making a slight angle with the first part. This 
incision reaches the bone between the tendons of the ex- 
tensor proprius pollicis and the extensor indicis. The 
bones are denuded first toward the radial side as far as 
possible, the head of the ulna next, the bones dislocated 
and sawn. 
_ After-treatment demands especially free and complete 
drainage of the wound. The palmar surface of the hand 
; and forearm 
should be sup- 
ported by a 
splint, the hand 
in dorsal flexion. 
Fig. 8288 shows 
Lister’s splint. 
Plaster of Paris, 
or any other splint material, may be used if the points 
are kept in mind that the wrist shall be in dorsal flexion 
and the splint allow of early manipulation of the fingers. 
Early and persistent passive motion of the fingers is ab- 
solutely essential to success ; and faradism of the mus- 
cles of hand and forearm is of great service. Prolonged 
and painstaking care alone secures the best results. 
RESECTION OF THE Hip came into use somewhat more 
recently than similar operations upon other joints, the 
first real resection recorded apparently being that of 
Anthony Whyte, in 1822. It was done for deformity, 
and the patient made a good recovery. The first opera- 
tion for gunshot injury was done by Oppenheim, in 
1829, during the Russo-Turkish campaign. The patient 
died of an intercurrent disease, plague or typhus. Re- 
section for caries was performed by Brodie, in 1886, and 
perhaps by Hewson, of Dublin, in 1828, although the 
precise occasion of this operation is variously stated. 
Ferguson’s operations, beginning in 1845, and those of 
some of his contemporaries, recalled professional atten- 
tion to resection of the hip, and it thenceforward grew in 
favor until it took its place as an established procedure. 


Fie. 8287, 


Fre. 8288. 


188 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


The discussion as to the value of resection has no- 
where been warmer than in regard to the hip-joint, at 
least when done for disease. The matter will again be 
referred to under the head of Indications. 

Strictly speaking, resection of the hip is ‘‘ complete”’ 
only when the acetabulum is more or less involved in 
the operation, as well as the head of the femur. In this 
sense ‘‘ partial” operations are commoner than ‘‘ com- 
plete,’ and the mortality for the latter is somewhat 
higher than for the former, owing, doubtless, to the 
greater gravity of cases which demand interference with 
the acetabulum, rather than to the greater severity of the 
operative procedure. 

Resection of the hip is done for gunshot wound, for 
caries, and, less frequently, deformity resulting from dis- 
ease or injury. It has also been done for ancient disloca- 
tions of the hip, traumatic *4 or spontaneous,” for recent 
luxation with fracture of the neck,*® for intracapsular 
fracture,*” for congenital luxation of the hip,** for acute 
suppuration of the hip, and even for acute infectious os- 
teomyelitis.*° In a case of the last mentioned kind the 
writer once excised simply as a palliative measure to re- 
lieve suffering. 

Results.—The mortality of resections of the hip for 
gunshot wounds has always been very high. Culbert- 
son’s tables make it 89.07 per cent., Gurlt’s tables, 88.23; 
for cases in military practice only, 89.92 per cent. There 
is a singular agreement in the results in various wars, as, 
for instance, our own war gives 90.90 per cent., while 
the German war gives 90.56 per cent. Gurlt gives the 
following as the results of resections at different periods : 
Primary, 92.68 per cent. ; intermediary, 94.11 per cent.; 
secondary, 89.39 per cent. ; late, 60 per cent. These 
figures of mortality may be compared with those of am- 
putation at the hip-joint and conservative treatment. 
Thus Otis states ‘‘ that of the cases of undoubted intra- 
capsular shot-fracture of the hip treated by conservation, 
98.8 per cent. had a fatal termination ; that in 66 cases 
treated by excision the fatality was 90.9 per cent., and 
that in 66 cases treated by exarticulation it was 88.3 per 
cent. The high death-rate of resection, however, was 
modified by the fact that the operation was done in nine 
cases where the injury to the pelvis and viscera was 
found to be such that all interference was uselesss, and 
the numerical comparison, therefore, is not a just one. 
Further, of six cases of resection of the hip in the United 
States service since 1865, and reported by Otis, four re- 
covered. Of the six recovered cases belonging to the War 
of the Rebellion, two could walk with a cane, one with- 
out support. In the other cases the limb was of little 
value. The results since 1865 were better. Gurlt gives 
for recovered cases ‘‘ very good,” 25 per cent.; ‘‘ good,” 
75 per cent. 

The mortality of resection of the hip, when done for 
disease, is very low, if death from the immediate results 
of the operation are considered. Culbertson’s tables con- 
tain 418 cases, with 174 deaths, or 41.62 per cent. ; or, 
omitting uncertain cases, 44.84 per cent. Only 29 deaths, 
or 6.93 per cent., resulted directly from the operation, 
leaving 37.91 per cent. as the result of the progress of 
the disease or its complications. The most extensive 
statistics of antiseptic operations are those of Grosch,*° 
who gathered 166 cases, 120 observed to the end, the 
mortality being 36.7 per cent. It will be noted that asep- 
sis has practically annulled the mortality from operation. 
Grosch’s results correspond closely with those of Cul- 
bertson, if operative deaths are left out.* The results 
of Grosch, K6nig, Caumont, and others show that the 
mortality of hip-disease from tubercular complications 
has not been diminished by antiseptic surgery. That 
the death-rate of excised cases is greater than that of all 
cases of suppurative hip-disease treated by expectancy or 
conservatively, is not an argument against resection in 
proper cases, as the operation is usually applied only to 
the graver cases. 


* The matter of statistics and of indications will be found discussed 
more at length in the writer’s article in N. Y. Med. Journal, November 
28, 1885, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Resection. 
Resection. 


Functionally, the results of resection for hip-disease 
cannot, statistically, be presented. Many cases have re- 
covered with admirable limbs, mobile and stable. See, 
for example, Fig. 8289, from Sayre. But such cases are 
relatively rare. Many never really are 
healed, and many others are healed with 
limited motion, or without any. The pre- 
cise percentage of each class cannot be 
given except for very small groups of 
cases. Hence the question has been de- 
bated, and, perhaps, as ably as by anyone, 
by Holmes,*! whether the 
results of excision are, on 
the whole, as good as those 
g of cures by anchylosis. 
i; Io the writer it seems 
m1 Clear that the results of 
=” excision are not, on the 
Hi] average, as good as anchy- 
losis in a good position. 
iea| For the function of the 
myiet lower extremity is sup- 

GF port as well as locomo- 
tion. Security in the 
support of the trunk 
is, in most occupa- 
A MUUIMNlit tions, more important 

MMT «than mobility at any 

: one joint. But this 

i fact does not touch 

those cases in which a 

‘“natural” cure can- 

: not be _ reasonably 

BiG) 3209, looked for. It is an 

argument only against precipitate and indiscriminate ex- 
cision. 

Indications.—In military surgery Otis holds that pri- 
mary excisions of the head or upper extremity of the 
femur should be performed in all uncomplicated cases 
of shot-fracture of the head and neck, that intermedi- 
ary excisions are indicated in similar cases where the 
diagnosis is not made out till late, and that secondary ex- 
cisions are demanded by caries of the head of the femur, 
or secondary involvement of the joint. These indications 
are influenced by the very high mortality attending con- 
servative treatment. Langenbeck*® finds the experience 
in conservatism during the Franco-German war to have 
been less dismal; he reports 25 recoveries against 63 
deaths, and in nearly all of the recovered cases the diag- 
nosis may be considered well founded. In view of the 
remarkable change in the prognosis of such injuries in 
civil practice, where antiseptic methods are used, it is im- 
possible to accept the gloomy view of Otis as final; and 
where asepsis is possible in the field, it seems entirely 
proper to treat conservatively uncomplicated cases of 
shot-injury of the hip where little comminution exists, 
and the general condition of the patient is good. But in 
the majority of cases the rule for resection holds good. 

For caries resection is indicated under the general rule, 
namely, whenever conservative treatment has failed or 
cannot succeed. As it has not been shown that, on the 
average, resection gives limbs more useful than natural 
cure, even after joint-suppuration, nor that, counting the 
period of after-treatment necessary to the securing of a 
good result, it materially shortens the duration of treat- 
ment, the indication remains entirely a vital one. If con- 
servative treatment probably cannot save life or effect 
cure, operative procedures are indicated. More specifi- 
cally, if a sequestrum or necrosis of the acetabulum or 
of the head or neck of the femur exists, resection is im- 
perative ; if pelvic abscess or advanced disease of the 
acetabulum is present, resection is the only alternative, 
even if only palliative ; if, by reason of caries or inveter- 
ate disease of the soft articular tissues, suppuration per- 
sists and impairs the general condition in spite of treat- 
ment, resection is called for. It may be called for in the 
rather rare cases of caries with little suppuration and 
great suffering, the so-called caries sicca, to relieve pain. 
Early resection, with the intent to arrest coxalgia before 


’ by strokes of the knife in 


conservative treatment has been fairly tried, cannot be 
considered as a necessary or advisable operation. 

In acute suppuration of the hip, arthrotomy with drain- 
age may obviate the necessity of resection, but an incis- 
ion suitable to either operation should be made, and the 
decision left until after exploration. 

Resection may be done for deformity when the latter 
is due either to bony or fibrous anchylosis, or to displace- 
, ment of the upper extrem- 
ity of the femur upon the 
dorsum ilii, with perhaps 
persistent sinuses. The op- 
erations for deformity have 
included not only resection 
of the hip-joint or its re- 
mains, but of the upper 
part of the shaft of the fe- 
mur as well as simple oste- 
otomy of the femur. These 
all, however, are here in- 
cluded, as they are all used 
as means of rectifying the deformity 
resulting from hip-disease. Resections 
for dislocations not connected with hip- 
disease have been alluded to above. 
Operative interference for deformity is 
called for when the position of the limb 
is such as to make locomotion difficult, 
and when there is a reasonable prospect 
of improvement by operation ; when, especially in women, 
the position of the limb makes cleanliness difficult, and 
causes much annoyance in connection with micturition, 
menstruation, etc.; also when the false position is attend- 
ed with pain. 

Methods.—Owing to the relative simplicity of the hip- 
joint, its excision is not difficult. In the majority of 
operations incisions over or behind the great trochanter 
have been employed. The three best known are Lang- 
enbeck’s, Sayre’s, and Ollier’s. They are all subperios- 
teal. The first (Fig. 3290) is made when the thigh is 
semi-flexed, by carrying the knife from the middle of 
the trochanter upward and backward in the line of the 
axis of the thigh, 
four or five inches 
toward the poste- 
rior superior spine 
of the ilium. The 
incision separates 
the fibres of the 
gluteus maximus, 
and divides the 
fascia lata and 
periosteum of the 
trochanter. The 
muscles inserted 
into the trochan- 
ter, front and back, are 
freed with the knife, their 
connection with the peri- 
osteum and fascia lata be- 
ing preserved as far as 
possible. The capsule is 
then completely divided 


Fra. 3290. 


wore. 
-? - 
Sree a 


the axis of the neck of the 
femur. The periosteum, 
with the capsular liga- 
ment and the insertion of 
the obturator externus, is 
separated all around the 
neck of the femur. The 
cartilaginous rim is divided, and a piece removed with 
the knife on both sides of the incision. The limb is ad- 
ducted and inverted, dislocating the head of the femur ; 
a narrow knife is thrust into the joint from behind, and 
the ligamentum teres divided. The head is protruded 
and sawn off. The trochanter is left if sound. The ace- 
tabulum is drained and the wound closed. 

Sayre’s procedure probably is that most frequently em- 


189 


Fie, 3291. 


Resection. 
Resection. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


ployed in this country. It is as follows : A strong knife 
is thrust down to the bone at a point midway between 
the anterior inferior spinous process of the ilium and the 
top of the great trochanter. The knife, still firmly in 
contact with the bone, is carried in a curved line over the 
ilium across the top of the trochanter, midway between 
its centre and its posterior border, and then forward and 
inward, making the whole length of the incision from 
four to eight inches, according to the size of the thigh 
(Fig. 3291). This incision should divide the periosteum 
throughout ; if it has not done so, the point of the knife 
must traverse the same course again until the division is 
complete. The wound is then held open with retractors, 
and with a narrow, thick knife a second incision is made 
through the periosteum only, at right angles to the first 
incision, about on the level of the lesser trochanter, or a 
little above it, and carried as far as possible around the 
bone behind’and before. This makes the incision through 
the periosteum an inverted T. Beginning at the angles 
of the two incisions, the periosteum is raised with the eleva- 
tor (Fig. 8248), before and behind. In the digital fossa 
the knife must be used to divide the muscular insertions, 
its edge being kept close to the bone. The elevator is 
then resumed, and 
the periosteum 
raised as far as can 
be done without 
breaking it. The 
limb is then slight- 
ly adducted, and 
the head of the fe- 
mur lifted out from 
the acetabulum. 
This manceuvre 
detaches the peri- 
osteum from the 
inner side of the 
bone, and should 
be done without 
violence, and care 
should be taken to 
denude only so 
much bone as is to 
be sawn off. If 
this dislocation 
cannot be easily 
accomplished, saw 
the bone 77 situ, 
and detach the 
fragment by means 
of the forceps and 
elevator. The bone is removed by the keyhole- or chain- 
saw, the line of section being just above the trochanter 
minor. Dr. Sayre always removes the trochanter major, 
as he holds that its retention prevents free drainage of 
the wound. When the operation is made in childhood, 
the larger part of the trochanter is still cartilaginous, and 
is turned off with the periosteum from the diaphysis. If 
the disease extends below the line of section, the bone 
should be thrust out from its periosteum and again sawn. 
The acetabulum is then examined; if diseased, gouged 
or scraped ; if perforated, all bone from which the in- 
ternal periosteum is detached should be removed. The 
sinuses are cleansed. 

Ollier’s incision is made thus * (Fig. 3292): The thigh 
being slightly flexed on the pelvis, say to 135 degrees, the 
incision begins four finger-widths below the crest of the 
ilium and the same distance behind the anterior superior 
spine. It runs down and slightly forward in the direc- 
tion of the fibres of the gluteus medius, to the prominent 
part of the great trochanter. It then changes its direc- 
tion and goes forward and downward in the axis of the 
shaft of the femur. The posterior lip of the wound is 
drawn back, the tendon of the gluteus maximus crowded 
back with the elevator, and the gluteus medius exposed. 
This muscle is divided parallel to its fibres, dividing, not 
cutting, them. The gluteus minimus is treated in the 
same manner, and the capsule opened from the cotyloid 
border to the digital fossa of the trochanter. The mus- 


Fie. 38292. 


190 


cular insertions are not separated from the periosteum. 
The head is pushed up, the round ligament cut, and the 
neck of the bone denuded as it is pushed up; when it is 
sufficiently exposed and protruded it is sawn off. 

Ollier also makes use of an.osteoplastic method.‘ The 
incision is curved convex downward, the centre being 
the lowest part, a fourth of an inch below the top of the 
trochanter, and the ends about an inch and a half (in an 
adult) before and behind the corresponding borders of 
the trochanter. The trochanter is exposed, sawn, or in 
childhood cut with a strong knife, at an angle of 45 de- 
grees with the shaft, and the piece broken off and turned 
up; the head and neck are then denuded and removed, 
and the trochanter replaced and sutured to the shaft if 
none of the latter has been removed. 

Langenbeck’s operation seems to have been founded 
upon the requirements of an operation made for gunshot 

injury, while those of Sayre 
and Ollier are particularly ap- 
plicable to operations for dis- 
ease. 

Besides these methods many 
others have been proposed and 
employed. Thus Roser * rec- 
ommends, in order to save the 
trochanter, a transverse incision 
from the outer side of the crural 
nerve to the root of the great 
trochanter. Lucke*' and Shede*? 
make a longitudinal anterior 
incision to the outer side of the 
crural nerve. R. W. Parker * 
makes an antero-lateral incision 
running from the anterior su- 
perior spine’of the ilium down- 
ward and forward to the anterior 
border of the great trochanter. 
It enters between the tensor 
vagina femoris and sartorius on 
the inner side, and the two 
smaller glutei muscles on the 
outer, exposing the capsule. 
If this is not already open it 
is incised with a blunt-pointed 
curved bistoury, parallel to and 
rather inside of the anterior in- 
ter-trochanteric line. The neck 
of the bone is sawn ¢n situ with 
a keyhole-saw and removed 
with the sequestrum forceps. 
The trochanter is left if not 
diseased. ‘These anterior inci- 
sions seem to present little of 
advantage over the older ones, 
although, if suppuration is 
overcome by aseptic precau- 
tions, they may be safe. If, 
however, much suppuration 
occurs, they have the decided disadvantage of poor 
drainage. If sinuses already exist in the locality these 
incisions may occasionally be found useful. 

Dr. Sayre dresses the wound by washing it out, filling 
it with Peruvian balsam, and stuffing it with oakum, the 
ends only of the wound being closed with stitches, and a 
tent of oakum in the middle serving for drainage. A 
layer of oakum is laid over the wound, and the limb 
neatly bandaged. He prefers to place the patient in the 
wire cuirass (Fig. 3293), which is previously well padded, 
and is fitted with extension screws at the feet. When a 
patient is firmly fixed in this apparatus, he can be moved 
with great ease without discomfort, and for very young 
and not very tractable patients it is a great convenience. 
Ordinarily, however, the usual antiseptic toilet of the 
wound may be used, and a firm antiseptic dressing with 
weight and pulley extension, make a very comfortable 
and satisfactory appliance. Fig. 8294 shows a good 
method of applying the antiseptic dressing. 

When the wound is considerably consolidated, the 
question of passive motion is to be considered. If mo- 


Ni 


: i\ 
| = ms 
iit ——— II S 


Fie. 3293, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Resection, 
Resection, 


bility of the new articulation can be had in conjunction 
with stability it is very desirable, but if but one can be 
had, in nearly every walk in life stability is much the more 


UA 


Fie. 3294, 


Hull, iil 


desirable. It has been urged, therefore, by some observ- 
ers of experience, that anchylosis after resection of the 
hip should be directly aimed at. If there is much de- 
struction or necessary removal of bone this is probably 
the wisest plan but if the case | 
gives hope of both, then passive 
motion may be begun after the 
parts are already moderately 
firm. For a considerable time, 
many months at least, the wear- 
ing of a support, such as the 
hip-splint (Fig. 3295), is of de- 
cided advantage in securing 
firmness of the forming new ar- 
ticulation. 

Operations for Anchylosis.— 
Rhea Barton, in 1826, operated 


(Gi 
Nis (a : 
IA | x 
C | : 
N 


WY OD-SMAANAAN'T 


re 
Fe 


To’ 


by resecting a V from the shaft (|g 
of the femur, with a good re- son 
sult. Similar operations fol- 

lowed. . 


' Sayre, in 1862, operated upon 
two patients for bony anchylo- 
sis of the hip.*#? The operation 
was essentially the same in both 
cases, and in the second case 
was as follows: An incision six 
inches long was made over the 
trochanter, as nearly as possible 
crossing its centre and going 
directly down to the bone. 
About the centre of this inci- 
sion another at right angles was made, in the posterior 
flap, carried only through the broad fascia. The bone 
was then denuded with the elevator, first in front to the 
trochanter minor, and then behind till the finger could 
surround the bone, with the exception of a thin, firm 
fascia between them on the front. This 
was pierced by a bent steel sound, and a 
chain-saw carried around above the tro- 
chanter minor, which served as a guide. 
About half an inch above the trochanter 
minor the saw was carried through the 
bone, at first upward and outward, then 
outward, then downward and outward, 
making a curved section concave down- 
ward. The saw was again carried 
around the bone, and commencing about 
an eighth of an inch before the begin- 
ning of the first section, a second scc- 
tion was made at right angles to the axis 
of the shaft of the bone (see Fig. 3296). 
The wound was drained and closed. 
Extension by weight and pulley. 

In the first case the result was very satisfactory func- 
tionally. The second patient did well, and gained con- 
siderable use of the limb. About four months after- 
ward was attacked with pneumonia and died tuberculous 


6 S— 4 = 


Fic. 8295. 


Fig. 8296. 


| instrument for making this and sim- 
| ilar operations. 


about six weeks later. 
formed in this case. 
Adams,*° in 1869, operated for anchylosis by the much 
simpler method of osteotomy of the neck of the femur. 
A tenotomy knife was carried 
straight down from a little 
above the top of the 
great trochanter to 
the neck. A+ small | 
saw (Fig. 3297) was \ 
inserted into the same 
track and the bone 
sawed through from 
before backward 
(Fig. 3298). Tenotomy 
of several muscles was 
necessary before the limb 
was brought into a 
straight position. Wound 
closed. Liston’s splint. 
Anchylosis occurred in the 
improved position, but the limb was 
very useful. In some cases since op- 
erated upon motion has been pre- 
served, at least for atime. Fig. 3299 
shows Dr. Shrady’s very convenient 


A very good false joint had 


It consists of a trocar 
and fenestrated cannula, and a saw 
fitting the same cannula. In use the 
trocar is thrust to the point which is 
to be sawed. The trocar is then with- 
drawn, the cannula being left in posi- 
tion, the screw-button on top, on the 
side opposite to the fenestra, being a 
guide to the position of the latter. 
The saw is then introduced through 
the cannula, and the section made 
without danger of wounding any 
parts except those intentionally di- 
vided. 

Volkmann, who formerly advocated Bag 2G 
sub-trochanteric osteotomy to correct deformity, has de. 
vised *! a ‘‘chisel resection” for anchylosis at the hip. 
The incision is Langenbeck’s (see ante). The great tro- 
chanter is cut nearly through about an inch below its 

summit, and the inner wall of the neck of the fe- 

: mur broken through. The inner side of the end 
\\ of the shaft is rounded with chisel and rongeur 
(NX until it is about as thick as the middle of the 
shaft. It is better to remove too much than 

too little. An acetabulum is then worked 
out with the gouge large enough to per- 

mit free motion of the new head. An- 
tiseptic dressing. Strong extension by 
weight very long continued, 
and very persistent passive 
motion. For most cases 
Volkmann still prefers oste- 


J.RE YNDERS—CO. 


considers the chisel resection indi- 
cated (1) when the anchylosis is 
double; one side should have an 
osteotomy for security, and one 
resection for locomotion ;* (2) 
when it is not absolutely certain 
that the disease has been sup- 
pressed ; (3) in great displacement 
of head of femur make osteotomy, 
and resect if necessary to bring 
bony surfaces together. 
See SRE RESECTION OF THE KNEE has 
an especial historical interest in‘that upon this joint the 
operation was first done for disease by Filkin (1762), and 
again, apparently independently, by Park (1781), who 


* This suggestion has been carried out (Mordhurst, Archiv f. Kl. Chi- 
rurgie, xxxi., 677). 


191 


Resection. 
Resection. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


first in modern times proposed the operation of resection 
as a formal method of treatment of diseased joints in- 
stead of, as previously it had been, an extemporaneous 


Fie. 8299. 


means of meeting emergencies, such as 
compound dislocations. In spite of 
the distinct advocacy of Park and the 
Moreaus, the operation was slow in gaining ground, and 
previous to 1850 the recorded operations were few, Cul- 
bertson giving but 54 out of a total of 745 in his tables. 
The revival of the operation was due chiefly to the en- 
deavors of Textor in Germany, and Fergusson in Eng- 
land. 

In order that a resection of the knee may be considered 
complete, the articular surfaces of both femur and tibia 
must be removed ; if one of these surfaces be left, how- 
ever extensive the operation in other respects, it is still 
partial. The removal of the patella is not considered 
necessary to make the resection complete. As of other 
joints, resection of the knee is done for gunshot wound 
and other injuries, for disease, and for deformity. 

Results.—The results of resection of the knee for gun- 
shot injury have been discouraging, owing to the high 
mortality. Culbertson’s tables show a death-rate of 75 
per cent., or for hospital cases alone, 87.5 per cent. 
Otis gives for the War of the Rebellion a mortality of 
81.4 per cent., which is much higher than the mortality 
of amputations at the knee-joint—56.6 per cent.—or for 
thigh-amputations for knee-injury—50.9 per cent. The 
same authority, collecting cases from all sources, gives 
the mortality after conservative treatment as 57.3 per 
cent. when there was fracture of the joint-bones, and 21.9 
per cent. when the wound did not involve the bone. Cul- 
bertson also gives the mortality of resection done for in- 
jury other than gunshot at 39.28 per cent., for disease at 
25.32, for deformity at 13.2. A. M. Phelps® has tabu- 
lated 329 cases of antiseptic excision of the knee with 31 
deaths, or 9.42 per cent., or (deducting 15 cases of phthi- 
sis, 1 ether death, 2 amyloid disease, 2 nephritis, 1 poi- 
soned wound) 10 deaths properly due to operation, or 3.08 
per cent. Likewise Bergmann reports excellent results 
for wounds of the knee-joint under antiseptic dressing 
(of wounds not involving bone out of 21 cases 18 recov- 
ered ; 3 under treatment). 

Culbertson shows that age influences mortality. The 
mortality of operations for disease under five years of 
age was 38.88 per cent.; from five to ten years, 16.19 per 
cent. ; from ten to fifteen years, 17.17 per cent. ; fifteen 
to twenty, 30.11 per cent. ; twenty to twenty-five, 39.39 
per cent. ; twenty-five to thirty, 37.3 per cent. ; thirty 
to forty, 41.55 per cent. 

As to function, after recovery from resection for gun- 
shot wound, 58.8 per cent. of limbs were reported ‘‘ use- 


ful;” 28.8 per cent. were subsequently amputated (Cul- | 


bertson). According to Gurlt (German wars from 1848 
to i871), 55.55 per cent. of limbs were ‘‘ very good ;” 
33.33 per cent. ‘‘good;” 11.11 per cent. ‘‘ very bad.” 
“Perfect” or ‘‘ good” results followed operations for 
injury in 82.3 per cent. of cases; for deformity in 87.3 
per cent., and for disease in 56.7 per cent. 

The functional failures’ are due in some cases to the 
destruction of the epiphysial cartilages. As is well 
known, the femur grows chiefly from its lower epiphysis, 
and the tibia from its upper one. If in childhood one or 
both of the epiphyses are totally removed the shortening 
of the limb may be excessive. Other failures arise from 


192 


non-union orimperfect union of the sawed surfaces. Usu- 
ally in resection of the knee anchylosis is aimed at. It is 
now known that without bony union, or even with con- 


| siderable motion at the false articulation, the limb may 


be a very useful one; but great stability of the new 
articulation is necessary to good use. ~ It not infre- 
quently happens, and particularly in children, that 
when the limb is walked upon it gradually becomes 
flexed at the knee to such a degree as to destroy its 
, usefulness. This flexion is due to the combined 
action of the weight of the body, the traction of 
the flexors of the legs, and, it is believed, by the 
greater growth of the anterior part of the 
==—_ = epiphysis. The two forms of failure have 
led to various technical devices to increase 
the solidity of the union, on the one hand, and to infor- 
mal operations, on the other, which should as far as pos- 
sible spare sound tissue and preserve the joint functions. 
The results of informal operations cannot be statistically 
stated, but they seem, from reported evidence, worthy of 
trial in favorable cases, even if, as some claim, relapses 
demanding subsequent excision sometimes occur. 

Indications.—Resection for gunshot injury in military 
practice has proved so fatal that unless aseptic surgery 
shall give better results it seems hardly to be indicated 
at all. Such improved results are still wanting. Gun- 
shot wounds of the knee without fracture seem, in the 
light of the latest experience (Bergmann) to do well 
without operation if antiseptically treated. If fracture 
exists, amputation is still the safest alternative. 

In fungous disease operative interference is indicated 
whenever such expectant treatment as the patient can 
command has failed to improve the condition, especially 
if there is a persistent suppuration, and in any case in 
which the functions of the joint seem to be hopelessly 
impaired, inasmuch as the anchylosis necessary to a use- 
ful limb can be much more quickly reached by antiseptic 
operation than by the tedious process of natural cure. 
Fungous disease presents peculiar features at the knee, 
notably in the relatively less extensive bone-lesions and 
the predominant fungous synovitis. The peculiar, slug- 
gish course of ‘‘ white swelling” renders interference 
proper without open suppuration or certain bone-disease. 
There is also a greater latitude of choice as to kind of 
operation than is usual at other joints ; namely, between 
arthrotomy, arthrectomy, resection more or less complete, 
and amputation. Arthrotomy, so valuable in acute joint- 
inflammations, has not proved equally efficient in fungous 
disease. The distinction between arthrectomy and true 
resection is not a very hard-and-fast 
one, inaSmuch as, besides the extir- 
pation of the diseased soft tissues, 
all diseased bone is gouged away, 
and although the typical forms are 
departed from, the resection may be 
as extensive as in the most formal 
procedure. If by resection the for- 
mal operation alone is meant, it 
seems to be less frequently indicated 
than formerly was supposed. In 
very young children, under five 
years of age, it is not called for; in 
older children the informal opera- 
tions will probably give at least as 
good results. Resection gives the 
best results, all things considered, in 
the age of adolescence, and next in 
early adult life. At this time of life 
the form of operative interference 
to be preferred is usually resection. 
The results become less satisfactory 
later on, and the choice between resection and amputation 
less clear ; after middle life, most surgeons prefer ampu- 
tation. 

Methods have been for this joint also very numerous. 
But the semilunar incision, convex downward, the H, and 
the transverse in its several varieties, are much the most 
frequently employed. ‘ 

If ina typical resection the semilunar incision (Fig. 


ne 


A 
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1 
I 
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Fie. 83800. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Resection. 
Resection, 


3300) is employed, the knife enters at the back part of one 
condyle and is carried somewhat downward, and crosses 
below the patella, and is carried to the back part of the 
other condyle. The point of the knife should be carried 
to the bone throughout its course, and divide the liga- 
mentum patelle. It may sometimes also divide the 
lateral ligaments. The flap is turned up, exposing the 
joint freely. The knife, kept close to the tibia, divides 
the crucial ligament, and section of the lateral liga- 
ments is completed. The lower end 
of the femur is then cleared, espe- 
cial care being used at the back of 
the bone to avoid wounding the ves- 
sels. The femur is now protruded 
and athin slice, carrying the articular 
cartilage, is sawed off. Figs. 3801. 
and 3302 (from Holmes) show the 
relation of the ordinary saw-cuts to 
the epiphyseal cartilages. If it be 
possible to avoid it, these cartilages 
should not be touched; diseased 
parts only should be removed. The 
saw would better be carried not quite 
through the bone, but the last part 
broken away to prevent danger to 
the popliteal vessels and nerve, the 
rough edges of the bone being sub- 
sequently smoothed. In sawing the 
femur,the cut should be parallel to 
the articular surface, and should re- 
move an equal amount from both 
condyles. The tibia is cleared and 
sawed in the same manner. There 
is a decided variance of opinion about the removal of 
the patella, some operators preferring to keep it as an 
extra strength to the anchylosis, and as preventing the 
tendency to flexion which is quite common, especially in 
children ; others preferring to take it away, as being of 
little use and a possible source of renewed disease. ‘The 
writer shares the latter opinion, and believes that if in a 
typical resection the patella is to be left, its inner surface 
should be shaved off, so that a better judgment of the in- 
terior condition of the bone can be formed, and in order 
to insure its closer union to the other bones. The dis- 
eased synovial membrane is scraped or cut away, and all 
suspected parts of bone gouged. 

If the transverse cut is used it may be just below the 
patella, and transverse to the axis of the tibia, in which 
case, as Ashhurst points out, if 
the knee is bent at the time of 
cutting, the incision becomes a 
semilunar one when the limb is 
straightened, and much like that 
already described. It may be 
made above the patella, giving 
convenient access to the upper 
pouch of the joint. Or, again, it 
may be made directly across the 
patella, at or slightly below its 
centre. If lateral offsets be added 
it becomes the H-incision, the 
upper and lower flaps being dis- 
sected and the remainder of the 
operation being as described for 
the semilunar incision. The in- 
Wi cision across the patella was pro- 
/ posed by Volkmann, and has been 
considerably employed. It  be- 
gins at the anterior border of one 
epicondyle and passes directly 
across the middle of the patella 
to the anterior margin of the other 
epicondyle. The joint is then opened on either side of 
the patella, the index-finger is thrust under the patella 
on either side for exploration, and if the operation is to 
proceed the bone is sawed across, the lower fragment 
turned down, and the joint cleared. The operation is to be 
finished as usual. This method facilitates extirpation of 
the joint. The section of the patella allows a judgment of 


Vouevi—15 


Fig. 3801. 


Fia@. 3302. 


the condition of that bone. If it is sound, it is left eitber 
entirely or with its inner surface shaved off. The frag- 
ments are then reunited by suture. Besides, Ollier rec- 
ommends that for traumatic resections the patella be di- 
vided vertically in the course of a median longitudinal 
incision. Langenbeck made a subperiosteal resection 
through an internal semilunar incision, the convexity be- 
hind passing over the posterior part of the internal con- 
dyle. Ollier also urges the subperiosteal method, and 
formerly used the external anterior 
incision shown in Fig. 3308. He 
has more recently *4 reeommended : 
a small H-shaped incision, the lat- 
eral cuts converging below, togeth- q 
er with lateral posterior drainage- 
openings made before the parts are 
removed. The patella is not re- 
tained, and section of the lateral 
ligaments is avoided if possible. 

Among modifications to secure 
greater fixation may be mentioned 
that of Neuber, who used the semi- 
lunar incision, and besides -the 
usual resection of the articular sur- 
faces trims off the posterior promi- 
nences of the condyles, shaves off : 
the front of the tibia and femur, 
and the posterior surface of the 
patella. The femur and tibia be- 
ing nailed together, the patella is 
nailed to their shaved surfaces so 
as to act like a clamp to hold the main bones in apposi- 
tion. Fenwick® also uses the semilunar incision and 
follows the customary method until the bones are to 
be sawn. A fine fretwork saw, in a butcher’s saw- 
frame, is then carried in a circular sweep over the con- 
dyles from before backward removing the cartilage and 
all diseased bone, both condyles being diminished equally, 
and the end of the femur is left rounded in an antero- 
posterior direction. The tibia is sawed from behind for- 
ward, with a concavity to fit the convexity of the femur. 
The patella is removed. Kocher seems to employ near- 
ly the same method. 

A. M. Phelps urges resection of the hamstrings as a 
safeguard against subsequent flexion. 

If arthrectomy is intended, it is well to choose an in- 
cision which will serve for resection if, after exploration 
of the joint, the latter operation seems to be preferable. 

The operations for deformity are cuneiform osteotomy 
above the condyles (Rhea Barton) ; simple osteotomy of 
the femur, and of the fe- 
mur and the leg bones 
(Barwell) ; removal of a 
wedge, including site of 
knee-joint (Buck), and 
breaking up of anchylosis 
followed by resection. If 
there is any doubt as to 
the persistence of disease 
at the joint, resection of 
the joint itself is the only 
operation. If the flexion is 
above aright angle, reduc- 
tion of the deformity will 
probably demand the re- 
moval of a block of bone 
which is not a_ perfect 
wedge, ?.¢., which hassome 
thickness behind. The 
technique has nothing pe- 
culiar. Any convenient 
incision may be used, the H or the semilunar being usu- 
ally most convenient. It is thought to be safer to break 
out the block or wedge before the entire thickness of the 
bone has been cut, and to finish with a chisel, gouge, or 
other convenient instrument. i 

It is usual to fasten the femur and tibia in apposition 
by sutures of wire or of catgut, or by nails or pins of bone. 
It is not necessary to use anything if the shape of the 


193 


Fie. 3303. 


“al 
Fra, 3804. 


Resection. 
Resection, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


sawn surfaces, as in Fenwick’s method, for instance, is 
such as will, with the help of a firm dressing, maintain 
the juxtaposition. It is not absolutely necessary in the 
ordinary forms of operation,®’ but some such device is 
valuable to prevent the thigh from rotation outward, 
while the tibia remains in position, which results in a 
bad intoeing when the limb is otherwise fit for use. The 
methods of introducing wire and nails have been de- 
scribed. Additional firmness is gained by deep stitching 
of the soft parts. 

The drainage should be from the posterior lateral an- 
gles of the wound, from the superior pouch, and other 
dependent points if necessary. . 

The antiseptic dressing is usually followed by a splint. 
Various devices have been satisfactorily employed, but 
for ordinary cases a good plaster bandage, fenestrated 
and bracketed, answers all purposes. A long anterior 
rod, shaped to the limb, bent at the knee into bracket- 
shape, and continued upon the dorsum of the foot, with 


Fie. 3305. 


rings for suspension (see Fig. 3305), as recommended by 
Watson, is an excellent addition to the plaster dressing. 
Suspension of the limb is usually comfortable, and _pre- 
vents or diminishes the danger of displacement of the 
fragments if the patient changes his position. Subse- 
quent dressings should be as infrequent as surgical clean- 
liness will allow, and the seat of operation be disturbed 
as little as possible. 

The time requisite for union varies greatly, but is 
much shorter with antisepsis than without. Patients 
are confined to bed sometimes only a month, but usually 
a considerably longer time is required. 

RESECTION OF THE ANKLE has suffered, in profes- 
sional estimation, from essentially the causes that hin- 
dered the general acceptance of wrist resections. The 
number of bones, the complexity of synovial membranes, 
and the propinquity of many tendons, give many lurk- 
ing places for disease, and often delay recovery, insure 
relapses, or destroy the functional value of the rescued 
foot. For these reasons many surgeons have preferred 
Syme’s or Pirogoff’s amputations. Better methods, how- 
ever, have very much diminished this antagonism to re- 
section. The results of limited operations are often ex- 
cellent, and if extensive ones, sometimes leave a foot that 
is not much more than a stump, but it is, nevertheless, a 
much more useful stump than is usually obtained from 
amputation. Strictly speaking, resection of the ankle 
means removal of the articular surfaces of the tibia and 
astragalus, with or without the lower end of the fibula ; 
usage, however, makes the phrase include more exten- 
sive invasion of the tarsus, at least as far as the mid-tarsal 
articulation. If both surfaces of the tibio-astragaloid 
articulation are removed, the resection is ‘‘ complete.” 
The operation was originally applied to the reduction of 
compound dislocations and fractures of the ankle, and, 
until about thirty years since, operations for injury con- 
siderably outnumber those for disease. Otis could find 
but three cases of resection for gunshot injury previous 
to 1861. 

Results,—The death-rate from resection of the ankle 
for gunshot wounds in 45 cases, collected by Culbert- 
son, was twenty-six per cent. Otis reports 33 cases from 
our own war, 7 only of which were technically complete, 
with a death-rate of twenty-nine per cent. He also col- 
lected 150 cases from other sources, nearly all more 
recent than our war, with a death-rate of 33.7 per 
cent. So far, therefore, the death-rate is higher than for 
ankle amputations, which in our war (Otis) was 25.1 
per cent. The same authority concludes that the func- 
tional results are not very satisfactory, and prefers the 
‘“judicious use of the gouge and the bone-forceps” to 
formal exsections, 


194 


In civil practice the results for injury are better, the 

death-rate, according to Culbertson, for 152 cases being 
12.5 per cent., and the functional results are better. Cul- 
bertson shows the death-rate for disease in 124 cases to 
have been but 8.06 per cent., which is not far from the 
mortality of Syme’s operation done under similar circum- 
stances. The death-rate of partial resections was but 
6.55 per cent. 
_ The operations made for injury usually result in an- 
chylosis, and often with feet in faulty position, which 
greatly impairs their usefulness. Recurrence of disease 
in the tarsus is frequent when the operation has been done 
for caries. These reasons have led to the increased favor 
accorded to informal procedures, 

Indications.—For gunshot injury, resection, in form, 
of the ankle-joint gives but indifferent results, and is in- 


Vou 
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Fre. 3306. 


dicated only under very favorable circumstances, and in 
cases which probably would do quite as well with in- 
formal removal of fragments and gouging. 

Compound fractures or dislocations call for resection, 
generally partial or atypical, when the injury is attend- 
ed with extensive damage to the soft parts, but not 
to nerves or vessels, or when the reduction of bones is 
difficult without the operation. Also, as a secondary 
operation, when suppuration has supervened upon a com- 
pound fracture and the tissues are already badly dam- 
aged, or cure is probable only through anchylosis, resec- 
tion gives a speedier termination. 

For caries, resection is rarely indicated in young chil- 
dren, and perhaps before puberty. In childhood, expec- 
tancy, with opening of abscesses, drainage, extraction of 
sequestra through sinuses, produces very satisfactory re- 
sults. Even when, at this age, the caries is extensive, 
évidement, or its modification of scooping and setoning, 
as urged by Sayre, often saves the foot with nearly or 
quite perfect functions. After childhood, more formal 
operations come into question. The operation selected 
should be that involving the least mutilation of the soft 
parts consistent with complete extirpation of the disease. 
The retention of the malleoli, or of one only, gives a solid- 
ity to the parts which favors union in good position. ' 

Methods.—The preference has been rather for lateral 
incisions, wholly or partly in the axis of the leg, as dam- 
aging the tendons. less than transvere cuts. There have 


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BEERS GBR: 
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Fie. 330%. 
been many varieties of thistype. Figs. 3306 and 3307 show 


one of them, recommended by Wyeth,**® which is made as 
follows: Commence an incision on the internal surface of 


a 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the tibia, about two inches above the tip of the inner 
malleolus, and carry it directly down to this point and 
thence forward from one inch to one inch and a half 
along the tarsus in the line of the metatarsal bone of the 
great toe (Fig. 3306). This incision extends a little an- 
terior to the astragalo-scaphoid articulation. <A light 
L-shaped incision is made upon the fibular side of the 
joint (Fig. 3307). With the Sayre periosteal elevator, 
lift from the diseased portions of bone the periosteum 
(with its attachments to the superjacent soft tissues un- 
disturbed). Expose the outer malleolus and fibula as 
high as it is deemed necessary to remove this bone, and 
divide it with the exsector or chisel. As soon as the 
piece is removed, the joint is thoroughly exposed to view. 
Now, in the line of the tibial incision, further lift the 
periosteum of the tibia and tarsal bones, and, by forcibly 
bending the foot inward, dissect the tibia and inner mal- 
leolus outward through the wound on the fibular side. 
The diseased surfaces of the tibia and fibula may be sawn 
off with an ordinary saw, or with the exsector. The 
line of section should be at a right angle to the axis of 
the shafts of these bones, and should first remove the ar- 
ticular cartilage. Should the disease extend higher than 
this, an additional slice of bone may be removed, or any 
small sinuses thoroughly scraped out with Volkmann’s 
spoon, and sponged out with sublimate, 1 to 1,000. The 
astragalus is now removed and the upper surface of the 
caleaneum sawn or chiselled off, so that a smooth and 
freshened surface is left. The cartilage should be scraped 
from the posterior articular face of the scaphoid. All of 
the soft tissues involved in the disease should be dissected 
away. The os calcis and tibia are now brought together, 
and if the sawn surfaces fit snugly with the foot at a 
right angle to the leg they are ready to be fastened. 
This is done by passing a nail or the Wyeth drill from 
the sole through the calcaneum up into the tibia. The 
drill is removed when sufficient firmness of the parts per- 
mits. 

Langenbeck’s subperiosteal operation also has bilateral 
incision. The external one consists of a cut about two 
and one-half inches long on the posterior border of the 
lower end of the fibula, and continues around the margin 
of the malleolus in a hook-shape. This is carried down 
to the bone, the fibula denuded without harm to the ten- 
don of the peroneus longus. The fibula is divided at the 
upper level of the incision with the keyhole-saw, the frag- 
ment carefully separated from the interosseous ligament, 
which must be preserved on account of its influence on 
the reproduction of bone, and, finally, from its ligament- 
ous attachments to the astragalus and calcaneum. If 
diseased, the articular surface of the astragalus is sawn 
off with a keyhole-saw from before backward. The in- 
ternal incision is anchor-shaped, the curved part about 
an inch and one-half long, follows the lower border of 
the malleolus; the straight part, about two inches long, 
is vertical on the inner side of the tibia. Subperiosteal 
denudation as before. The tibia is sawn with keyhole 
or chain-saw, the remainder of its attachments carefully 
severed and the fragment removed, the detached piece 
of astragalus being removed afterward. 

The great objection to the lateral incisions has been 
the imperfect exposure of the interior of the joint gained 
when they are used, which leads to the overlooking of 
points of disease and consequent relapses. Many opera- 
tors, therefore, prefer the semi-lunar incision in some 
form, either anterior or lateral. Hancock** made an in- 
cision which beginning behind and about two inches 
above the external malleolus passed forward beneath 
that process across the front of the joint and terminated 
about two inches above and behind the inner malleolus. 
The cut divided skin only and the flap was dissected up, 
the peronei tendons detached from their grooves and 
drawn aside and the external lateral ligament cut. The 
fibula was cut off with bone nippers one inch and a 
half above its lower extremity. The foot was thrown 
over and the internal lateral ligament cut, the artery 
being saved and tendons of the tibialis anticus and flexor 
communis detached from their grooves. The foot was 
dislocated outward, the lower end of the tibia sawn off 


Resection. 
Resection, 


about a half-inch above the articulating surface and the 
astragalus removed. 

_ Ashhurst ® expresses his preference for ‘‘a semi-lunar 
incision, made to pass around the lower border of the outer 
malleolus, and then continued longitudinally in the line 
of the fibula.” All tendons are saved except the per- 
oneals, which are divided, the lower end of fibula re- 
moved, the astragalus wholly or partly removed. The 
foot is bent inward, the tibia cleared, its malleolus cut off 
with bone forceps, a short incision is made on the inner 
side of the limb, and the tibia sawn with a keyhole 
saw. 

Kocher ®! makes an external semi-lunar incision from 
outside of the tendo-Achillis below the malleolus nearly 
to the extensors. The peroneal tendons being exposed, 
each is tied with a double ligature and cut between the 
ligature. The joint is freely opened, the foot bent in- 
ward, all disease searched for and removed. The di- 
vided tendons are reunited by a suture carrying a needle 
at both ends. Both needles are thrust into the upper 
segment a little distance apart, out at its cut end, into 
the cut end of the other segment and out upon the sur- 
face at different points the cut surfaces approximated and 
the suture tied. Kocher thinks that this gives a firmer 
suture than ordinary stitches. 

Hueter * favored an anterior transverse cut with sub- 
sequent suture of tendons. 

Vogt ™ has devised a somewhat novel method. He 
makes an incision just outside of the extensor tendons, 

beginning between the tibia 

or fibula above and running 

| down to the junction of the 
/ caleaneum and cuboid. The 

fascia is divided, the ten- 

dons with their sheaths care- 

fully detached from the 

parts beneath and drawn 

strongly inward. The ex- 

tensor brevis is then cut and 

the outer lip of the wound 

drawn outward, and the 

capsule of the 
joint split open 
from top to bot- 
tom and with 
knife and elevator 
detached on both 
sides from the 


{ 


PPTL TTP raat} 


Fie. 3308. 


bone. The head and neck of the astragalus are then 
cleared and astragalo-scaphoid ligament cut through. 
Then a second incision is made from the first, beginning 
rather below the middle of the latter and running back- 
ward under the external malleolus. While the peroneal 
tendons are avoided the cut is carried down to the astrag- 
alus. The foot is separated, the ligament is cut away 
from the front of the malleolus and the interosseous liga- 
ment divided by a strong knife thrust into the aperture 
between the astragalus and os calcis. The foot being still 
supine the head of the astragalus is drawn outward with 
a strong hook, the fasciculus of the internal lateral liga- 
ment between the malleolus and the astragalus is cut ; 
the latter bone is then drawn forward and its posterior 
connections cut and the bone removed. Through the 
cavity thus made all the adjoining bones can be readily 
examined and the extent of the subsequent resection, 


195 


Resection. 
Respiration. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


whether with saw, gouge, or spoon depends upon the 
necessities of the case. 

Mikulicz,* in 1880, performed what he styles an osteo- 
plastic resection of the foot, which is intended for the re- 
lief of extensive disease of, or injury to, the posterior 
bones of the tarsus or of their covering tissues, and as a 
substitute for amputation at the ankle or in the leg. It 
seems ® that the operation had been done in 1871 by 
Wladmiroff, but, the published account being in Rus- 
sian, was overlooked until after Mikulicz had reinvented 
it. The operation is performed thus: The patient lies 
‘ upon his stomach. An incision is carried from the tu- 
bercle of the scaphoid bone on the inside right across the 
sole to a finger’s breadth behind the base of the fifth 
metatarsal bone. From each end of this incision others 
are carried upward and backward to the base of the mal- 
leolus of the same side. These again are joined by a cut 
across the back of the ankle dividing the tendo Achillis 
(Fig. 3308). All these cuts are carried to the bone. The 
flap is dissected from above, the joint opened from be- 
hind, the lateral ligaments cut, the 
astragalus and calcaneum are care- 
fully dissected out and detached at 
the medio-tarsal joint. The mal- 
leoli and articular surface of the 
tibia and the posterior part of the 
cuboid and scaphoid bones are then 
sawn off, as shown by the dotted 
lines. The foot is brought back, 
the sawn surfaces adjusted, and the 
wound closed. Fig. 3309 shows 
the foot resulting in Mikulicz’ 
case. Hopkins modified the opera- 
tion by using bone pins to secure 
the parts together, by suturing the 
divided tendons, and attaching the 
tendo Achillis to the plantar fas- 
cia. The ends of the resected pos- 
terior tibial nerve were also sut- 
ured. This author has collected 
twenty-two cases of this operation ; 
two died some months later of pul- 
monary tuberculosis, one having 
had a useful foot in the meantime ; 
in one a subsequent resection of 
the rest of the tarsus was necessary, 
and in three subsequent amputa- 
tion was performed. The remaining sixteen have useful 
extremities. 

The after-treatment of ankle-resection should be fixa- 
tion in a good position with as few changes of dressing 
as practicable. The gypsum bandage or gypsum ante- 
rior splints with suspension-rod will suit as many cases 
as any one form of support. The suspension of the limb 
is a security against faulty position of the foot. 

THE SMALL JOINTS of both the hand and the foot occa- 
sionally require excision for the same causes as the larger 
joints. The indications are those of resections in general 
under corresponding circumstances, due importance be- 
ing given to the value of function saved in a finger- 
joint. For injury informal procedures are generally pref- 
erable. 

The phalangeal joints of the fingers are generally re- 
moved through slightly curved lateral incisions, single or 
double, as necessary. 

The “metacarpo- ‘phalangeal joints are best removed by 
dorsal straight incisions beside the extensor tendons, the 
latter being avoided by manipulation. The bone forceps 
is ordinarily used for section of the bones. 

The corresponding joints of the toes are removed by the 
same method as those of the fingers. As the thumb is 
pre-eminently valuable to the hand, so the great toe is to 
the foot. In removing the metatarso-phalangeal joint of 
the great toe, the incision may be on the inside and semi- 
lunarin form. The operation has been recommended for 
hallux valgus, especially if complicated with painful 
bunion, 

In both upper and lower extremity the resected parts 
should be kept separated by traction until the state of re- 


Fie. 3309, 


196 


pair permits passive motion. The latter should be be- 
gun early, to preserve the function of the joints. 
Leroy Milton Yale. 


1 The Excision of Joints, by Richard M. Hodges, M.D. Boston, 1861. 

2 Traité des résections, etc., tome i., chap, iii., 1885. 

3 British Med. Journal, 1887, i.. p. 389. 

4 Archiv fiir klinische Chirurgie, Band xxvi., S. 22. 

5 Cases in Surgery, with Remarks, p. 57, London, 1770. 

6 Philosophical Transactions, vol. Ixiv., p. 853. Abridged edition, vol. 
xiii,, p. 539. 

ae and Surgical History of War of Rebellion, Part II., vol. ii.. 


8 Die Gelenk-resectionen nach Schusswunden, §. 1290, Berlin, 1879. 
® Archiv f. Klin. Chir., B. xvi. 
10 British Medical Journal, May 22, 1880. 
11 Med. and Surg. History, Part vis vol. ii., p. 661. 
12 Arch. f. Klin. Chirurgie, Bd. xvi., p. 418. 
Kee Esmarch : Surgeons’ Handbook, Clutton’s English translation, p. 
14 Traité de la Régénération des Os, t. ii., p. 819, Paris, 1867 (abbrevi- 
ated). 
15 Bull. et Mém. de'la Soc. de Chirurgie, 1883, p. 591. 
16 Op. cit, p. 916, note, 
17 Esmarch’s Handbook. Clutton’s trans. 
18 Régénération des Os, t. ii., p. 340. 
19 Klinik d. Gelenkkrankheiten, § 632, edition of 1871 ; also, Deutsche 
Zeitschr. f. Chirurgie, Bd. IL., 8. 71. 
20 Wien. Med. Presse, xxiv., §25. See this article for summary of osteo- 
plastic operations. 
21 Operative Surgery, Second Edition, p. 154. 
22 On Excision of the Wrist for Caries, Lancet, 1865, vol. i., p. 808 et 
seq. 
23 Prize Essay, p. 628. 
a Résection pathologique du Poignet, Revue de Chirurgie, 1883, p. 


25 Gazette Médicale de Paris, May 13, 1882, p. 241. 

26 Métral: Thése de Lyon, 1882; De la Resection sous- -périostée du 
Poignet ; ses résultats définitifs, p. 65. 

27 G, A. Otis: Med. and Surg. History, Part II., vol. ii., p. 1010. 

28 Hueter: Arch. f, Klin. Chirurgie, viii., p. 102. 

29 Tancet, April 1, 1865, p. 335 et seq. 

30 Hsmarch’s Handbook. Clutton’s translation, p. 247, somewhat ab- 
breviated. 

31 Bulletin et Mémoires de la Société de Chirurgie de Paris, 1888, p. 
292, 

32 Traité de la Régénération des Os, t. ii., 1887, p. 579. 

33 Métral: Thése, 1882, p. 45. 

34 Sidney Jones: Lancet, 1884, ii., 870. 

35 W. Adams: Proceedings Med. Chir. Society, 1885, p. 274. 

36 Wipperman: Arch. f. kl. Chirurgie, Bd. xxxii., S. 440, Literature. 

37 J. W. Howe: Medical Record, 1878, xiv., 394. 

38 Heusner: Arch. f. kl. Chirurgie, Bd. xxxi., 666; Schuessler: Ber- 
lin. klin. Wochensc., Bd. xxiv., 8. 398. 

39 Jan. Driesen : Centralblatt f. Chirurgie, 1880, 674. 

40 Centralbl. f. Chirurgie, 1882, S. 228. 

41 Address in Surgery, British Med. Journal, 1880, ii., 212. 

42 Archiv f. klin. Chirurgie, Bd. xvi. 

43 Régénération des Os, t. ii., p. 384. 

44 Revue de Chirurgie, 1887, p. 398. 

45 Chirurgisch-anatomisches Vade-mecum. Stuttgart, 1870. 

46 Centralbl. f. Chirurgie, 1878, v., 681. 

47 Verhandl, der Deutsch. Gesellsch. f. Chirurgie, 1878, Pt. I., p. 68. 

48 Trans. Clinical Society, 1880, p. 105. 

49 Orthopeedic Surgery, first ed., pp. 427 et seq. 

50 British Med. Journal, December fe 1870. Reprint, 1871, p. 11. 

51 Centralblatt f. Chirurgie, 1880, p 

52 History, Part III., vol. ii., p. HES 

58 Trans. Med. Soc, State of N. Y., 1886, p. 586. 

54 Revue de Chirurgie, 1883, p. 268 et seq. 

55 International Encyclopedia of Surgery, vol. iv., p. 535. 

56 Transactions International Congress, London, 1881, vol. vi., p. 384. 

57 See discussion in N. Y. Surgical Society, Medical News, 1885, xlvi., 
41 15. 

58 Med. Record, October 15, 1887, p. 511. 

59 Operative Surgery of Foot and Ankle, 1873. 

60 International Encyclopedia, vol. iv., p. 525. 

681 Dumont: Arch, f. KI. Chir., xxxiv., 318. 

62 Arch, f. Kl. Chirurgie, 1881, p. 812. 

63 Centralb. Kl. f. Chirurgie, 1883, p. 289. 

64 Archiv f. Kl. Chir., Bd. xxvi. 

85 Hfopkins, Md. News, December 3, 1887, p. 649. 


RESORCIN: RESORCINOL. Resorcin, chemically 
Metadioxybenzene, CeH,(OH)2, is one of a trio of iso- 
meric diatomic phenols, of which pyrocatechin and hy- 
droquinone are the other two members. 

Resorcin occurs in colorless crystals, having a peculiar 
smell, resembling that of carbolic acid, and a bitter-sweet- 
ish taste. Resorcin dissolves readily i in water, and still 
more readily in alcohol and in ether. In its effects resor- 
cin resembles its congener, carbolic acid, but is, in general, 
less active than that substance, and, in particular, very 
much indeed less poisonous, constitutionally. Resorcin 
inhibits bacterial growth, but probably less potently than 
carbolic acid. Locally the drug is without effect upon the 
sound skin, but applied, undiluted, to a moist mucous 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Resection. 
Respiration. 


membrane, it is mildly caustic, while at the same time 
anesthetic and healing. By reason of the anesthesia it 
produces, resorcin may be applied even to such sensi- 
tive parts as the mucous membrane of the larynx (An- 
deer). Internally, resorcin may be given in very con- 
siderable doses, as compared with carbolic acid, and such 
doses, administered to a fevered subject, will show toa 
marked degree the peculiar antipyretic effect so charac- 
teristic of the phenols. After a dosage of from 2.00 to 
3.00 Gm. (from thirty to forty-five grains) there set in, 
in a few minutes, quickening of heart-action and of 
breathing, reddening of the face, and buzzing in the ears, 
with giddiness. Within fifteen minutes sweating be- 
gins, speedily becoming active, whereupon the antece- 
dent derangements abate, and at the same time the py- 
rexial temperature rapidly falls—so rapidly as perhaps 
to reach the normal point within an hour. The sweat- 
ing does not last long, so that after the lapse of an 
hour from the time of dosing, the fever-patient may have 
a naturally moist skin only, with temperature and pulse- 
rate reduced to thenormal. But while defervescence by 
resorcin is quick to occur, it is also quick to give way to 
the natural tendency of the fever to regain its former 
height. Within from two to four hours, therefore, the 
temperature often begins its succeeding rise, and within 
a single additional hour may have attained its original 
height. Such rapid after-risings of temperature may be 
attended by a chill. Resorcin is variable in its action ; 
sometimes the fall of temperature is slight, and some- 
times the by-effects are excessive and even alarming. 
Thus, after medicinal doses, there have been observed 
delirium and illusions, with muttering speech and con- 
vulsive trembling of the hands, and, in one case at least, 
a deep comatose sleep. In overdosage resorcin is com- 
petent to induce constitutional poisoning after the gen- 
eral type of poisoning by the phenols—giddiness, insensi- 
bility, profuse sweating, great reduction of temperature 
and general collapse, with olive-green coloration of the 
urine, being the prominent symptoms. Such alarming 
condition has followed a succession of doses increased 
from half a drachm to two drachms. Therapeutically, 
resorcin is used for both local and constitutional medi- 
cation. Locally, resorcin is possible for a simple ‘‘an- 
tiseptic ” effect, but is surpassed’in this therapeusis by so 
many other agents as to be little used for the purpose. 
But for a combined antizymotic and healing effect the 
local application of resorcin may be quite serviceable. 
Thus injections of a five per cent. aqueous solution have 
been made into the bladder, in cystitis, and into sup- 
purating cavities, with good effect, and salves of resorcin 
have abated malignant and syphilitic ulcerations, In- 
ternally resorcin has been used for its antipyretic action, 
in which application the medicine presents the feature 
of a fair degree of ‘safety and efficiency combined ; but 
the action is evanescent and attended by disagreeable 
excitement and sweating. The dose of resorcin for an 
antipyretic effect ranges from 2.00 to 4.00 Gm. (from 
thirty to forty-five grains), best given in divided doses 
and administered, dry, in a wafer or capsule, or in 
solution in water, sweetened and aromatized. Constitu- 
tional effects are also asserted (Andeer) to be procurable, 
in diseases attended by an affection of the skin, by inunc- 
tion of resorcin in admixture with vaseline, in proportion 
of from five to eighty per cent., such effects being the 
abatement of symptoms in so-called zymotic diseases. 
Andeer claims to have thus produced striking ameliora- 
tion in such diseases as small-pox, scarlet fever, measles, 
and leprosy, by inunctions, over the whole body, of re- 
sorcin-vaseline. Edward Curtis. 


RESPIRATION, PHYSIOLOGY OF (Gr., avamvon, 
avdnvevois ; Lat., respiratio; Fr., respiration ; It., res- 
pirazione; Ger., Athmung). There are three distinct 
conceptions of respiration in medical and popular litera- 
ture, representing three stages in the progress of knowl- 
edge concerning this subject: (1) That it consists of the 
mechanical process of supplying the lungs withair, gills 
with water, etc. (see below, under Mechanics of Respi- 
ration); (2) that it is the change taking place in the 


blood during its passage through a respiratory organ 
(lung or gill) (see below, under External Respiration) ; 
(8) the conception held at the present day, that it is the 
taking up of oxygen and the giving off of carbon diox- 
ide by living matter ; or, in other words, it is that part 
of the nutrient process which has to do with nutriment 
and waste in the gaseous form, and that the mechanical 
movements for supplying air or water, and the changes 
occurring in a respiratory blood, are only accessories of 
the essential process, and are sometimes absent. 

Respiratory Media.—These are the sources from which 
oxygen is obtained for respiration, and into which car-’ 
bon dioxide is excreted. They are air, and water con- 
taining oxygenin solution. If an animal breathes in the 
air, its respiration is said to be aérial ; if in water, 
aquatic. In some cases—in tadpoles, for example—both 
media are used at the same time.*+ 

Direct and Indirect Respiration.—In organisms of 
minute size, like the ame@ba, the living substance is all 
so near the oxygen in the sur- 
rounding medium (water) 
that oxygen is taken directly 
from the water, and carbon 
dioxide is given off directly 
to it (Fig. 3810). In ani- 
mals of larger size, especially 
those of complex organiza- 
tion, if the respiratory me- 
dium simply bathed the sur- 
face of the body, most of the 
living matter would be too 
far from the oxygen supply 
to enable the organism to 
carry on its functions with 
the highest efficiency ; hence 
there are present special re- 
spiratory organs to facilitate 
the furnishing of oxygen to 
the tissues, and the removal 
of carbon dioxide from them. 

In the larger protozoa, as 
the infusoria, cilia are present on the surface, which, by 
their motion, produce currents in the water, or change 
the position of the animal, in either case insuring fresh 
supplies of the respiratory medium. Water is also taken 
into the body, thus bringing the oxygen into intimate 
contact with the living substance farthest from the sur- 
face. 

In the metazoa the size of the body is often_considera- 
ble, and more elaborate means are employed to bring 


Fie. 3310.—Diagram of an Amceba, 
Illustrating the Direct Respira- 
ticn of Minute Aquatic Animals, 
in which the living substance 
takes oxygen directly from the 


surrounding medium, and re- 
turns carbon dioxide directly to 
it, no respiratory organs being 
present. O, oxygen; COk, car- 
bon dioxide. 


(a 


Fig. 3311.—Diagram Illustrating the Direct Respiration of Insects, in 
which Air is conveyed to the Tissues through Tubes (tracheeze), 
The tissues take oxygen directly from the air, and return carbon di- 
oxide directly to it, no respiratory blood being present. O, oxygen 5 
CO., carbon dioxide. As indicated by the arrows pointing in the two 
directions, the tissues take more oxygen from the air than they give 
off carbon dioxide to it. Air, the air in the trachea. Tissue, all 
the tissues ,of the insect’s body are here represented by a piece of 
striated muscular fibre. 


the respiratory medium in proximity to the living sub- 
stance. In some of them—the sponges, for example— 
there are water canals in all parts of the body, through 
which streams of water constantly flow, thus bringing 


* In the forms of bacteria known as ane@robic, é.e., living in situations 
devoid of free oxygen, the oxygen needed for respiration is, according to 
Bernard,', 2, obtained by breaking up some of the compounds in the sur- 
rounding medium. ; 

+ When an animal, like a tadpole, employs beth air and water as re- 
spiratory media at the same time, the carbon dioxide seems to be princl- 


pally excreted into the water. and the oxygen mainly derived from the air 
(Science, vol. vii., p. 894, 1856). 


197 


Respiration. 
Respiration. 


the oxygen in contact with the tissues, and removing 
carbon dioxide from them. In still higher forms—7n- 
sects, etc.—there is a complex system of tubes, called 
tracheew, extending from the exterior to every organ and 
tissue, and serving to conduct air to and from every 
part. The living substance can thus take oxygen di- 
rectly from the air in the tubes, and return carbon diox- 
ide directly to it, 4,9 (Fig. 3311). It will be seen from 
the above that what may be properly designated direct 
respiration—that is, taking oxygen directly from the 
respiratory medium by the tissues, and returning car- 
bon dioxide directly to it by them—is found in both 
aérial and aquatic animals. 

In man and the other vertebrates, also in many inver- 
tebrates, this direct respiration is not found, but there is 
a circulating liquid—respiratory blood—containing heemo- 
globin or its equivalent, which serves as a carrier of 
oxygen from the respiratory medium to the tissues, and 
of carbon dioxide from them back to the respiratory 
medium in return. ‘There are also present special respir- 
atory organs (gzlls for aquatic and lungs for aérial respi- 
ration). To make the respiratory organs efficient, there 
is a complex nervous, muscular, and bony or cartilaginous 
mechanism for constantly supplying the respiratory or- 
gans with fresh air or water, and constantly removing 
that which has become vitiated. Finally, there is pres- 
ent a complex vascular mechanism for the circulation of 
the blood. 

The form of respiration just described is called indirect 
respiration, for the reason that the tissues do not get the 


oe el 


Ae SE Beh eg == 
preter] 


—-- 


Fra. 3312.—Diagram Illustrating Indirect Respiration by Means of Res- 
piratory Organs and a Respiratory Blood. Air or Water, the respira- 
tory medium bathing the respiratory membrane and supplying the 
blood with oxygen and removing carbon dioxide from it, Lung or 
Gill, the respiratory membrane. Heart, the central and motor part 
of the circulatory system. This system, except at the heart, is rep- 
resented only by the endothelial lining common to the entire sys- 
tem. The arrows extending along the vessels indicate the direction of 
the blood-current. O, oxygen; COz, carbon dioxide. As indicated by 
the arrows pointing in the two directions, more oxygen is taken up 
by the blood and the tissues than there is carbon dioxide given off in’ 
return. The diagram also indicates that the carbon dioxide is mainly 
in the plasma, and the oxygen in the red blood-corpuscles. The pres- 
ence of the oxygen in the corpuscles gives the blood a lighter color, as 
indicated by the shading of the corpuscles; as also indicated by the 
shading of the corpuscles, the arterial blood is not fully saturated with 
oxygen, nor is the venous blood entirely devoid of it, Tissue, all the 
oe of the body are here represented by a piece of striated muscular 

Les 


oxygen directly from the air or water, but indirectly 
through the respiratory blood ' (Fig. 3312). 
RESPIRATORY ORGANS.—In man and the other animals 
in which a respiratory blood is present, and the respira- 
tion is consequently indirect, the respiratory organs con- 
sist essentially of a thin expanded membrane, the respira- 
tory membrane,’> bathed on one side, by the respiratory 
medium, and on the other by the respiratory blood, which 
is spread out in a thin, almost continuous sheet in the 


198 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


capillaries. This respiratory membrane, in man and the 
mammals generally, is in the form of two great elastic 
sacs called lungs, in which the surface is repeatedly 
folded, thus forming an almost infinite number of second- 
ary sacs—the pulmonary alveoli, vesicles, air-sacs, or air 
cells (Figs. 3313 and 3317). The lungs are placed in the 


o 


Fig. 3318.—The Trachea, Bronchi, and Ultimate Termination of the 
Bronchi in the Lungs. (A) Ventral view of the larynx, trachea, and 
bronchi, and of the lungs in outline and opened so as to show the tree- 
like branching of the bronchi (Sappey). 1-2, the larynx; 3-38, the 
trachea; 4, bifurcation of the trachea to form 5 the right, and 6 the 
left bronchus; %, division extending to the cephalic or superior, 8 to 
the middle, and 9 to the caudal or inferior lobe of the right lung; 10, 
bronchial division to the cephalic or superior lobe, and 11 to the caudal 
or inferior lobe of the left lung ; 12, ultimate ramification of the bron- 
chi; 13, contour of the lungs; 14, summit; and 15, base of the lungs. 
(B) Two lobules from the lung of a new-born child, half diagram- 
matic and magnified twenty-five diameters (Killiker). Three ultimate 
bronchial tubes or lobular bronchioles are shown, but the terminal 
lobule is shown on but two of them. a,.@, Lobules; 0,b, alveoli or 
air-vesicles; c,c, terminal bronchial tubes or Jobular bronchioles. 
(C) A single lobule in section, magnified (Dalton). a, Terminal bron- 
chial tube opening into 6, the alveolar or lobular passage ; C,¢,¢,c, air- 
vesicles or alveoli. The pulmonary capillaries ramify in the shaded 
partitions between the alveoli. 


air-tight chest or thorax, and communicate with the ex- 
terior through the respiratory or air-passages (Fig. 3315). 
In shape the lungs conform accurately to the cavity left 
in the thorax by the heart and great vessels ; that is, the 
costal surface of each lung is convex, while the mesal 
surface is somewhat concave where it is moulded to the 
surface of the heart. At the base the lungs rest upon 
the diaphragm, and from their elasticity follow all its 
varying shapes (Fig. 3319). At the apex the lungs are 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Respiration, 
Respiration, 


bluntly pointed, fitting the corresponding cavity in the 
cephalic or upper part of the thorax. 

In man the right lung is divided into three somewhat 
unequal lobes by two fissures extending from the costal 


i 
| 


ZEW 
Z By Ae / \ ! 
SSA Wy Z H 
\\\i WZ ut \ 
= ri m . \\> 
ve Rolls 


{ 
eM) Um 
Wa 
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ik (| 
I 


‘an 
! 


| 


Hy \ lit We 
NL HN 


Fic. 8314.—Ventral View of the Lungs, Trachea, Heart, and Great Vessels. 
(Gray.) The lungs are slightly-inflated, and separated so as to bring into bet- — ie sci 
The right lung is divided by two fissures into three respiratory medium. 


ter view the heart, etc. 
lobes, and the left one by a single fissure into two lobes. 


surface toward the root of the lung. The left lung is 
divided into two lobes by a single fissure (Fig. 3314). The 
so-called root of the lung is at the point of suspension of 
the lung, and each is composed of a bronchus, the 
pulmonary blood-vessels, lymphatics, and nerves, and 
the connective tissue binding these structures together 
(Figs. 33138 and 3314). Each lung is covered by a se- 
rous membrane, a reflection of the corresponding pleura, 
which, commencing at the root, is reflected over the 
entire surface, entering the fissures and forming a com- 
plete envelope for the lung. The connective-tissue layer 
of the pleura covering the lungs is directly continuous 
with their connective-tissue framework, so that the pul- 
monary pleura forms an essential part of the lung-struct- 
ure. 

The Respiratory or Air-passages are tubes or openings 

serving to conduct the air to and from the lungs. They 
are the two nasal passages, sometimes also the mouth, the 
pharynx, which like the mouth is also common to the 
alimentary canal, the larynx, trachea, and bronchi (Figs. 
3313 and 3314). The bronchi continually divide, like the 
branches of a tree, without anastomosing, and finally ter- 
minate in sac-like enlargements which are the true respi- 
ratory parts of the lungs (Figs. 3313 and 3317). From 
‘this arrangement of the true respiratory parts of the 
lung at the ends of the bronchi the lung is sometimes 
not considered as composed of a great sac, as stated 
above, with foldings of the surface and a minute bron- 
chial twig connected with each minute fold, but it is 
supposed to consist of a great number of small, inde- 
pendent sacs closely bound together. On this view, the 
comparison with a tree, especially one with divided 
leaves, might be continued, each leaf representing an 
ultimate lobule of the lung (Figs. 3313 and 3317). 

The air-passages of the lungs, and the respiratory pas- 
sages in the nose, are lined with ciliated epithelium. In 
each case the motion of the cilia produces a current to- 
ward the pharynx. This current carries dust and mucus 
into the pharynx, from which they are readily expelled. 
(See also articles on the Bronchi, vol. i., and the Minute 
Anatomy of the Lung, vol. iv.) 


Vascular and Nervous Supply of the Lungs.—The blood 
going to the lungs is of two kinds and from two sources : 
(1) The impure or venous blood from the right side of 
the heart going through the pulmonary artery to the 
lungs to be purified or arterialized ; and (2) pure or 
arterial blood from the left side of the heart going 
through the bronchial arteries to the lungs for the 
nourishment of their substance. The first, after puri- 
fication, is returned to the left side of the heart by the 
pulmonary veins. The second, after serving for the 
nourishment of the lung-tissue, is returned in part 
through the bronchial veins to the right side of the 
heart, and in part through the pulmonary veins to 
the left side of the heart; in other words, part of the 
arterial blood of the bronchial arteries is returned as 
arterial blood directly to the left side of the heart 
from which it was sent, without first passing in the 
regular way into the systemic veins and the right side 
of the heart © 7. ‘‘In their course together through 
the lung the artery is usually found above and be- 
hind the bronchial tube, and the vein below and in 
front.” 7 The bronchial arteries and their branches 
ramify in the lung-tissue without such definite rela- 
tions to the bronchi as with the pulmonary vessels. 

The nerves of the lungs are derived from the 
vagus and the sympathetic, and form a dense plexus 
on the dorsal and another on the ventral side of the 
root of each lung (the so-called anterior and posterior 
pulmonary plexuses). From these plexuses the nerves 
ramify in the substance of the lung, following the 
bronchi. 

EXTERNAL RESPIRATION.—Under this heading are 
included the changes which occur in the respiratory 
blood during its passage through the lungs or gills, 
and also the changes occurring simultaneously in the 


According to the view of chemists and physicists, 
the earth’s atmosphere, or the air, as it is more com- 
monly called, is a mechanical mixture composed princi- 


SSS SWQ 


NOSE 


45—-— Tongue 


a 


f) ~-~ Réinice Glottictis 


— — -Trachec 


eS 


= 
cEsophaqus - 4-Yo= 
: Seat || 


Cardiac 


Shhincter -\— 


Diaphragr -- es e 
Inteshines — — == C bs \) 


ue —Pylo PLS 


Abdominal Muscles 


hhe Bladtile 


= \ the Bladcler. 


Fig. 3815.—Diagrammatic Section of the Body. 


Sphrerroters_ 
Avie 


(Kirkes.) 


pally of oxygen and nitrogen, with a minute quantity of 
carbon dioxide and a varying amount of watery vapor. 


199 


Respiration. 
Respiration. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


The composition of the air from various parts of the 
earth’s surface has been found nearly uniform. When 
dried and reduced to the standard temperature and press- 
ure (a temperature of zero centigrade and a pressure of 760 
mm, of mercury), the composition is about as follows : * 


OXY 2ONs os seas. +s sc eet eto LEDC LAUGOE 
Witrogens, 5 6 LE Le eR 
Carbon dioxide. 0102. ch bickic eels) eee 


100.60 per cent. 


Air coming from the lungs (expired air or breath) of 
man, or one of the other warm-blooded animals, compared 
with the inspired or atmospheric air, shows the following 
changes, due to its sojourn in the lungs: (1) A marked 
decrease in the amount of oxygen; (2) a great increase in 
the quantity of carbon dioxide ; (8) slight if any change 
in the amount of nitrogen ; (4) usually an increase in the 
“quantity of watery vapor; (5) the temperature is closely 
approximated to that of the body, being usually warmer 
than the surrounding air; (6) traces of organic matter 
have been added ; (7) traces of ammonia are often pres- 
ent, and sometimes odors from substances taken into the 
stomach, as alcohol, garlic, etc. 

The surrounding air is usually at a lower temperature 
than the body, and is therefore heated by the body when 
taken into the lungs. In this case it increases in volume, 
following the law for the expansion of gases by heat. If 
the temperature of the air is higher than the body, it is 
cooled by being inspired and diminishes in volume, fol- 
lowing the same law. But after making allowance for 
changes in temperature and in the amount of aqueous 
vapor present, the expired air is usually slightly less in 
volume than the inspired air, due to the fact that the 
volume of oxygen absorbed from it is greater than that 
of the carbon dioxide added to it. This diminution is 
variously estimated from 1 to 2.5 per cent. of the original 
volume inspired. 

Owing to the change in volume, a comparison of the 
percentage composition of inspired and expired air does 
not furnish exact information concerning the quantitative 
changes which the air undergoes in the lungs. These 
changes can only be determined accurately by comparing 
the absolute amount of the various constituents of a known 
volume of ixspired air with the absolute amount of the 
various constituents of the same air after it is expired.’ + 

Gases of the Blood.—It was thought by Lavoisier,? and 
those who followed his teachings, that carbon dioxide 
was formed in the lungs by an oxidation of the waste 
materials brought to the lungs by the blood. This view 
was found untenable by later investigators, who proved 
that the arterial blood was cooler than the venous. This 


* While it was formerly supposed that the composition of the atmos- 
phere in a given place was constant, later investigations have shown that 
there is considerable variation ; the oxygen has been found to vary from 
20.45 to 21.01 per cent., and the carbon dioxide from 0.0206 to 0.0417 per 
cent,§ 

+ It is apparently assumed by many writers on respiration that, if the 
percentage composition of inspired air and that of expired air are com- 
pared, one can determine accurately the changes occurring in the air dur- 
ing its sojourn in the lungs, thus neglecting the diminution in volume. 
For example, in the excellent works of Wundt (Physiologie des Menschen, 
4th ed., p. 388), and Foster (Text-book of Physiology, 8d ed., p, 841), per- 
centage compositions of inspired and expired air are given with the state- 
ment that, when dried and compared at the standard temperature and 
pressure, the expired air is '/, 9th to !/,)th less in volume than the same 
air when inspired. 

Inspired air: Oxygen, 20.81 per cent. ; nitrogen, 79.15 per cent.; car- 
bon dioxide, 0.04 per cent, 

Expired air: Oxygen, 16.038 per cent. ; nitrogen, 79.557 per cent. ; car- 
bon dioxide, 4.88 per cent. ; 

The loss in oxygen by the air, and its gain in carbon dioxide, are both 
determined by comparing the percentage differences, without appar- 
ently taking any account of the diminution of volume. It is further 
stated by Dr. Foster, with reference to the nitrogen: ‘‘ The quantity of 
nitrogen in the expired air is sometimes found to be greater, as in the 
table, but sometimes less, than that of inspired air.” While it is true 
that the percentage quantity of nitrogen in the expired air is greater, as 
shown in the table, the absolute amount is less, provided there is the 
diminution in volume described. Taking the least diminution mentioned, 
1/9th or 2 per cent., then 100 c.c. of inspired air would measure but 98 
c.c. when expired. If, now, 79.557 per cent. of this is nitrogen, the total 
nitrogen in the 98 c.c. of expired air would be (98 x 79.557) =77.96586 c.c. ; 
and as in the 100 c.c. of air originally inspired there were 79.15 c.c, of 
nitrogen, there has been an actual diminution of (79.15 — 7.96586) = 
1.18414 c.c. of nitrogen, instead of an increase as stated by Dr. Foster. 


200 


could not be the case if oxidation sufficient to produce 
all the carbon dioxide appearing in the expired air took 
place in the lungs, It was also shown that, in blood from 
any part of the body, carbon dioxide and oxygen could 
be obtained directly without chemical means ; and that 
more carbon dioxide could be obtained from venous than 
from arterial, and more oxygen from arterial than from 
venous, blood. At the present day it is known that the 
respiratory process occurring in the lungs is an absorp- 
tion of oxygen from the air by the blood, and a return to 
the air of carbon dioxide already existing in the blood. 

The exact office of the blood in respiration could only 
be determined by discovering the nature and relations of 
the gases of arterial and venous blood.” * 

From one hundred volumes of blood about sixty vol- 
umes of gas may be extracted. This does not diminish 
the volume of the blood. The gas is composed of oxy- 
gen, nitrogen, and carbon dioxide, the proportions of these 
gases varying in the different kinds of blood. 

In order that the results shall be of the greatest value, 
the two kinds of blood from which the gases are ex- 
tracted should be from the same animal, under similar 
conditions. According to five such double analyses of 
dog’s blood by Schoeffer,® the following averages were 
obtained from 100 c.c. of blood: 

Arterial Blood: Oxygen, 19.2 ¢.c.; nitrogen, 2.7 c.c. ; 
carbon dioxide, 39.5 c.c. 

Venous Blood: Oxygen, 11.9 c¢.c.; nitrogen, 1.7 ¢.c. ; 
carbon dioxide, 45.3 c.c. 

This table shows that in 100 c.c. of arterial blood there 
are 7.3 c.c. more oxygen, and 5.8 c.c. less carbon dioxide 
than in the same volume of venous blood. From nu- 
merous determinations made by other observers, Zuntz 
gives as an average, an increase of 8.15 per cent. of oxy- 
gen and a decrease of 9.2 per cent. of carbon dioxide in 
100 c.c. of arterial blood as compared with the same vol- 
ume of venous blood. According to the very numerous 
(nearly two hundred) determinations of the gases of ar- 
terial blood of the dog by Bert and Pfliiger, the gases in 
100 c.c. of blood are as follows :* Oxygen, 18 to 20 c.c.; 
nitrogen, 1 to 2 c.c.; carbon dioxide, 38 to 40 c.c. In hu- 
man arterial blood the gases were found by Setschenow ® 
in the following quantities in a single determination : 
Oxygen, 21.6 ¢.c.; nitrogen, 1.6 c.c.; carbon dioxide, 40.3. 
So far as this single determination goes, the gases in hu- 
man blood agree very closely in quantity with those 
found in dog's blood, and any conclusions drawn from 
observations on the gases of dog’s blood might probably 
be legitimately applied to human blood. 

Arterial blood is of nearly uniform composition through- 
out the entire body, containing a slightly less percentage of 
oxygen in the smaller arteries farthest from the heart, due 
to the diminished number of blood-corpuscles as shown 
by the lower specific gravity,® and in part, probably, also 
to the true respiration occurring in the blood itself. The 
venous blood differs considerably in composition in dif- 
ferent parts of the body, hence that for the extraction 
of the blood-gases should be taken from the right heart 
or the pulmonary artery, where it is mixed, if a general 
average is sought. A comparison of the gases of arterial 
and venous blood from any part of the body shows, 
however, wherein lies the difference between them so far 
as respiration is concerned, and it is found to be a 
difference only in the proportions in which oxygen and 
carbon dioxide are present in the two kinds of blood. 
Arterial blood may, therefore, be defined as blood con- 
taining a relatively large percentage of oxygen (eighteen 
to twenty per cent.), and a relatively small percentage of 
carbon dioxide (thirty-eight to forty per cent.). 

Venous blood may be defined as blood containing about 
eight per cent. less oxygen and six to eight per cent. 
more carbon dioxide than is present in arterial blood. In 
ordinary respiration the blood is not saturated with either 
of the respiratory gases, as is shown by shaking blood 


* The terms arterial and venous blood are unfortunately used in two 
senses, viz., in a morphological sense, relating to the kind of blood-vessel 
containing the blood without regard to its quality, and in a physiological 
sense, referring solely to its quality without regard to the vessel contain- 
ing it. The terms are used only in the lattér sense in the present article. 


— ee 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


with them. If shaken with pure oxygen or with air, 
blood will take up about twenty-three per cent. of its 
volume of oxygen, instead of twenty per cent. as in or- 
dinary respiration, and if it is shaken with pure carbon 
dioxide the blood will absorb about its own volume of 
that gas.!° 

Relations of the Gases in the Blood.—It is believed that 
but a small amount is in simple solution, but that the 
greater part is in loose chemical combination. This is 
supported by the fact that when blood is put under the 
mercurial pump (Fig. 3316), a small amount of gas is 
gradually given off, following the Henry-Dalton law for 
the absorption of gases by liquids; but 
the larger part of the gas comes off only 
when the pressure falls to about twenty 
millimetres of mercury ; then it is sud- 
denly given off. 

The oxygen simply dissolved in the 
blood plasma has been found to exceed 
but little the amount that water dissolves 
at the same temperature. It has been 
proved conclusively that the main part 
of the oxygen in the blood is combined 
with the hemoglobin in the red _ blood- 
corpuscles (see also article Blood, vol. i.). 
The relations of the carbon dioxide are © 
not quite so simple, for although the 
blood contains less carbon dioxide than 
would be absorbed by water at the same 
temperature, it does not follow the law 
for the absorption of gases by liquids; 
and it is the prevailing belief among 
physiologists that it is all chemically 
combined in the plasma of the blood, 
very little being in the corpuscles. As 
part of the carbon dioxide is readily re- 
moved from the blood by the mercurial 
pump, it is called the ‘‘ loose” carbon di- 
oxide, and is supposed to be united with 
the soda of the blood in the form of a 
bicarbonate ; while the part (‘‘ fixed” 
carbon dioxide) which cannot be pumped 
from the blood serum without first add- 
ing an acid, is supposed to be united to 
the soda in the form of a carbonate. It 
has been found by experiment that in removing the 
blood-gases the hemoglobin acts like an acid, enabling 
all the carbon dioxide to be pumped out without adding 
an acid. If the red corpuscles containing the heemo- 
globin are first removed, only the “‘ loose ” carbon dioxide 
can be obtained, as stated above, unless an acid is first 
added.° The nitrogen in the blood seems to be in simple 
solution. 

Color of the Blood.—It has been found that hemo- 
globin containing oxygen (oxyhemoglobin) is of a bright 
scarlet color, 7@.e., the color of arterial blood, while 
hemoglobin not containing oxygen (reduced hemoglobin) 
is of a darker color, that is, the color of venous blood 
(Fig. 3312). This is true of the hemoglobin in the blood, 
whether it is in the blood-corpuscles or dissolved in the 
plasma, and it is entirely independent of the carbon di- 
oxide that may be present. This is shown by the blood 
of animals dying of carbon dioxide poisoning in a con- 
fined atmosphere of pure oxygen, *!!, Under ordinary 
circumstances, however, the color of the blood is a good 
test for determining its respiratory quality, as carbon di- 
oxide escapes at the same time that oxygen is absorbed. 
But it is truly arterial only when its hemoglobin is 
nearly saturated with oxygen and the plasma contains 
a moderate amount of carbon dioxide (see above). 

Gas-interchange in the Lungs.— When the venous 
blood reaches the lungs it is spread out in a thin sheet 
in the pulmonary capillaries and separated from the air 
on two sides, in many places only by the epithelium of 
the capillaries and that lining the alveoli of the lungs 
(Fig. 3317). The blood being thus practically in contact 
with the air, oxygen passes through the membrane sepa- 
rating the air from the blood into the blood, in accord- 
ance with the law for the absorption of gases by liquids ; 


Respiration. 
Respiration. 


but as soon as it reaches the blood-plasma, the reduced 
hemoglobin combines chemically with it to produce oxy- 


Ds SIM IAV’ SD: 


US 
SSUES VCHAIBSING 


Fig. 3316. — Diagram of 
Pfliger’s Mercurial Pump 
for Extracting Blood- 
gases. (Landois.) A, blood- 
bulb; B, froth-chamber ; 
C, drying chamber; D, 
tube connecting E and ©, 
and containing a mano- 
meter for determining the 
extent of the exhaustion ; 
EH, fixed bulb containing 
mercury; F, open and 
movable bulb containing 
mercury; G, heavy rub- 
ber tube connecting the 
two bulbs (E and F); H, 
two-way tock allowing the 
gases to pass from A, B, C, 
to E, or from E to H; J, 
eudiometer filled with 
mercury; K, section of 
the two-way cock H, 
showing the passage from 
E to H;3 a, a’, stop-cock, 
opening upward in a, and 
downward in a/; b, c,d, e, f, stop-cocks; g, connection between the 
collecting and drying part of the apparatus and the pump; h, glass 
tube connecting the bulb E with the eudiometer J: i, mercury into 
which the eudiometer and the tube h dip; v, dish of mercury (pneu- 
matic trough) ; w, support in which the bulb F is raised and lowered 
by the ratchet-wheel shown at the right. The following directions for 
the use of this pump are taken from Landois: The blood-bulb A is first 
exhausted by means of a mercurial pump, and then carefully weighed. 
The end ‘of the stop-cock a is tied into a blood-vessel and the cock 
turned so that the blood flows into the blood-bulb. When a sufficient 
amount of blood is collected the cock is turned in the position (a/), and 
after cleaning the outside of the blood-bulb it is again carefully weighed 
to ascertain the amount of blood that has been collected. The frothi- 
chamber (B), as its name implies, is to catch the froth formed during 
the energetic evolution of the blood-gases. It is connected with the 
other parts of the apparatus, on both sides, by means of stop-cocks, 
The drying chamber Cis composed of a U-tube filled with pumice stone 
saturated with sulphuric acid, and at the base of the U-tube is a bulb 
partly filled with sulphuric acid. The blood-gaves in traversing this 
chamber are completely dried. In working the pump, the whole ap- 
paratus is emptied of air by filling the bulb E with mercury, by raising 
the bulb F, after turning the cock H.in the position K, so that the air 
in E can pass out through the tube h, which is not yet dipped into the 
mercury, and then turning the cock H so that it will connect with the 
rest of the apparatus. All the other cocks except a and b are opened, 
and the bulb F is lowered until part of the air is exhausted, then the 
cock H is turned to the position of K and the air is got rid of by raising 
F, This process is repeated until the manometer in D shows a com- 
plete vacuum. Then the cock H is turned to the position K, and the 
bulb F raised until mercury runs out of the tube h, when the cock is 
turned to the position H, and the tube h is placed in the pneumatic 
trough v, under the eudiometer J. A vessel of water at about 60° C, is 
now raised so as to immerse the blood-bulb, and the cocks, except a, are 
opened and the bulb F lowered. After part of the gas has passed over 
to E, the cock H is turned to the position K, and the gas 1s forced over 
through the tube h into the eudiometer J. This process 1s repeated 
until, as shown by the manometer in D, the gases are all extracted. 


hemoglobin, leaving the plasma as poor in oxygen as 
before. The absorption of oxygen by the plasma there- 


201 


Respiration. 
Respiration. 


fore continues until all the reduced hemoglobin is oxi- 
dized and changed to oxyhemoglobin, and the plasma is 


Fic. 5817.—Diagram of Part of a 
Pulmonary Lobule, to Show 
the Relations of the Various 
Parts, especially the Blood 
Capillaries and the Alveoli. 
A, A, A, Alveolar or lobular 
passages ; a, a, pulmonary al- 
veoli, air-vesicles, or air-cells. 
These open either into the al- 
veolar passages singly or in 
groups; B, ultimate bronchial 
tube or lobular bronchiole. It 
is lined with ciliated epitheli- 
um and opens into the alveolar 
passages on one side and joins 
other bronchioles on the other ; 
C, CC, capillary . containing 
blood - corpuscles. The capil- 
lary is exposed to the air on 
two sides, being separated from 
the air only by the epithelium 
lining the alveoli. In the act- 
ual specimen all the partitions 
are filled with capillaries; I, 
opening into the alveolar pas- 
sage of an infundibulum or 
group of alveoli. 


saturated with oxygen at the 
temperature of the blood and 
the partial pressure or tension 
of the oxygen in the alveolar 
air. * 

This explains why the oxy- 
gen needed for respiration is 
obtained by the blood indepen- 
dently of the partial pressure 
or tension of the oxygen in 
the air, provided the tension 
does not fall too near the 
point of dissociation of oxy- 
hemoglobin ; for, according 
to the law of absorption of 
gases by liquids, a certain 
amount of oxygen enters the 
plasma of the blood whether 
there is a greater or less 
amount of oxygen in the air 
than normal. The reduced 
hemoglobin combines with 
the oxygen to produce oxyhee- 
moglobin independently of the 
tension of the oxygen. If the 
air is very rich in oxygen, the 
hemoglobin of the blood is 
quickly changed to oxyheemo- 
globin, fora sufficient amount 
is rapidly .absorbed by the 
plasma and thus brought into 
combining distance of the he- 
moglobin. If, on the other 
hand, the tension or partial 
pressure of the oxygen in the 
alveolar air is small, the he- 
moglobin will still combine 
with the same amount, but it 
will take a longer time, from 


the slowness with which the 
oxygen is absorbed and brought into combining distance 
by the plasma. 

At the same time that the oxygen is passing from the 
alveolar air into the blood, carbon dioxide is passing from 
the blood to the air ; hence the designation of the process 
as an exchange of gases. The same principles are sup- 
posed to govern the exit of carbon dioxide as for the 


* Partial Pressure, Tension.—Although these subjects belong to phys- 
ics, a brief consideration of them may not be out of place, since the 
terms are so often used in discussing the interchange of gases in respi- 
ration. So far as a mixture of gases, unconnected with liquids, is con- 
cerned, these two expressions are used interchangeably. The meaning 
is, that as gases in a mixture exert no pressure upon each other, each 
exerts such a pressure or has such an expansive force as though it ex- 
isted alone. This expansive force or pressure is expressed in millimetres 
of mercury, measured at the standard temperature and pressure (temp., 
0° C.; bar., 760 mm. hg.); hence, the partial pressure or tension of a 
gas in a mixture is obtained by multiplying the atmospheric pressure by 
the percentage volume of the given gas. Thus, the oxygen of the air 
forms 20.81 per cent. by volume of the atmosphere; hence its partial 
pressure or tension is 760) x 20.81 per cent. = 158.156 mm. hg. Know- 
ing the partial pressure in millimetres of mercury, the corresponding 
percentage by volume is readily obtained by reversing the above process ; 
thus, 158.156 + 760 = 20.81, the per cent. by volume desired. 

When a gas is dissolved in a liquid, the term tension alone is applied 
to it. This means the force by which the gas tends to escape from the 
liquid. The tension in this case is also expressed in millimetres of mer- 
cury or in percentages by volume of the gas. When either of these is 
known, the other is obtained, as described above for the partial pressure 
of a gas in a mixture. The tension in millimetres of mercury and the 
corresponding percentage by volume indicate the amount of the given gas 
which should be present in an atmosphere overlying the liquid, in order 
that none of the gas shall escape from the liquid and that no more shall 
be absorbed, It has no reference to the absolute amount of gas absorbed 
by aliquid. That varies with each liquid and each gas, 

In general, in two gases, a gas and a liquid separated or not by a 
membrane, or in two liquids separated by a membrane, if there is a dif- 
ference in the tension or partial pressure of the same gas in the two situ- 
ations, or a difference in the tension of the given gas in the liquids, or 
in the liquid and the overlying air, there will be a diffusion of gas from 
the situation in which the given gas is at the higher, to that in which it 
is at the lower, tension, and this will continue until equilibrium is estab- 
lished. On the other hand, if the tension is already the same in the two 
situations, no diffusion of the gas will occur. 


202 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


absorption of oxygen—the air in the alveoliof the lungs 
contains carbon dioxide at a less tension than it possesses 
in the blood, so that the excess of carbon dioxide tends 
to pass from the blood to the air to establish equilibrium. 
The case is not so simple as this, however, for, as the 
entire amount of carbon dioxide in the blood is in com- 
bination, it could not be expected ‘to follow the laws of 
diffusion determined by difference of tension. If it is in 
true chemical combination it has no tension in the blood. 
The explanation has been sought in the fact that oxy- 
hemoglobin acts as an acid in setting free the carbon 
dioxide, and this action seems to be all the more energetic 
at the moment when the oxygen is taken up to form the 
oxyhremoglobin. The pulmonary epithelium covering 
the alveoli (Fig. 3317) is also supposed to assist by actively 
excreting carbon dioxide. Finally, as the amount of 
carbon dioxide in venous blood may be represented by a 
tension of 41 mm. hg., and the partial pressure or tension 
of the air in the pulmonary alveoli is only 27 mm. hg.,° 
it is supposed that this difference in tension is sufficient, 
with the assistance of the acid-like action of the oxy- 
hemoglobin, to dissociate the combined carbon dioxide, 
when it would be subjected to the laws of absorption of 
gases, and would escape to the air of the alveoli, where 
the carbon dioxide tension is lower. Certain it is that 
this transfer is constantly taking place. Equilibrium 
would, however, soon be established between the gases 
of the blood and the alveolar air if either or both were 
stationary ; but both are constantly changing, the one by 
diffusion and currents, the other by circulation ; hence 
equilibrium is never established, and the respiratory gas- 
interchange between the blood and the air in the lungs is 
continuous throughout the whole of life. 

INTERNAL OR TissuE RESPIRATION.—The question 
still remains to be answered : ‘‘ What is the ultimate des- 
tiny of the oxygen removed from the air, and what is 
the source of the carbon dioxide added to it?” After it 
was conclusively shown that the formation of carbon 
dioxide did not take place in the lungs, it was supposed 
that its formation took place in the blood in all parts 
of the body, the oxygen taken up in the lungs serving to 
oxidize the waste matter poured into the blood. This 
view was found to be untenable, for very easily oxidiz- 
able substances, like pyrogallic acid, do not become oxi- 
dized when placed in the blood of a living animal; 
and if the arterial blood is followed in its course through- 
out the body, it is found that while the blood in the ar- 
teries is of nearly uniform character, as soon as it comes 
into intimate contact with the tissues in the capillaries 
the oxygen markedly diminishes, and the carbon dioxide 
greatly increases, in amount. That the oxygen dimin- 
ishes in amount during its passage through the tissues 
may be demonstrated on a living animal by examining 
the light which traverses some thin membrane like a 
frog’s web, or the wing of a bat, through a spectroscope. 
The light will show the two bands characteristic of oxy- 
hemoglobin (see articles Blood and Blood-Stains, vol. 
i.). If the leg of the frog, or the wing of the bat, is com- 
pressed sufficiently to stop the circulation, the single 
band characteristic of reduced hemoglobin will soon ap- 
pear, showing that the oxygen has been given up by the 
oxyhemoglobin. According to Vierordt!® the same may 
be observed in man by examining through a spectro- 
scope the light which traverses the crack between two 
fingers. The two bands of oxyhemoglobin will appear 
as long as the blood circulates freely ; but if a string be 
wound tightly around the fingers, thus stopping the cir- 
culation, the single band of reduced hemoglobin will 
soon appear. ‘These demonstrations do not show, how- 
ever, that the waste material was not first poured into 
the blood of the capillaries and oxidized there. That it 
is the tissues that take up the oxygen and give out the 
carbon dioxide, and that the carbon dioxide is not pro- 
duced in the blood, is definitely proven by the following : 
If a living tissue, muscle for example, is removed from 
an animal and deprived of blood, and placed in a va- 
cuum, or an atmosphere of pure nitrogen or hydrogen, 
the muscle will continue to produce carbon dioxide, and 
if irritated will contract, showing that it is alive. If it 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Respiration. 
Respiration. 


is placed in an atmosphere of oxygen or in the air, 
oxygen will be taken up directly, and carbon dioxide be 
given off directly, as described in the direct respiration of 
the ameba, etc. If muscle or other living tissue is 
placed in arterial blood, some of the oxygen will disap- 
pear, and carbon dioxide will appear in its place. Fi- 
nally, Oertmann and Pfliiger have shown that in frogs in 
which the blood had been entirely replaced by normal 
salt solution, the respiratory changes take place in a nor- 
mal manner for a considerable time, and are nearly as 
great as when the blood was present. 

From the facts just stated, and many others, physiolo- 
gists feel warranted in asserting that the tissues take up 
the oxygen and give off the carbon dioxide—that is, the 
true respiratory process occurs in them, and not in the 
lungs or in the blood. If the first knowledge concern- 
ing respiration had been obtained from animals in which 


\jdaeans ance Sauendatet 
eekanuacenennanecksocauneaoee 


sa 
AT Ahi 
{mm 


watery vapor; xX, exit-tube from the respiratory chamber. 


experiment. 


the respiration is direct (see above), no respiratory blood 
or elaborate apparatus being present, it would have been 
seen from the beginning that respiration is solely for 
the tissues, no matter how elaborate the appliances 
for supplying the oxygen and removing the carbon 
dioxide. 1) %8,9, 12 

The laws governing the gas interchange between the 
blood in the capillaries and the tissues are supposed to 
be the same as those obtaining in the lungs, viz., the 
oxygen-tension in the tissues and the lymph bathing them 
is far lower than in the blood-plasma, hence diffusion 
toward the tissues occurs. This goes on until the oxygen- 
tension in the plasma is so low that the dissociation of 
some of the oxyhemoglobin follows, raising once more 
the tension in the plasma above the dissociating point ; 
but as the tissues are continually taking the oxygen 
and combining it, the oxygen-tension of the plasma soon 
falls again below the dissociating point, and more oxygen 
is given off to it by the oxyhemoglobin. This process 
is continuous, for as fast as the oxygen comes into com- 
bining distance in the tissues, it is united in a compound 
more stable than oxyhemoglobin; consequently, no mat- 
ter how low the oxygen-tension may fall in the lymph 


Fie. 3318.—Pettenkofer’s Respiration Apparatus, (Landois.) a, opening in the respiration 
’ chamber for the entrance of air; b, vessel containing pumice-stone saturated with sulphuric 
acid, for drying the expired air; C, gas-meter for measuring the air from the respiratory 
chamber after it is dried ; K, bulb containing sulphuric acid to dry the expired air that is to 
be analyzed ; M, M, suction apparatus constructed on the principle of Miiller’s mercurial 
valve, and driven by a steam-engine; n, small tube conducting part of the air from the 
respiratory chamber to the analyzing apparatus, where its composition is determined; N, 
apparatus for analyzing the air before it enters the respiratory chamber; P, P, double suc- 
tion-pump, driven by a steam-engine, for drawing the air through the respiratory chamber ; 
q, manometer ; R, tube filled with a standard baryta solution, for determining the carbon 
dioxide ; u, small gas-meter to measure the analyzed air, less the carbon dioxide and the 
The air from both the top and 
the bottom of the respiratory chamber is drawn into this tube, so that it shall be of an 
average quality; Z, respiratory chamber in which the person or animal remains during the 


surrounding the tissues, the oxygen compounds formed 
by them are not dissociated, and the oxygen-tension in 
the tissues outside the blood-vessels is always lower than 
in the blood ; consequently the diffusion of the oxygen 
is always away from the blood toward the tissues. - 

_ The carbon dioxide in the tissues and lymph surround- 
ing them is at a considerable, and always increasing, ten- 
sion, while in the blood it has practically no tension, as 
it is all in combination, and there is a continuous dif- 
fusion of the carbon dioxide from the position of higher 
tension in the tissues to that of a lower tension in the 
blood. 

The blood itself is a tissue, and all the respiratory 
processes go on in it as in any other tissue. 

Relations of the Oxygen in the Tissues.—The changes 
through which the free oxygen passes after it is 
taken by the tissues, before reappearing in the car- 
bon dioxide or other excretory product, belongs, 
perhaps, more properly to the general subject 
of nutrition, yet a brief discussion may not 
be out of place here. 

The oxygen is probably combined, in some 
way, with other chemical substances into the 
highly potential or explosive forms of mat- 

ter which, in breaking up, give rise to 
the special form of activity characteristic 
H p of the special tissue, and leave less po- 
tential compounds, one of which is in- 
variably carbon dioxide. This is shown 
from the fact that if a muscle, for exam- 
ple, is removed from the body, and freed 
from blood, it yields no oxygen to the 
mercurial pump, showing that neither 
free oxygen nor that loosely combined is 
present; yet the muscle will contract 
vigorously when stimulated, and it gives 
off carbon dioxide continuously—more 
during the contraction than at rest. As 
there was no free oxygen present, the car- 
bon dioxide must have been formed by 
the breaking up of some compound con- 
; taining oxygen previously stored in the 
& tissue, That this is also true of an entire 
animal, as well as for the individual tis- 
sues, was proved by Spallanzani, Ed- 
wards, and Pfliiger, who kept frogs, at a 
low. temperature, in an atmosphere of 
pure nitrogen or hydrogen, for several 
hours—that is, much longer than the 
slight amount of oxygen remaining in 
the air of the lungs or in the blood could, 
have lasted—yet the animals continued 
to live and produce carbon dioxide. 
This could not have been the case if oxy- 
gen had not been stored in the tissues 
previous to the experiment. 

From what was said under the head of Huternal Res- 
ptration it is evident that the free oxygen disappearing 
from the air in the lungs is not immediately returned 
to the same air, combined with carbon, in the form of 
carbon dioxide, for it has been shown that this combina- 
tion does not take place in the lungs; so, likewise, the 
carbon dioxide returned to the blood of the capillaries” 
does not contain the same oxygen that had been just 
taken up from the blood by the tissues; but it may 
have been stored in them, forming part of their living 
substance for a considerable time. The time interven- 
ing between the absorption of the oxygen and its re- 
appearance in the carbon dioxide depends, no doubt, 
somewhat on the bodily activity of the animal. It is 
certain that man and the other warm-blooded animals, 
in which the processes of life are carried on with great 
vigor, can endure the deprivation of oxygen as well as of 
other food for a shorter time than the cold-blooded ani- 
mals, 

The Respiratory Income and Outgo, and the Circum- 
stances Affecting Them.—As the oxygen disappearing 
and the carbon dioxide appearing in respiration have 
been traced to the tissues, the respiratory activity of 


203 


Hespiration. 
Respiration, 


the tissues can be ascertained by determining the amount 
of oxygen supplied to them and the carbon dioxide ex- 
creted. A determination of the total gas-interchange 
in the lungs will not, however, give the total amount 
of oxygen absorbed, and of carbon dioxide excreted, 
as there is a considerable gas-interchange taking place 
through the skin and through mucous surfaces other 
than the lungs. The respiratory interchange through the 
skin, in man and the other animals with a thick and 
comparatively dry epidermis, is a very small fraction 
(about 345) of that taking place in the lungs. Accord- 
ing to the determinations of Aubert and Lange, the 
average amount of carbon dioxide excreted by the skin 
in twenty-four hours is about four grams, or 2,000 c.c. 
This amount is increased by an elevation of tempera- 
ture in the surrounding air. Part of this carbon diox- 
ide is not due to respiration, but to decomposition go- 
ing on at the surface of the skin (Hoppe-Seyler 7°). 
amount of oxygen absorbed by the skin is less than the 
carbon dioxide excreted in the proportion of 100 c.c. of 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


with carbon forms but one volume of carbon dioxide gas, 
The diminished amount of the oxygen appearing in the 
carbon dioxide is explained from the fact that part of 
the absorbed oxygen is used in forming compounds 
other than carbon dioxide. 


TABLE FROM PETTENKOFER AND VOIT, SHOWING THE TOTAL GAS-EX- 
CHANGE, THE RESPIRATORY QUOTIENT, AND THE AMOUNT OF WATER 
EXCRETED IN TWENTY-FOUR Hours BY A MAN UNDER VARIOUS Con- 
DITIONS OF Foop AND AOTIVITY : !3 


—— 


oxygen to 128 to 610 c.c. of carbon dioxide.*®® 


It is comparatively easy to determine the amount of 


respiratory gas-interchange going on in the lungs and 
through the skin ; but it is difficult or impossible to de- 
termine directly the change through the mucosa of the 
nose and that of the alimentary canal from swallowed 
air; consequently, in determining the total respiratory 
changes going on in an animal, such a method as that of 
Pettenkofer’s, in which the entire income and outgo of 
the animal is ascertained, must be used (Fig. 3318). It 
is desirable, however, to estimate the part taken in the 
total gas-exchange by the different organs involved, so 
that the part played by each may be known. 

In the method of Pettenkofer the amount of carbon 
dioxide excreted is determined directly, but the amount 
of oxygen absorbed is determined indirectly, as follows: 
To the weight of the person or animal at the beginning 
of an experiment is added the weight of solid and liquid 
nourishment taken during the experiment; this sum is 
then subtracted from the weight of the body at the end 
of the experiment, plus the solid, liquid, and gaseous 
excreta. The difference represents the oxygen used by 
the animal during the experiment. 

From data furnished in the table in the next column, 
and by other investigators, the total amount of oxygen 
taken up by an adult man in 24 hours averages about 
750 grams (523,088 c.c.), and the carbon dioxide excreted 
in the same time averages about 900 grams (456,514 c.c.). 
The oxygen reappearing in the carbon dioxide is consid- 
erably less than that absorbed during the same time. 
This may be readily seen by comparing the volume of 
the two gases, as one volume of oxygen when united 


Carbon di- 5 
& _ | Oxygen ab- Respiratory} Water ex- 
Diet, etc. rae mes sorbed. quotient. creted. 
Grams. Grams, Grams, 
I. Fasting. 
day ..... 427 450 Unc 0.69 444 
Rest | night 32 ¢ 788 330 { 780 0-4 0-69 385 t 829 
(day..... 379 |p 420 | 66 (9 pg | 463 
act Rest} int 7 | 16 ¢69 | gag f 748 071 {0-8 oi 814 
day ...| 980 922 73) 1,425 14 vom 
Labor fare . { 1,187 11,072 1194 ¢ 0-81 | 'g59 {1,777 
II. Mixed diet. ; 
ye 533 235 1.75) 344 
Resy cone a7} 912 fra ¢ 709 0.58 ¢ 9-80 434 ¢ 88 
ay ile 539 469 0.84 534 
Rest | OP aos 8 450 5 919 0-65 50-7 ‘5 ¢ 15009 
dayit.:: 527 418 | 09 8 eels 
Rest | ee 403 ¢ 930 | 449 (867 | 92654 9-78 | 514 L957 
day ...| 885} 295 2.18 1,095 t. 
Labor } ne 400 f 1-285 BBO f 905 0-445 0.88 ye { 2,042 
day ...| 828 79514 ane | 0.%6 1,035 } 
Labor } night, 306 ¢ 1184 21] { 1,006 1.06 ¢ 9-82 977 f 412 
III. Diet largel 
nitrogenous. 
day .... | 580) 632 0.67 ) 696 
Rest | nignt..,| 433 ¢ 008 is ¢ 850 rat po-8 414 19110 
day ..... 596 566 | 644 
Rest | gly 2 Dey: { 1,038 pe | 876 son {0.86 Len 1 1,207 
IV. Diet non-ni- 
trogenous. 
day ..... 508 523 0.71 566 
Rest { G87» 331 839 ae } 808 0:94 ¢ 0-74 ae \ 92s 
Rest 4 day ...¥% 522 @| 551 0.69 681 


Following Pfliiger, most physiologists designate the 
relation or ratio between the volume of carbon dioxide 
excreted and the volume of oxygen absorbed in a given 
CO. 

om 
varies considerably with different conditions of the body, 
as will be seen below and by consulting the table above. 

The respiratory activity of man is greater than that of 
animals larger than himself, but less than that of many at 
least of the warm-blooded animals smaller than himself, 
as will be seen from the following table. In this table 
the amounts given represent what each animal, retaining 
its normal respiratory activity, would show if it weighed 
one kilogram and the experiment continued one hour :8 


time as the respiratory quotient This ratio 


Name of animal and total weight Oxygen absorbed per | Carbon dioxide excreted merc eay Authori 
in kilograms, hour and kilogram. per hourand kilogram. Quotient, a uthority. 
Cubic cen- Cubic cen- 
Grams. timetres, Grams. timetres. 
DAS, SOU Se ices eet 28 sa Basins oto t el git eer 0.518 361 0.619 814 0.869 Speck. 
ORO he tae eae tee oie town idole atc ey eae ae Ai gate 0.437 217 Het Pettenkofer and Voit. 
Bill Call ell Dees, Pee nc: Soca tek oy vee eee 0.481 336 0.571 290 0.862 Reiset. 
PCCD MO ie ects yates held te cats [he dee one, San, | 0.490 343 0.671 841 0.994 OY 
DG, CSUs ioc entten tee tsttee ae cack fics 24 bien page AO 814 1.188 604 0.742 Regnault and Reiset. 
Rebbity 2. (80 jccwepesenk cee ey. sok we cs eel ees 0.877 618 1.107 563 0.918 E # 
Bieri, 1280 Fee bo ee hee eee re Fe ot | 1.058 740 1,327 675 0.913 ae es 
Sparrow, 0,022 | 9.595 6,710 10.492 5,334.5 0.795 wp xt 
PR POR BE ioe 0. Seas dh Mace nts RA ORLA cei al 0.083 58.8 0.063 44 23 0.741 Ee ee 
Wockchafersi. ciscaes weotee ey ae ee ont ape ee | 1.076 52 1.1699 594.8 0.791 ee = 


Conditions Affecting the Respiratory Gas-interchange. 
—Bodily activity of any form exerts two influences: 
the absolute amount of oxygen absorbed and of carbon 
dioxide excreted are both greatly increased. The rela- 
tive amount of the two gases is more nearly equal during 
action than at rest. In some cases of activity and appar- 
ent rest this quotient may approach or even exceed unity, 
showing that oxygen stored at some previous time is be- 
ing drawn upon (see table from Pettenkofer and Voit). 
Sleep and hibernation being conditions of profound re- 
pose, the respiratory activity is greatly lessened. The 


204 


relative amount of oxygen absorbed increases in most 
cases, showing that oxygen is being stored for future use. 
The respiratory quotient consequently falls considerably 
below unity. In hibernating animals this quotient may 
fall below one-half (0.399 to 0.588, Regnault and Reiset). 
’ During digestion the respiratory activity is increased, 
the amount of carbon dioxide approximating more closely 
to the amount of oxygen absorbed than when fasting. 
This is especially true if a vegetable diet is taken in 
which there is considerable starch. In fully-fed animals 
there appears to be also a slight excretion of nitrogen 


* 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


through the lungs. In fasting animals nitrogen appears 
to be absorbed in small quantities in the lungs. 

The respiratory activity is greater in children than in 
adults, in boys than in girls, in men than in women. 
The absolute amount increases with age and body weight 
in both sexes until puberty. In women it then remains 
nearly stationary (except during gestation, when it is 
greatly increased) until the cessation of the menses, when 
it increases for a few years. In men there is a gradual 
increase until the thirtieth or thirty-fifth year, then nearly 
a standstill until about the fiftieth year. Beyond fifty 
there is in both sexes a gradual decrease in the respiratory 
activity, following the decrease in general bodily activ- 
ity.14 
TABLE FROM SCHARLING 2? SHOWING THE VARIATION IN RESPIRATORY 

ACTIVITY IN PERSONS OF DIFFERENT AGE AND SEx. 


, Carbon diox- 
a ey Os ideexcreted 
Age and sex; weight in kilograms. é per hour 
aL a id’ kilo- 
four hours. 
gram. 
Grams. Grams. 

_ Man, age, 35 years; weight, 65.5 kilos. ...... 804.72 0.512 
Soldier, age, 28 years; weight, 82 kilos ...... 878 .95 0.497 
Boy, age, 16 years ; weight 57.75 kilos ....... 822.69 0.594 
Woman, age, 19 years; weight, 55.75 kilos .. 608 .22 0.455 
Boy, age, 934 years; weight, 22 kilos ........ 488 .14 0.925 
Girl, age, 10 years ; weight, 23 kilos ......... 459 .87 0.833 


Man and the other air-breathing animals have become 
so accustomed to the mixture of oxygen and nitrogen 
found constantly in the air, that this mixture is undoubt- 
edly the best adapted for health and comfort ; but ow- 
ing to the fact that the absorption of oxygen and the ex- 
cretion of carbon dioxide are regulated by the activity of 
the tissues, and that they are largely chemical processes, 
the respiration goes on practically unchanged in widely 
varying conditions of the atmosphere. In an atmosphere 
of pure oxygen the respiratory processes go on normally. 
If the amount of oxygen in the air falls considerably be- 
low the amount normally present, there is a feeling of dis- 
tress, especially upon muscular activity, as the hemo- 
globin cannot get the oxygen fast enough, owing to the 
low oxygen-tension in the air and its consequent slow ab- 
sorption by the blood-plasma, Thus, in an atmosphere 
containing less than fourteen per cent. of oxygen dysp- 
noea occurs upon exertion; if it contains but seven per 
cent., breathing in repose is difficult; and if it falls to 
three or four per cent. there is rapid asphyxia, although 
there is no excess of carbon dioxide. The asphyxia 
produced by lack of oxygen is accompanied by violent 
spasms, while that resulting from an excess of carbon 
dioxide, when plenty of oxygen is present, is not usually 
accompanied by spasms.§ 

By a greatly diminished atmospheric pressure the re- 
spiratory gas-interchange is diminished in rapidity, and 
by an increased pressure it is increased. If the pressure 
of the atmosphere falls below two hundred and fifty 
millimetres of mercury warm-blooded animals soon die, 
owing in part to the slowness with which the oxygen 
comes into combining distance with the hemoglobin, and, 
according to Hoppe-Seyler, in part to the liberation of 
bubbles of gas in the blood, and the consequent plugging 
of the blood-vessels. Under an increased atmospheric 
pressure the oxygen enters the blood-plasma more rapidly, 
and hence comes into combining distance with the hamo- 
globin in such quantity that it may be fully saturated, 
and hence ready to supply the tissues more generously 
than under ordinary circumstances. If the pressure is 
too great (ordinary air at a pressure of fifteen atmospheres, 
pure oxygen under a pressure of three atmospheres) the 
animal dies of asphyxia, as if no oxygen were present. 
This is comparable with the non-combustibility of phos- 
‘phorus in pure oxygen, and its ready combustibility 
when the oxygen is diluted with nitrogen, or if it is di- 
minished in pressure. *® 

Variations in temperature have a marked effect in 
changing the respiratory activity. In cold-blooded ani- 
mals the respiratory activity is in direct proportion to 


Respiration, 
Respiration, 


the rise in temperature up to the maximum not inimical 
to health. With the warm-blooded animals, in which 
the body temperature is maintained at a nearly uniform 
standard, the respiratory activity is lessened with an in- 
crease of temperature, and increased with a diminution 
of temperature. 

WATER, ORGANIC MATTER, ETC., EXCRETED BY THE 
Lunes.—Strictly considered, the excretion of water and 
other substances from the Jungs may not properly belong 
to the subject of respiration ; it is usually so included, 
however, as the excretion takes place from organs which 
are primarily organs of respiration, and it is a constant 
accompaniment of breathing. Under ordinary circum- 
stances there is given off by the lungs about one litre of 
water in twenty-four hours. This water is derived from 
the mucous surface of the lungs and the air-passages. 
The amount of water required to saturate the breath with 
moisture depends largely upon the hygrometric conditions 
of the atmosphere, That is, if the air contains very lit- 
tle moisture a great deal must be added to it in the lungs 
to bring it to the point of saturation at the temperature 
of the body. On the other hand, if the air is warm and 
nearly saturated with aqueous vapor, only a little will be 
necessary to complete the saturation. If the air is warmer 
than the body, and saturated with moisture, it will be 
cooled in the lungs, and water will be deposited until the 
point of saturation at the lower temperature is reached. 
That is, the expired air may be cooler, and contain less 
watery vapor than the inspired air, but this is uncom- 
mon. Air containing considerable moisture is more com- 
fortable to breathe than dry air. If it contains too much 
moisture there is produced a feeling of closeness, and if 
too little, the evaporation from the air-passages is so rapid 
that they become parched. For this reason it is more 
comfortable to sit in an artificially heated room in which 
watery vapor is constantly mixed with the heated air. 

In addition to the watery vapor exhaled, there is con- 
stantly a smatl amount of organic matter given off with 
the breath. The exact nature and amount of this or- 
ganic matter have not been determined, owing to the dif- 
ficulty of so doing. It is this substance which produces 
the chief deleterious effects in breathing air over and 
over. The amount of carbon dioxide present in a room 
containing several individuals is usually not sufficient to 
produce any serious effects, as is shown by the continu- 
ous breathing of air containing a considerable amount of 
carbon dioxide by men when mining coal. The carbon- 
dioxide tension in the air of an inhabited room, how- 
ever, is a good guide as to the wholesomeness of the air, 
for, if the carbon dioxide was produced in breathing, the 
air will also be loaded with the more dangerous organic 
matter, which cannot be so readily estimated. The lungs 
may also act as excretory organs in eliminating sulphur- 
etted hydrogen and ammonia from the system, and also 
alcohol and various essential oils, like turpentine and 
those giving the odor to garlic, etc., which had been pre- 
viously taken into the stomach.° 

MEcHANICS OF RESPIRATION.—Under this heading are 
included all the movements necessary for the supply of 
the respiratory organs with pure air and the removal of 
that which has become vitiated. For this respiratory 
ventilation, as it is often called, two very definite acts 
occur—inspiration, or breathing air into the lungs, and 
expiration, or breathing air out of the lungs. 

Inspiration.—This is forcing air into the lungs, and is 
brought about entirely by muscular movement, as fol- 
lows: The glottis is widely opened, rendering the pas- 
sage to the lungs free; the diaphragm contracts, thereby 
flattening its arch and increasing the cavity of the thorax 
lengthwise (Fig. 3319). At the same time the muscles 
attached to the curved and sloping ribs contract, rotating 
and raising the ribs, and thus enlarging the thorax 1n Its 
two transverse diameters (Fig. 3320). The enlargement 
of the thoracic cavity lessens the atmospheric pressure 
within it, and as there is no communication between the 
thoracic cavity and the air, the air rushes into the elastic 
lungs through the air-passages; the lungs stretch and 
completely fill the enlarged cavity in the thorax. 

Expiration.—This is forcing the air out of the lungs. 


205 


Respiration. 
Respiration. 


In normal breathing it follows inspiration without a 
pause, and is brought about, in quiet breathing, by the 
relaxation of the inspiratory muscles, the weight of the 
elevated ribs and chest-walls, and the elasticity of the cos- 
tal cartilages; by the elasticity of the abdominal walls 


Fie. 3319.—View of the Thorax, with the left side removed to show the 
position of the diaphragm in various phases of inspiration and expi- 
ration. (Rosenthal.) A, position of the diaphragm in strong expira- 
tion ; B, its position in moderate, and C, in deep inspiration. 


and the abdominal organs; and, finally, by the elasticity 
of the lungs, which were put on the stretch during inspi- 
ration, 

Whenever, by any form of bodily activity or any other 
cause, the lungs cannot be thus sufficiently ventilated, the 
respiratory movements become more vigorous and the 
respiration is said to be labored. Whenever this occurs, 
muscles not employed in quiet inspiration are brought 
into action, and the expiration is no longer due to gravity 
and elasticity alone, but is 
aided by muscular contrac- 
tion. 

In the following list are 
given the muscles which 
aid directly in inspiration 
by making the thoracic cav- 
ity larger, or in expiration 
by diminishing that cavity ; 
or they may aid indirectly 
by furnishing fixed supports 
for other muscles which can 
act directly on the thorax 
with more advantage there- 
by ; or they may assist by 
opening more widely the 
air-passages. This list, 
which also gives the nerves 
supplying the muscles, is 
copied from Landois.§ 

Ordinary Inspiratory 


the Skeleton of the Thorax, show- 
ing the position of the ribs and 
sternum in expiration (light shad- 
ing) and in inspiration (dark shad- MMyscles (the muscles in ac- 


aoe) Boclned.) tion during quiet breath- 
ing): The diaphragm (nervus phrenicus) ; the Mm. leva- 
tores costarum longi et breves (Ramzi posteriores, Nn. 
dorsalium) ; the Mm. intercostales externi et intercartila- 
ginei (Nn. intercostales). 

Auatliary Inspiratory Muscles (muscles brought into ac- 
tion during labored and forced inspiration). 

(A) The ordinary inspiratory muscles named above. 

(B) Muscles of the Trunk : The three Mm. scaleni (Ram 
musculares of the plexus cervicalis et brachialis) ; M. 
sternocleidomastoideus (Rami externus, N. accessorit) ; M. 
trapezius (ft. externus, N. accessorii et Ram, musculares 


206 


»~REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


plexus cervicalis) ; M. pectoralis minor (Nn. thoracici an- 


' tertores) ; M. serratus posticus superior (WV. dorsalis scapu- 


le); Mm. rhomboidei (NV. dorsalis scapule) ; Mm. exten: 
sores columne vertebralis (Ram. osteriores nervorum 
dorsalium); Mm. serratus anticus major? (WV. thoracicus 
longus). 

(C) Muscles of the Larynx: M. sternohyoideus (Ram. de- 
scendens hypoglossi); M. sternothyroideus (Ram. descendens 
hypoglosst) ; M. crico-arytenoideus posticus (WV. laryngeus 
inferior vagt); M. thyreo-arytenoideus (JV. laryngeus in- 
Sertor vagi). 

(D) Muscles of the Face: M. dilator narium anterior et 
posterior (VV. facialis); M. levator ale nasi (1. facialis) ; 
in gasping for breath the dilators of the mouth and nares. 

(E) Muscles of the Pharynz : M. levator veli palatini (1. 
facials) ; M. azygos uvule (NV. facialis). 

Muscles in Action during Labored Hapiration: The ab- 
dominal muscles, including the obliquus externus and 
internus, and transversalis abdominis (Vn. abdominis in- 
ternis anteriores e nérvis intercostalibus, 8th to 12th); Mm. 
intercostales interni, so far as they lie between the osseous 
ribs,* and the infracostales (Wn. tntercostales) ; M. trian- 
gularis sterni (Vn. intercostales) ; M. serratus posticus in- 
ferior (Ram. externt nerv. dorsulium) ; M. quadratus lum- - 
borum (Ram. musculare e plexu lumbalt). 

Rate of the Respiratory Movements, Apnea,—According 
to the numerous observations of Hutchinson,!® Sibson, 
and others, in quiet breathing there occur in the adult 
from eighteen to twenty inspirations and expirations per 
minute, or about one breath for every four heart-beats. 
The number of respirations, that is, the number of in- 
spirations and expirations, is greater in children than in 
adults, and in those in the prime of life than in old age. 
In small animals, like the rat, the rate is far greater than 
in man (100 to 200 per minute), while in some at least of 
the larger animals it is slower than in man (rhinoceros, 
6 per minute).® 

Any circumstance increasing bodily activity in any 
form causes an increased rapidity of the respiratory 
movements to supply the extra oxygen demanded, and 
to remove the extra carbon dioxide formed. If the num- 
ber and depth of the respirations are increased volunta- 
rily, the total amount of oxygen absorbed and of carbon 
dioxide exhaled is not increased beyond what is due to 
the extra muscular exertion required in so breathing ; 
for the respiratory gas-interchange is controlled entirely 
by the tissues, not by the respiratory movements. The 
expired air will, however, contain less carbon dioxide 
and more oxygen than usual, as the carbon dioxide ex- 
creted is more largely diluted by the extra amount of air, 
and the larger amount of air supplying a definite amount 
of oxygen is less impoverished than a smaller amount 
would be. If one breathes deeply and rapidly for a short 
time, it is easier to hold the breath for a considerable time 
afterward than when breathing ordinarily. Somewhat 
similarly, if artificial respiration be performed on an ani- 
mal—a rabbit, for example—that has been in nowise in- 
jured, the animal will remain, for a considerable time 
after the artificial respiration has ceased, without breath- 
ing ; the respiratory movements will then commence, 
and gradually increase in vigor until the animal breathes 
in a normal way as before the artificial respiration. It 
has been demonstrated, in one case at least, that a human 
being will show the same phenomena under the influ- 
ence of artificial respiration after tracheotomy.”! This 
cessation of breathing has béen designated apnea by 
Rosenthal.!® It has received three explanations: (1) 
That of Rosenthal, who supposes that on account of the 
purity of the air in the lungs produced by the extra ven- 
tilation, the hemoglobin of the blood becomes entirely 
saturated with oxygen, and this supply lasts for a consid- 
erable time before more is needed to keep the blood up to 
the ordinary standard of purity. (2) That of Gad,° who 


* The controversy begun by Haller and Hamburger concerning the ac- 
tion of the internal intercostal muscles is still continued. At present, 
however, the majority of physiologists agree with Hamburger that the 
internal intercostal muscles between the bony part of the ribs act as ex- 
piratory muscles, while those between the costal cartilages act as inspira- 
tory muscles. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


supposes that on account of the purity of the air in the 
lungs the blood can get all the oxygen needed, and get 
rid of its carbon dioxide for a considerable time without 
further ventilation of the lungs. (38) That of Hoppe- 
Seyler,'® who thinks the cessation of breathing is due to 
the exhaustion of the respiratory muscles. This view 
seems less satisfactory than either of the others, for in the 
case of the rabbits no muscular exertion was required on 
their part to exhaust their respiratory muscles, and fur- 
thermore, muscular activity tends to increase, not dimin- 
ish, the rapidity of the respiratory movements. 

Rhythm and Type of the Respiratory Movements.—In 
normal quiet breathing, beginning with inspiration, in- 
spiratory movements are rapid and continuous, then ex- 
piration follows without a pause, but proceeds more 
slowly than inspiration, the ratio being, inspiration six, 
expiration seven, for adult men. In women, children, 
and the aged the ratio is, inspiration six, expiration 
eight or nine (Sibson). After expiration there is in many 


Fic, 3321.—Diagrams Showing the Change in Form of the Thorax and 
Abdomen during Respiration in the Male and the Female. (Hutchinson. ) 
A, outlines of the male, and B, outlines of the female figure, indicating 
the different phases of the respiratory movements; @, a, outline of 
the body in full expiration ; in this condition the lungs contain only 
the residual air. 6, b, heavy continuous line; the outer margin in- 
dicates the contour of the body in ordinary inspiration, and the inner 
margin in ordinary expiration; the thickening of the line over the 
abdomen in the male, and over the thorax in the female, indicates 
that the greater movement occurs in the abdomen of the male (abdom- 
inal type of respiration), and in the thorax of the female (costal type 
of respiration) ; the entire thickness of the line represents the amount 
of tidal air; in ordinary inspiration the lungs contain the residual, 
the reserve, and the tidal air. c, c, dotted line giving the contour in 
the deepest inspiration ; the thorax is greatly expanded, but the ab- 
domen is less so than in ordinary expiration; in the deepest inspira- 
tion the lungs contain the residual, the reserve, the tidal, and the com- 
plemental air (see below). 


cases a slight pause (expiration-pause) before the begin- 
ning of the following inspiration. This pause is not 
always present, and is always absent except in quiet 
breathing. The movements of a complete respiration 
are then, (1) a rapid continuous inspiration, (2) a some- 
what slower expiration immediately following the in- 
spiration, (3) in many cases a slight pause before the fol- 
lowing inspiration. 

The respiratory movements in some individuals are 
more especially due to the elevation of the ribs, and in 
others to the contraction of the diaphragm ; consequently 
these movements have been divided into two correspond- 
ing types by Hutchinson,'* viz., costal respiration, in 
which the enlargement of the chest is due largely to the 
elevation of the ribs, and abdominal respiration, in which 
the chest-cavity is enlarged most by the contraction of 
the diaphragm, with the consequent movements of the 
abdominal walls. The costal type is most common in 
women, the abdominal type in men. In children of both 
sexes there is no marked difference in type, and in the 


Respiration. 
Respiration. 


adult the differences are only noticeable in quiet breath- 
ing. In labored breathing the movements of the chest 
are most noticeable in both sexes (Fig. 3321). 

Two explanations have been offered for the great prev- 
alence of the costal type in the female: (1) That it is due 
to the habitual use of tight clothing around the waist ; 
and (2) that it is a kind of reservation against the period 
of gestation. Hutchinson found the costal type marked 
in twenty-four girls, varying from eleven to fourteen 
years, who had never worn tight clothing around the 
waist.!6 On the other hand, Mays” found by careful 
experiments, made according to the graphic method, 
that in eighty-two North American Indian girls, varying 
from ten to twenty-two years, the abdominal type of 
breathing was marked in nearly every case. The experi- 
ments of Mays would indicate that the primitive and 
natural type of respiration in the female, as well as in 
the male, is the abdominal ; but in comparing the obser- 
vations of Mays and Hutchinson on subjects which had 


Fie. 3322,—Diagram of Hutchinson’s Spirometer. (Landois.) A, grad- 
uated cylinder serving as a receiver for the breath ; it is supplied with 
a stop-cock at the top for the ready expulsion of air, and is balanced by 
weights passing over pulleys. B, mouth-piece with tube reaching 
nearly to the top of the graduated receiver (A), when the latter is sunk 
in the reservoir ready for an experiment; there is a stop-cock in this 
tube near the first angle to prevent regurgitation of air. C, reservoir 
for the graduated receiver. In using the spirometer the reservoir and 
graduated receiver are filled with water, or, to prevent the absorption of 
carbon dioxide, with a saturated aqueous solution of common salt (Na- 
Cl.). When ready for an experiment, the stop-cock at the top of the 
receiver is closed and that in the tube of the mouth-piece opened, and 
the breath forced into the receiver. The receiver rises as fast as the 
breath displaces the water. After the breath is forced into the receiver 
the stop-cock in the tube of the mouth-piece is closed, and the water 
outside and inside the receiver brought to the same level, so that the 
air within the receiver shall be at the atmospheric pressure. The 
amount of breath within the receiver is then read directly from the 
scale attached to the receiver. For accurate measurement the breath 
should stand a few minutes to acquire the temperature of the liquid 
over which it is collected, then the various corrections for aqueous 
vapor tension, and the variations from the standard temperature and 
pressure, should be made. 


been equally free from the effects of tight clothing, it 
would appear that the type of respiration may differ in 
the females of different races. 

Respiratory Ventilation.—In very young children the 
lungs are nearly emptied at each expiration, so that the 
ventilation is nearly complete ; but after the first period 
of infancy a large amount of air remains constantly in 
the lungs, and only a limited amount of this is changed 
at each breath. Hutchinson and others have investigated 
with great assiduity the question as to the total capacity 
of the lungs, the amount of air in them under various 
conditions, the amount of air inspired and expired at 
each breath, etc. When the subject was first studied 
there were great hopes that it would give valuable aid in 
discovering and treating disease, but these anticipations 
were not realized. Its chief value is in hygiene ; for, by 


207 


Respiration. 
BRhatany. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


showing how much air is breathed by an individual in an 
hour, and knowing by analysis the contamination of the 
air due to being breathed once, data are furnished for the 
ventilation of rooms and buildings. For determining the 
various amounts of air expired under various conditions, 
Hutchinson !* invented a kind of gasometer, called by him 
a Spirometer (Fig. 3322). In the following table is shown 
diagrammatically the relative position and amount of the 
different volumes of air that may be in the lungs at the 
same time. 


Complemental air, 1,600 c.c. 


Breathing or tidal air, 500 c.c. 
Breathing or vital capacity, | 
J 


3,700 c.c. Reserve air, 1,600 c.c. 


ae 


** Collapse” air, 800 c.c. 


Residual air, 1,600 c.c. 


Total capacity of the lungs, 
5,300 c.c 
Stationary air, 3,200 c.c. 


‘* Minimal” air, 800 c.c. 


Complemental air is the amount of air that may be 
inspired after an ordinary inspiration. 

Breathing or tidal air is the air inspired and expired at 
an ordinary breath. 

Reserve air is that which may be expired after an 
ordinary expiration. 

Residual air is that which cannot be expelled from the 
lungs by the most forcible expiration. It is composed of 
two nearly equal portions, the ‘‘ Collapse” air, which 
escapes from the lungs when the chest is freely opened, 
and ‘‘ Minimal” air; that which remains in the lungs 
after the thorax is opened. 

Breathing or vital capacity. 'This is the amount of air 
which may be forced from the lungs after the deepest 
possible inspiration. It is the sum of the reserve, the 
tidal, and the complemental air. 

Stationary air. 'This is the sum of the reserve and the 
residual air, and is so named as, under ordinary circum- 
stances, these two volumes of air remain constantly in the 
lungs. 

Many experiments have been tried to determine the 
amount of change of the air in the lungs by a single 
breath. From the nature of the problem no method is 
wholly satisfactory. The one originally proposed by 
Davy is most used. It consists of inhaling a known 
volume of pure hydrogen, and then analyzing the expired 
air. If no mixing of the hydrogen with the air already 
in the lungs takes place, then the expired gas, like the 
inspired, would be pure hydrogen. By actual experi- 
ment it is found that, supposing 500 c.c. of pure hydrogen 
are inhaled, only 170c.c. of hydrogen are exhaled, the re- 
maining 330 c.c. being air. That is, 330c.c. of the inhaled 
hydrogen displace the same amount of air. If, now, it is 
assumed that in ordinary breathing 500 c.c. of air are 
inhaled, and the 330 c.c. of this remain as with the hydro- 
gen, and displace a similar amount of vitiated air, then the 
amount of renewal must be the ratio between the air in 
the lungs before the inspiration—that is, the reserve and 
the residual air (8,200 c.c.), and the fresh air (830 c.c.) re- 
maining in the lungs after each expiration—#iy5 = 0.103. 
This has been termed the coefficient of ventilation,® and 
in the case given shows that only about one-tenth of the 
air in the lungs is changed at each breath. The inter- 
mixture of this fresh tidal air with the reserve air in the 
air-passages is due largely to the currents produced by 
inspiration, but the residual air in the alveoli and smallest 
air-passages must depend mostly on diffusion for its 
purification. 
itated by the swaying to and fro of the air as the chest 
alternately expands and contracts, to the jars produced 
by the heart-beats and the pulsation of the pulmonary 
arterioles, and also to the ciliary currents in the bronchi. 
It would seem reasonable to suppose, therefore, that the 
air in the alveoli remains of a nearly uniform quality, 
and that it contains a greater percentage of carbon 
dioxide, and a less percentage of oxygen than the 


208 


This diffusion is no doubt greatly facil- . 


expired air. The direct experiments of Wolfberg and 
others, however, show that there is but little difference 
in the composition of the alveolar air and that which 
may be expired by a full expiration. This seems to show 
that the diffusion in the lungs is very rapid.® 

Pressure in the Air-passages.—-This varies in inspiration 
and expiration. It is measured by connecting a manom- 
eter with the nose or mouth, or, in an animal, with the 
trachea, and noting the variations in the columns of 
mercury during inspiration and expiration. In man, 
when there is a perfectly free entrance for the air to the 
lungs, the aspiration, suction, or negative pressure during 
quiet inspiration is about 3 mm. of mercury, and during 
expiration the positive pressure is from 2 to 8 mm. In 
forced inspiration the aspiration may reach 57 mm. hg., 
and in forced expiration the pressure may rise to 87 mm. 
hg. If the air-passages are closed, so that no air can enter 
or leave the lungs, then the aspiration or negative pressure 
is from 30 to 74 mm. hg., when inspiratory efforts are 
made ; and when expiratory efforts are made the pressure 
is 62 to 100 mm. hg. 

The elastic lungs are during life and the complete in- 
tegrity of the thorax somewhat stretched. If the trachea 
of a dead person is connected with a manometer and then 
the thorax freely opened, the elasticity of the lungs will 
show a pressure of 6mm. hg. If the lungs are fully in- 
flated, then the pressure due to their elasticity will be 
measured by about 30 mm. hg. This shows very graph- 
ically the part played by the elasticity of the lungs in ex- 
piration.®,!? 

The respiratory sounds and the interaction of the cir- 
culatory and respiratory movements have already been 
treated in this HANDBOOK, the first under Chest, vol. ii., 
p. 82; the second under Blood-circulation," vol. i., pp. 
563, 566. 

The Respiratory Centre and the Nerves of the Respiratory 
Apparatus.—As with all the other muscles and organs of 
the body those belonging to the respiratory apparatus are 
well supplied with nerves. The names of the nerves sup- 
plying the respiratory muscles are given above in the list 
of the muscles. It has further been found that the whole 
complex mechanism of respiration is under the control 
of a nerve-centre, termed from its office the respiratory 
centre ; and from the fact. that an animal invariably dies 
after its destruction, it is called the vital point (nwud vital). 
This centre is situated in the medulla, near the origin of 
the vagus nerve. While it has been known from the 
time of Le Gallois !® that this centre exists in the medulla, 
the question whether it is a reflex centre, acting only in 
accordance with afferent impulses from without, either 
through special nerves like the vagus, or through those 
from the entire system, or whether it is an automatic 
centre acting in accordance with changes going on within 
itself, was for a long time unknown. It is now quite 
well established that the centre is automatic, although its 
action may be greatly modified by afferent impulses. It 
is a matter of common experience that one’ can cease 
breathing for a limited time, or can greatly increase the 
number and depth of the respirations, at will; also that 
a dash of cold water causes most persons to take a deep 
breath, and by the application of snuff or dust to the nose 
a sneeze is produced. So coughing, which is likewise 
only a modified respiratory act, is induced by an irrita- 
tion of the glottis, etc. While, therefore, the centre is 
constantly being influenced from without, the final proof 
of its automatic action is given by the following experi- 
ments : 

In 1879 Flint ® showed that if the thorax of an animal 
is opened and artificial respiration kept up sufficiently to 
aerate the blood well, no respiratory efforts are made by 
the animal; but if the vessels going to the medulla are 
clamped, cutting off the supply of arterial blood to the re- 
spiratory centre, violent respiratory movements are made, 
although all the rest of the body is well supplied with ar- 
terial blood. On the other hand, if clamps are put on 
the vessels so that oxygenated blood can go only to the re- 
spiratory centre, no respiratory movements will be made, 
although all the rest of the body is suffocating. 

Anatomically and physiologically, the respiratory cen- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Respiration. 
Rhatany. 


tre is symmetrical, there being one on each side, as is 
shown by the continuance of the respiratory movements 
after cutting the medulla longitudinally. If one side 
of the centre is then destroyed the respiratory move- 
ments cease on that side, but continue on the other. 
There are also many reasons for supposing that the res- 
piratory centre is composed of an inspiratory and an ex- 
piratory part, the expiratory part being cephalad, or in 
front of the inspiratory part. ® 1§ 

The stimulus acting on the respiratory centre to arouse 
its activity seems to be the blood which circulates in it. 
If this blood contains too small an amount of oxygen 
the centre sends out stimuli to the inspiratory muscles, 
and then, slightly later, to the expiratory muscles. An 
excess of carbon dioxide seems also to have a stimu- 
lating effect on the respiratory centre, chiefly the expira- 
tory part: (Bernstein).'° The lack of oxygen is the more 
potent factor in arousing the respiratory centre, how- 
ever, as is shown by the fact that the most violent respi- 
ratory efforts are made when a deficient supply of ox- 
ygen is present in the air supplied to the lungs, although 
there may be no excess of carbon dioxide. If there is 
plenty of oxygen in the air, and an excess of carbon 
dioxide, the animal often dies from carbon-dioxide poi- 
soning, without spasms. 

Besides the main respiratory centre in the medulla, 
other centres, called accessary respiratory centres, have 
been described as present in the myel or spinal cord, 
and also in the brain; but at present exact informa- 
tion concerning thesé centres, if they exist, is very 
meagre. ® 


REFERENCES. 


In preparing this article, constant reference has been made to the Eng- 


lish, French, and German journals of physiology, and to the text-books 
and larger works on physiology and physiological chemistry. The bib- 
liography is especially full in Bert, 9; Gamgee, 20 ; Milne-Edwards, 19; 
Reid, 15; Rosenthal, 18; and Zuntz, 8.- As some of the authors are 
referred to several times, the pages are given in the order of the refer- 
ences. 


1 Bernard, Cl.: Lecons sur les Phénoménes de la Vie Communs anx 
Animaux et aux Végétaux. Twovols. Paris, 1878-1879. Vol. ii., pp. 
185, 179, 149. : 

2 Béclard, J,: Traité Elémentaire de Physiologie, 7th Ed. Paris, 1880. 
Pp. 336, 337. 

3 Bell, F. J.: Comparative Anatomy and Physiology. London and 
Philadelphia, 1885. P, 210, f 

4 Flint. Jr., A.: The Physiology of Man. 5 vols. New York, 1868- 
1874) Voli pasoan a, 

5 Flint, Jr., A.: A Text-look of Human Physiology. 3d Ed., pp. 154- 
166. New York, 1884, (See also N.Y, Med. Jour., November, 1877, and 
Amer. Jour. of the Med. Sc., July, 1880.) 

6 Landois, L. (Translated by Stirling): A Manual of Human Physi- 
ology, including Histology and Microscopic Anatomy. From the fourth 
German edition. Philadelphia, 1885. Pp. 222, 58, 260, 265, 264, 257, 268, 
277, 234, 878, 247, 876, 877. 

7 Quain’s Anatomy, 9th Ed. London and New York, 1882. Vol. ii., 
p. 52U. 

8 Zuntz, N.: Blutgase und respiratorischer Gaswechsel, in Hermann’s 
Handbuch der Physiologie, Bd. iv., II. Theil. Leipzig, 1882. Pp. 111, 
118, 37, 35, 36, 65, 88, 114, 182, 144, 157, 101, 106. 

® Bert, Paul: Lecgons sur la Physiologie Comparée de la Respiration. 
Paris, 1870. Pp. 270, 18, 140, 30, 393. 

10 Hermann, L.: Lehrbuch der Physiologie, 8th Ed, Berlin, 1886. 
Pp. 101, 108, 124. 

11 Dalton, J. C.: A Treatise on Human Physiology, 7th Ed. Philadel- 
phia, 1882. PP. 252. 

12 Foster, M.: A Text-book of Physiology, 3d Ed. London and New 
York, 1880. Pp. 367, 368, 331. 

13 Hoppe-Seyler, F.: Physiologische Chemie, III. Theil. Berlin, 1879, 
Pp. 580, 534, 520. 

14 Kirkes’s Handbook of Physiology, revised by Baker and Harris, 
11th Ed. London and New York, 1885. P. 193. 

15 Reid, John: Article Respiration, Todd’s Cyclopedia of Anatomy 
and Physiology, vol. iv., pt. i. London, 1847-1849. P. 380. 

16 Hutchinson, J.: Article Thorax, Todd’s Cyclopzedia of Anatomy 
ene Physiology, vol. iv., pt. ii. London, 1849-1852. Pp. 1085, 1080, 

64. 

17 Martin, H. N.: The Human Body. New York, 1881. P. 367. 

18 Rosenthal, J.: Athembewegungen und Innervation derselben, in 
Hermann’s Handbuch der Physiologie, Bd. iv., II. Theil. Leipzig, 1882. 
Pp. 264, 242, 244, 

19 Milne-Edwards, H.: Lecons sur la Physiologie et l’Anatomie Com- 
parée de Homme et des Animaux. 14 vols. Paris, 1857-1880. Respi- 
ration in vol, ii., p. 151. 

20 Gamgee, A.: A Text-book of the Physiological Chemistry of the 
Animal Body. London, 1880. P. 123. 

21 Fell, Geo. E.: International Medical Congress, September, 1887. 

22 Mays, Thos. J.: Experimental Inquiry into the Chest Movements of 
the Indian Female. Therapeutic Gazette, May 16, 1587. 


Simon H. Gage. 
Vou. VI.—14 


RHATANY (Arameria, U. S. Ph.; Kramerie Radix, 
Br. Ph.; Radix Rhatanie, Ph. G.; Ratanhia, Codex 
Med.). The roots of some species of Krameria, espe- 
cially K. triandra Ruiz and Pavon, and K. [zina Linn. 
(Kk. tomentosa St. Hi- 
laire), order Polygala- 
cee (Leguminose, Kra- 
meri@, Luerssen). 

Krameria triandra 
is a low shrub with a 
thick, dark - colored, 
woody, branching root, 
and straggling, slender, 
branching stems. These 
latter are from one- 
third to one metre in 
length, the longer re- 
clining or horizontal, 
the shorter erect ; bark 
grayish-brown, twigs 
greenish - gray, silky. 
Leaves alternate, ses- 
sile, obovate, lanceo- 
late, spiculate, silky- 
hairy. Flowerssolitary, 
axillary near the ends 
of the branches, calyx 
of four scarlet sepals, 
cruciform, the lateral 
sepals shorter than the 
others. Petals four, 
also scarlet, the two 
upper erect, spatulate, 
the two lower short, 
broad, and glandular. 
Stamens three, short 
and thick. Pistil sim- 
ple; ovulestwo. Fruit 
spherical, silky, and 
spiny. ‘This species is 
indigenous’ to high, 
sandy slopes in Peru 
and Bolivia, and is the 
source of the Red Peru- | 
vian Rhatany. 

K, Izina has alarger, 
smoother, more brown 
or purplish root, longer leaves, smaller and duller-colored 
flowers, and five sepals. It grows inthe West Indies, and 
in Central and South America. Its root, whichis fully as 
good as the other, is known as Savanilla, New Granada, 
or Violet Rhatany. There is very good reason for placing 
this anomalous genus near 
the sub-order Cesalpine in 
Leguminose. 

Rhatany root was noticed 
by Ruiz in 1784, as used 
by the women of Huanaco 
and Lima for the preserva- 
tion of their teeth, and by 
him was introduced into 
Spain a year or two after 
(Fliickiger), whence it soon 
became known. 

Peruvian Rhatany (root) 
‘ig about one inch thick, 
knotty and several-headed 
above, branched below, the 
branches long, bark smooth 
or scaly, deep rust-brown, 
about one-twelfth of an 
inch (2 millimetres) thick, 
very astringent, inodorous; 
wood pale-brownish, tough, with fine medullary rays, 
nearly tasteless. The root of Krameria tomentosa (Say- 
anilla Rhatany) is less knotty and more slender, and has 
a dark purplish-brown bark about one-eighth of an inch 
(8 millimetres) thick. 

Both varieties have essentially the same medicinal 


209 


Fic, 33823.—Krameria Triandra; flower- 
ing branch. (Baillon.) 


Fie. 8824.—Krameria Triandra ; 
flower. (Baillon.) 


Rhatany. 
Rheumatism. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


properties and composition. The most important con- 
stituent (of the bark—the wood is nearly inert) is Rha- 
tania-tanniec acid, existing to the extent of about twenty 
per cent.; a brilliant, deep-red, amorphous mass, soluble 
in alcohol, incompletely so in water; with perchloride 


Fie. 3325.—Krameria Triandra; fruit, entire and in section, (Baillon.) 


of iron it gives a dull-green color. When exposed to the 
action of diluted acids, and under other circumstances, 
this tannin is decomposed into sugar and Ithatania red, 
This substance is much less soluble in water than the 
tannin, and is also but little soluble in alcohol and ether. 

AcTIoN AND Use.—Rhatany is a reliable and useful 
astringent, owing to itslarge per cent. of tannin, and is 


ee +8) 


é 
° 


aaoen 


ute 


SA 


See 


Fie, 3326.—Krameria Triandra ; transverse section of root. (Baillon.) 


applicable to all the conditions where gallic or tannic acid 
is useful. The crude drug may be given in powder, but 
seldom is, as the large amount of woody tissue is a disad- 
vantage. Dose, one or two grams (gr. xv. ad xxx.). The 
following officinal preparations are all good: Extract 


210 


(Hztractum Kramerie) for pills, strength about #; Fluid 
Extract (Hatractum Kramerie fluidum), strength +; and 
Tincture (Tinctura Kramerie), strength t. 

ALLIED PLANTS.—There are a dozen or more South 
American species of Krameria, all astringent, and several 
are in use in the countries where they grow. 

ALLIED Drues.—See NUTGALLS, CATECHU, etc. 

W. P. Bolles. 


RHEUMATISM, ACUTE ARTICULAR. Synonyms: 
Rheumatic Fever, Acute Rheumatism, Acute Rheumatic 
Polyarthritis. 

Definition.—Acute articular rheumatism is a specific 
inflammation which attacks the structures in and around 
the large joints. Asa rule, two or more articulations are 
affected, and the inflammation moves from one to an- 
other. It is scarcely ever followed by suppuration. It 
is accompanied by severe febrile disturbance. In a large 
proportion of cases the fibro-serous structures of and about 
the heart are also affected by the inflammatory process. 

HMistory.—This disease has doubtless existed from the 
earliest ages, but the term rheumatism was first applied 
to it by M. Baillon, who published a treatise on the sub- 
ject in 1642. The term was afterward applied by many 
authors to inflammation of the joints generally. We now 
distinguish under several heads diseases which formerly, 
by some, were called rheumatic, viz. : 1, Articular rheu- 
matism ; 2, gout; 8, rheumatoid arthritis ; 4, muscular, 
and 5, gonorrheeal, rheumatism. 

Articular rheumatism may conveniently be divided 
into (a) acute, (0) subacute, and (ce) chronic forms. 

Morbid Anatomy.—Opportunities for making post-mor- 
tem examinations in cases of acute rheumatism are rare. 
The synovial membrane is found congested, the inner sur- 
face being rather dull in appearance, with a serous fluid 
filling the cavity of the joint. This fluid contains masses 
of epithelium. Occasionally pus is found in the exuda- 
tion. The structures around the joint are also inflamed. 
Sometimes the tendinous structures are filled with a yel- 
lowish serum. The cartilage often shows signs of inflam- 
mation. 

Symptoms.—The onset of the disease is marked by dif- 
ferent features in different cases. The attack is some- 
times preceded by a slight chill followed by fever. In 
many cases there is a premonitory stage, during which 
wandering pains occur in the joints, and there is observed 
a peculiar puffy condition about the ankles. Ina few 
instances the pericardium or endocardium is first attacked. 
In such cases the patient first notices a sense of oppres- 
sion, with dull pain, in the chest. When the disease has 
become established the most prominent symptoms are as 
follows: Pain and swelling of the larger joints of the 
body ; elevation of temperature with general febrile dis- 
turbance; the occurrence of excessive perspiration. The 
joints most often affected are the knee, elbow, wrist, and 
the smaller joints of the hands and feet. The hip and 
shoulder may also be attacked, but the swelling is less 
apparent in these, owing to their being covered by large 
muscles. The swelling is often accompanied by some 
redness and tension. Neither of these latter symptoms 
is aS prominent as in gout. The pain is more or less 
acute; it is sometimes dulJl and aching, but more fre- 
quently it is severe and excruciating. It is increased by 
the slightest movement ; even the shaking of the bed will 
make it moreintense. The patient is thus rendered quite 
helpless, and speaks of having lost the use of his limbs. 
The pain is more severe at night than during the day. 
The swelling of the joints varies very much in different 
cases. In some it is but slightly marked, and is not ac- 
companied by much redness, or tenderness on pressure. 
In others, again, the swelling is excessive, so that the ar- 
ticulation presents a red, shining, tense appearance, very 
much resembling gout except that the surrounding veins 
are not enlarged. It is remarkable how quickly the 
swelling may subside. A joint may present the most 
severe symptoms on one day, and the next it may have 
almost resumed its normal condition. The intense in- 
flammation usually lasts four or five days, and on its 
disappearance other articulations may become affected. 


> 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


The same joint may be attacked two or three times dur- 
ing the illness. The inflammation passes from one joint 
to another so rapidly that some have considered it an 
example of metastasis. As a rule, however, the second 
series of joints are attacked before the first are entirely 
normal. Pitting on pressure occurs in some delicate pa- 
tients. Suppurationis a very rare sequence in rheumatism. 

The presence of excessive perspirations is a very fre- 
quent symptom. They occur in exacerbations, when the 
sweat often possesses a peculiar, sour odor. This is due 
to the presence of an acrid substance rather than to excess 
of lactic acid. A red, papular eruption, together with 
sudamina, frequently appears on the skin, the result of 
profuse sweating. 

A peculiar erythematous eruption, peliosis rheumatica, 
has been noticed in some cases of acute rheumatism. 
The rash does not differ from erythema multiforme, as 
we now use that term. Urticaria is present in some 
cases. The temperature during an attack rises to 102° or 
104° F.; in some cases of hyperpyrexia it rises to 110° F. 
The fever is of a remittent rather than a continuous 
character. The temperature is usually higher in propor- 
tion to the number of joints attacked. The tongue is 
coated thickly with a white fur. The saliva, which is 
normally alkaline, becomes acid. There is lossof appetite 
with more or less nausea. The bowels are constipated. 
The urine is scanty, high-colored, and strongly acid in 
reaction ; its specific gravity is higher, owing to increased 
quantity of urates and urea; on standing a reddish sedi- 
ment is formed. Albumen is sometimes found in small 
quantity during the febrile stage and during convales- 
cence. The pulse is increased in frequency, often out of 
proportion to the rise in temperature. This may be due 
to severe pain or to the onset of cardiac trouble. The 
respirations are frequent and often shallow. They be- 
come greatly hurried when there are severe heart-com- 
plications. The red corpuscles of the blood are much 
decreased in number, and the amount of fibrin is in- 
creased. 

In a large proportion of cases, the fibro-serous struct- 
ure of the heart is attacked. The endocardium is much 
more frequently affected than the pericardium, the pro- 
portion being as six to one. In a few cases the muscular 
wall is also involved. ' The structures are attacked in the 
same way as the joints, the result of the elective affinity 
of the poison. Their involvement is not an instance of 
metastasis, nor should it be regarded as a complication, 
but simply as a part, of the disease. Rheumatic inflam- 
mation of these structures differs from that of the joints 
in two or three particulars. The exudation contains 
lymph, often becomes organized, and occasionally degen- 
erates into pus. Pericarditis is usually accompanied by 
a dull pain beneath the sternum and a sense of oppres- 
sion in the chest. By auscultation a friction-sound can 
be heard most distinctly over the base of the heart. This 
soon disappears as the serum accumulates in the pericar- 
dial sac. The presence of the latter is diagnosed by the 
increased cardiac dulness and diminished cardiac im- 
pulse. The endocardial inflammation is confined almost 
altogether to the left side of the heart. Its presence is usu- 
ally made known by abnormal valvular murmurs, which 
are heard on auscultation. It may here be stated that 
one often hears abnormal heart-murmurs, during an at- 
tack of rheumatism, which disappearin afew days. In 
some of these cases it is difficult to say whether endocar- 
ditis was present or not. Two theories have been given 
to explain such cases: First, that there is a temporary 
dilatation of the heart ; second, that an endocarditis may 
exist which undergoes rapid resolution. For further de- 
tails, see vol. iii., pp. 583 and 584; and vol. v., p. 573 
et seq. 

The duration of acute rheumatism varies much—it may 
disappear in five or six days, or it may last as many 
weeks. The average duration is from two to three weeks. 
The patient is scarcely ever free from pain and fever dur- 
ing this period, and there are frequently exacerbations, 
which are followed by periods of comparative relief. 
There is a strong tendency to relapse, and many: patients 
are subject to repeated attacks of the disease. 


Rhatany. 
Rheumatism, 


Unusual Events and Complications in the Course of Acute 
Rheumatism.—A frequent complication is pleurisy of the 
left side, which is said to occur in ten per cent. of all 
cases in which the heart is involved. Bronchitis, con- 
gestion, cedema of the lungs, and catarrhal pneumonia 
are sometimes concurrent with acute rheumatism. In 
rare cases inflammation of the meninges of the cord and 
brain complicates the disease. 

Delirium, convulsions, and coma have been recorded. 
Chorea sometimes follows rheumatism in children. 
Acute delirium occurs in cases of hyperpyrexia. Or- 
ganic changes of the nerve-centres from embolism are 
among the possibilities. A few singular cases of rheu- 
matic hyperpyrexia have been recorded by Ringer, Mac- 
lagan, and others. In these the temperature rises some- 
times to 110°. They are marked by the presence of acute 
delirium, which rapidly passes into coma; such cases 
are very frequently fatal. They often commence and 
continue for a few days in the ordinary way, when sud- 
denly the temperature rises and the patient becomes de- 
lirious. Ithas been found necessary to reduce the tempera- 
ture by the application of ice, and some cases have been 
saved inthatway. Itis probable that the excessively high 
temperature is due to impairment of the heat-centre in 
the bulb, and the brain-symptoms result from the effect 
of heat upon the nerve-substance. 

SuBACUTE RuHEUMATISM.—Under this head cases 
have been described in which only two or three of the 
joints are affected at one time, and the pyrexia is of a 
mild type, the temperature not rising above 100° F. The 
duration is usually much longer than in the acute cases, 
but the joints are not permanently affected and serious 
heart-trouble does not follow. This subacute variety 
forms a connecting link between the acute and chronic 
forms. In a few cases the disease, after attacking two 
or three joints, finally settles in one articulation. . This is 
usually the case in the gonorrheeal form, but it also oc- 
curs sometimes in the acute and subacute varieties. 

Ettology.—Exposure to dampness and cold has gener- 
ally been considered the principal factor in the causation 
of rheumatism. Severe muscular exertion, attended by 
overheating of the system and followed by chilling of 
the surface, is a frequent cause. Neither of these will 
produce rheumatism unless the patient is predisposed to 
the disease, either from hereditary or acquired taint. An 
hereditary predisposition, according to Fuller, is present 
in thirty-four per cent. of all cases. A long residence in 
adamp and cold climate seems to render the system liable 
to an attack. Age has a strong influence in predisposing 
to rheumatism. It does not often attack children under 
fifteen years of age, nor adults over forty-five. One is 
more subject to it between the ages of fifteen and thirty 
than at any other time of life. The heart is not often at- 
tacked after forty years of age. The same person may 
suffer from several attacks. The number of males af- 
fected is somewhat larger than the number of females. 
The former are more exposed and more frequently en- 
gaged in severe muscular exercise. Season and climate 
exert a predisposing influence. It is most prevalent in 
the cold, moist climate of the temperate zone. On this 
continent most cases occur in the latter part of the winter 
or early spring. Occupations which require great mus- 
cular effort in a warm atmosphere predispose to rheuma- 
tism. Washerwomen, bakers, maid-servants, moulders, 
and laborers generally are among those especially liable 
to the disease. Diet probably exerts some influence ; the 
ingestion of an excessive amount of saccharine and 
starchy food increases the tendency to this malady. Cer- 
tain diseases appear to have an etiological relationship. 
In the desquamative stage of scarlet fever, a mild form 
of articular inflammation sometimes presents itself. In 
dengue, hemophilia, gonorrhcea, and in the puerperal 
state, a special tendency to inflammation of the joints 
appears to be present. In some of these latter diseases 
the polyarthritis is often of a pyeemic form. 

Pathology.—Rheumatism must be considered as_a gen- 
eral disease with local manifestations. The febrile con- 
dition appears to be a primary rather than a secondary 
element in the process. The inflammatory condition 1s 


211 


Rheumatism, 
Rheumatism, 


of a special character, and is the result of a materies 
morbi existing in the blood. It has a tendency to attack 
the fibro-serous structures connected with the locomotor 
apparatus and with the heart—in other words, those 
structures subject to movement and strain, <As to the 
nature of the materies morbi, there has been much dif- 
ference of opinion. According to Prout’s theory, lactic 
acid is the foreign constituent of the blood which causes 
the local inflammation. The arguments in favor of this 
view may be briefly stated as follows: First, that in 
acute rheumatism we always have an excess of the acid ; 
second, that in some cases of diabetes, where lactic acid 
had been given for a few weeks, symptoms of rheuma- 
tism were developed; third, that the injection of lactic 
acid into the blood of lower animals has resulted in the 
production of endocarditis. The malarial theory has 
been strongly advocated by Dr. MacLagan. He is of the 
opinion that the excess of lactic acid is the result rather 
than the cause of the rheumatic process, and that the es- 
sential cause of the disease is a miasm which enters the 
system from without. He finds strong confirmation of 
his theory in comparing rheumatism with remittent and 
intermittent fever. According to this view, the salicy- 
lates act by destroying the malarial poison, and thus 
check the disease at its commencement. 

Hueter is of the opinion that the micrococci pass into 
the blood through the sweat-glands, and first set up en- 
docarditis, From this source emboli pass into the gen- 
eral circulation. 

The nerve theory, which was first promulgated by Dr. 
I. K. Mitchell, and afterward supported by such emi- 
nent clinical authorities as Gull, Weir Mitchell, Charcot, 
and Jonathan Hutchinson, has received much attention. 
According to this theory the exciting causes, cold or 
dampness, produce an impression on the surface of the 
body which is conducted to the vaso-motor and trophic 
centres by the afferent nerves. The joints and other 
structures become affected through these systems. One 
would suppose, if this were the correct view, that the 
disease would come on much more quickly after expos- 
ure than is really the case. By combining these various 
theories we may, perhaps, arrive at a fairly correct view 
of the nature of rheumatism. This special form of in- 
flammation is the result of the presence of abnormal 
products in the blood, of which lactic acid appears to 
be the most prominent. Their existence may be due 
to several causes. One of these may be the entrance into 
the blood of a special micro-organism, as taught by Reck- 
linghausen and Klebs. Another cause may be an heredi- 
tary condition of the system, in which there is deficient 
power of assimilation. Prolonged exposure to a damp, 
cold atmosphere may produce the same result. It is a 
singular fact that prolonged and severe muscular exer- 
tion should so often light up the disease. In such cases 
it is probable that, previous to the exertion, the system 
-contained all the abnormal products possible, and that 
the sarco-lactic acid evolved during exertion was just 
sufficient to turn the scale. 

Prognosis.—The prognosis of rheumatism is favorable, 
so far as the immediate result is concerned. Death rare- 
ly takes place during the acute attack, unless there are 
serious complications. The pathological changes which 
sometimes take place in the heart structures are often the 
cause of death at a later period. When a case of acute 
rheumatism terminates fatally, it is usually the result of 
severe heart trouble. In such cases the cardiac walls 
are often affected. The prognosis is also favorable, so 
far as the joints are concerned. Permanent changes in 
the articulations are rare, unless the disease becomes 
chronic. 

Treatment.—The therapeutics of rheumatism is still 
in an unsatisfactory state, as may be inferred from the 
number of remedies recommended. For years the alka- 
line treatment, as taught by Fuller, was very largely 
adopted. According to this method the bicarbonate of 
potash or soda was given in large and frequently re- 
peated doses, until the urine became alkaline or neutral 
in reaction. This can be accomplished in from twelve to 
twenty-four hours. Fuller gave sodium bicarbonate, one 


212 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


and a half drachm ; potassium acetate, one-half drachm, 
in three ounces of water, to which half a drachm of citric 
acid was added just before administration. This dose 
was repeated every three or four hours until the urine 
became alkaline. As a rule, in general practice the al- 
kalies are not given in such large doses, nor so frequently 
repeated. This may explain, as Dr. Howard suggests, 
the difference in the recorded results. The theory upon 
which this treatment is based is, that by the administra- 
tion of alkalies we counteract the acid condition of the 
blood and of the secretions. It has been proved that by 
this method we are enabled to mitigate the severe pain 
of rheumatism, but it is doubtful if by it the duration of 
the disease has been shortened or heart complication pre- 
vented. Drs. Gull and Rees published a number of 
cases, thirty-five in all, in which the expectant plan had 
been adopted. No specific remedy was administered. 
The average duration of the acute symptoms, when the 
heart was not involved, was a little over eight days; 
when the heart was affected, the duration was about 
twenty-two days. 

Other remedies, such as quinine, tincture of iron, col- 
chicum, propylamine, and lemon-juice have been recom- 
mended from time to time. 

Salicin.—Dr. MacLagan, in 1876, published, in the 


London Lancet, his experience in the administration of — 


salicin in acute rheumatism. He commenced to use it 
in 1874, and was so struck with the decidedly good results 
obtained that he spoke of the remedy with great con- 
fidence. 

About the same time Kolbe, in Germany, discovered a 
method of obtaining salicylic acid from carbolic acid. 
This drug was used in rheumatism by Stricker and Riess 
with much success. An account of their experience was 
published in the early part of 1876. The appearance of 
these papers marked an era in the treatment of rheuma- 
tism. Salicin and the salicylates have since been largely 
employed, and we are now in a fair position to judge of 
the results. The latter may be epitomized as follows: 
(1) The salicyl compounds have a decided action in 
mitigating the severe symptoms when they are admin- 
istered early and in frequently repeated doses; (2) the 
average duration of the disease has been shortened by 
these remedies ; (3) they do not prevent heart com- 
plication ; (4) relapses occur more frequently when the 
salicyl treatment has been used. It has also been asserted 
that patients do not rally so quickly after they have taken 
these drugs. Dr. MacLagan recommended salicin to be 
given in from twenty to forty grain doses every hour at 
the commencement of the attack. Salicylic acid may be 
administered in twenty-grain doses every hour until the 
urgent symptoms are relieved. Itis now usually given in 
combination. with soda, in the form of sodium salicylate. 
It is necessary to continue the salicylate during con- 
valescence to prevent relapses. One great drawback to 
the use of the salicylates is their irritant action on the 
stomach. This is much relieved when a simple solution 
is taken in aerated-water. Weakness of the heart’s action 
has been noticed after large and repeated doses. ‘This 
has been so marked in some cases as to require the use of 
stimulants. A buzzing sound in the ears and temporary 
deafness are almost universally experienced after the use 
of the salicyl compounds. Dr. Howard, of Montreal, 
recommends the administration of citrate of potassium 
in combination with sodium salicylate. He also recom- 
mends benzoate of ammonia in cases where the salicyl 
compounds have failed. Latham recommends the salicy- 
lic acid made from salicin as a better preparation than 
that made from carbolicacid. Oil of gaultheria has been 
recommended by Dr. Kinnicutt, of New York, who used 
it in a number of cases instead of sodium salicylate. It 
is composed of ninety per cent. of methyl salicylate, and 
ten per cent. of terebine. Ten to fifteen minims are given 
floating on milk, or dropped on loaf-sugar. The effects 
are very similar to those of the other salicyl compounds. 
In the later stages quinine is indicated in moderate doses. 
Dr. Bartholow gives the following excellent rules for 
treatment. He divides cases of acute rheumatism into 
three classes: (1) In fleshy persons, those, for instance, 


wee. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


who drink beer to excess, the disease is generally sub- 
acute and lengthened in character. In these, alkaline 
treatment, as given by Fuller, is of the most service. (2) 
In ordinary cases of the acute disease in a previously 
healthy subject the salicyl compounds are the proper 
remedies. (8) In anzemic cases tincture of iron in large 
and repeated doses will have the best effect. In these 
latter cases the salicyl compounds are more likely to pro- 
duce weakness of the heart’s action than in strong per- 
sons. 

Local Treatment.—Wrapping the affected joints in cot- 
ton batting is usually the only local treatment adopted. 
Dr. Herbert Davies, of London, recommends the appli- 
cation of blisters over the swollen articulations. These 
seemed to reduce rapidly the local inflammation, but the 
frequent production of strangury was a decided draw- 
back to the treatment. Tincture of iodine has been rec- 
ommended asa local application. Belladonna liniment 
with a solution of opium is often of service in relieving 
pain. Fuller’s lotion consists of Battley’s solution of 
opium (an English preparation), 3 j.; potassium carbon- 
ate, Zss.; glycerine, Zij.; water, 3 vj. It may be freely 
applied. As rheumatism is a general rather than a local 
disease, its successful treatment will depend rather on 
internal than external remedies. 

General Measures.—The patient should be placed in a 
well-ventilated room. The temperature should be mod- 
erate and constant. The clothing ought not to be so 
heavy as to increase the perspiration. The body should 
be frequently rubbed with a dry towel, so as to remove 
the excessive perspiration. A light, unstimulating diet 
is the safest during the acute stage. Tonics and good 
diet are indicated in the stage of convalescence. Stimu- 
lants are rarely needed. James HL. Graham. 


RHEUMATISM, CHRONIC ARTICULAR. Syn.: Ar- 
thritis Rheumatica Chronica, Rheumarthritis Chronica. 
Chronic articular rheumatism is a mild but persistent in- 
flammation affecting the ligaments, synovial membranes, 
cartilages, and sometimes the capsules of the joints. It 
may be limited to any one of these structures, or it may 
pervade them all at the same time. It may be limited to 
the structures of a single articulation, but more frequently 
it affects several simultaneously or in quick succession, 
more especially the smaller joints of the extremities. 

Morsip ANATOMy.—The morbid actions constituting 
chronic rheumatism, affecting the fibrous structures con- 
nected with the articulations, pretty uniformly induce 
more or less plastic exudation or proliferation and thick- 
ening of the parts, but with no tendency to purulent de- 
generation or formation of pus. In cases of long stand- 
ing the thickened and dense ligaments often coalesce 
with the softer tissues ; the villi in the interior of the 
joints become hypertrophied, and the cartilages become 
uneven and undergo some fatty changes, causing the 
whole joint to appear enlarged, altered in shape, and 
much less movable than natural. When the synovial 
membranes are involved, a small quantity of turbid se- 
rous fluid is often found in them, which is generally much 
increased temporarily by occasional subacute attacks, to 
which such cases are very liable from sudden and severe 
atmospheric changes. 

ErroLtocy.—Chronic articular rheumatism is often the 
sequel of more acute attacks ; but many cases are chronic 
ab initio, and are of particularly frequent occurrence in 
cold, damp, and variable climates, and among such 
adults as are much exposed to cold and wet in connec- 
tion with severe physical exercise. Living or working 
in cold and damp rooms or workshops, or standing with 
the feet and hands much in water, actively dispose to at- 
tacks of chronic rheumatism, more especially in the 
smaller articulations of the upper and lower extremities, 
and in the lumbar region of the spine. Consequently, 
washerwomen, housemaids who do much scrubbing, and 
coachmen or those who wash carriages, are particularly 
liable to this form of disease. But cases are occasionally 
met with in all classes, and in those engaged in any of the 
various occupations, although the disease occurs very 
rarely in childhood or youth. 


Rheumatism. 
Rheumatism, 


Symproms.—When chronic articular rheumatism is the 
sequel of acute attacks, the affected joints remain slightly 
swollen, with stiffness and some soreness on motion, which 
is usually diminished by continuous moderate exercise, 
but returns again after a few hours of rest. There is no 
redness of the surface nor increased heat, and generally 
but slight tenderness to the touch, except when the dis- 
ease is aggravated by the supervention of more acute 
symptoms from fresh exposure to the primary causes. 
At such times the dull, aching pain is increased, especially 
during the night; there are moderate general febrile symp- 
toms, and some serous effusion into such synovial sacs as 
are involved in the inflammation. In a few days these 
more active symptoms subside, leaving only the usual local 
stiffness and dull pains that belong to all cases of chronic 
rheumatism, whether preceded by acute attacks or not. 
In nearly all cases the pain in the affected part increases 
during the middle and latter part of the night, and is less 
during the day. Still more marked increase of the pains 
accompanies almost every change in the atmosphere in 
the direction of cold and wet. -So true is this that many 
rheumatic patients detect the developing atmospheric 
changes earlier than are indicated by either barometer or 
thermometer. In some rare cases, in which the ligaments 
and tendons become not only indurated but closely ad- 
herent to their sheaths and to the soft parts surrounding 
them, all motion is interrupted, constituting a form of 
anchy losis. ; 

A few cases of this kind bave come under my observa- 
tion, in which the knees, ankles, and smaller joints of the 
feet, together with the elbows, wrists, and articulations 
of the hands and fingers had become fixed at different 
degrees of flexion, thereby rendering the patients unable 
to get either the hand to the head or both feet on the floor 
at the same time. The most common and constant symp- 
toms of chronic articular rheumatism are dull pains in 
the affected parts during the night, especially during 
the transition seasons, when frequent atmospheric changes 
occur ; and stiffness with some pain on rising from the 
bed in the morning, which diminishes or disappears by 
moderate exercise during the morning hours. 

In a large proportion of cases the general health of the 
patient is good, and all the important functions are per- 
formed with regularity. In many, however, the skin is 
more dry, the urine is scanty and high-colored, the bowels 
are habitually costive, and there are acid eructations or 
flatulency. 

DraGNnosis.—To distinguish chronic rheumatic arthri- 
tis from traumatic, scrofulous, or nervous affections of 
the joints, is not generally difficult. The dull character 
of the pain, its proneness to increase at night, and to be 
greatly influenced by atmospheric changes; the greater 
stiffness and soreness on motion after rest, diminishing 
with exercise ; the middle or advanced period of life, and 
the entire absence of any tendency to suppuration, are 
so characteristic of chronic rheumatism, and so nearly 
the reverse of what occurs in the history of other at- 
fections of the joints, that few mistakes need be made 
unless through carelessness or want of attention to all 
the facts and circumstances of each case. 

Proagnosis.—This, so far as relates to the continuance 
of life, is always favorable in this disease, but almost 
equally unfavorable so far as regards complete and per- 
manent recovery. In some comparatively recent cases 
I have seen permanent recoveries, usually, however, in 
consequence of removal to a more favorable climate ; and, 
in a large majority of cases, much relief or mitigation of 
the disease has been obtained by proper and persistent at- 
tention to such prophylactic measures as are available. 

TREATMENT.—As just intimated, the successful man- 
agement of cases of well-established chronic rheumatic 
arthritis is a task of great difficulty. This is owing 
largely to the fact that much the larger number of these 
cases occur among the laboring classes, and in indivi- 
duals who can neither afford to separate themselves 
from further exposure to the predisposing and exciting 
causes of the disease, nor be induced to adopt such meas- 
ures, habitually, as would best protect them from the 
effects of the further exposures. These patients gener- 


213 


Rheumatism. 
Rheumatism, 


ally call for the aid of their physician only when they are 
suffering from an exacerbation of their symptoms, and 
cease to heed his directions as soon as the more active 
symptoms have subsided. When called to such cases, I 
have found no remedies for internal use more beneficial 
than the salicylate of sodium, or acetate of potassium, in 
solution with either the fluid extract or tincture of phyto- 
lacca decandra, cimicifuga racemosa, or senecio aureus 
and stramonium. ‘The following is a convenient and 
efficient formula : 


BR. Salicylate of sodium. ..25 grams = 3 vj. 
Fl. ext. phytolacca dec... ..60 c.c.= § ij. 
Tinct. of stramonium..... 1D Oe = 39y- 
Simple ‘elixir -f.07, 5. NO CGiz= 5 1186. 


Mix, and give four cubic centimetres (3 j.), in a little 
sweetened water, every four or six hours, until the more 
active symptoms are relieved. If the bowels should be 
irritable or too loose, the cimicifuga or senecio may be 
substituted in place of the phytolacca in the same propor- 
tion to the other ingredients. If the fresh aggravation of 
symptoms has been sufficiently severe to cause some in- 
crease of temperature, with dry skin and white coat upon 
the tongue, early and more certain relief may be obtained 
by giving, in addition to the other remedies, five or six 
decigrams (gr. viij. or x.) of Dover’s powder and two 
decigrams (gr. iij.) of calomel at night, followed by a 
saline laxative in the morning. For permanent relief 
or palliation of chronic arthritis it is necessary to main- 
tain, as far as possible, a healthy and natural action of 
all those organs and functions concerned in the work of 
eliminating the products of tissue-changes, and other 
waste and foreign material, from the blood. The best 
means for doing this are chiefly hygienic rather than 
medicinal. To lessen the effects of sudden and extreme 
atmospheric changes, underclothes of flannel or other 
non-conductor of heat and electricity should be habitu- 
ally worn next to the skin ; damp and cold rooms should 
be avoided; both physical and mental exercise should 
be as uniform as possible, extremes in either direction 
being avoided ; the diet should be plain, nutritious, and 
sufficient in quantity and variety to furnish all the ele- 
ments for healthy nutrition; and the drinks should be 
such as do not retard molecular changes in the blood and 
tissues, nor lessen important excretory functions. Good 
watér, milk in any form, and tea and coffee of moderate 
strength, may be used ad libitwm ; but all forms of alco- 
holic drinks, whether fermented or distilled, lessen molec- 
ular changes and the elimination of excretory material, 
and favor the accumulation of such material in the blood 
and tissues, and therefore should be entirely avoided. In 
addition to all these ordinary hygienic measures, the use 
of a warm alkaline bath, followed by light, rapid friction 
with dry flannel, once or twice a week, has been found 
of much service in cases characterized by habitually dry 
skin and high-colored urine. The best time for the bath 
_is just before retiring to bed in the evening. In cases 
where the circumstances of the patient will permit, a 
permanent change of 1esidence from a cold, damp, and 
variable climate to one that is mild and dry, will be the 
surest mode of obtaining permanent relief. The use of 
mineral waters containing an excess of alkaline carbon- 
ates, both for drinking and bathing, also proves bene- 
ficial in many cases. 

Strict attention should be given, in all cases, to the 
keeping of the digestive organs and the secretory func- 
tions generally in as healthy a condition as possible. Thus 
far I have said nothing regarding local applications to 
the affected joints. In comparatively recent cases, and 
in temporary exacerbations of old cases, painting the af- 
fected parts with tincture of iodine until the skin becomes 
tender will do some good; or a cautious application of 
oleate of mercury and morphine may be made morning 
and evening, for two or three days, and be followed by a 
liniment containing camphorated soap liniment, 260 grams 
( % viij.,) and menthol, 6 grams (3 jss.) ; this may be ap- 
plied two or three times a day. 

A great variety of local applications, including gentle 
and continuous currents of electricity, have been devised 


214 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


and recommended by different writers and teachers ; but 
experience has demonstrated their effects to be either 
useless, or only temporarily beneficial. Chronic rheumat- 
ic arthritis is liable to be complicated with gonorrhceal, 
syphilitic, and gouty constitutional conditions of the pa- 
tient. Of course, in such cases the treatment must be 
varied to meet the indications afforded by these compli- 
cations, NV. 8. Davis. 


RHEUMATISM, GONORRHEAL. This is an arthri- 
tis, rheumatoid in character, involving a single joint, or 
at most only a few joints, and in those first attacked gen- 
erally persisting in a chronic manner for a number of 
days or weeks; rarely or never suppurating ; with never 
serious, and sometimes no, constitutional disturbance ; 
usually on subsidence leaving some thickening and stiff- 
ness of the joints, which may endure for months or per- 
manently ; depending on some irritation of the mucous 
membranes of the genital or the genito-urinary canal, 
usually gonorrheeal in character. It has no relation with 
ordinary rheumatism, and the name gonorrhceal rheuma- 
tism is misleading. A better name is urethral arthritis. 
Writers on the subject show, by lack of uniformity in 
descriptions of the disease, as it occurs typically, that 
they are not entirely agreed as to where to draw the line 
between this and other rheumatoid affections. 

Errotoay.—The disease attacks individuals of any age 
from puberty up to fifty years. The greater number of- 
patients are men—less than seven per cent. being women. 
Neither seasons nor temperature particularly influence its 
occurrence or course ; nor does atmospheric humidity or 
the state of the barometer. Rheumatic subjects are not 
more prone than others to acquire it; the claim has been 
made, probably on insufficient grounds, that they are less 
so, and that arheumatic diathesis is protective against this 
affection. A lowered condition of the system, bad sur- 
roundings, cold-catching, and exposure, seem to have no 
direct influence in producing it. Almost without excep- 
tion it follows urethral or vaginal irritation or inflamma- 
tion of some description. Nearly always the irritation is 
gonorrheeal; probably the exceptions do not aggregate 
one per cent. of the cases, and many of the cases recorded 
as exceptions are open to challenge. Arthritis occurs oc- 
casionally in cases of simple inflammation of the urethra 
due to passing the sound or catheter, or to the treatment of 
a stricture, but in such cases it will usually be found that 
gonorrhea had previously existed, if not arthritis also. 
It is one of the rarest clinical observations to see an ar- 
thritis resembling this disease follow a non-specific ureth- 
ritis or vaginitis in a person who never had gonorrhea. 
One attack of gonorrhceal rheumatism rather predisposes 
to another, and in the same joints. A patient may have 
several successive attacks, each following promptly upon 
a fresh gonorrhea, and each involving the same articula- 
tions. It has been claimed that irritation of the posterior 
portion of the urethra must be more prone to produce 
arthritis, since the affection is never observed in the early 
days of a gonorrhea, or when only the anterior portion of 
the urethra is involved, and since it is less likely to follow 
a first attack of gonorrhaa than a subsequent one, when 
the posterior part may be expected to be most affected. 
Apparent recovery often fails to remove all the products 
of the inflammation of the joints ; some thickening of the 
tissues about the articulation is usually left, which may 
itself be the element that invites a fresh attack. 

Arthritis follows only a small proportion of cases of 
gonorrhea, probably not over two per centum. 

Besides the poison and the irritating effects of the 
urethritis, a positive personal predisposition seems to be 
required for the occurrence of the rheumatoid affection. 
The joint inflammation rarely follows promptly the out- 
break of urethritis ; usually a few days, sometimes sey- 
eral weeks, intervene between them. Statistics that 
seem reliable appear to show that about sixty per cent. 
of the cases occur in the third and fourth weeks of the 
gonorrhea. The arthritis may come on just as the gon- 
orrhea is fading away, but usually some change is no- 
ticeable in the symptoms of the latter, some aggrava- 
tion often, before the former occurs. Mild cases of 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Rheumatism, 
Rheumatism, 


gonorrheea are nearly or quite as likely to lead to ureth- 
ral arthritis as are severe ones. 

Several theories of the etiology of this disease have 
been brought forward, but no one of them is proven. 
One is that a poison which is characteristic of gonorrhea 
—possibly a micro-organism, the gonococcus, or some 
other—is actually absorbed or taken up from the mucous 
membrane, and, infecting the system, falls with most 
force on the parts of greatest susceptibility, which are 
the joints. It is even claimed that gonococci have been 
found in the products of the inflammation about the 
joints and in the blood. But this theory leaves unex- 
plained the few well-authenticated cases of arthritis fol- 
lowing non-specific urethritis ; it is irrational to suppose 
in them the existence of such a poison as the theory re- 
quires. Another view is that the arthritis is a reflex 
phenomenon. Another holds that the inflammation ex- 
tends from the mucous membrane to the sacral plexus 
of nerves and the spinal cord, and causes disturbance of 
trophic nerves, which in turn causes the arthritis, as this is 
produced in diseases of the spinal cord. This theory is as 
plausible as any. It makes the virus of gonorrhea of no 
effect, except to cause an irritation—other irritants might 
_ do as well or as badly, and cause as many cases if they 
were as common. But the fact of the relative insuscep- 
tibility of women to the disease is left unexplained by 
all the theories. 

SyMproms.—Gonorrhceal rheumatism usually begins a 
few days after the outbreak of the gonorrhcea that causes 
it, with mild febrile symptoms, and slight swelling with 
some pain and tenderness Over one or more joints. Fre- 
quently at the beginning a number of joints are affected, 
the symptoms soon disappearing from all but one or two, 
where they remain often for weeks. The joints of the 
lower extremities are most frequently involved, and of 
these the ankle is much the oftenest affected. Next in 
frequency of attack is the knee, but the hips, shoulders, 
elbows, and wrists may be involved, as well as the joints 
of the hands and feet, the articulations of the jaws, the 
spine, and the pelvis. A majority of writers state that 
the knee is most often the seat of the disease, and, of 
the larger joints, the ankle the least often. Such state- 
ments must be based on personal observation in particu- 
lar fields of practice. In the observations of the writer, 
in both hospital and private practice in Chicago, the 
ankle cases outnumber all others. One, or at most two, 
joints are usually all that become, or that continue, 
affected, and the arthritis continues in these—which are 
frequently the joints first attacked—till the end of the 
sickness, which is from two to twelve or more weeks in 
duration. In probably a fifth of all the cases the lesion is 
confined to a single joint. 

The swelling, at first slight, increases gradually until it 
attains sometimes formidable proportions, and may thus 
remain for many days in spite of any and all treatment. 
The heat in the part is not great, nor is the tenderness 
usually, and the swelling, if it is discolored at all, has a 
dull redness quite in contrast with the appearance of an 
actively inflamed joint. The swelling and inflammation 
are evidently mostly of the tissues about the joint proper, 
since pressure of the articular surfaces against each other 
rarely causes pain. Any considerable motion of the 
limb or manipulation of the joint, however, causes pain, 
usually of a mild character, but sometimes severe and 
lasting long after its occasion has ceased. 

As it occurs in the majority of cases, the general aspect 
and character of the arthritis stamp it as a process of a 
subacute and sluggish character. The signs and symp- 
toms of intense and sthenic inflammation are wanting. 

Usually there is but slight effusion into the joint. Hy- 
drarthrosis occurs in a small minority of the cases, mostly 
of the knee, in some of which effusion is extreme, but in 
most it is slight. When dropsy of the joint does occur 
the inflammation of the tissues about the joint is rela- 
tively less severe, and the slight degree of the synovial 
inflammation is evidenced by the fact that aspiration of 
the fluid is often not followed by its reappearance. 

There is, with the rarest exceptions, no destruction of 
the tissues of the joints, hence suppuration and ulcera- 


tion of the synovial surfaces and structures are among 
the most infrequent occurrences, 

As the affected joint slowly improves, the swelling 
abates, but it rarely disappears rapidly, and generally 
some stiffness of the articulation persists for a long time, 
or permanently. At times the effusion within and about 
the joint attains such a degree of consolidation that the 
joint is immobilized by a false anchylosis. A few cases 
are recorded where several, and one where nearly all, 
the joints of the body became fixed and motionless from 
successive attacks of this disease. In the cases of anchy- 
losis moderate swelling remains about the joint, but the 
latter may become quite insensitive, and locomotion and 
bodily movements may be attended with the sole incon- 
venience resulting from the slight or complete abolition 
of motion in the articulations affected. 

The constitutional symptoms of the disease, uncom- 
plicated, are very rarely severe, and, after the first few 
days, may be absent. They embrace merely the evi- 
dences of a mild inflammatory fever, with its usual dis- 
turbances of the functions of the system, with anorexia, 
general pains, and restlessness, The temperature and 
pulse-rate are rarely high, and at the end of from three to 
seven days the system has usually resumed its normal 
conditions, except as to the local lesion. The general 
symptoms of ordinary acute rheumatism, such as contin- 
ued fever, free perspiration, and excessive deposit of 
urates in the urine, are absent in this affection. Occa- 
sionally the arthritis is attended with more or less neural- 
gia, which may become extreme. The pain is sometimes 
most severe in cases attended with slight inflammation 
and swelling. 

The occurrence of the arthritis does not influence the 
gonorrhoea, except during the first few days of fever. 
This condition may retard its recovery slightly ; but as 
soon as the system resumes its normal condition, the gon- 
orrhcea may improve,and pass on to recovery long before 
the joint affection. Indeed, in some cases the arthritis 
appears to exercise a decidedly beneficial influence on the 
gonorrhea, 

COMPLICATIONS AND PECULIARITIES. — Urethral ar- 
thritis may be complicated by inflammation of the burse, 
the muscles, and the periosteum in the neighborhood of 
the swollen joints, by endocarditis, pericarditis, menin- 
gitis, myelitis, by adenitis, or by pyeemia. Ophthalmia 
occurs as a complication of the gonorrhcea by transmis- 
sion of the poison to the conjunctive, rather than as a 
complication of the gonorrheal rheumatism, The com- 
plications referred to are rare ; the cardiac lesions being 
the most common. Probably more than four-fifths of 
all the cases of gonorrheal rheumatism run the typical 
course already referred to without complications of any 
sort. Certain it is that heart lesions are not, in this dis- 
ease, sufficiently frequent even to suggest any such pre- 
disposition in this direction as exists in ordinary acute 
rheumatism. As to the other lesions, whether they are 
complications of the gonorrhea or of the rheumatism, is 
often uncertain. This is particularly the case with pye- 
mia, which may more rationally be supposed to arise 
from an inflamed urethra discharging quantities of pus, 
and perhaps being prodded by injection-tubes, if not 
worse instruments, and harassed with irritating med- 
icines, than from arthritis, unless the joint be open to the 
air and suppurating. 

Morspip ANATOMY.—The usual lesion is a deposit of 
plastic material in the tissues about and of the joint. 
The failure of absorption of this is the common cause of 
the false anchylosis. Sometimes the effusion is into the 
joint-cavity. In these cases the synovial membrane is 
chiefly involved; in them the effusion may contain 
flakes of fibrine and leucocytes. Large effusions into 
the joints are very rare. Suppuration is extremely un- 
usual, as is also erosion of the bony tissues. In exceptional 
cases the inflammation travels up the synovial sheaths. 

DraGNosis.—This affection is liable to be confounded 
with a number of other diseases; among them acute 
rheumatism, chronic articular rheumatism, and the ar- 
thritis of pyeemia. From acute rheumatism it may be dis- 
tinguished by the greater tendency in the latter to migra- 


215 


Rheumatism. 
Rhinoscleroma. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


tion of the inflammation from joint to joint, by the 
greater intensity of the constitutional symptoms, and by 
the greater severity of the local pain and tenderness, as 
well as by the greater tendency to heart-lesion. 

Chronic rheumatism may be confined to a single joint, 
or a few joints ; but it very rarely causes such consid- 
erable swelling as is general in gonorrheeal rheumatism ; 
and it nearly always fluctuates with changes in the baro- 
metric pressure, being worse on the approach of a storm 
—times of low barometer,—a behavior most unusual to 
urethral arthritis. The arthritis of pysemia is most likely 
to be mistaken for this disease when the source of the in- 
fection is in the neighborhood of the urethra, when non- 
specific suppuration in the urethra, the prostate gland, 
the body of the penis, or some of the veins of these or- 
gans, has caused the pyemia. But usually some of the 
characteristic general symptoms of pyzemia, and which 
are almost unknown in gonorrhceal rheumatism, make 
the diagnosis clear. 

It must. be borne in mind that true acute articular 
rheumatism may occur in the course of urethral arthri- 
tis. 

Gonorrhcal rheumatism should be suspected, regard- 
less of sex or condition, whenever, in a person of an age 
at which gonorrhea is liable to be contracted, one or two 
joints become inflamed or swollen, without much serous 
effusion, showing little tendency to recovery, and pursu- 
ing the sluggish and peculiar course already described. 
It is not necessary to suppose every such person to have 
gonorrheea ; urethral or vaginal irritations not gonorrheeal, 
even other irritations, may cause the disease. But true 
gonorrhea is found sometimes in unexpected quarters. 
It has more than once occurred to the writer, in hospital 
practice, to discover the true cause of what had been sup- 
posed to be an obstinate subacute rheumatism in the ankle 
of a young woman of supposed purity, in her confession 
of an irregular life and of having an irritating leucorrhea 
and frequent, painful micturition. In all cases of arthritis 
that are not clearly of the character of ordinary rheuma- 
tism, inquiry should be made as to the condition of the 
urethra, both past and present, to ascertain whether there 
are any pus-discharging surfaces. 

Proenosis.—The prognosis of an initial attack is fa- 
vorable.. Complete ultimate, albeit slow, recovery usually 
takes place, with some stiffness, however, remaining long 
after other evidences of the disease are gone. But each 
successive attack is more severe than the preceding, is 
more chronic, and more rebellious to treatment ; and the 
danger of false anchylosis ‘increases with the repetitions 
of the attacks. Persons are increasingly obnoxious to 
attacks of this disease with successive gonorrhceas, and 
after a gonorrhcea—especially if it has been followed by 
the arthritis—this affection is very liable to occur from 
any slight and non-specific urethral irritation, like that 
resulting from the touch of a catheter or sound, or even 
from urethral catarrh due to cold or any excess. 

After a joint has remained swollen and stiff for six 
months, the prospect of its recovery is small, and any 
amelioration of its condition will generally be vexatious- 
ly slow. 

The various complications make the prognosis more 
grave, in degree varying according to their character and 
severity. 

TREATMENT.—The first step in the treatment is to 
cure the gonorrhea. Often at the outbreak of the ar- 
thritis the gonorrheea is insignificant ; sometimes when 
severe at the moment of the appearance of the joint- 
trouble, it rapidly subsides if the constitutional symp- 
toms are not marked. When it does not subside prompt- 
ly, it should be treated as the first measure toward the 
betterment of the arthritis. There can be small expecta- 
tion of any substantial improvement in the latter while 
the urethra is still inflamed. Not only should the gon- 
orrhcea be cured as rapidly as possible, but all possible 
sources of irritation of the urethra should be removed ; 
the urine should be rendered unirritating and be kept so ; 
the diet must be unstimulating, large draughts of bland 
liquids must be drunk, and the bowels are to be kept open 
with cooling laxatives. 


216 


Therapeutic measures are want-. 


ing to relieve directly many of the most obstinate cases 
of the arthritis ; this will often, in spite of everything, 
drag along for months, but the substantial benefit that 
comes from removing all other irritations, and especially 
that of the genito-urinary system, is always within reach. 

The acute symptoms of inflammation and fever may 
profitably be combated by the usual measures of ano- 
dynes for pain and discomfort—laxatives, low diet, qui- 
nine, hot fomentations, and, in cases of high temperature, 
antipyretics. This treatment is demanded alike for the 
comfort of the patient and for the possible abbreviation 
of this stage of the disease, although as to its great value 
in the last-named direction there is some doubt. 

The post-acute stage, that in which the disease is con- 
fined to one or a few joints, may be treated with some 
advantage by the internal administration of alteratives 
—the iodide of potassium, biniodide or bichloride of 
mercury in moderate doses, and locally with rest, coun- 
ter-irritants of croton-oil, tincture of iodine, frictions, 
and pressure, according to the needs of the case. Nei- 
ther the salicylates nor any other of the so-called specific 
treatments for acute rheumatism have any special influ- 
ence in this disease. 

The course of many cases is extremely chronic, and 
often the practitioner is in doubt whether the most active 
treatment particularly hastens the recovery from the 
joint-affection. After the acute stage is fully passed the 
joint-thickening may be somewhat reduced by the sys- 
tematic employment of massage. False anchylosis of 
long standing is remediless, except, perhaps, by breaking 
down by force the adhesions, and making and maintain- 
ing motion of the joint, a manceuvre that has been rec- 
ommended. Norman Bridge. 


RHIGOLENE. Of the products of the fractional dis- 
tillation of petroleum the lightest is obtainable as a fluid 
by condensation, and consists mainly of the paraffin 
butane, a body gaseous under ordinary conditions. This 
condensed distillate is termed cymogene. The distillate 
of next higher boiling-point boils at about 18° C. (64.4° 
F.). Such distillate consists largely of the fluid paraffin 
pentane (‘‘ amylic hydride”), CsHis, and is the substance 
commonly known as rhigolene. Rhigolene is a colorless, 
mobile fluid of slight and not unpleasant odor and taste ; 
very light, very inflammable, and, as its boiling-point 
predicates, very volatile. It mixes in all proportions 
with common (ethylic) ether. Rhigolene was proposed ° 
by B. W. Richardson as a substitute for ether for the 
production of local anzesthesia by freezing, after his 
method. Because of the low boiling-point of rhigolene— 
lower than that of ether—the cold produced by the evap- 
oration of a spray of rhigolene is very intense and very 
rapidly attained. Dr. Richardson has himself observed 
an area of skin become hard, white, and insensible at 
the expiration of two seconds after beginning the driving 
upon it of a rhigolene-spray. But such very rapid freez- 
ing Dr. Richardson finds undesirable, because the intense 
cooling of the superficial frozen area prevents the ab- 
straction of heat from below, and so unduly limits the 
depth to which the anesthesia can be carried. Hence 
Dr. Richardson prefers and proposes a mixture of rhigo- 
lene and anhydrous ether in equal parts. Rhigolene 
dissolves camphor, spermaceti, and iodine, and has been 
used by Richardson, again, as a solvent of those bodies 
for use for local applications. A rhigolene-solution of 
camphor and spermaceti together Richardson finds an 
excellent conjoint cooling anodyne and healing appli- 
cation to burns. The vapor of rhigolene, inhaled after 
the manner of vapor of chloroform, is readily taken, and 
produces general anesthesia with great rapidity. But 
in this application rhigolene has shown itself dangerous, 
and has never come into practical use. 

Edward Curtis. 


RHINOSCLEROMA. Under this head Hebra described, 
in 1870, a disease seated in the nose, nasal passages, and 
pharynx, characterized by nodular swellings and infil- 
tration of the affected parts, and a stony induration. As 
its name implies, the nose is the part most affected, and 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the disease afterward involves the surrounding skin, the 
lips, and the mucous membrane of the mouth, the phar- 
ynx, and the larynx. It appears in the shape of smooth 
or nodular masses which are sometimes isolated, but gen- 
erally merged into one another, so that the whole forms 
a connected mass. ‘These nodules are very firm, slightly 
elastic, and sharply circumscribed from the surrounding 
healthy skin. The skin covering the growth is of a bright 
or dark red color, shiny, and contains many small blood- 
vessels, which form a visible net-work. It is perfectly 
smooth, and the hair- and gland-follicles are absent. The 
growth appears very similar to a keloid or hypertrophic 
scar, the skin having the same smooth, shiny character 
which is the result of the absence of hair-follicles and 
glands. Asarule, the growth first appears as a thicken- 
ing and induration of the septum cutaneum, or of one of 
the ale, without any inflammatory phenomena. After 
the disease has lasted many months the nose appears 
broader and flatter than normal, and the nostrils are rigid 
and dilated. On feeling the growth the peculiar hardness 
characteristic of it can be appreciated. The nose feels as 


eh 


Fig, 3327.—Rhinoscleroma; case of Tanturi. (Copied from Schulthess. ) 


if it were cast in plaster of Paris, and the dilated nostrils 
cannot be closed. Hebra compares this induration with 
that of an initial syphilitic sclerosis, and says that the best 
idea of it can be obtained by supposing it to be one im- 
mense smooth chancre. It isnot painful, except on press- 
ure. In the course of time the disease advances in two 
ways. The most frequent course is along the nasal pas- 
sages to the pharynx and palate. The nodular masses and 
induration extend backward, narrowing, and in some 
cases entirely closing, the nasal passages. The soft pal- 
ate is attacked, becomes greatly thickened, and is fre- 
quently so deformed that it merely resembles a thick cord. 
Adhesions often form between the palate and the poste- 
rior wall of the pharynx, and deformities similar to those 
produced by extensive syphilitic ulceration and cicatriza- 
tion may result. From its beginning in the nose the 
morbid process may extend to the upper lip and the 
mouth. The lips become nodular and thickened, and the 
orifice of the mouth may be so narrowed that operative 
procedures are necessary to enable the patient to take food. 
The gums and hard palate are more rarely affected. 
When this takes place the gums are swollen and indu- 
rated, the teeth become loosened and drop out, and the 
alveolar processes atrophy. From the mouth the disease 


Rheumatism. 
Rhinoscleroma, 


may extend to the palate and pharynx, but in most cases 
infection follows from the other direction. The changes 
produced in the larynx are of great importance. The 
growth may involve the epiglottis and the mucous mem- 
brane of the larynx, producing fixation of the epiglottis, 
with aphonia, suffocation-phenomena, and epileptoid at- 
tacks. Catti has described a case in which the larynx 
was first attacked, and two years after this the character- 
istic growth in the nose appeared. In a case recently de- 
scribed by Schulthess, the disease appeared to have begun 
in the lachrymal duct, and made its first appearance as a 
nodule in the corner of the eye. After several years the 
nose, pharynx, and larynx became successively involved. 

The growth advances very slowly. From its first ap- 
pearance it often takes four or five years for the nodule 
to attain a superficial diameter of four or five centimetres 
(14 to 2 inches), and cases are often seen which have lasted 
twenty years or more. In the case described by Schul- 
thess the disease at the time of publication had lasted 
twenty-four years. Ten years had elapsed from its first 
appearance before the tumor-masses in the nose appeared, 
and the larynx became involved six years after this. 

The absence of any tendency to suppuration and retro- 
grade changes is one of the most striking features of the 
growth. Microscopically, the areas of fatty degeneration 
and coagulation necrosis, so common to most of the 
granulation-tumors, are not found. Even when it is 
cut into, and a piece excised, the wound quickly be- 
comes covered with epidermis, and the part removed is 
soon replaced. On cutting into the tissue it is surpris- 
ing with how much ease the knife enters it. 

The subjective symptoms depend entirely upon the 
functional disturbances produced by the growth. The 
most prominent is the dyspnoea produced by the narrow- 
ing of the respiratory passages. The affection seems to 
exert absolutely no influence on the general constitution, 
independent of the functional disturbances spoken of. 
There is never any metastasis nor involvement of the 
lymphatic glands. The affected parts are never painful, 
except on pressure. Occasionally there may be a dac- 
rocystitis, from an involvement of the lachrymal duct 
and a growth in the corner of the eye. 

The first histological description of the disease was 
given by Kaposi, who studied some of the earlier cases 
published by Hebra. He describes the growth as a small- 
cell granulation-tumor, and regards it as a species of sar- 
coma. He denies that there is any transformation of the 
round cells into connective tissue, although he speaks of 
the cicatrization produced in the palate and elsewhere. 
Mikulicz, basing his conclusions upon a careful histolog- 
ical study, regards the entire process as chronic inflam- 
mation. According to him, a part of the round cells be- 
come changed into spindle-cells and connective tissue, 
which afterward undergoes cicatricial contraction. The 
microscopic study of the growth is best made by excising 
small pieces and hardening them in alcohol. Sections 
may then be made and stained with various reagents. 
Like most of the other granulation-tumors, the growth is 
principally composed of small round cells. Among these, 
sometimes lying singly, at other times in groups of two or 
three, are large cells which are more or less characteristic 
of the growth. In the older portions of the growth the 
round cells are pretty uniformly distributed throughout 
the tissue, but they are never so closely packed together 
as in most of the other granulation-tumors. The large 
cells have a protoplasmic net-work and contain two or 
three nuclei. They frequently contain round masses of 
a hyaline or colloid material, which stains with most of 
the aniline colors. A similar material is found in irreg- 
ular masses scattered throughout the tissue between the 
cells. The cellular infiltration extends up to the epider- 
mis, which is very thin, but which passes uninterruptedly 
over the growth. In places the epidermis sends down 
long projections into the tissue beneath, The glands 
generally atrophy and disappear, though in some Cases, 
after closure of the ducts, small cysts are formed. Tn 
the younger portions of the growth the cellular infiltration 
is not so extensive, and is principally seen around the 
vessels. Bands of connective tissue with spindle-cells are 


217 


Rhinoscleroma. 
Rhinoscopy. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


seen here and there, but the amount of connective tissue 
present is not so much as one would expect to find in 
view of the extraordinary hardness of the growth. In 
addition to these larger bands small masses of fibres are 
found here and there between the cells. The firmness 


of 
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which have been spoken of as characteristic of the dis- 
ease. In addition, they are found in the interstices of 
the tissue and in the lymphatic vessels with which the 
tumor is abundantly supplied. They are short rods, and 
under low powers have more the appearance of micro- 


of 
929 


Fig. 3828.—Section through a Noduie of Rhinoscleroma. > 60. 


of the tumor is principally due to the presence of the 
hyaline colloid material. 

In 1882 Fritsch reported that he had found constantly 
in the rhinoscleroma short bacilli, which he was able to 
cultivate in aqueous humor. He made inoculations with 
the cultures, but did not get any results. From the con- 


Sepa <SS = 


cocci than of bacilli. In the large cells they are in groups 
of from ten to twenty. In the lymphatics they are gen- 
erally free. Cornil and Alvares described as characteris- 
tic of them small clear masses or capsules which sur- 
rounded them. Sometimes there is a constriction in the 
middle, giving the appearance of two bacilli enclosed in 


Fie. 3329.—Bacilli of Rhinoscleroma in Lymphatics. (Cornil and Alvares.) > 1,000. 


stant presence of these bacteria he regarded them as 
causative of the disease. The best description of the 
bacteria is given by Cornil and Alvares, from whose 
drawings the accompanying figure is taken. The bacte- 
ria are principally found in the large protoplasmic masses 


218 


SS" 


a single capsule. The capsule is best seen after staining 
with aniline water gentian violet, and then decolorizing 
with iodine. The bacteria present the most striking simi- 
larity to the Friedlander pneumonia-bacilli, and can be 
distinguished from these neither by their morphological 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


characters nor by culture. They have recently been 
made the subject of careful study by Paltauf and Eisel- 
berg. They made numerous inoculations in various ani- 
mals, and succeeded in producing in mice the same 
changes that are produced by the pneumonia-bacilli. It 
is difficult to say with certainty whether or not these bac- 
teria are the cause of the growth. They are invariably 
present, and their situation in the large cells and lymph- 
atics shows that their presence is not an accidental one. 
Remarkable as is their resemblance to the Friedlander 
bacilli is, we are by no means justified in regarding them 
as identical. The very fact of the extreme rarity of the 
rhinoscleroma and the frequency with which Friedlander 
bacilli are found speaks against this view. In addition 
to this, the rhinoscleroma has a well-defined geographi- 
cal distribution. Most of the cases have been found in 
Vienna, which may be regarded as the home of the dis- 
ease. A few cases have been found elsewhere in Aus- 
tria, a few in Italy, and one (that of Schulthess) in 
Switzerland. Nocases have been met within the United 
States, although several have been seen in Central Am- 
erica. 

The diagnosis of the disease is comparatively easy. 
Hebra has given the following as the most marked char- 
acteristics: 1, The seat of the disease, which is in the nose 
or in parts immediately adjacent to it; 2, the peculiar 
hardness of the part affected ; 3, the extremely slow de- 
velopment ; 4, the sharp limitation of the growth, and 
the absence of cedema or of any inflammatory reaction in 
the surrounding tissues; 5, the absence of retrograde 
metamorphosis ; 6, the inutility of all internal treatment ; 
7, the benign character of the growth as regards the or- 
ganism, even when it has lasted years; 8, the absence 
of pain except on pressure. The only affections with 
which there is any probability of confounding it are 
syphilis and epithelioma. From the former it may be 
distinguished by its circumscribed growth, absence of 
ulceration, and the inutility of specific treatment ; from 
the latter by absence of ulceration, its painless character, 
history of slow growth, and absence of infiltration, of 
the surrounding tissue. 

The treatment is confined to excision of parts of the 
growth, when it endangers life by closure of the nares, 
etc. No medication has been found to be of any avail, 
and by reason of the extent of the growth complete ex- 
cision has not been found to be practicable. Frequent 
operations are necessary, as the portions removed are 


quickly reproduced. 
W. T. Councilman. 


RHINOSCOPY. Inspection of the nasal cavities and 
retro-pharynx is accomplished by two methods of exam- 
ination. These are anterior rhinoscopy and posterior 
rhinoscopy. 

Preliminary to the investigation of the nasal canals, it 
is well to observe the exterior of the nose. From the 
appearance of this, some suggestion may be obtained as 
to the existence of abnormalities within. Thus, deflec- 
tion of the nasal septum is often attended with irregular- 
ity of external contour; the presence of an intra-nasal 
growth is attended with bulging of the alee or distortion 
of the nasal bones, causing in extreme cases the appear- 
ance known as ‘‘ frog face ;” occlusion of the nasal pas- 
sages and mouth-breathing are associated with the pecul- 
iar upturning and enlargement of the end of the nose, or, 
on the other hand, with the pinched, atrophied, and col- 
lapsed condition of the ale commonly observed in such 
patients ; chronic catarrh is attended with congestion and 
thickening of the alee ; and, finally, there may be actual 
depression of the bridge of the nose from surgical injury 
or from tertiary syphilis. 

Although by no means infallible, the above are often 
useful guides toward a diagnosis. Again, the ease with 
which the exit of air is effected through one nostril, the 
question as to whether or not the patient can breathe for 
any length of time with the mouth closed, the existence 
of fetor in the expired breath, the quality of the voice, 
and the condition of the olfactory sense, are points of 
importance in the examination which are capable in 


Rhinoscleroma, 
Rhinoscopy. 


many cases of conveying information, and which should 
not be neglected. 

Inspection of a wide nostril may sometimes be par- 
tially accomplished by placing the patient opposite a 
strong light and then forcing upward the tip of the nose. 
This, however, is unsatisfactory. For the accomplish- 
ment of a thorough examination it is necessary to use, 
first, a good light ; and, secondly, something in the way 
of a speculum by which the nostril can be dilated and 
the light thrown into the 
dark and remote passages 
which are to be examined. 

Both anterior and pos- 


terior rhinoscopy may be TT Zia 
efficiently performed by Zw 
FS REYNDERS—Co SSN 


means of sunlight, and in 
some cases this is to be pre- 
ferred. In most instances, 
however, the simplest and 
most convenient method 
will be by artificial light, and with the appliances used 
in the performance of laryngoscopy (see vol. iv., p. 385). 

For the performance of anterior rhinoscopy many in- 
genious specula have been devised. Among the differ- 
ent kinds commonly sold by the instrument-makers, 
those pictured in the accompanying cuts (Figs. 3380 to 
3382) Will be found useful and convenient. 

A very valuable form of nasal speculum is that of Sig- 
mund, a tubular instrument made of hard rubber. and 
shaped like an ear-speculum. | It is particularly useful in 
the application of the galvano-cautery to the nasal cavi- 
ties. An excellent substitute for a nasal speculum may 
be improvised from a common hair-pin by bending both 
ends of the pin in oppo- 
site directions, and thus 
forming a double curve, 
jy one end of which is 
held in the operator’s 
hand and the other 
pressed outward against 
the ala of the nose. 

Among other good 
varieties may be mentioned Fraenkel’s, Bosworth’s, Cres- 
well Baber’s, and John N. Mackenzie’s. 

For the performance of anterior rhinoscopy the patient 
should be seated as for a laryngoscopic examination, 
and the arrangement of the light, the head, mirror, etc., 
should be the same as for the latter (see vol. iv., p. 386). 
The blades of the speculum should then be introduced 
into the vestibule of the nose and separated. The vesti- 
bule itself is lined with integument and furnished with 
an abundant growth of short, stiff hairs, which, for facil- 
itating the examination, it is sometimes desirable to cut 
off. This, however, is seldom necessary. At the poste- 
rior superior limit of the vestibule is the opening of the 
anterior nares. Here the integument changes its char- 
acter and becomes 
mucous membrane. 
Professor Wilhelm 
Meyer, of Copen- 
hagen, has observed 
that in cases of 
chronic catarrhal 
disease the charac- 
teristics of the ex- 
ternal integument 
are preserved to an unusual distance posteriorly. Upon 
inspecting the nasal fossa, which is brought into view 
by the nasal speculum, the patient’s head being bent 
somewhat forward, the first objects seen will be the an- 
terior aspect of the inferior turbinated body and the lower 
part of the cartilaginous portion of the nasal septum. 
Beyond these may be seen the inferior meatus, the floor 
of the nose, and the lower border of the inferior turbi- 
nated body. Tilting the head a little backward, the re- 
mainder of theinferior and part of the middle turbinated 
bodies come into view. And, bending the head back- 
ward still farther, the uppermost part of the middle tur- 
binated body and the roof of the nasal fossa can be seen. 


219 


modified, 


Fie. 3331.—Goodwillie’s Speculum. 


wy 


if Up S 


Fia. 3382.— Jarvis’s Speculum, 


Rhinoscopy. 
Rhubarb. 


The superior turbinated body may sometimes be demon- 
strated anteriorly, although this is unusual. Under in- 
spection in the above positions, with the head turned a 
little to one side, the corresponding parts of the septum 
can be demonstrated. 

The color of the nasal mucous membrane varies in 
different situations. The anterior and inferior border of 
the inferior turbinated body, and the floor of the fossa, 
are usually bright red, while the septum and the inferior 
border of the middle turbinated body are of a paler hue. 


Fig. 3333.—a, Outer lip of anterior border of middle turbinated body; », 
angle of middle turbinated body ; c, lower border of middle turbinated 
body ; d, inferior turbinated body ; e, tubercle of septum ; 7, outer wall 
of nasal cavity. In diagrams A and B, the margins of the middle tur- 
binated body, hidden by the tubercle of the septum, are indicated by 
dotted lines. (Cresswell Baber.) 


The description of the contour of the parts seen by an- 
terior rhinoscopy, and their recognition by one not ac- 
customed to such examinations, are matters of consider- 
able difficulty. They have been made much more clear 
and easy by the excellent work of Mr. Cresswell Baber, 
of Brighton, England, who, through a series of diagrams 
and illustrations, has sought to depict the real conditions 
normally present, and to assist the learner in understand- 
ing the variations in form which may occur in patholog- 
ical states. The accompanying diagrams, while intended 
to illustrate the different appearances of the tubercle of 
the septum, convey an excellent idea of the neighboring 
parts. 

As will be seen from these cuts, the extent of view ob- 
tained of the middle turbinated body will depend largely 


7a 4 
Fie. 3335, 


Fias. 3334 and 3385 represent respectively the right anterior rhinoscopic 
view of a man, aged twenty-four, before and after erection of the an- 
terior end of the inferior turbinated body. (About twenty minutes 
elapsed between the times of drawing the two sketches. ) 

In Fig. 33834, a is the collapsed anterior end of the inferior turbinated 
body; } is the inner surface of ditto, which leaves a space between it 
and the septum, through which the palatal movement can be plainly 
seen. Above, the middle turbinated body c is visible, its neck being 
hidden by the tubercle d. 

In Fig. 3835, @ is the erected inferior turbinated body, terminating 
above in the swollen ‘* neck” 6, which almost entirely conceals the mid- 
dle turbinated body. The upper parts of the drawing are slightly dia- 
grammatic. (Cresswell Baber, ) 


Fia. 3334. 


upon the prominence of the tubercle of the septum. 
Undue prominence of this part may be reduced by the 
application of cocaine. When the erectile tissue of the 
anterior angle of the inferior turbinated body (a, Fig. 
3335) is tumefied, this body appears as a rounded, shin- 
ing eminence, having a smooth surface, which is in con- 
tact with or close to the nasal septum. Above, it is pro- 
longed into a broad neck (Fig. 3335, 5), the inner or free 
margin of which, if its erection be extreme, is in con- 


220 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


tact with the septum, and completely conceals the mid- 
dle turbinated body. 

When the soft parts lining the anterior aspect of the in- 
ferior turbinated body and the lower part of the septum 
are tumefied, or hypertrophied, the entrance of light to 
the nasal fossa will be greatly facilitated, as has been sug- 
gested before, by the use of cocaine. This drug, applied 
in a solution of from two to four per cent., will cause 
more or less complete retraction of the projecting tissues, 
and thus render possible a far more thorough and satis- 
factory inspection. 

In the examination of the anterior nares, a short, deli- 
cate probe will give much assistance, as by its use the 
appearances conveyed to the eyes can be verified or dis- 
proved, the consistence of various parts fairly estimated, 
and, with the aid of a pledget of absorbent cotton, secre- 
tions which obscure the view may be removed. In all 
cases in which secretion exists, it must be recognized, 
and, if too great in amount to be dealt with in the way 

wy just alluded to, it should be removed by 
means of atomized spray or the ordinary 
nasal douche. Of the three methods the 
spray is likely to do the least injury, and is 
in a large proportion of cases the best. 

Posterior rhinoscopy, or inspection of the 
nasal cavities and the upper pharynx from 
behind, is accomplished by means of a pow- 
erful light, a mirror similar to that used in 
laryngoscopy, only smaller in diameter, and 
a tongue-depressor. The conditions, as to the 
illumination and as to the position of the pa- 
tient, are the same as for the performance of 
laryngoscopy (see vol. iv., page 386). The 
simplest and best form of rhinoscopic mirror, 
and the one in by far the most general use, is 
illustrated in Fig. 8336. <As the re- 
flecting surface is at best very small, 
and as in the use of the mirror 
much depends upon the perfection 
of its form in regard to certain details 
of shape and construction, it is im- 
portant that the following points 
should be observed in selecting one: 
The reflecting surface should be per- 
fect, the mirror itself as thin as can 
be made, and not more than one-six- 
teenth of an inch in thickness, while 
the metallic edge in which it is en- 
cased should encroach upon its re- 
flecting surface as little as possible. 
Again, the shaft should be attached 
directly to the margin of the mirror, 
and not form an angle after leaving 
it; and finally, the shaft should be 
slightly flexible, so that, should oc- 
casion require, the angle at which it 
3! is set into the mirror may be altered. 

ee Tongue-depressors are offered by 
the instrument-makers in great variety. These should be 
silver-or nickel-plated, and as free as possible from pro- 
jections and irregularities of surface, so that absolute 
cleanliness may be easily secured: One of the most use- 
ful varieties ever devised is that invented many years 
ago by Tiirck. (For the use of the tongue-depressor and 
the examination of the lower pharynx, see vol. iv., page 
387.) 

For the performance of posterior rhinoscopy the patient 
should be placed in the laryngoscopic position, and a 
strong light should be thrown into the pharynx, the 
tongue being depressed. The rhinoscopic mirror, warmed 
to the temperature of 100° Fahrenheit, should be passed 
backward to the soft palate, behind which it should then 
be gently placed, care being taken not to provoke irrita- 
tion by touching any of the adjacent parts. The posi- 
tions necessary to a successful examination are well 
illustrated in Fig. 3337. The position of the velum 
palati should be such that the space between it and the 
posterior wall of the pharynx should he as wide as pos- 
sible. In other words, the velum being perfectly re- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Rhinoscopy. 
Rhubarb, 


laxed, should hang well downward and forward. This 
may be accomplished by directing the patient to en- 
deavor to breathe through the nose, the mouth being 
open, or by his pronouncing a purely nasal sound. 
The mirror having been introduced, the hand of the 
operator should be carried outward, so that the entrance 
of light to the pharynx may be unobstructed. By reason 
of the size and configuration of the upper pharynx, it is 


Fra. 3337.—Posterior Rhinoscopy. (Cresswell Baber. ) 


necessary to change the position of the mirror in order to 
demonstrate the whole cavity. The recognition of the 
different parts is somewhat difficult and confusing to the 
beginner, who will find it of great assistance to observe 
the following suggestions: In the first place, the nor- 
mal anatomy of the region should be thoroughly un- 
derstood. This may be easily acquired by studying the 
illustrations of the naso-pharynx in any standard work 
upon anatomy (see Fig. 3338). Upon introducing the 
rhinoscopic mirror, let the first endeavor be to demon- 
strate the vomer, which is not only the easiest object to 
bring within the field of the mirror and to recognize 
when seen, but, being in the median line, may serve as a 
point of departure for the rest of the examination ; for, 


Le, Yypre ee = 
a4 Kg Ss: 
y eo ca i, I \S = = 
ly SS SS | == 
Ly EA \ 
a) 


2 Oi fF 
AUT We, 
1 


i 7 
DE y 
—____SSSVSS 


Frc. 3338.—The Rhinoscopic Image. 1, Vomer; 2, nasal passages: 3, 
superior meatus; 4, middle meatus; 5, superior turbinated bone ; 6, 
middle turbinated bone; %, inferior turbinated bone; 8, pharyngeal 
orifice of Eustachian tube ; 9, upper portion of fossa of Rosenmuller ; 
11, glandular tissue at the vault of the pharynx ; 12, posterior surface 
of the palate and uvula. (Cohen.) 


starting with this and carrying the light upward, the roof 
of the nasal fossee and the vault of the pharynx, with 
Luschka’s tonsil, will come into view; while forward 
will be seen the posterior extremities of the three turbi- 
nated bodies, and outward the lateral wall of the pharynx, 
the orifice of the Eustachian tube, and the parts adjacent 
to it on the corresponding side. 

In the examination of the upper pharynx certain diffi- 


culties may arise. Thus, the pharyngeal space may be 
unusually narrow, and the neighboring walls so thickened 
congested, and coated with mucus, that it is impossible 
to gain a view of the regions above. Cleansing the 
mucous membrane and the application of a solution of 
cocaine, under such circumstances, will sometimes render 
a fair demonstration possible. The fact remains, how- 
ever, that in certain infrequent instances the pharyngeal 
space is so reduced in size that an examination with the 
mirror is impossible, even in skilful hands. Yet such 
cases, it must be admitted, are sure to be less and less fre- 
quently met with as the experience and dexterity of the 
examiner become greater. Where examination with the 
mirror is impracticable, the method of palpation may be 
employed. Great caution and gentleness should be ob- 
served in its application. 

An elongated and thickened uvula may offer a serious 
obstacle. Amputation of the redundant portion will ren- 
der the examination easier. 

Irritability of the pharynx may be overcome by the 
application of a solution of cocaine—two to four per 
cent.—or by the rapid drinking of ice-water, or the suck- 
ing of cracked ice. 

Finally, it may sometimes be necessary to draw the 
velum palati forward by means of some form of instru- 
ment or device suitable for the purpose. Of the instru- 
ments which have been proposed, the most useful is a 
simple probe, covered with the material used in the Eng- 
lish flexible, woven catheters. This seems less irritating 
than the unprotected metal. 

Surgeon-General Wales, of the United States Navy, 
has devised the plan of passing a piece of tape backward 
through each nostril to the pharynx, and thence under 
the velum and forward, until the end is brought out of 
the mouth ; the two ends of each tape are then tied to- 
gether with sufficient tension to draw the velum well 
upward and forward. For operations in the upper phar- 
yux this method, or some modification thereof, is very 
useful. D. Bryson Delavan. 


RHUBARB (Rheum, U. S. Ph.; Rhet Radix, Br. Ph.; 
Radiz Rhei, Ph. G.; Rhubarbe de Chine, Rhubarbe de Mus- 
covie, Rhubarbe de Perse, Codex Med., etc.). 

‘The root of Rhewm officinale Baillon, and of other un- 
determined species of Rhewm, Order Polygonacee,” U.S. 
Ph. ‘‘ The root, more or less deprived of its bark, sliced, 
and dried, of Rheum palmatum Linn.; Rhewm officinale 
Baillon, and probably other species. Collected and pre- 
pared in Chinaand Thibet,” Br. Ph.; of R. officinale, etc., 
Ph. G.; of R. palmatum Maxm.; R. tanguticum Linn. ; 
R. officinale H. R. N., etc., Codex Med. 

The sources of Asiatic Rhubarb, for they are undoubt- 
edly several, are not known with anything like exactness, 
although upward of half a dozen have been designated 
by travellers and botanists. Most of these, upon exam- 
ination of the structure of their roots grown in Europe, 
can be proved not to be the same as the commercial Rhu- 
barb, but one or two may still be the same. The general 
features of the genus are familiar in the cultivated ‘‘ Pie- 
plants,” R. Rhaponticum, etc. They are large perennial 
herbs with very thick, fleshy roots, and immense leaves. 
The flowering stems, from four to ten feet high, are 
thick, hollow, more or less leafy and branching. Flow- 
ers small, numerous, green or whitish, sometimes pink or 
red. They have a six-parted perianth, nine stamens, and 
a three-cornered, one-ovuled superior ovary, with three 
recurved styles. The ovary is surrounded at its base by 
scales or glands. It develops into a three-angled, one- 
seeded achene. There are twenty or more species, all 
from Central and Southern Asia. 

R. officinale Baillon. This fine, large species is one of 
the. latest discovered, being made known through French 
missionaries in Thibet, in 1867. Specimens were sent 
about that time to Paris, where they have grown well, 
and from whence plants have been obtained for other 
gardens. It is quite hardy, grows freely, and produces 
a root that microscopically agrees with Asiatic Rhubarb. 
It is a large, handsome species, developing a thick, aerial, 
branching stem, several inches in diameter and a foot or 


221 


Rhubarb. 
Rhubarb. 


more long, tapering to a blunt apex, and covered with 
brown leaf-bases. It is internally fleshy and yellow, or 
orange. Roots also very large and thick. The lower 
leaves are very large, on long, cylindrical petioles, and 
form a pyramidal mass of foliage six or eight feet in di- 
ameter; their blades are roundish, heart-shaped, pal- 
mately veined, deeply lobed and serrate; the veins and 
petioles are very thick ; under-surface pubescent. Flow- 
ering stems from five to eight feet high, much branched, 
terminating in numerous graceful, spike- ,. 
like clusters of flowers. sie a 

R. palmatum Linn. has long been con- fy 
sidered one of the sources of Rhu- ‘ee 
barb. Itis also a very large herb. — 
It has deeply lobed leaves on semi- __ | 
cylindrical stems, and a rather close +“ 
paniculate and compound inflores- 
cence. It is a tenderer 
and more delicate plant 
than the preceding, and its 
root, at least as cultivated 
in Europe, does not corre- 
spond in structure with 
Asiatic Rhubarb 
(Flickiger). It is 
a native of Chinese 
Tartary. Var.tangu- & 
ticum, according to ¢ = 
M. Przewalski, is 
cultivated and col- 
lected in the place 
of that name in the 
Province of Kansu, 
of Northern China. 


Fiq. 3339.—Rheum Officinale. 


Besides the above, the following certainly do not pro- 
duce genuine Rhubarb, although they have been consid- 
ered to do so at one time or another. They are sources, 
however, of European Rhubarb, and are besides exten- 
sively cultivated in Europe and here for their pleasantly 
sour petioles, which by high cultivation and blanching 
grow very large and long. 

R. LRhaponticum (Pie-plant) has semi-cylindrical peti- 
oles, and entire, wavy, heart-shaped leaves ; R. undulatum 
has the upper side of the petiole concave, and sharply 
pointed leaves ; &. compactum Linn. has serrated leaves ; 
RF. australe has round, broadly heart-shaped, rough leaves, 
etc. 

All the above are from Central Asia, but they have 
been cultivated for a considerable time in Europe, either 


222 


(Baillon. ) 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


as ‘‘pie-plants” or on account of having some historical 
connection with the source of Rhubarb. 

Of the varieties of Rhubarb there is but little useful to 
say, as they are often distinctions without a difference, 
since they are named, not from the species of Rheum, 
often not even from the places where they are collected, 
but from the towns or markets whence exported to 
Europe. ‘‘Turkey Rhubarb,” exported through Asia 
Minor, has long since been obsolete; so is the so-called 
Turkey (Russian) Rhubarb of modern times. Both had 
their origin, like the present supply, in China or Thibet. 
Indian and Chinese Rhubarbs are spoken of now, but they 
have no essential differences, and are probably all Chinese 

in their origin. European Rhubarb (see below) is a 
distinct product, from R. Rhaponticum. 
Hisrory.—Rhubarb has been used in China from 
the remotest ages (2700 B.c., Fliickiger), and possible 
references to it are found in the earliest European 
books on medicine. As early as the seventh cen- 
tury of our era, there can be no doubt of its oc- 
currence in Europe, and by the tenth or eleventh 
«¢ it was well known and highly valued. It was 
<* always, until recently, an expensive drug, on ac- 
count of the long transportation required 
4 to bring it to market. One of the earliest 
routes was westward along the wastes of 
Central Asia, through the Caspian region 
to the Black Sea, or Asia Minor. It was 
long ago imported, too, by water from In- 
dia as now, or rather around the Cape of 
Good Hope, and came in other ways, partly 
by land and partly by sea, through Persia or 
Egypt. For the past two hundred years 
traffic between China and Russia, through 
Siberia, has permitted this drug to be 
brought, by a long and _ painful 
=a route, to Europe through that 
es 2 country, terminating in Mos- 
cow. for about a hundred 
years previous to 1860 the 
Russian Government 
monopolized the Rhu- 
barb trade between 
Siberia and the Chi- 
nese provinces, and 
established an exceed- 
ingly strict inspection 
of all the roots ex- 
ported that way, con- 
demning and destroy- 
ing all but what was 
absolutely perfect. 
In this way an excep- 
tionally fine quality 
was obtained, and ex- 
ported, after its long 
hard journey, from 
Moscow. Curiously, 
in England and this 
country the old and 
entirely inappropriate 
name ‘*‘ Turkey Rbu- 
barb” was given to 
this variety. Since 
1860 this inspection has been discontinued, and this grade 
of Rhubarb has entirely disappeared from English and 
American commerce. The increased facilities of trans- 
portation from various Chinese ports, as well as from the 
whole of Asia, have also drawn the course of transporta- 
tion southward. 

Of the collection of Rhubarb but little detail is known. 
Several travellers have seen it in one district or another, 
and described it in general. The roots are dug, some- 
times at least, in the fall, the larger ones and the root- 
stocks only being taken, and these are dried, according to 
some, by artificial heat ; according to other reports, by the 
sunalone. That some pieces are strung upon cords to dry 
is evident enough; also that the roots are in some way de- 
prived of their outer surface. The old Russian Rhubarb 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Rhubarb. 
Rhubarb, 


showed the marks of the knife where it was peeled in 
good-sized slices, but the present Chinese pieces are all 
smooth and rounded, as if finely filed or scraped into 
shape after drying, or possibly smoothed by the attrition 
of long transportation. 

DESCRIPTION.—Chinese Rhubarb is met with in pieces 
of various sizes and shapes, deprived of the cortical 
layer, having a smooth, rounded, and bright yellow-buff 
surface, evidently finally prepared after the root has 
dried. The most common form is cylindrical or barrel- 
shaped, as the roots, up to four or five centimetres in 
diameter, appear to be generally dried without splitting ; 
larger than this they are cut longitudinally, and ‘“‘ flat 
Rhubarb” is the result. Besides these pretty uniform 
shapes, it is sometimes quite irregular. A small hole 
near one end, with its margins somewhat discolored, is 
usually present, and shows that the pieces are strung in 
rows to dry ; bits of string are also frequently found in 
these perforations. Rhubarb is usually very clean and 
carefully sorted before it reaches us ; even the different 
shapes and sizes are in some measure packed separately ; 
here it is often again re-sorted, and the choicest-looking 
pieces are reserved for retailing whole, while the rest is 
ground, or it may be sawed in little cubes 
or prisms. The outer surface of regular 
pieces, where the bark is not too deeply cut 
away, shows numerous fine, deep orange, 
lozenge-shaped spots (the ends of the med- 
ullary rays), separated by a pretty regu- 
lar net-work. of white lines. These rays, 
in the interior of the root, are arranged 
with the greatest irregularity, generally in 
the cortical zone of the section, having a 
somewhat radiate tendency, but by no 
means always obviously. Near the cam- 
bium region is an irregular cir- 
cle of small dark stars (as they 
appear in transverse section), 
about two millimetres in diame- 
ter, composed of short rays 
radiating from a point or short 
axis. Similar stars are seen 
more sparsely, also, in the inte- 
rior parts of the root or stem. 
These stellate markings are only 
found on the larger pieces, the 
roots under two centimetres in 
diameter being wholly without 
them ; but, when present, they 
serve to distinguish with cer- 
tainty Chinese Rhubarb from the 
very much cheaper European sort. 
Rhubarb, to be of good quality, 
should be bright in color, glistening 
and brittle upon fracture, beautifully 
and clearly veined, and gritty when 
chewed, It has a bitter, very dis- 
agreeable astringent taste, and a pe- 
culiar, also disagreeable, aromatic 
odor. 

ComposITion.—There is almost no woody tissue in 
Rhubarb. The white part consists of soft parenchyme, 
containing starch and crystals of oxalate of lime; the reddish 
lines and spots are medullary, and contain the active con- 
stituents and coloring matters. Both portions probably 
contain the mucilage, etc., of which the root has ten or 
fifteen per cent., as well as albuminoids, and other com- 
mon plant-substances. No single constituent has been 
found in this root to represent all its activity, con- 
sequently no ‘‘active principle” of it is in the market, 
although one or two of the substances named below can 
be obtained of the chemists. Indeed, the composition of 
Rhubarb is still in many respects very obscure. The 
following list is quoted from M. I. Schmidt by Huseman, 
and bears date 1874: Tannin, 2.106 per cent.; pheoretin, 
0.65 ; chrysophan, 0.05; chrysophanie acid, 4.70; emodin, 
0.50; ash, 12.15. Of these one of the most important is 
chrysophanic acid, This is an orange-yellow compound, 
crystallizing in needles or six-sided prisms ; it is without 


taste or smell, and can be partially sublimed. Cold 
water dissolves almost none of it; hot water dissolves a 
little, making a yellow solution. It is more soluble in 
alcohol, ether, ete., and in some acid and alkaline solu- 
tions. Chrysophanic acid is not peculiar to Rhubarb, 
but is also found in other species of Rhewm, in the docks 
(Rumex), as well as in Parmelia parietina Ash, and other 
lichens. The chrysarobin of Goa is a related product. 
Although this acid is easily obtained from Rhubarb, ac- 
cording to Professor Kubli, it does not exist in the root, 
but is the result of a glucoside decomposition of the next 
substance chrysophan, under 
the influence of a ferment pres- 
ent in the rogt and made active 
by maceration in water. Chry- 
sophan is also a yellow, crys- 
talline body. It hasa distinctly 
bitter taste, is readily soluble in 
warm water and diluted alco- 
hol, and in alkaline solutions, 
the latter with a red color. 

Ether does not 
dissolve it. 
Boiled with di- 
lute acids it 
yields the chry- 
sophanic acid 
andsugar. Hmo- 
din is in orange- 
yellow, silky 
crystals. It is 
more soluble in 
alcohol, and less 


fe 
"y 


\ te é ; 
=) Se 
\ : 


(Me > 
LEY 


so in benzol, than 
chrysophanic 
acid ; to alkaline 
solutions it gives 
. acherry-red color. 
| Several species of Rhamnus 
| I contain this derivative. heo- 
O tannic acid is a hygroscopic 
yellow powder of astringent 
taste, reducing iron with a 
greenish-black color; it dis- 
solves readily in water and 
spirit, and precipitates mucus and albumen. Pha@oretin, 
as well as aporetin, erythroretin, is a not very well-defined 
resinous substance, existing only in minute quantity. 
The composition of Rhubarb, as at present known, does 
not give much clew to its quality. 

AcTION AND Ust.—When chewed Rhubarb stimulates 
the saliva. In small doses, in the stomach, it seems to 
act as a digestive stimulant ; in larger ones it appears to 
be a simple purgative, hastening along the contents of 
the bowels by increased peristalsis, carrying the liquid 
contents of the small intestine rapidly down, to soften 
and force along the more solid mass in the colon and rec- 
tum, Intestinal secretion is supposed to be less stimu- 


223 


Fic. 3340.—Leaf of Rheum Pal- 
matum ; variety, tanguticum. 
(Baillon.) 


Rhubarb. 
Rickets. 


lated by it than by salines or the cathartic resins. Its 
coloring matters are absorbed, and may tinge the milk 
andurine. Really our knowledge of the details of the ac- 
tion of this, and many other vegetable cathartics, is much 
more vague than is desirable. Their gross action is evident 
enough, and the comparative liability to produce nausea, 

Utes eae vomiting, colic, col- 
lapse, etc., is pretty 
well understood ;_ but 
how much is peristal- 
sis, how much retarded 
absorption, how much 
increased secretion, 
how much biliary stim- 
ulation, is known of 
very few. Rhubarb is 
mild and pretty certain ; 
it produces compara- 
tively little pain, no 
depression in moderate 
doses, and its action is 
not prolonged. The 
tannin in it is credited 
with producing some 
constipation after its 
use, but the simple 
emptying of the bowels 


without irritation of 

Fra. 3341.—-Piece of Round Chinese Rhu- 
barb, showing the white lozenge-shaped the mucous membrane 
reticulation on its surface and the ir. Would be enough to ex- 


regular medullary rays on the section. plain this result. Rhu- 

(Baiions barb is given in almost 
all conditions where simply emptying the bowels is de- 
sired. 

ADMINISTRATION. —Rhubarb is offered by the Pharma- 
copeia in a great variety of forms; it is also found ina 
good many of the popular proprietary laxative mixtures. 
It makes a fine, deep-yellow powder which is sometimes 
given, but not often, on account of its very nauseous 
taste. Two or three decigrams (gr. iij. ad v.), once or 
twice a day, would be a very mild tonic-laxative dose; a 
single dose of a gram (gr. xv.) is mildly, while one of two 
grams (gr. xxx.) would be severely, cathartic. Rhubarb 
in substance is frequently taken by chewing and swal- 
lowing a piece of the root as large as a pea or a bean, 
once a day or so, preferably after eating ; the taste in 


oot . - TS ~ ee x a 
Ft aN OS IN Pyar) Seetne ~ 


we ae 
en ESTEE! Ss 
tes 4 De Be] Se 


cet 
“a tans 


seal ai 
in 
a 


1S 


22% 
Upoxd 
WYO I> 
Te ) 
& 

2. 
ce) 
g 


C 
O 


A 
iy 


BIEN, 
aN 


A. 
M, 


(@ q 
ce 
Cra 
MUA 
Te 


this way being less nauseous than that of the powder. 
The tonic, almost carminative, action of Rhubarb upon 
digestion, has made it widely used in this way. The 
following are the preparations of the U. 8. Pharmaco- 
poeia : 

Extract (Extractum Rhet), made by exhausting with 
alcohol and water, and evaporating; strength about 3 ; 
useful for pills and mixing with other pill-masses. 


224 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Pluid Extract (Hatractum Rhet Fluidum), strength, 4, 
less used than the tinctures, is an ingredient of the fol- 
lowing : 

Mixture of Rhubarb and Soda (Mistura Rhet et Sode) : 


Bicarbonate of Soda .......... 30 parts. 
Fluid Extract of Rhubarb..... 30S 
Spirit of Peppermint.......... OU ska: 
Water enough to make........ 1,000 “ 


It is an excellent laxative for indigestion, or diarrhea 
with fermenting intestinal contents. 

Pills (Pilule Rhei): Rhubarb, three parts ; soap, one 
part ; each pill contains three grains of Rhubarb. 

Compound Pills of Rhubarb (Pilule Rhet Composite) : 
Rhubarb, two grains; Purified Aloes, one and a half 
grain; Myrrh, one grain; Oil of Peppermint, one-tenth 
of a grain, in each pill. 

Compound Powder of Rhubarb (Pulvis Rhei Compositus) : 
Rhubarb, twenty-five parts; Magnesia, sixty-five parts ; 
Ginger, ten parts. Corresponds to the mixture. 

Tincture of Rhubarb ( Tinctura Rhet), strength, +2;, with 
zé0 Of Cardamom. 

Aromatic Tincture (Tinctura Rhet Aromatica) contains : 


RbUbarbk wn ot eee ene murt rte ae eee ace 
Cinnamon goose oe eas kemien cae lice a 
ClO VES 5). semugelsic: Se erte icy a sta eet tene 4 * 
NULMEP Wh cloacae ee Tae mai Sone 
Diluted Alcohol enough to make one hundred parts. 
The most desirable preparation as a general cathartic. 
Sweet Tincture (Tinctura Rhet Dulcis) : 


Rhubarb 4 7iek eae ces eats ere ATES. 
Glycyrrhiza ie ier ia ci eae 
Anise 240%. Si icah eee rele. eras 
Cardamom sh 27 tee errant eld ae 
Diluted Alcohol enough to make one hundred parts. A 
desirable preparation for children, as the licorice masks 
somewhat the disagreeable taste. 
Wine (Vinum Rhet), strengh +5, with 745 of calamus 
in sherry wine, a duplicate of the tincture. 
Syrup (Syrupus Rhet): 


Rigibarbies tes yee OP i ARE tras UR eG roe 
CDNA ORAS Rie ey Socio cats Wace ase ae, 
Carbonate of Potassium......... 6 ‘ 
SUCHE terri. ee a Shs vies pte aU 


Water enough to make one thousand parts. Like the 


sweet tincture, the sirup is a very popular cathartic for 
infants and children. 


ALLIED PLaANtTs.—The genus contains about twenty 
species, most of whose roots have qualities similar to the 
above. Several of these, R. Rhaponticum, and others, are 
cultivated in Austria and elsewhere in Europe for this 


Fic. 3343.—European Rhubarb. 
(Fliickiger. ) 


(Fliickiger.) 


purpose, and the European product is trimmed and pre- 
pared so as to closely imitate the Chinese. It can gener- 
ally be told by its duller color, more spongy texture, ab- 
sence of gritty crystals when chewed, and the more 
regular arrangement of its medullary rays; the stellate 


rT 


oe 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Rhubarb, 
HRickets, 


spots are absent. The foliage of Rhubarbs is bitter and 


sour; by cultivation the above and several other species 
have developed very large and pleasantly acid petioles, 
which, especially if partially blanched or shaded, make a 
Malic and oxalic 


delicious vegetable for tarts and stews. 
acids and their salts, and ni- 
trate of potassium, are among 
their constituents. 

The order contains besides : 
Bistort, Polyganum Bistorta 
Tourn; Buckwheat, Hagopy- 
rum esculentum Monch; Docks 
and Sorrels, Rumex sp. var. 
These latter (docks) resemble 
Rhubarb somewhat in the 
composition of their roots, 
but as their tannic matters 
are in excess of their laxative 
ones, they are not cathartic. 

ALLIED Drues.—The dif- 
ferent species of Rhamnus 
(Buckthorn, Cascara Sagrada, SUS 
Frangula, etc.) appear, in their ELS Sag ah At a tea ead 
action on the bowels, and, IML. (Fifckiver.) Le Labia) 
some respects, In composition, 
to be more like Rhubarb than most cathartics. Senna, 
Wahoo, Blue Flag, and Podophyllin in small doses may 
also be mentioned, as well as perhaps Castor-oil. Aloes 
acts more upon the large intestine, the drastics and sa- 
lines are more depressing, hydragogue, and violent. Sul- 
phur and Magnesia are less active, but not dissimilar in 
kind to Rhubarb. None of them has the later astringent 
effect of the one under consideration. 

The following list of substances used to increase the 
movements of the bowels, partly from Brunton, appears 
to be very well arranged : 

Laxatives: Honey, Molasses (and food made with it), 
Manna, Cassia Fistula, Tamarinds, Figs, Prunes, Stewed 
Apples, Sulphur, Magnesia. 

Simple Purgatives: Aloes (?), Rhubarb, Senna, Fran- 
gula U.S., Cascara Sagrada, Castor-oil, etc.; also Calomel 
(single dose). 

Drastics: Elaterin, Colocynth, Jalap, Scammony, Gam- 
boge, Podophyllin, Croton-oil. ; 

Salines: Sulphate of Soda, Sulphate of Magnesia, 


Phosphate of Soda, Tartrate of Potassium, Bitartrate of | 


Potassium (very mild), Citrate of Magnesium. 
Cholagogues : Aloes, Rhubarb, Mercury (various prep- 
arations), Enonymin, Iridin, Podophylin. 
W. P. Bolles. 


RICE (Azz, Codex Med.). The grain 
of Oriza sativa Linn., Order, Graminee. 
A water- or swamp-grass originally 
from India, cultivated there for ages, 
early introduced into Southern Europe 
and the warmer parts of America, and 
forming the principal food-product of 
many tropical races of men. It has 
been divided into numerous garden 
varieties differing in the length of its 
glumes, color, size, and shape of its 
grains, etc. 

For use, the grains are deprived of 
their husks and pericarps by beating, 
rubbing, or passing between rollers, 
by which means the embryo also is 
shelled, or rubbed out. The prepared 
grain, consisting entirely of the peri- 
sperm, needs no description. It hasa 
smaller amount of mineral and albumi- 
nous constituents than other cereals, 
and a larger amount of starch (eighty- 
five to ninety per cent.). Rice starch 
Fig. 3346.—Flower of is also a commercial product ; it con- 

Rice. (Baillon.)~ gists of exceedingly minute polyhedral 

granules. (See STARCH.) # 

Rice has no medicinal properties, it is simply an almost 
pure farinaceous food, and is neutral and unirritating to 


Vou. VI.—15 


the bowels ; on this latter account it is often given in 
dysentery and diarrhoea. Rice-water, made like barley- 
water, by boiling whole rice in a large proportion of 
water and pouring off the clear liquid, contains a little 
soluble starch, and is employed as a demulcent drink. 
ALLIED PLANTS, etc., see STARCH. W. P. Bolles. 


RICHFIELD SPRINGS, Location and Post-office, Rich- 
field Springs, Otsego County, N. Y. 

AccEss.—By the New York Central & Hudgon River, 
the New York, West Shore & Buffalo, and the Delaware 
& Lackawanna Railroads. 

ANALYysI8 (Professor C, F, Chandler).—One gallon 
contains : 


Grains. 
Hydrosulphatelof sodium’, 92. ie... eee eee soe. 1.7189 
Hydrosulphate of calcium...............2-..+000- 0.0908 
Sul phabeyoipMOtassaescmcs a lee el enn abort 1.6656 


Bulplate of lime ec ed. ec eeor a ae a 112.3379 


Sulphate: OLstroutiane ns. caer oe ae une eee 0.0105 
SUlP RACE LOfbaritia 1 Gael eee ener een nny Mane D trace 
SipMalerotemagnesinn ao) me sa alee a ste ene 5.1498 
My drosnlphite OMeoGa see enact ae cities ae seein 0.3801 
Bicarbonate of magnesia ........ See eee Breast ee 31.7408 
Bicanponateol Tron tas cen eee eet ce oabe eh trace 
Phosphiateronelimeteny setum ois ene mee aise epee a 0.0067 
Chilorid esomesOcu yt sane cet see oes eee eee ene 0.5249 
OhionideroL hthinmre. sao we cence ete 0.0165 
BATTEN TIER PR Ep ema Ua hers, ARS RPT EE MERC ATT CUE KES UN RO Me, trace 
SILT Ge ae eee nel hl Pes ae, Poteet are a tem emits, Welabay be 0.6415 

DOU Nee a eee ce ree ee wee eh apna NO Biss 

Gas. Cubic inches, 


Hulphunertedsiydroceneenn ne eee wee cece ate 14.206 


The above analysis is of the water of ‘‘The Great White 
Sulphur Spring.” 

THERAPEUTIC PROPERTIES.—These well-known sul- 
phur waters are among the best of their class. The pict- 
uresque situation and classical associations add materi- 
ally to the popularity of the resort. The diseases for 
which these waters are famous are chronic catarrhs, 
rheumatism, and skin affections. 

Richfield Springs is situated about sixty miles west 
from Albany, on Canaderaga Lake, at an altitude of 
seventeen hundred feet. The surrounding country is 
devoted to farming, and affords many beautiful drives, 
especially about Otsego Lake, five miles distant, famous 
as the scene of some of Cooper’s ‘‘ Leather-stocking 
Tales.” The hotel accommodations are first-class and 
ample. Of late years Richfield has become a favorite 
and popular summer resort. George B. Fowler. 


RICKETS. Syn.: Rachitis; Fr., Nouwre, Rachi- 
tisme, Ger., Hnglische Krankheit. A disease of child- 
hood, arising from perverted nutrition, affecting nearly 
every tissue of the body, but chiefly and most con- 
stantly characterized by a softening of the bones, with 
resulting deformities. It occurs most frequently in chil- 
dren under three years of age, the greater number of 
cases apparently originating during the second year of 
life, at the period when weaning is usually accomplished ; 
and though the bone symptoms may make their appear- 
ance at a later period than the end of the third year, care- 
ful inquiry will generally establish the fact of the oc- 
currence of some of the manifestations of the disease in 
earlier life. 

The etiology of rickets is obscure. It is usually sup- 
posed to be due to insufficient or improper food and im- 
pure air. Yet, though of undoubted importance, these 
are not the sole factors in the causation of this disease ; 
for of the thousands of children living in the crowded 
tenements of our cities, constantly inhaling a vitiated at- 
mosphere, and seldom receiving proper nourishment, but 
few, comparatively, are the subjects of rickets. On the 
other hand, the children of well-to-do parents, living un- 
der vastly better hygienic conditions, are by no means 
exempt. 

Parrot advanced the theory that rachitis is a develop- 
ment of hereditary syphilis ; but he stood almost alone 
in this view, and since his death the theory has had few 
supporters. Fournier, indeed, asserts that rachitis is so 
frequent among children the subjects of hereditary syph- 
ilis, that there must be some relation between the two 


225 


Rickets, 
Rickets. 


affections. He believes that syphilis may act indirectly 
as a cause by producing malnutrition. But this is very 
different from the theory of Parrot, who believed that 
hereditary syphilis was the sole cause of rickets; that 
rickets, indeed, was hereditary syphilis. In the ‘* Report 
of the Collective Investigation Committee of the Norwe- 
gian Medical Association” (Christiania, 1887) it is stated 
that, out of two hundred and forty-two cases of rickets, 
it was possible to find some evidences of syphilis in the 
parents in only nine instances. 

Oppenheimer assumes the disease to be a manifesta- 
tion of malarial poisoning, basing his belief upon the 
periodicity that has been frequently observed in some of 
the symptoms. He states that rickets occurs chiefly in 
localities in which malaria is most prevalent ; but this 
assertion is not borne out by observation, for the disease 
is of greatest frequency in cities, where malaria is weak- 
est, and is very rare in tropical regions, where the most 
pernicious forms of malaria prevail. 

It has been asserted that the children of young par- 
ents are more often rachitic than those of older parents, 
but the writer has been unable to verify this assertion by 
a study of the statistics at his command. 

The influence of heredity has been denied. It is an 
undeniable fact that the mothers of rachitic children often 
themselves show evident traces of the disease, but this may 
possibly be ascribed to the fact that they were brought 
up under similar conditions. That there is, however, at 
least a racial predisposition to rachitis, is a fact of daily 
observation. In this country the disease is seen for the 
most part in children of parents born in European coun- 
tries, with the exception possibly of the Irish, among 
whom it would seem to be for some reason less common 
than among those of the Anglo-Saxon and Latin races. 
The children of white native Americans are compara- 
tively seldom attacked, but negroes are almost without 
exception rachitic. This predisposition to rickets in the 
colored race would seem to be an acquired one, for it is 
said that native Africans seldom, if ever, show any evi- 
dences of the disease. 

The first symptoms are often developed during conva- 
lescence from whooping-cough or some other of the de- 
bilitating diseases of childhood. In the present state of 
our knowledge the most that can be said is that rickets 
is a disease occurring in children predisposed by heredi- 
tary or racial influences, in whom the assimilative func- 
tions have become impaired by poor food, bad air, absence 
of sunlight, or the influence of debilitating disease. 

Pathology.—Of the pathology of rickets even less is 
known definitely than of its etiology. Numerous theories 
have been advanced, most of which are, however, based 
solely upon the changes observed in the bony structures, 
leaving out of consideration the pathological processes 
occurring in other tissues. 

The urine in this disease contains an excess of phos- 
phates, while the bones are markedly deficient in earthy 
constituents ; and upon this fact is based the theory of 
an increased formation of acid in the system, whereby 
the earthy materials are dissolved out of the osseous 
structures. The nature of this acid, however, has never 
been determined, and its existence even remains a matter 
of conjecture only. 

The changes occurring in the bones are much too com- 
plicated and varied to admit of a purely chemical ex- 
planation. The new bone formed beneath the periosteum 
is soft and deficient in earthy matter, and the animal 
matter seems also to be abnormal, as it has been found 
by some observers not to yield gelatine on boiling. The 
epiphyses are enlarged, and ossification at these points 
proceeds slowly and with great irregularity. The border 
of ossification does not present a clearly defined, straight 
line, aS in normal bone, but is serrated, the new bone 
shooting far up into the cartilage in some places, while at 
other points streaks of unossified cartilage are observed 
extending for some distance along the shaft of the bone. 
The medullary cavity is advanced beyond the border of 
ossification, and is filled with a reddish pulpy matter. The 
jamella of bone are loosely imposed one upon the other, 
so that sometimes, in fresh specimens, they may be peeled 


226 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


off like the layers of an onion. Spontaneous incomplete 
fractures not infrequently occur, giving rise to much of 
the deformity usually attributed to a simple bending of 
the bone. Separation at the epiphysis (diastasis) may 
also take place, and when occurring at the hip may 
simulate congenital dislocation. 

Ossification in the flat bones proceeds in the same ir- 
regular manner. In the cranium the fontanelles remain 
open for a long time, the sutures are not firmly united, 
and are apparently depressed, owing to an elevation along 
the borders of the bones similar to the enlarged epiphyses 
of the long bones. The earthy matter is not deposited 
regularly, but here and there soft spots may be felt in 
which the osseous formation is wanting. This deficiency 
is most common in the occipital bone, and constitutes the 
condition known as craniotabes. 

The liver, spleen, and lymphatic glands are frequently 
enlarged and harder than normal. The brain is often 
hypertrophied, the change involving chiefly the white 
substance. The muscles are flabby, poorly developed, 
and on section seem to be paler than normal. The liga- 
ments are nearly always relaxed. 

Symptoms.—The earliest stage of rickets is character- 
ized by no pathognomonic signs, and may readily escape 
recognition. The only symptoms are those of imperfect 
nutrition. The appetite is good, but the child does not 
seem to thrive. It is a little peevish and out of sorts, 
and the usual means resorted to by the mother or nurse 
to restore good nature are unavailing. It is most con- 
tented when alone, and resents any playful overtures, 
especially objecting to being tossed in the air or trotted 
upon the knee, sports which perhaps occasioned delight 
at an earlier period of its existence. Growth is retarded, 
the rounded cheeks and plump limbs lose their chubby 
outlines, and the child looks puny and wizened. Occa- 
sional attacks of diarrhoea may alternate with obstinate 
constipation. 

Now the disease is established and its true character 
becomes revealed. The desire to be let alone becomes 
more positive, and is due to a hyperesthesia of the 
skin, so that even a light touch may cause actual pain. 
The little patient will lie quietly for hours in its crib if 
undisturbed, but cries and betrays apprehension upon 
the mere approach of anyone who, it fears, is about to lift 
it. The weight of the bedclothes even seems to cause 
pain or discomfort, and, perhaps in consequence of this, 
the child is found uncovered as often as it is visited by 
the mother or nurse. There is profuse sweating, espe- 
cially about the head, to such a degree oftentimes that the 
pillow is soaked by the perspiration. The action of the 
bowels is irregular, and attacks of diarrhoea with very 
offensive stools frequently occur. 

The muscles become soft and flabby. Some writers 


speak of a rachitic paralysis, but this is incorrect; the . 


muscles are weak and often atrophied, but the atrophy 
is rather that of disuse, and no real paralysis exists. The 
ligaments are relaxed, and the joints are in consequence 
abnormally movable. The child makes no attempts to 
walk or stand, but cries if placed upon its feet. Some- 
times it is even unable to sit up; the back is bowed, and 
the head lolls from side to side, the patient having no 
power to steady it. 

The teeth appear late and at irregular intervals; they 
are poorly formed, and early become carious. 

There is but little, if any, elevation of temperature. 
The appetite usually is good, sometimes excessive, and 
thirst is a fairly constant symptom. 

The picture here presented is that of the early stage of 
typical severe rachitis, prior to, and during the com- 
mencement of, the stage of softening of the osseous tis- 
sues. The symptoms vary greatly in severity, sometimes 
being so slight as to escape remark by the mother ; but 
careful questioning will usually elicit the admission that 
the child was noticed to perspire freely, and that it had a 
habit of constantly throwing off the bedclothes. The 
most painstaking investigation will not seldom fail to 
develop any fuller history than this. 

The second stage is that of softening of the bones, 
through which ™any of the characteristic deformities of 


iw 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


rickets are produced. All the bones of the body are sub- 
ject to this change, though, in mild cases, the deformity 
is chiefly confined to the lower extremities, which become 
bent under the weight of the body. It is probable, also, 
that the muscles have some part in the production of the 
deformity in the long bones. But the more common oc- 
currence of distortion in the lower extremities is seem- 
ingly due to the fact that these members have to bear the 
weight of the body. ‘The upper extremities are less often 
bent, and when they are curved to any extent it is gen- 
erally because the child has been allowed to crawl, thus 
throwing some of the weight on the arms. During this 
period the symptoms of the first stage usually continue, 
though with decreasing severity ; or, in the milder cases, 
a marked amelioration may take place ; the muscles regain 
their strength, the ligaments grow less yielding, the out- 
lines of the limbs become rounded, and the child gains 
rapidly in weight. But this improvement in the general 
health has its disadvantage in causing increased deformity 
of the lower extremities, by forcing them to sustain a 
greater weight while the bones are still more or less 
yielding. 

The head, in a typical case of rachitis, is elongated, and 
flattened upon the top and at the sides, the occiput is 
projecting, and the frontal bosses are prominent, thus 
giving to the head, when viewed from above, a rec- 
tangular appearance (déte carrée, caput quadratum). The 
features are small, and the cranium in consequence ap- 
pears to be greatly enlarged, when it really may be 
smaller than. normal. Dr. Henry N. Read (New York 
Medical Journal, August 29, 1885) states that the ratio of 
the greatest antero-posterior diameter to the base-line of 
the cranium is altered. Normally this should be, as 
pointed out by Dr. Samuel Gee, as 6:5. But in rickets 
Dr. Read has found that the antero-posterior diameter of 
the cranium is always lengthened in proportion to the 
base-line ; in a case reported of not very marked rachitis 
this ratio was as 7+:5. There is sometimes an actual 
increase in size, due to hydrocephalus. The fontanelles 
are open, the sutures loosely knit, and lying in a groove 
caused by the prominent edges of the bones on either 
side. The soft spots in the occipital bone, due to imper- 
fect ossification, may sometimes be felt. This condition 
(craniotabes) is said to be one of the earliest and most 
constant anatomical features of rachitis. The writer has 
not, however, found it with anything approaching the 
constancy asserted of it by most authors. 

The ligaments and muscles of the spine are weak, the 
bodies and intervertebral cartilages are soft, and the con- 
sequent deformity is a posterior curve (kyphosis) in the 
dorsal region, with at times compensatory lordosis of the 
cervical and lumbar portions; usually, however, the 
kyphosis is complete and involves the entire length of 
the spinal column. Lateral curvature, or scoliosis, due to 
rickets, is a much less common deformity than kyphosis, 
though it is by no means rare. 

The scapula usually suffers but little change; some- 
times it is thickened, but more often is smaller than 
normal. The clavicle is thickened, its articular ends are 
enlarged, and it presents an exaggeration of its normal 
curves. Deformity of the arm and forearm, when at all 
pronounced, is found generally in children who cannot 
walk, but crawl upon their hands and knees. The curve 
of the humerus is outward, with its greatest convexity at 
the point of insertion of the deltoid muscle. The convex- 
ity of the curve of the forearm shows itself on the dorsal 
aspect. A very constant sign of rachitis, even in slightly 
marked cases, is the enlargement of the epiphyses at the 
wrist, the swelling being the more readily appreciated 
here because of its superficial location. 

The softening of the ribs, when marked, is a constant 
source of danger, owing to the impediment thereby of- 
fered to free respiration. The heart is also very con- 
stantly hypertrophied in marked cases, in which the soft- 
ening of the chest-walls is pronounced. The thorax is 
bulging at the sides, but the ribs recede before uniting 
with their cartilages, forming a groove running from above 
downward and inward on each side of the anterior wall of 
the chest. Each rib is enlarged at its junction with the 


Rickets. 
Ricketts, 


cartilage, forming a row of knobs just anterior to the 
depressed line, and which has been called the rachitic 
rosary. The sternum projects forward in fancied resem- 
blance to the keel of a ship, or the breast-bone of a fowl 
(pectus carinatum, chicken-breast). The lower ribs are 
flaring, being pushed out by the enlarged liver and 
spleen. The abdomen is swollen from the same cause, 
and also from flatulent distention of the bowels, which 
occasions much suffering to the little patient. 

The deformity of the pelvis in the female may prove a 
serious obstacle to parturition in later life. The sacrum 
projects forward, and the acetabula are pushed in by the 
weight of the trunk; a horizontal section of the true pel- 
vis thus presents the appearance of a trefoil. 

The neck of the femur forms a more nearly right angle 
with the shaft than is normal; the latter is bowed out- 
ward and forward. The deformity sometimes consists of 
a sharp curve, with the concavity looking outward, at the 
lower end of the femur, producing one form of knock- 
knee ; the tibia also sometimes presents a bend at its up- 
per part, similar to that of the lower end of the femur, 
which contributes to produce the same deformity. Bow- 
legs is caused by an outward curve of the tibia, or of the 
tibia and femur, associated usually with a relaxed condi- 
tion of the lateral and crucial ligaments of the knee. The 
tibia not infrequently presents an anterior curve at its 
lower third. The fibula usually follows the curve of the 
tibia, though in rare cases it may remain straight, in 
which case the external malleolus will project too low 
down and cause pain and difficulty in walking. The 
malleoli are enlarged and prominent. Flat foot (talipes 
valgus) frequently results from stretching of the plantar 
fascia, with consequent breaking down of the arch of the 
foot, and also from softening of the bones of the tarsus. 

The chief cause of the deformities in rickets is the 
weight of the body acting upon the long bones of the 
extremities and causing them to bend or break ; not in- 
frequently the curves are due to a green-stick fracture 
rather than to a simple bowing. Muscular action is, 
however, a frequent, and sometimes the sole, factor in 
the production of deformity. The misshapen thorax is 
aresult of atmospheric pressure and muscular contrac- 
tion combined. 

The last stage of rickets is the stage of cure. The con- 
stitutional disturbances, in cases in which they have con- 
tinued through the second stage, now subside, and the 
child seems again to enjoy the perfect performance of all 
the animal functions. The bones become firm from a 
deposition of the earthy constituents, but there is nota 
simple restoration of the osseous structures to the nor- 
mal; for, with the irregularity peculiar to rickets, in 
which the balance-wheel of the animal machine seems to 
be wanting, there is an excess of action ; the process of 
ossification, so long delayed, now runs wild, and the soft 
animal matter becomes converted into ivory rather than 
bone. Any deformities which have been overtaken by 
this process, called eburnation, while still uncorrected, 
become fixed and incapable of cure by other than opera- 
tive measures. 

Sometimes a spontaneous straightening of the bowed 
limbs occurs during this stage. This occurrence is diffi- 
cult of explanation, but it is possibly due to an increased 
growth on the concave side of the bone. 

A child who has been profoundly affected with rickets 
never attains the full stature which he would have 
reached had he remained free from the disease. In a 
given family, the children who have suffered from rick- 
ets, even though they be free from deformity, are always 
shorter than their unaffected brothers and sisters. 

The prognosis of rachitis, apart from its complications, 
is favorable as regards life; very few children die from 
rickets alone, but many succumb to bronchitis and laryn- 
gismus stridulus, appearing as complications of the dis- 
ease. A simple bronchitis, which would pass almost un- 
noticed in a healthy child, becomes a most serious disease 
in one affected with rickets, in whom the ribs are soft and 
yielding. The elasticity of the thoracic walls 1s impaired, 
the lungs can neither receive nor expel a normal amount 
of air, and when a further impediment is added to respl- 


227 


Ricketts. 
Roanoke Springs. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


ration by the presence of inflammatory secretions, the 
condition of the child becomes precarious indeed. 

Another complication, through which the life of the 
child is jeopardized, is laryngismus stridulus. This af- 
fection is stated by some writers to occur only as a con- 
sequence of rickets, the origin of each attack being attri- 
buted to cerebral pressure from the weight of the softened 
cranium resting upon the brain. It certainly occurs most 
frequently, if not solely, in rachitic children. 

The prognosis, as regards deformity, if mechanical 
treatment be neglected, is unfavorable. The curved 
bones, it is true, do at times straighten themselves as the 
disease subsides, but such a favorable result is doubtful, 
and can seldom be predicated in any individual case. 
But little can be done by way of prevention of the pelvic 
deformity, the consequences of which in after-life, in 
females, are often most serious. A spontaneous rectifi- 
cation of this deformity seldom, if ever, occurs. Fortu- 
nately it is of rare occurrence, except in the most severe 
forms of the disease. 

The treatment of rachitis is twofold, viz., the treatment 
of the disease, and the prevention or correction of de- 
formity. All measures which tend to improve nutrition 
are beneficial. Light and airy sleeping apartments, easily 
digestible and not too watery food, pure mountain or sea 
air, plenty of sunlight, perfect cleanliness, all are of the 
utmost importance. A change should always be sought ; 
if the child live near the sea, mountain air is more likely 
to be of benefit, and conversely, those from inland towns 
should be taken to the sea-shore. Salt-water baths, in 
moderation, sometimes prove in the highest degree bene- 
ficial. Unfortunately, the children of the poor, living in 
the crowded quarters of large cities, are seldom able to 
avail themselves of such treatment. Yet much may be 
done, even here, by a more careful observance of some 
of the simplest rules of hygiene, to give instruction in 
which is the first duty of the medical attendant. The 
child may be taken every day, or every other day, to the 
parks or outskirts of the city ; or, if the town is by a river, 
to the water’s edge or upon a ferry-boat. If the parents 
live on the first floor of a tenement-house, they should 
seek rooms on the upper floors, where the air is presum- 
ably less impure. Great care should be taken in guard- 
ing against the sudden changes of our climate, since even 
a slight bronchitis is liable to prove fatal. As these chil- 
dren always lie uncovered, in spite of the most watchful 
care, they should sleep in flannel garments which cannot 
be thrown off. Cod-liver oil and the compound syrup of 
the hypophosphites are useful when they are not rejected 
by the stomach ; they may be administered in combina- 
tion, or the oil may be given in winter, and the hypo- 
phosphites in summer. Eucalyptus globulus, in doses 
of ten to forty minims of the tincture, three or four 
times a day, is said to be often very beneficial. 

Much has been written of late years for and against the 
use of phosphorus, as recommended by Kassowitz, in the 
treatment of rachitis. Many regard this drug as a real 
specific in rickets, while others, after a long experience, 
condemn it as useless, if not harmful. The writer’s ex- 
perience with it has not been sufficiently extensive to 
warrant him in expressing a positive opinion. But in 
some dozen cases in which he has tried it, it has seemed 
to be of service. 
dose is 3} to zh grain twice or three times a day. The 
phosphorus should not'be given dissolved in cod-liver oil, 
as recommended by some, for such a mixture is not per- 
manent, and soon becomes inert. The ethereal solution 
and the solution in bisulphide of carbon are probably the 
best forms in which to administer it. The latter may be 
prepared after Hasterlik’s formula as follows: 


BR. Phosphori...... ae as ee 0.01 (gr. 4). 
Carbonei bisulphidi ,....... 0.25 (gr. iv.). 
= A Gur destillate:? 2.2202: 100.00 ( 2 iij.). 


The dose of this is half a teaspoonful, which may be 
given in syrup, or, preferably, with an equal amount of 
cod-liver oil. The solution should be kept in a well- 
stoppered bottle away from the light. 


228 


No bad effects were observed. The 


Treatment of the deformities should be instituted early, 
before the bones become hard, and should be persevered 
in without intermission. The mechanical treatment of 
rachitis is no less important than the hygienic and med- 
icinal, and in no case should it ever be neglected under 
the idea that the deformities will correct themselves. 
No child who has received intelligent instrumental treat- 
ment need grow up with crooked legs or a crooked spine 
as a result of rickets, and every adult who suffers from 
such misfortune is a living witness of parental or medical 
neglect. For the management of the special deformities, 
see under their respective headings. 

Thomas L. Stedman. 


RIO DE JANEIRO. The accompaning chart, repre- 
senting the climate of the city of Rio de Janeiro, Brazil, 
is likely to interest some of the readers of the REFER- 
ENCE HANDBOOK, as giving them a fairly typical show- 
ing of a truly tropical climate (although, to be sure, not 
an extreme example of this class), and also as conveying 
more accurate information than is generally possessed re- 
specting the climate of the largest commercial city of the 
South American continent. - As a health-resort proper, 
Rio de Janeiro is not for a moment to be considered ; 
but as a temporary halting-place for invalids undertaking 
a long sea voyage it is worthy of consideration. <A 
knowledge of its climate will also be of service to such 
business men as are, by the necessities of their calling, 
compelled or prompted to make this city a place of more 
or less permanent residence. 

Foreigners, whenever possible, would do well, how- 
ever, to make some one of the higher-lying towns of 
Brazil, situated at no great distance from Rio, their place 
of residence, at least during the warmer months, in order 
to escape the continuous heat and great atmospheric hu- 
midity which combine to make the climate ef the city 
itself so debilitating. The German colonies of Petropolis 
and Novo Friborgo may be specified as good places of 
resort at this season. Petropolis is but two and a half 
hours’ distant from Rio, and Mr. C. C. Andrews, in his 
work on Brazil, tells us that ‘‘a few business men make 
the round trip daily.” Novo Friborgo lies one hundred 
and twenty miles to the northeast of Rio. For an inter- 
esting account of the climatic conditions prevailing at 
the last mentioned of these two places, see the London 
Lancet of July 19, 1884. The high ground immediately 
back of the city will also be found more comfortable and 
more agreeable as a place of residence than the low-lying 
and thickly built business portion of the town. 

Yellow fever, which was formerly a great scourge at 
Rio, has become of late years far less prevalent. Small- 
pox appears to be endemic, as in most, if not all, of the 
larger cities of South America, and as in many of the 
large cities of Europe. 

The climatic chart of Rio, here published, was very 
kindly obtained for the writer by his friend, Mr. Charles 
L. Jacobson, and was prepared by Mr. T. O. Gunton, of 
Chester, England. The following passage is extracted 
from Mr. Gunton’s letter to Mr. Jacobson enclosing the 
chart, and dated Lisbon, May 8, 1885: ‘‘I have been 
unable to record the velocity of the wind, as I have no 
instrument for the purpose. However, the Rio climate 
may be thus very briefly described : In normal weather 
there blows a mere light air from the north, which is 
known as the land-breeze ; then at 1 P.M., or thereabout, 
springs up the sea-breeze ; a fresh breeze from the south 
and southeast (part of the trade-winds from southeast), 
lasting until about four or five o’clock, when it dies 
down, and the nights are usually calm and quiet. Only 
at periods of change of moon is this weather upset by an 
occasional sou’wester, when heavy rains are preceded 
by violent gusts of wind which develop into dust-storms, 
and then comes rain, heavy weather out at sea, which 
lasts two or three days; then the weather takes up again 
until next time. 

‘‘The figures are my own, except the rainfall, which 
was given me in millimetres, and I converted the figures 
into inches on the .03937 ratio.” 

In conclusion, the reader’s attention is called to the fact 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Rickets. 
Roanoke Springs. 


Climate of Rio de Janeiro.—Latitude 25° 54’ 23" 8.; Longitude 48° 8' 84" W.—Period of Observations, January 1, 1884, 
to December 31, 1884.—Hilevation of’ Place of Observation above the Sea-level, 327 feet. 


A AA B Cc D E F Gin eit” 
: = g beadlhads 
o wy | =o 
3 Z E d5Ss 593 
) S S elie ae 
qa ui H SoS\ Sg s 
oa ® 5) ie aah eats yoke 
EE gis) eRe eg e528 
ae 8 SI mes a) aos g 
vo OD es . So =| Lois} 
ee Agi | Ming Caps oes 
Mean temperature of months ES Mean temperature Be — |Absolute maximum!Absolute minimum ||‘S 228 °S°¢ 
at the hours of st 3 for period of ob- a2 =e temperature for| temperature for||Ha52 4,_’a3 
S servation. A=ie By period. period. g ° 8\)a0, 8 
ae ice) =] gad) Diet 
ha ac | 3 pees /Gos3 
Bg 8 5 ag Begg 
2 oO | | o © PEL g Ha 
BS || 2 z $085 Sofs 
c 3 5 \SwSs| eas a 
> > > Seas tase 
<q < <q [ona as \ch'@ =| 
L — ays 
7 A.M. 1PM. 10 P.M. Highest.| Lowest. Highest. | Lowest. | Highest.| Lowest. | 
Degrees.| Degrees. | Degrees.|| Degrees.|| Degrees.) Degrees.|| Degrees.) Degrees,| Degrees. | Degrees. | Degrees.| Degrees. |} 
January.... 74.89 78.13 75.05 76.02 85.02 68.82 79.21 73.00 95.18 74.30 78.26 64.58 16 14 
February "5.52 81.03 16.51 77.68 83.12 70.10 $1.03 74.76 95 .54 74.12 77.00 63.50 ut 12 
March ..... 75.18 79.41 76.83 77.14 81.48 73.86 79.80 74.60 91.94 78.26 77.00 66.38 16 16 
Aip¥Yal 252-32 ue 77.52 73.76 44.33 84.66 67.78 77.52 71.43 92.30 70.70 74.66 62.60 15 13 
BY eects 68.25 73.67 70.70 70.87 76.53 63.68 73.67 68.09 85.28 68.54 72.50 58.10 12 14 
JUNE s ee, 66.97 72.41 69.89 69.75 74.98 64,14 42.41 66.97 82.94 66.74 69.62 59.54 || 15 13 
SULY oN koe as 65.69 40.97 67.78 68.14 71.07 65.12 90.97 65 53 79.34 69.80 67.10 59.18 16 
August..... 63.93 68.55 65.58 66.02 42.26 61.32 68.55 63.19 82.94 64.40 66.02 59.22 17 14 
September.. 67.37 71.92 69.31 69.53 76.08 63.21 71.92 66.83 86.54 64.76 68.00 61.70 138 10 
October .... 69.89 72.30 69.89 70.69 82.23 64.81 73.34 67.94 92.30 68.54 71.78 60.80 15 13 
November.. 72.69 74.93 (2071 (3.44 86.77 64.40 74,93 70.62 99.50 66.20 76.82 60.80 18 13 
December... 74,28 78.00 74.67 75.65 83.84 69.99 78.00 72.46 98.06 72.14 75.38 64.94 13 15 
SPTIN Gt. sal! Miete ses SeaceiSedudh (teense SEO ANN ae Aca es Fa il as ; E Sue Le Fen eea ee |! oetek ca Nomeeeee 
SSILNITNICT SD, uleusoe clean lt cate e ap meses ove Sse Gleam ireetae ce eee ered c cles Ser) Vie UAacoos the wisdoeb: alll Usa edsal  peobcc il MAND Soc diame lMeNnmor ace tecrarcc 
PXTEEUININ Teeee leew ct. | eaters - [oiserey 2% TORUS il PRBS WANE vcanics Boreal | bP ress 18 ree eae PRE Me Tile cae Ran | Pare iced? 1 ll-gelatatee sanlinneereer ets 
WVIMEGR Seeiietrceces: © |b wascsee In beaters oe Siam | ete Ree era (Memcrtecic/e Ui Mitetesice.t ite wecicie ch tity Ceare cence IN Pec ects PES POE: lw caieceinn Vile wate crn ieeceeets 
Year -+22- ai liemeiarctetene Sono ts al lonader SrA OMIM Teche NMR se closer Tt lil) occ are aise Micacnce md ecto see oe Scott MIC Mecce sc en ieee ces. I Basse 
J K L M N Grammes 
a fz Calciim bicar bon aterm sttcacceve seis eee altars store ieee ie pene 
Bog | } Magnesium bicarbonate... 6:06. Ui sade eee ene oe ce 0.0707 
aS | 4 a A Ee HerrausiDICarbOnater sins voce ia aie ck ok ee ete 0.0514 
g e pee ieee Ber Te Mengandas bicarbonate... 208.050. 2. 02siou. eens. 0.0043 
Spaheees eet OF Gouiinmamintare art oh. OLS kik oe eae Pe 1.2130 
S28 | 33 wa | ‘od hey Calciumlsdlphates rdf An0 coe oe cee ee aes 0.0557 
cael 3 = | 3 2 
2 AES q Ete ae Namnesinimn eulphaberat eed: see ais @% eee asl 0.243 
eh a 5 8 Bee Potassiuna sulphate cs... Cees loess eee e'g pee nes 0.0605 
ae) ic) or 3 fj 
Sa g a a H IMagmesitiin CHIOLiGeng eis feiss cco ateieie ste ele fe '4 Oe ac re yay 0.0847 
Bias a OES Be Bk EIR IS BROT i as ape 0.0044 
pepe lRof rhs). ee aay eats SPCOHAeS He sae aon Ion taceece usp 0.0572 
Brom PWC OU AOR I rs ON Rs tay a a EE: GAPE eee RSE he trace 
MP ANUALY, coset cans eos cots cere k 88a satel 30.60| 80.6 20 7.39 N.W. — 
HODEUALY.cc,- cas stoke cecies eccenes «© 32.04; 82.8 15 6.65 K. EDOLAL ete, See oe Acie ee aoe ateticlers oiaic heme ts 3.5296 
Maroliyent oe, OE fa hs coats 25.56| 79.6 24 6.46 N.E. ; P ; 
ROC oles Megawatts hae 29.70} 78.4 | 20 | 14.74 | S.W. These waters are used chiefly in the treatment of con- 
LEN EEE SEE aoe Tag AG Oe ec a ee gestive disorders of the abdominal viscera, and in anemia. 
SUD Oth eae cee citee accuses hameecehe 23.40| 79.9 26 0.51 E. ’ 
fe AO A SEY ER SAGE PRN 20,16) 77.1.1. 24. | 1.12) | N.E. Ti Tos 
oe oe meet it be 
PLOT DER saris se stele aus clciaicints aterm slots i “a ‘ j \.N.E. - woes Aus 
QCtOber oo. seeeeseseeescereseeee ees EES ASCE PROS Tes RIVIERA. The article describing the Genoese Riviera 
NOVEIN Der ee ae: Penton were) meee be At ic 8 : : ° : 
Deceriber eh cck iki, sh, coer oms 33.12} 80:7 | 20 | 409 | E. will be found in the Appendix. 
Soria tre ATane oti Se S182 79.7 | 66 | 7.06 'N.N.W. ROANOKE RED SULPHUR SPRINGS. eae ie 
SUMIMACT A aie alae aleisidie ls slices stoale sine siete 38.70} 79.3 6) 13st: 5 ) bs e u ur 
Mat 32:04, 81.0 | 68 | 20:50 (N.N.E. | 220Kke County, Va. Post-office, Roanoke P 
Wiliteh $7.4. 70 SPA. sith Seti BA, 84:20] 78.5 | 5Y | 16.45 E. Springs, via Salem, Roanoke County, Va. | 
PY CAI G aM e ce ene cca ia ane eso ones 44.28 | 79.6 254 | 57.13 | N.N.E, Accrss.—By the Norfolk & Western Railroad to Sa- 


* January to March. 


+ April to June. 
t July to September. 


§ October to December. 


that the term ‘‘ fair,” as employed in column L, is not to 
be interpreted in the technical sense adopted by the 
United States Signal Service, and explained in the general 
article on climate (vol. ii., page 191), but is rather to be 
understood in the equally technical sense in which this 
term is used by English writers, viz., as applying to days 
on which no actual fall of rainoccurs. Moreover, it is to 
be noticed that the duration of the period of observations 
upon which are based the data of this Rio chart was but 
a single year ; the bearing of this fact, especially upon 
the interpretation of columns B, C, and D, is to be borne 
in mind. All of Mr. Gunton’s figures for temperature 
were given in Centigrade, and have been by me converted 
into Fahrenheit. Huntington Richards. 


RIPPOLDSAU is a spa in Baden, in which are four 
medicinal springs, three of which are employed for in- 
ternal medication, and one for bathing. The names of 
the springs are the Badequelle, Wenzelsquelle, Leopolds- 
quelle, and Josefsquelle. The composition of the last 
named, according to the analysis of Bunsen, is as fol- 
lows. One litre contains : 


lem, thence by stage to the Springs, nine miles. 
Anazysis (Professor M. B. Harden).—One gallon of 
231 cubic inches contains : 


Grains. 
Calcium’ carbonate. ae ve oem elec ici etsisie ses lalate e's 6.53650 
Magnesium carbonate <2. cece sce oe ce ns sccieece ce 5.82876 
Dithinm CATHONACE TE Ms so ccatals ocle stele sistetiain sie: S oe 0.01549 
Manganese carbonate .....22..0-.-..+-ssccrsensce? 0.01624 
PON <CALDON ALE tanpettercisle ooalocrats ete 1a. chet elon elt elelwiare'e%s'e Retin 
Copper carbomatan..c yo<deaecdececsaecensssecs ss race 
Sodium chloride ssc sels eceas cece = ei Ser ore 0.24401 
AMMONIUM CHIOTIAG ess 4 he ceiciea Viel sielse © visisielee se 0.01801 
Calcium phosphate . 2.5... icc. cece sees ssecncers (0.02931 
eadsulphatieir vem ces sie acctisiee «sia ste'er cleien sh cine else trace 
arin niisttl PIU we 10's cle als de ¥ o1cre ee e's ofeielatsicle’s sitar trace 
Strontium sulphate!.. 015.5. jose cscs cbse cscs esesee 1.71000 
@alcinmi sulphate petecs ts tenet sh daas sfelentsiele 2.19142 
Sodium sulphate! .... 2 Sees oul csc cw ce ss west ee 3,08 19 
Potassium sulphate vine... veselc cence «25-202 se 0.382626 
Sodium hyposulphite ..........-+..2--er ec eeseees 0.03046 
AMMONIUM MILERDE Jou. ac ee ses cease tins sales ss ee 0.0547 
OOH 2 ain Grice b BRIO PAINS ICRO CID UO ROE 0.00648 
SUL CA See ete tte ies Sik Nie cre Mateo sees ae Fie, t95e 0.83851 
Organic matter, jf). sci c- ss pees cls Me was Se oes 0.76005 
APRON TCH dete ee tsa ol tic rerere cide siaic sieiereta sraratele eisai inate trace 
“ 21.70197 
Carbonic anhydride combined with monocarhbo- 
nates to form bicarbonates .........-+++++0+e05> __ 5.96680 
AHOLT TI townie Ae. SARA RG ane CICR OOOO Oy OnIeCnact 27.66877 
Cubic inches of gas per gallon : 12.40 
Carbonioanhydride. 2... 6,-5.5. - = ec ese se ee en 
Sulphuretted hydrogen .........eee+eeeeereeeee ) 


229 


Roanoke Springs. 
Rocky Mt. Springs. 


THERAPEUTIC PROPERTIES.—These are excellent al- 
kaline, chalybeate, sulphur waters, of a mild and agree- 
able type. 

The springs are situated in the southeastern part of 
Virginia, at an altitude of over two thousand feet above 
sea-level. The country is mountainous, with forests of 
pine, and there are many natural objects of interest 
within driving distance. The hotel and cottages fur- 
nish ample accommodations for two hundred and fifty 
guests. GEED AGE. 


ROCHEFORT is an important town in France, situ- 
ated on the Charente River, near its mouth. There is an 
artesian well here, the water of which, issuing at a tem- 
perature of 105° F., is employed, both internally and 
externally, for therapeutic purposes. The following is 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


its composition, according to an analysis of M. Roux. 
One litre contains : 


Grammes 

Sodiumuisulphatews.a-nn hese etie cee eine aiaihisietele are Sines 2.590 
Caleium sulphate a. os sc ce awics eee oe ace vee eC ner: 1.8238 
Marnesium:sulphates. oe .ca: soos eeu cnc ce teen 0.504 
Sodiumichloride ss, Witelede cee ete Reece ae 0.754 
Magnesium" chlorides. Sivecccmeacn cease asec eenter 0.023 
Oalcinm chloride tie. ncac sede wee tae ee ee 0.0384 
Calcinm'carbonatéyi.. o. cco. osc tec cect ee eee ores 0.313 
Magnesium, carbonate nn eee ciao ree ee ere eee 0.033 
Berrous,carbonater’. Useanscne eerie ee oo eee 0.085 
CAV 111 Soe) toce case Hiss oi coils earn eae teas ie ee «an oe One 0.005 
Pel D Ret, Nevin ao. Aenea ie rer RA Bia a 8 EES A re Be 0.017 
Iodine, bromine, organic matter, etc ................ 0.083 

TOGA Fe a cieise es ee ns ee ciole Ie ieee cap etane Meee 5.714 


There are also traces of manganese and arsenic. 
This water is employed in the treatment of engorged 


Climate of Rochester, N. Y¥Y.—Latitude 48° 8', Longitude 77° 42’.—Period of Observations, November 1, 1870, to December 
31, 1883.—Hlevation of Place of Observation above the Sea-level, 500 feet. 


| A AA B Cc D E F Gi 
‘ o oO b> A 1 , 
3 5 5 PEeL|EEES 
4 a se 5 se ~ 
Ed 5 5 Se Ae Eo As 
Shy © ® “Sok|"aoe 
6a i= =) ap avlohad, 
Be 5 g ea" alse” & 
om Pod P=) ce, ae Tp o/T-4 On 
2 } 5 Absolute maximum ||/Absolute minimum ||,,4 =| 2 
Mean temperature of months go wo eae ee eh temperature for temperature for S BS Si CFSE 
at the hours of || a g red eiie ae a a =e period. period. Bee z Bgee 
$6 eS | 38 Eaesleaes 
& Sercleses 
alk 8 AS a|R5° 8 
ae & & geeb|eee2 
ee = = SLeS|S2es 
cob) eassiegwsa 
5; > > Segoe sss 
= < <4. Gans |e aa 
TAM, 3 P.M. 11 P.M, Highest. | Lowest. | Highest. | Lowest. || Highest. | Lowest. 
Degrees. | Degrees. | Degrees. || Degrees, || Degrees. | Degrees. || Degrees, | Degrees. |, Degrees. | Degrees. || Degrees. | Degrees. | 
January....| 22.9 26.4 24.4 36.5 18.2 30.9 16.9 69.0 39.0 15.0 | —12.0 21 29 
February...| 22.6 28.2 25.1 32.6 14:8 34/1 18.5 63.0 46.0 10.0. | 12.0 21 19 
arch teste 28.2 34.4 30.1 40.1 22.2 39.4 24.9 69.0 47.0 16.0 7.0 25 28 
April ?.25 40.1 47.5 42.9 52.5 35.5 51.4 35.1 83.5 61.0 35.0 11.0. oped 28 
May «acne 53.7 62.7 56.8 64.2 50.1 65.7 46.9 90.0 73.0 34.0 28.0 28 27 
June typ tcr 63.3 rier 65.9 69.8 61.0 74.1 55.1 94.0 85.0 48.0 36.0 20 19 
Jalyee 68.0 77.0 70.9 W4.1 68.2 80.0 62.1 96.0 86.0 54.0 48.0 20 17 
August..... 65.9 13.7 69.4 73.3 67.1 78.6 60.6 96.0 85.0 54.0 47.0 19 21 
September..| 58.6 67.6 61.8 71.2 56.2 42.8 55.2 98.0 78.0 46.0) 34:0 25 17 
October... 47.3 55.3 50.4 57.6 45.6 61.0 44.0 87.0 73.0 36.0 19.0 20 21 
November..} 34.4 39.4 36.2 40.6 26.6 45.0 31.5 71.0 54.0 25.0 1:0 20 16 
December..| 26.4 29.6 27.8 36.1 19.5 35.4 23.6 70.0 42.0 26.0 2 et10 20 25 
SACRA AS Se: 43.2 49.5 38.7 eee eee ap 
ha cil aie dectk 68.7 iiog 66.5 : as. eR ae be ae 
ons bce Gaeasiaee 49.4 54.5 44.9 ; ite eee aA 
ac Wn, neces 25.7 32.6 20.4 i Bee ade hes oe betel 
sage el al monroe 46.8 49.6 43.9 se pein te al tee Se ro Oe 
K |L/| M N Oink. Ss : : : 
ee ae Teaetsaet eke Be Tid a: ent here introduced for convenience of reference. <A detailed 
Sai) 8 i K aie : buf explanation of this and of other similar charts is given in 
os a 3 Sy 3 Ss =| © us ao ° ° oe 
ee o gil Se | ‘se 5 =: Ey the general article on Climate (vol. ii., pages 189 to 191), 
8A be gS en oar a eae s where also the reader will find suggestions as to the best 
esl } Ad . 
SS | Se | ek | og | 28 2 4% | ess | method of using these charts. 
Se a* gui fo | gad) ¢ Sg | sac Rochester lies in the so-called ‘‘ Lake Region ” of the 
88 & a 5S css > Be | b28 | United States, the city itself standing but seven miles 
aie 8 OS a. 5 Bick ay distant from the southern shore of Lake Ontario. A ref- 
Inches.) From erence has already been made to the winter cloudiness 
Taney BO Oly Be Se 8 a eet) echareverizing athemcli lee gotetiis ster Ote (seem unter 
February...| 75.0 | 76.9 | 10.8] 38.3 | 14.1 | 2:68 W. 11.3 5 : 
March...... 76.0 | 75.7 | 11.0} 3.9 | 14.9 | 38.41 W. 11.6 Portland, Me., on page 782 of vol. v.). A compari- 
gic Ba) et ws] ge | are | Bet |W | 8 | son of columns K, L, ML, N, and O in this Rochester 
June. «eos... 58.0) 65.7 | 12.6| 7.6 | 20.2 | 3.16 W. 8.3 chart, with the like columns in the chart for New York 
Aususie2| 49:0 | 67s |is7| 10l | str | $05 | sw. | @9 | City, will demonstrate the decidedly greater cloudiness 
Beptember..| 64.0) 69.6.) 13.3) 8.8 | 21.1 )02.35 | Swe) Bt and relative humidity during the winter season at Roch- 
Novernber.,| 70:0 | 75:5 | 9:3; 29 | 122 | x01 | Sw" | 103 | ester. The rainfall, which at New York is seen to be 
December..| 81.0 | 79.9 | 6.8] 0.9 7.7 | 3.07 W. 10.8 least in winter, is, at Rochester, least in autumn ; but 
Spring ti, 97.0 68.2 84.0 20.4 544 9.36 W. 10.5 throughout the year the Vaan of the rainfall is more 
ummer.. ! 6. 4t. cena 9.73 W. 4.6 i j . j 
Autumn...| 970| "0 | 323 is2 | s07 | ses | sw. | os | evenly distributed at the latter than at the former place, 
Winter ..... 82.0/ 79.0 |258| 5.7 | 81.5 | 9.06 | WwW, 11.1 winter not being that comparatively rainless season at 
‘Sede ona Mie eae 2) Die ah be beeen oie Ww. 9.6 | Rochester which it is at New York, although the winter 


| 


conditions of the abdominal organs, in anemia, and in 
debility during convalescence from acute diseases. Ex- 
ternally it is used to promote the healing of indolent 
ulcers, to stimulate granulations, and hasten cicatriza- 
tion. Danis, 


ROCHESTER. The accompanying chart, represent- 


ing the climate of the city of Rochester, N. Y., and ob- 
tained from the Chief Signal Office, at Washington, is 


230 


rainfall of the two places is very nearly the same, and is, 
in fact, slightly greater at New York than at Rochester. 

On the other hand, during the six months, April to 
September, inclusive, the relative humidity of the atmos- 
phere is markedly lower at Rochester than at New York, 
and the cloudiness is nearly the same at the two places ; 
during the mid-summer months actually less at the for- 
mer than at the latter. Thus, during the winter season 
Rochester is decidedly damper and more cloudy than 
New York ; during the summer season, and especially 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, Foaneke Springs. 


the mid-summer season, New York is markedly damper 
and a trifle more cloudy than Rochester. 
Hoh, 


ROCKBRIDGE ALUM SPRINGS. Location and Post- 
ofice, Rockbridge Alum Springs, Rockbridge County, 

2. 

AccEss.—By the Chesapeake & Ohio Railway to Go- 
shen, eight miles from the Springs. 

ANALYsISs.—One pint contains : 


| 


| = a 

a S =| 

ig ag +g 

SOLIDS. a ae ray 

yaes| Ay pagel 

< < < 

< < < 
Grains Grains. Grains 

Chloride of sodium............. 0.053 0.126 0.055 
Sulphate/of potassay.. eee esi ae ee oa Lanes ieee ek 
Sulphate of magnesia..... ..... 0.135 0.220 0.552 
Sulphatevof limes ese: 0.180 0.408 0.413 
Protoxige ol sren. 5.69.2 aes. oe 0.460 0.608 0.587 
Alimindseree teen eae eter fee 1.846 2.238 3.011 
Crenate of ammonia........... 0.175 0.088 0.1538 
Bilicateso£, sOdaiesivne cece sine CG) peaks), Mei > pee eo © ln) eae 
Sulphuric acid (free).........-. | 24347 1.908 0.689 
Silicievacid (iree)@un nesses ss see) tn 0.355 0.213 
Organicemattersces ee ee cele ee) | fines dees 0.127 
A Wat Ns eee Se». Soe Ome 5.514 6.167 5.800 
GAS. Cubic in. Cubic in. Cubic in, 
Carbonic) acid te. tei. ts ossks ss ORG 1.9 ee 


THERAPEUTIC PROPERTIES.—There are here nine alum 
springs and one pure chalybeate, and their remedial value 
is attested by the decided cures effected in many in- 
stances. The alum waters are tonic and astringent. Their 
taste is astringent, and their temperature averages about 
50° F. They cure catarrhal diseases of the alimentary 
and genito-urinary tract, and are famed for their bene- 
ficial influence upon chronic skin diseases, glandular en- 
largements, chronic ulcers, and, in fact, all scrofulous de- 
generations. 

An experienced physician resides at the Springs, and 
directs the use of the waters. 

The situation of these Springs is in the northwestern 
part of Virginia, in a glen at the base of North Mountain 
on the south and Mill Mountain on the north, amid the 
beautiful scenery of this section. The lawn, of about 
fifty acres, is partially surrounded by several fine hotels 
and cottages, affording accommodations for seven hun- 
dred guests. Geo, B. Fowler. 


ROCKBRIDGE BATHS. Location and Post-office, 
Rockbridge Baths, Rockbridge County, Va. 

Accress.—By the Baltimore & Ohio (Harper’s Ferry 
& Valley Branch) Railroad to Timber Ridge Station, 
thence by stage to the baths, four and one-half miles. 

THERAPEUTIC PROPERTIES.—These waters are princi- 
pally employed as baths. They contain iron, lime, soda, 
magnesia, potassa, and iodine. 

The springs are beautifully situated on the banks of 
the North James River, on the old stage road, passing 
through the celebrated Goshen Pass, from Goshen to 
Lexington, about ten miles from either place, amid some 
of the most picturesque scenery in Virginia. There are 
hotel accommodations at the baths. GaBAL. 


ROCK CASTLE SPRINGS. Location and Post-office, 
Rock Castle Springs, Pulaski County, Ky. 

Accress.—By the Louisville & Nashville Railroad 
(Knoxville & Bardstown Branch) to London, thence by 
stage to the Springs, eighteen miles. 

THERAPEUTIC PROPERTIES.—This is one of the waters 
which should prove beneficial in disorders of digestion 
and allied complaints, simply from its purity; as the 
writer holds that the imbibition of pure water (in excess 
in disease) is one of the greatest aids in treatment. 


Rocky Mt. Springs. 


ANALysIs (Dr. Peters).—Composition in 1,000 parts : 


Grains. 
Carhonate Ofaronerse cette raat ec rcie one ee ee .0045 
Carhonate‘ol limear.. ces sce sti eels sens nn oe eee ome ne .0488 
Carbonate of macnesiaiis. nei ack oe ddch coceccy ohn 0148 
(Held in solution by carbonic acid.) 
Silpbateror NM yen ees ec es here la ate Cole 0029 
Sulphate Ol mar wesian css. caste wemeraen a iene 008 
STU MALE/ Oly BOG Ger essen ci erstettante <lalesere cove scented eee otto .0531 
Chionidewttsodimts en cetacetee crc eeae ee .0026 
SHU KCT) Ris cicero mints Lack MICAS IER ip EAE OI See eee .0128 
EO allies tee ee Seat eerees Stat) Sr oP The eiere tA oie a ea Si hs 0.1881 


The water contains 0.980 part per thousand, by weight, of 
free carbonic acid. 


Rock Castle Springs is situated in Southeastern Ken- 
tucky, on the Rock Castle River, amid the wild and 
picturesque scenery of the Cumberland Mountains. The 
invigorating mountain air, the delightful atmosphere 
during the summer, the thermometer rarely rising above 
85° F., and then for a few hours only, the nights being 
so cool as to require blankets during the entire season, 
and the grand scenery, have made this a favorable resort. 
The hotel, surrounded with wide verandas and a beauti- 
fully shaded lawn, has accommodations for two hundred 
and fifty guests. It is situated in a gorge at the base of 
a mountain four hundred feet high, and looks out on the 
river, on the opposite side of which there is a correspond- 
ing mountain height. Hunting, fishing, boating, excur- 
sions to the numerous points of interest in the neighbor- 
hood, bowling, etc., furnish ample amusement for the 
guests of the hotel. George B. Fowler. 


ROCK ENON SPRINGS. Location and Post-office, 
Rock Enon Springs, Frederick County, Va. 

Accress.—By Baltimore & Ohio Railroad (Harper’s 
Ferry & Valley Branch) to Winchester, thence by stage 
to the Springs, sixteen miles and a half. 

ANALYysIS (Professors Gale and Mew. Chalybeate 
Spring).—One gallon contains : 


Grains, 

WALDONA LOCO LMI mane hci sre cinicees Pocieteletec ete e ¢ cus eres ALG 
Carbonate Of SOdaera auc: ok amiea ee aetna ase ve owen oe 1.21 
Carbonate of: protoxade of JPon ee... ona.eek occ oen.. ch 14.25 
Carbonate of protoxide of manganese................ 1.05 
Sniphateiol MACIESI any see scree sistas ole wie, oe svoncle ey aierale 12.89 
Up MAcCe OL MIM e sy senra ected ce eanecie cote rato, so stare ce 3.56 
Chiorideof maenesivim es. sae os. cea aaustoe ne coeeee 11S 
PE NUTROS UN OE oA hy SS eR PCE ee Ree OnE Opes OMICS Bee Tae 0.80 
SHIGE pk OB i Ali tone yess react ORs oe apo eR CC REM aes 0.42 

HOLE Lees mere et eee Ie Ca ais, re See ais torets oe aiek ates 40.43 


THERAPEUTIC PROPERTIES.—This is a quiet retreat, 
and the use of the alkaline calcic waters has been of 
great service to many worn and exhausted constitutions. 
Accurate thermometric records show that the tempera- 
ture during the summer never rises above 78° F. 

Besides the Chalybeate there are two other mineral 
springs: ‘‘The Walnut,” the water alkaline and its action 
diuretic and aperient, and ‘‘ The Old Capper,” efficacious 
in rheumatism and diseases of the skin. These three, to- 
gether with five limestone springs, are close by the hotel. 
In the neighborhood are four sulphur springs of excellent 
quality. 

Rock Enon Springs are situated in the northeastern 
part of Virginia, about forty miles west of Baltimore, on 
the western slope of the Great North Mountain, amid 
grand and picturesque scenery. The hotel possesses all 
the conveniences for the health, comfort, and amuse- 
ment of its guests. It is supplied on every floor with 
pure water from the ‘‘Great Cold Spring” on Pinnacle 
Mountain, and the sanitary arrangements are complete. 
There are delightful walks and drives through the sur- 
rounding mountains and valleys. 

The facilities for bathing are excellent, including hot 
and cold mineral and pure water baths, and a swimming 
pool seventy-five by twenty-five feet. 

George B. Fowler. 


ROCKY MOUNTAIN SPRINGS. JZocation, Boulder 
County, Col. ; Post-office, Jamestown, Boulder County, 


Col. Res 
Access.—By Union Pacific Railway (Colorado Divis- 


231 


Rocky Mt. Springs: REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Roetheln. 


ion) from Denver to Boulder, thence by stage twelve 
miles to Springs. 
Anatysis (C. T. Jackson).—One pint contains : 


Grains 
Garbonate Of s0day. =. .co., uisteuso se ereeee raeatote os 0.474 
Carbonate ol magnesia’... sacs cere eee tae 0.049 
Oarbonateof lime 0S. fe ic eteractore eiois coerce ee oe 5.414 
CarbonnteofibOn’..scscw . ae cate ero eae ee 0.262 
CRLOviGe DL SOGITIM oo eee eee cic er eet ome aac 0.620 


Sulphate of BOA, +. .neatea careoenl celeritete 18.075 


Todide and bromide of sodium... ...4.00k so. ee eniee 0.162 
Silicate Of BOdAw oo lee Re eee ree 0.500 
Total <2ccsiioe elev eae Sete ore rete C ee antes ener 20.656 


THERAPEUTIC PROPERTIES.—Mild alkaline, cathartic, 
and tonic waters. 

These springs are situated in Northern Colorado, two 
miles from Jamestown, at an altitude of six thousand 
five hundred feet above sea-level. There are hotels and 
bathing facilities at the Springs. George B. Fowler, 


ROETHELN. DEFINITION AND History.—Rotheln is 
an exanthematous disease of mild character, attended 
with a slight elevation of temperature, propagated by 
contagion, and bearing a close resemblance to measles and 
scarlatina. It is widely known in this country under the 
above appellation, and also, in common parlance, by the 
term ‘‘German Measles.” The latter name being Eng- 
lish, is generally used. Thus in its nomenclature Rétheln 
resembles the other exanthemata, which have each a 
technical and a common name. The Germans, however, 
use the names Rotheln and rubeola as synonyms ; and this 
tends to confusion, since we signify by rubeola the dif- 
ferent disease, true measles or morbilli. Various other 
names have been given to the disease by different writers, 
prominent among them being epidemic roseola, rubeola 
scarlatinosa, rubeola morbillosa, rubeola notha, and ru- 
bella. The last-mentioned name has been suggested as 
most appropriate, since it is a diminutive of rubeola, and 
thus the two words express the analogy existing between 
the two diseases, just as do the terms variola and vari- 
cella. For the reason, however, that R6étheln is more 
widely recognized, the writer retains it in this article. 

Rétheln is, as far as definite knowledge is concerned, 
a new disease. As late as 1886 the ‘‘ Index Medicus ” 
gives it no separate place, and the articles on the subject 
are grouped under the heading of measles ; yet the num- 
ber of communications, treating of this affection, which 
have been written during the past ten years or so, will 
aggregate more than one hundred. Before that time, 
however, the disease had been from time to time spoken 
of, as far back as a century and over; though until the 
time of the present generation the greater number of ob- 
servers did not consider it a distinct disease, but believed 
it to be a modification of measles, generally, and in some 
instances of scarlatina. Mention was made of epidemics 
in 1845 and 1853, and in 1873-74 the disease was carefully 
described, though under the name of epidemic roseola. 
In Germany attention was given to the subject many 
years before any English or American writings appeared. 
Now almost all physicians grant its individuality, and 
the arguments supporting this view will be presented 
hereafter. 

AGE OF PATIENTS. —R6theln is generally classed as one 
of the diseases of childhood ; and, since there are no 
clearly proved instances of its second appearance in the 
same individual, it follows that those affected are usually 
young in years; the general rule being that any one of 
the contagious exanthemata is experienced but once in the 
lifetime of an individual. Still, it is much less promi- 
nently an affection of infants and children under five 
years of age than are the other eruptive fevers. Adults 
are frequently attacked, but the majority of those who 
suffer from this disease contract it some time before the 
age of puberty. In other words, the time of life when 
susceptibility is greatest is between the ages of two and 
fifteen years. Young infants do not seem to contract it, 
and it is believed that sucklings are not susceptible. As, 
however, it is a disease of less frequent occurrence than 
measles or scarlatina, and as it seems to be less actively 


232 


contagious than those diseases, many growing children 
escape it ; and these facts constitute a possible explana- 
tion of the circumstance that adults are not infrequently 
attacked during the prevalence of an epidemic. 

The season of the year does not seem to exert any 
influence on its prevalence. Epidemics occur indiffer- 
ently in hot and cold weather. 

ErroLocy.—Rétheln is propagated by contagion, and 
by this means alone. The materies morbi is believed to 
be portable, but the cases in which the source can be 
traced point toward the necessity of close contact for 
the transmission of the disease from the sick to the well. 
In a single epidemic the total number of cases among 
those unprotected by having previously experienced the 
disease is found to be small in comparison with the 
other contagious exanthemata. Especially is this notice- 
able with reference to measles, which will attack, simul- 
taneously or successively, all the susceptible children in 
a household almost with certainty ; while we generally 
meet with a single, or perhaps two, cases of Rotheln, and 
the greater number of those exposed, in greater or less 
degree, escape. J. Lewis Smith, in one epidemic, saw 
forty-eight cases in twenty-one families—an average of a 
little more than two to each family. In an institution, 
such as an orphan asylum, the number of cases would 
be comparatively larger, since the exposure would be of 
necessity greater at first. Isolation, therefore, can be ex- 
pected to accomplish more in the direction of prevention 
than it does with measles or scarlatina. 

Rétheln is encountered almost exclusively in epidemics, 
and sporadic cases are very rare. This is probably more 
decidedly the case with Rétheln than it is with scarlatina, 
and possibly also with measles. 

Considerable difficulty is experienced in tracing cases 
of Rétheln to their sources—largely, no doubt, because 
affected persons are frequently unconfined, owing to the 
general mildness of the disease, and the absence of alarm 
concerning it. Undoubtedly, however, if its origin could 
always be traced, an exposure to contagion would be dis- 
covered. In other words, it is practically certain that 
the disease does not originate de novo ; nor is it produced 
by general causes, such as improper hygienic surround- 
ings in the matter of poor ventilation, overcrowding, 
or insufficient or improper dietary conditions. On the 
contrary, it is not found to be a disease of greater pro- 
portionate prevalence in tenement-house districts, where 
the conditions referred to are in prominent existence. 
A large proportion of the cases are encountered in the 
families of the better classes, and, most of all, in insti- 
tutions, such as orphan asylums. 

We may reasonably conclude that Rétheln is less ac- 
tively contagious than measles or scarlatina, since so 
many of those exposed escape. Under the same condi- 
tions of exposure the number of cases arising of either 
of those two diseases would probably considerably ex- 
ceed those of Rétheln. 

The age at which susceptibility is greatest has been 
mentioned, being considerably more advanced than that 
which obtains with the other exanthemata; but as yet 
there is little definite knowledge as to the stage of the 
disease itself in which propagation by contagion is most 
likely to occur. We can only say that the probability is 
in favor of contagiousness during the whole course of 
the disease—from the time when prodromal symptoms, 
if present, appear, until the eruption has entirely disap- 
peared. 

CuinicAL History.—Stage of Incubation.—Much at- 
tention has been given to the duration of the stage of in- 
cubation—the time elapsing between a traceable exposure 
and the onset of the disease. This is frequently made 
difficult of accurate investigation for the reason before 
mentioned, that isolation is not observed because of the 
mild character of the affection, and sometimes even con- 
finement within doors is not enforced. The general ex- 
perience is that this stage occupies from fourteen to 
twenty-one days; though in some epidemics the dura- 
tion has been considerably less. Shuttleworth had the 
opportunity of ascertaining, in an asylum, that twenty- 
one days elapsed after the first case before the second oc- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Rocky Mt. Springs. 
Roetheln. 


curred, isolation being enforced, and two days later two 
fresh cases developed. Goodhart says that the incuba- 
tion, in 23 out of 25 cases, was from fourteen to twenty- 
two days. Edwards gives six days as the shortest, and 
twenty-one days as the longest. Cheadle ascertained it 
to be eight days in one instance, nine in another, and 
(approximately) twelve days in five more. Griffith’s ex- 
perience was that in 26 cases the eruption appeared be- 
tween the fifth and twelfth days after the first case. 
Therefore, it must be granted that considerable variation 
exists in the length of this stage, although we may con- 
sider that a period of fourteen days represents the aver- 
age. The incubative stage of measles is much more con- 
stant—standing at thirteen and fourteen days. 

Stage of Invasion.—In very many instances the eruption 
is the first thing calling attention to the existence of sick- 
ness. Since many of the patients are old enough to de- 
scribe any subjective symptoms which may be present, 
it follows that the stage of invasion is frequently attended 
with little or no disturbance of general health. With 
children too young to describe their own sensations, the 
attention of parents is often attracted by no manifestation 
whatever—such as restlessness, or crying, or digestive 
disturbance—until the eruption becomes visible. It is, 
however, probable that there is always present a slight 
rise of temperature, not sufficient to cause discomfort ; 
and close questioning might elicit an admission of a feel- 
ing of malaise. But, as stated, the breaking out of the 
rash is what causes uneasiness, and leads patients or par- 
ents to consult a physician for the purpose of ascertaining 
the nature of the sickness. 

There are, on the other hand, cases in which there is 
more or less decided disturbance of health prior to the 
appearance of the eruption. Epidemics undoubtedly 
vary greatly in severity, as do individual cases in a single 
epidemic ; and from the average of descriptions it would 
appear that the disease is more severe, as well as of 
more frequent occurrence, in Europe than in the United 
States. ‘These more severe cases present certain indica- 
tions of sickness, before the rash appears, which, taken 
in connection with known exposure, point toward Rétheln 
as the oncoming disease; but, in themselves, they have 
little value as regards the differential diagnosis, especial- 
ly, from scarlatina and measles. The symptoms, when 
present, have special reference to the mucous membranes 
of the air-passages, and to the digestive system. They 
are: mild inflammation of the throat and tonsils, shown 
by swelling and redness on examination, and by pain and 
slight cough ; a slight degree of coryza ; conjunctival 
irritation, lachrymation, and a little tendency to eedema- 
tous swelling of the eyelids. Nausea and anorexia have 
been frequently observed, and in rare instances vomit- 
ing. Frontal headache in a few instances is the source 
of much discomfort. The digestive disturbances appear 
to have been prominent in some, and absent in other, 
epidemics. With these symptoms, and, it is not improb- 
able, in their absence, there is a rise of temperature to 
99° or 100° F. in mild, and as high as 103° in severe, cases. 
In addition to these indications there is one symptom 
highly characteristic of the fully developed disease, as 
will hereafter be seen, which has been observed in the 
prodromal stage. This is enlargement of the post-cervi- 
cal lymphatic glands—not those at the angle of the jaw, 
as obtains in scarlatina and diphtheria, but those in the 
back of the neck. This enlargement should always be 
looked for, since it is the only feature of diagnostic value 
in the stage of invasion. Jaccoud found it, in five out of 
thirty-two cases, four or five days before the efflorescence. 
Associated with this, stiffness of the neck with pain on 
movement of the head, in slight degree, should be sought 
for. 

Any throat inflammation present might easily be ac- 
counted for in expecting scarlatina to develop ; and 
coryza, cough, and conjunctival irritation belong to the 
clinical history of measles. Rise of temperature also, of 
course, accompanies the onset of both these diseases ; 
and consequently, excepting only the glandular enlarge- 
ment, as far as these general symptoms are concerned, 
it is only in their lesser degree of severity that they are 


characteristic of Rétheln rather than of the other two af- 
fections. 

. These indications, when present, precede the eruption 
by a period, in the great majority of cases, of less than 
twenty-four hours ; although in some instances malaise is 
present for three or four days before this stage is ended. 
Cheadle, in describing a severe epidemic, observed that 
the prodromal symptoms persisted longer in severe than 
in mild cases. Edwards gives the average duration as 
three days. 

It is therefore observable that the stage of invasion, 
when present, is subject to considerable variation—both 
as to length and severity—and is, in fine, a much more 
uncertain quantity than is that of scarlatina or measles. 

Stage of Hruption.—The prominent feature of the dis- 
ease is the eruption, often, as before stated, being the 
only phenomenon perceptible, and generally being by 
far the most prominent manifestation of a condition of 
sickness. Very great differences, in different epidemics 
and in individual cases, are to be found; and, consider- 
ing the eruption alone, a diagnosis might well be diffi- 
cult, if not impossible. As the symptoms other than the 
eruption, such as those found in the prodromal stage, 
present considerable variation, and as this fact holds 
with the eruption itself, we may conclude that the dis- 
ease, as a whole, is far less stable than scarlatina and 
measles. These are more than variations of degree— 
they affect the essential characters of the symptoms and 
of the eruption. 

Scarlatina, for instance, may be very mild or very 
severe as regards the throat inflammation and fever ; and 
its eruption may be difficult of detection, or as marked 
as a pronounced rash of erysipelas ; but these are differ- 
ences of degree, and the sore throat and eruption are uni- 
formly present, and are sw? generis. The same rule holds 
with measles. The essentials of the disease—the catarrh 
of the respiratory tract, and the characteristic eruption— 
may, one or both, be very mild or very severe ; but they 
must both be present in any case where the diagnosis is 
undoubted. Rdotheln, on the other hand, may consist, 
from beginning to end, of the eruption only, or may 
present some of quite a variety of symptoms affecting 
the mucous membranes of the air-passages or of the 
digestive apparatus. 

Regarding the eruption itself, its characteristic points 
are as follows: Its color is generally a pale rose, less 
distinctly rose-hued than that of measles. It is very fre- 
quently brownish, brownish-red, and sometimes quite 
distinctly brown, with no tinge of rose or pink to be de- 
tected, and giving the general effect of duskiness. 

As to location, no part of the surface is entirely ex- 
empt. The palms of the hands, the soles of the feet, and 
the scalp have been observed to present it ; although usnu- 
ally it is not to be found in those regions. Asa general 
rule, the face, trunk, arms, and legs break out successive- 
ly before the final disappearance of the rash; although 
cases are often described in which the affected area is 
much less extensive. 

Either the face or the upper part of the body may be 
first affected, and the spread of the eruption is rapid—one 
day or less sufficing for its appearance on the remoter 
parts after its initial appearance. The maximum of in- 
tensity is very quickly attained. Beginning on the face, 
for example, in very faintly marked spots, after a period 
of a few hours, and certainly within one day, it will be at 
its height, and the spots will be plainly visible. Then 
a fading process sets in, gradually progressing, accom- 
panied with, or followed by, some desquamation, and 
continuing for about two days; so that, in any selected 
locality, from the first appearance to the final disappear- 
ance, an average period of three daysisoccupied. This, 
however, is not a definitely fixed time ; sometimes it 
embraces but two days, and at other times it is protract- 
ed to six or seven. 

The duration of the eruption as a whole, without ref- 
erence to any special part of the surface, is consequently a 
little longer than that of its presence in a given locality— 
by the time occupied in the spreading from the region 
first to that last attacked. As this generally requires one 


233 


Roetheln. 
Roetheln. 


day, or somewhat less, the eruptive stage of the disease 
can be expected to continue about three days on the 
average, though subject to the variation spoken of, hav- 
ing as extremes two and seven days. It will be observed, 
from the rapidity of development in a selected locality 
as compared with the rapidity of the spreading to other 
regions, that different parts will present the eruption in 
greatly varying conditions; and that at no given time 
will it be at its maximum uniformly over the entire sur- 
face of the body. In other words, it may even reach its 
height in one part before appearing in another. This is 
a point of value in diagnosis, and of contrast to scarla- 
tina and measles, in both of which there is generally a 
stationary period as regards the spread and intensity of 
the eruption after the maximum has been attained. 

The eruption is papular. If the hand is passed gently 
over it, a sense of roughness, at least, is perceptible, 
showing a certain degree of elevation above the surround- 
ing skin. From this very slight condition of elevation 
differences are to be found up to a state in which the 
elevation is distinctly and at once visible—as much so as 
in a fully developed rash of measles. But, in some de- 
gree, elevation of the spots is always present, and there- 
fore it is a mistake to describe the eruption as macular. 

The size of the papules is one of the points in which 
there is considerable variation. In general they are 
smaller than the papules of measles, varying from the dia- 
meter of a pin’s head to that of a pea. In a certain 
proportion of cases the spots are so small as to constitute 
mere punctation, and the skin presents the appearance of 
being covered with innumerable fine dots. They are of 
irregular shape, but with a more decided tendency to as- 
sume the circular form than those of measles. In a given 
case there is generally some uniformity in the matter of 
size—either the papules are for the most part of the larger 
size, or they are nearly all small. Still greater differences 
of size have been described, however, papules of one-third 
of an inch in diameter having not infrequently been en- 
countered. 

Generally the skin between the papules presents a per- 
fectly healthy appearance, although careful investiga- 
tion will occasionally reveal the existence of minute fine 
lines or processes connecting adjoining papules. <A gen- 
eral erythematous redness of the skin has also been no- 
ticed. Confluence of the papules is very rare, though 
not uniformly absent. 


Vesicles have been observed, but this has clearly been 


a coincidence, and not at all a part of the ordinary course 
of the eruption. They are probably found quite as often 
with measles, and in either case must be regarded as 
anomalous. The eruption has been observed to suddenly 
disappear, and after a short time to reappear ; and unus- 
ual warmth, as from heavy clothing, renders it more dis- 
tinctly visible. A certain amount of itching is often pres- 
ent, though not severe, and the heat and burning, which 
are a source of discomfort in scarlatina and measles, 
are not at all pronounced in Rotheln. 

To sum up the characteristics of the eruption, we may 
make a division of the cases into two classes, which cor- 
respond with the descriptions formerly given of rubeoloid 
Rotheln on the one hand, and scarlatinoid on the other. 
In each variety the tesemblance to the other disease, as 
far as the eruption is concerned, may be very close— 
often sufficiently so to render the diagnosis extremely 
uncertain, if the other points of history and symptoma- 
tology be not carefully considered. 

In the first class of cases, comprising the greater num- 
ber, the papules are of larger size, perhaps abundant 
enough to be considered confluent, of somewhat irregular 
shape, pale rose color, and raised considerably above the 
skin. It will be seen that this state of affairs can obtain 
with measles quite as well as with Rotheln. 

In the second class the papules are smaller, more cir- 
cular in shape, less elevated above the skin, of darker 
hue, much more numerous, and sometimes very closely 
aggregated, so as to give the punctated appearance al- 
luded to. If this be the appearance, there may easily be 
nothing in the eruption by which to discriminate it from 
a scarlatinal rash at the onset or during the first day of 


234 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the disease. A fully developed rash of scarlatina is con- 
tinuous, leaving no skin normal in appearance between 
the eruptive spots; and in Rotheln the papules are dis- 


tinctly separated from each other. 


Taking, therefore, an extreme case of either variety, 
it will be found that other points in symptomatology and 
history are requisite, and possibly a delay for one or two 
days may be necessary, in order definitely to eliminate 
doubt in the diagnosis. 

Desquamation.—Desquamation is the mode, or perhaps 
a better term would be the accompaniment, of the termi- 
nation of the eruption, beginning on the second or third 
day. It is furfuraceous in character, never occurring in 
large scales or pieces of skin as in scarlatina. It is fine, 
and in this resembles more the desquamation of measles. 
It is much less decided than in scarlatina, and is often so 
slight in amount as to be perceived only on very care- 
ful inspection, and frequently passes unnoticed by either 
the patient or the physician. Many writers on the sub- 
ject do not make mention of the process, and frequently 
the statement is made that it is not a part of the clinical 
history of the disease. The writer cannot contradict this, 
though holding the view that it is present in some de- 
gree in all cases. As fading of the color of the eruption 
very quickly sets in, and is progressive until its final dis- 
appearance, the desquamation is the accompaniment of 
this. 

The desquamation is not to be found affecting at one 
time the entire surface which has presented the eruption. 
It follows the appearance of the rash, and, consequently, 
is visible on one part of the surface before it is on an- 
other. Furthermore, it does not take place over the 
entire affected surface—much of the eruption fades away 
without desquamation, and the latter is to be searched 
for about the trunk, legs, and arms especially. The face 
and extremities usually escape. In this there is another 
point of resemblance to measles. 

Following the customary division of the eruptive fevers 
into stages, we may consider the stage of desquamation, 
fading, or decline, to occupy the time from the second 
day of the eruption to the end of the disease. But it 
must be borne in mind that the line of division between 
these two stages, v.e., of eruption and of desquama- 
tion, is much less distinctly marked than in scarlatina 
or measles. 

Occasionally a faint staining or pigmentation has re- 
mained for several days after the disappearance of the 
rash proper. 

Symptoms other than the Eruption.—These have been 
in part considered under the head of premonitory symp- 
toms, or those presenting themselves in the stage of inva- 
sion, and are, in great part, simple continuations of them. 
They are found, like those of scarlatina and measles, to 
have special reference to the mucous membranes of the 
nose, throat, and conjunctiva, together with more or less 
disturbance of the digestive functions. The inflamma- 
tory condition of the throat and tonsils, which is the 
most frequent of these symptoms, varies greatly in de- 
gree, and, beginning in the stage of invasion, persists up 
to the time when the rash has reached its height, and 
then subsides with the disappearance of the rash. Slight 
cough sometimes persists a few days longer. The con- 
junctival irritation and the cedematous swelling of the 
eyelids are not often pronounced, and follow much the 
same course as the throat-symptoms. 

The nausea, which presents itself often enough to call 
for special mention, is generally noticeable only until the 
rash has developed. 

The tongue is commonly coated, but does not at all pre- 
sent the appearance of the strawberry tongue of scarla- 
tina. All these symptoms, when present at all, are of 
decidedly milder character than they are in scarlatina 
and measles. 

The temperature range has been referred to as being 
liable to differences in epidemics and in individual cases. 
As a general rule, the rise is much less than that of the 
two other diseases. An elevation of one to two degrees— 
to 994° or 1003° F.—is what we may look for, persisting 
about three days, and in the given case not presenting 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Roetheln. 
Roethelin,. 


the fluctuations characteristic of measles, but remaining 

at the same level until its final subsidence. 

The pulse and respirations are accelerated in propor- 
tion to the rise of temperature. 

In general a severe case presents a greater variety of 
these symptoms, as well as a greater severity, and a mild 
case, absence, or nearly such, of them. 

The single phenomenon, over and above the eruption, 
which is characteristic, and one might almost say pathog- 
nomonic, of Rétheln, is the enlargement of the post-cer- 
vical and sub-occipital lymphatic glands. Probably in 
no case is it found wanting. This occurs at the onset of 
the disease, and therefore, as stated, may not infrequent- 
ly be discovered before the appearance of the eruption. 
The number of glands affected varies from one or two 
up to seven or eight. Search should be made for them 
from the occiput down to the level of the shoulders, and 
toward the middle of the neck rather than at the sides or 
near the angle of the jaw. In scarlatina, diphtheria, and 
other throat affections, the glands which present enlarge- 
ment are those at the angle of, as well as beneath, the 
lower jaw. In such instances the swelling seems to be 
proportionate to the severity of the throat inflammation, 
and to be associated with it, as in adenitis in the neigh- 
borhood of inflammation elsewhere in the body. But the 
adenitis of Rétheln cannot be so explained, as it is found 
equally in the cases with considerable sore-throat, and in 
those with none. Therefore it should be regarded as a 
distinct phenomenon of the disease, and not as an acces- 
sory. 

Associated with the enlargement is stiffness of the 
neck, and pain on moving the head, in some degree, 
though never very severe. The enlargement itself va- 
ries, the glands being of about the size of a split pea or 
bean ; suppuration does not occur, and the swelling and 
pain subside with the disappearance of the eruption. 
Occasionally a single gland will remain perceptibly en- 
larged, though painless, for an indefinite length of time. 

Valuable as this point is, there are yet sources of er- 
ror, and glandular enlargement from other causes must 
be excluded. 

The condition which we recognize as struma, indicat- 
ing the general condition of ill-health due to bad hygienic 

surroundings and malnutrition, has, as a prominent feat- 

ure, general glandular enlargement, perceptible in the 
groins, axillee, etc., as well as in the neck ; and syphilis 
may present the same condition. Accordingly, search 
should be made in those other localities before assigning 
a cervical adenitis to an oncoming, or present, attack of 
Rotheln. Enlargement of the glands at the angle of the 
jaw is to be attributed to other causes, Children with 
eczema capitis have, almost always, large lymphatic 
glands in the neck. 

During an epidemic of measles in 1886, the writer 
made investigation with special reference to this point, 
and found that in 24 out of 29 cases an enlargement of 
glands exactly similar to that of Rotheln was present, 
and constituted a prominent feature of the cases. This 
was evidently a peculiarity of that epidemic, as the writer 
has neither before nor since found it to be the case, ex- 
cept in isolated instances, Griffith states that he has not 
infrequertly found it. Care was taken to render the di- 
agnosis of measles certain, and mention is made of this 
point here to show that the adenitis characteristic of 
Rétheln is not absolutely pathognomonic, and will not in 
itself suffice for differential diagnosis from measles. 

Non-identity with Measles and Scariatina.—The writer 
has, of necessity, made frequent mention of Rotheln as 
contrasted with scarlatina and measles, and the reasons 
for considering it to be an independent disease must now 
be considered. There are still some who consider it a hy- 
brid, consisting of elements drawn from both those dis- 
eases, and being intermediate in character between them. 
This position is scarcely tenable, and is not supported 
by clinical facts; since the greater number of cases, 
though having points in common with both, present, 
each one, strong points of resemblance to one or the 
other of the two affections, and not to both at the same 
time. That is, any single case is either decidedly scar- 


latinoid or decidedly rubeoloid ; and the differential diag- 
nosis lies between two and not three diseases, Further- 
more, hybrids are not at all common, and analogy is 
opposed to this view. Generally, what is called a hy- 
brid can be resolved into its elements, and may be pro- 
nounced a conjunction of two or more disease-conditions. 
Undoubtedly scarlatina and measles may be found co- 
existing in the same individual, or following each other 
so closely as to overlap, the inmates of a household 
being exposed to and contracting both diseases at the 
same time, or in rapid succession. These cases, how- 
ever, present the phenomena of both diseases in such a 
manner and degree as to exclude uncertainty in the diag- 
nosis, and they bear no closer resemblance to Rétheln 
than any single well-pronounced case of either disease. 

The question of its identity with one or the other of 
these diseases calls for more careful consideration. 

There are but few who believe Rétheln to be identical 
with scarlatina, but many consider it of the same nature 
as measles. In a scarlatinoid case the principal points 
in common are: the short: period of invasion, the exist- 
ence of some sore-throat, and the fine punctate appear- 
ance of the rash at first. R6theln is liable to be con- 
founded only with a very mild case of scarlatina ; for the 
vomiting, high fever, pronounced sore-throat, and char- 
acteristic tongue of average scarlatina are not encoun- 
tered in the former disease. The points of difference 
are most prominent in the longer duration of the eruption 
in scarlatina, its greater uniformity, its macular charac- 
ter, the nature of the desquamation, and the presence of 
sequele which do not occur in Rétheln. In addition to 
which the adenitis of Rétheln is not to be found in the 
other disease. 

As to measles, the similarity also exists in a certain pro- 
portion of cases of mild character. The symptoms which 
may be common to both are the rose color and papular 
character of the rash, the shorter duration of the period 
of eruption, the fine desquamation, and possibly the 
adenitis. The main point of difference is the presence, 
in measles, of two or three days of fever, with catarrhal 
inflammation of the respiratory mucous membranes, 
uniformly preceding the eruption. The sequele of 
measles, also, are not to be expected in Rotheln. 

As stated, these resemblances are encountered only in 
extreme cases. Average cases of each disease have spe- 
cial characteristics sufficient to clear away doubt ; and the 
differences just enumerated go far toward proving non- 
identity in either direction. But the strongest reason 
for believing in the individual nature of Rétheln—consti- 
tuting, indeed, a conclusive proof—is that no mutual 
protection is afforded. That both scarlatina and measles 
are, if the expression be allowed, auto-prophylactic, has 
been proven by thousands of observations. Second at- 
tacks of scarlatina are so rare as to be curiosities in the 
history of medicine ; and with measles, although the rule 
is not so free from exceptions, yet a second attack is a 
very infrequent occurrence. This rule applies to Rétheln. 
As yet there are few, if any, authentic records of second 
attacks. But when the question of mutual protection, 
which would be a sine qua non to the supposition of 
identity, is considered, the most conclusive evidence of 
its absence is presented. 

Of J. Lewis Smith’s 48 cases, 19 had had measles, and 
1 contracted the disease subsequently. Of Shuttleworth’s 
30 cases, more than half had had measles, and 4 scarla- 
tina. In one case the patient had measles five months, 
and scarlatina one month, before. In 18 of the cases, 
where subsequent observation was possible, 7 contracted 
measles, and 6 scarlatina, after the lapse of a few years. 
Goodhart observed that 39 out of 63 cases had had 
measles. 

Instances might be multiplied to a very large number, 
but it is unnecessary ; for the non-existence of mutual 
protection is too well established to admit of doubt. 
There is, however, another aspect of this question, or, 
rather, another explanation of the facts, which has been 
presented with considerable appearance of probability. 
It is that R6étheln is simply the modification of measles 
presented in second attacks, bearing the same relative 


235 


Roetheln. 
Roses. 


position that varioloid does to small-pox. There are two 
reasons for regarding this position as untenable. The 
first is, that pronounced attacks of true measles have, in 
a large number of instances, followed, and not preceded, 
Ro6theln, and these cases have presented no modification 
in kind or severity of the symptoms which go to make 
up the clinical history of measles. This applies with 
equal force to scarlatina. The second reason is, that in 
the individuals who have been the subjects of second 
attacks of measles, the symptoms have been as uniform 
and pronounced as in the first. 

On the contrary, a much closer analogy can be traced 
between small-pox and varicella on the one hand, and 
measles and Rotheln on the other. The ratio is much the 
same in regard to corresponding severity, and in similar- 
ity of appearance of the eruption. 

The final separation, in the minds of medical men, of 
the former pair from each other, was beset by the same 
uncertainties as that of the latter. 

Another fact of significance is that Rétheln occurs in 
epidemics, when neither scarlatina nor measles is pre- 
vailing ; and, in the same epidemic, most of the cases 
will be rubeoloid, and a smaller number scarlatinoid. 

Text-book descriptions of measles commonly refer to 
a variety of the disease under the designation of ‘‘ ru- 
beola sine catarrho,” this name indicating a condition in 
which there is fever, with an eruption similar to that of 
ordinary measles, and at the same time absence of the 
inflammation of the respiratory apparatus. Perhaps it is 
fair to consider these as cases of Roétheln ; and a significant 
observation made by Watson, in his ‘‘ Practice of Med- 
icine,” gives support to this view. He says: ‘‘It is ob- 
served that rubeola sine catarrho confers no protection 
against recurrence—is commonly succeeded by an attack 
of measles in its true form.” Meigs and Pepper make 
the same observation as to their experience. 

To summarize, the points demonstrating the non-iden- 
tity of Rétheln with measles or scarlatina are : 

1. The difference in clinical history. 

2. Absence of mutual protection. 

3. Absence of modification in second attacks of those 
two diseases. 

4, Occurrence of epidemics while the other two are 
not prevailing. 

5. In any epidemic, resemblance of some of the cases 
to one, and of some to the other, of the two diseases. 

A further differentiation of the two varieties into two 
distinct diseases is possible ; but it would be a refinement 
almost beyond our present powers of observation. 


Dracnosis.—The diagnosis is principally made by pro-. 


cess of exclusion, because, at the outset, the presence of 
scarlatina or measles is generally suspected. From scar- 
latina at the outset, or in the first day or two of sickness, 
in certain mild cases, the points of difference are: In 
Roétheln, the absence of, or presence in a milder degree, 
of sore-throat ; the absence of the strawberry tongue, and 
the existence of a whitish coating if any change be pres- 
ent; the absence of continuity of the eruption ; and the 
presence of post-cervical adenitis, the glands at the angle 
of the jaw being unaffected. After the lapse of two or 
three days the course of the eruption in Roétheln is to 
reach its maximum and begin to disappear quickly, and 
the desquamation, ‘when perceptible, is fine, and not in 
flakes or patches of some size. 

Pronounced cases of scarlatina do not resemble Rétheln 
sufficiently to render the diagnosis uncertain. 

From measles the discrimination is to be based mainly 
on the absence of the stage of fever with catarrh pre- 
ceding the eruption, or its very mild character and 
shorter duration. The cervical adenitis has much weight, 
though it is not absolutely conclusive. Though the 
rash may very closely resemble that of measles, yet the 
papules are less elevated, smaller, less aggregated, less 
decidedly rose-colored, and run their course more quickly 
—desquamation setting in two or three days before it 
would be likely to occur in measles. 

Subjoined is a comparative table of these three dis- 
eases in their different stages, giving also the average 
duration of each stage. 


236 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


SCARLATINA, MEASLES. 
Stage I.—Incubation. 
Duration, sixtotwenty- Two to fourteen days, 
one days. 
Inconstant, 


ROTHELN. 


Twelve to fifteen days, 


Constant. 
Stage I1.—Invasion. 


Less than one day. 
Never absent. 
Vomiting. 

Decided sore-throat. 


Two to four days. 
Never absent. 


One day or less. 
Often absent. 
Malaise, slight. 
Sore-throat and lach- 
rymation. 


Drowsiness, cough, co- 
ryza, conjunctivitis, 
photophobia. 

Cervical adenitis. 


Temperature, 99°-100°, Temperature, 108°+. Temperature, 102°+. 


Stage ITT.—Eruption. 


Six to eight days. 
Begins on chest. 
Macular. 


Four to five days. 
Begins on face. 
Papular, decidedly. 


Three days. 
Begins on face or chest. 
Papular, slightly. 


Pale rose, or darkerand Deep-red scarlet. Rose. 
brownish. 
Not continuous, Continuous. Not continuous. 
Ceases spreading in Ceases spreading in Ceases spreading in 


three or four days. 
Stationary period of 

two to three days. 
Burning, often great, 


two or three days. 
Stationary period of 
two to three days. 
Burning and itching, 
decided. 


one or two days. 
No stationary period. 


Burning or itching, 
slight. 
Stage IV.—Desquamation., 


Very slight and fine. In scales of quite large Furfuraceous,and often 


size. not pronounced. 
Overlaps stage of erup- Preceded by stationary Preceded by stationary 
tion. period. period. 


Lasts two orthreedays. Lasts ten days, and Lasts about four days, 


sometimes longer. 


= Leaves dull colored 
stains. 
Complications, 
Acute form of Bright’s Bronchitis. ’ 
disease. 
None characteristic. Rheumatism. Pneumonia. 


Otorrhoea,and necrosis Tuberculosis, 
of temporal bone. 
Inflammation of the in- 
testines, 

In addition to these other exanthemata, certain simple 
skin diseases must be considered in the diagnosis. Some- 
times the eruption of miliaria papulosa (prickly heat) 
resembles that of R6étheln ; but it occurs in well-defined 
patches of several inches in diameter, is associated with 
unusual sweating, and lasts many days longer. Also, 
there are no febrile and constitutional symptoms accom- 
panying miliaria, and the itching is usually great. 

The most careful investigation possible into the origin 
or sources of contagion should be made; and in cases of 
doubt a positive diagnosis should be withheld for one or © 
two days. It may be advisable to explain the uncer- 
tainties, and to adopt the precautions as to isolation, etc., 
necessary in scarlatina. 

CoMPLICATIONS.—Complications or sequele charac- 
teristic of the disease do not exist. A condition of 
transient albuminuria is spoken of, but it is not indica- 
tive of renal disease. After the rash disappears we may 
expect to find the usual condition of health present. The 
prognosis is therefore good. 

TREATMENT.—Because of the mildness of the disease 
there is generally nothing called for in the matter of 
medication—simple restriction of diet and avoidance of 
exposure during the continuance of the elevated temper- 
ature being all that is necessary. Practically the inter- 
est and importance attaching to Roétheln lie in recogniz- 
ing it as a separate disease, and in the exclusion of the 
more serious affections, scarlatina and measles. 

BrBLIoGRAPHY.— Besides the treatises of Meigs and 
Pepper, J. Lewis Smith, Vogel, Day, Goodhart, Eustace 
Smith, and Ellis, on ‘‘ Diseases of Children ;” those of 
Bristowe, Bartholow, Loomis, Aitkin, and Flint, on the 
‘* Practice of Medicine ;” and Da Costa’s work on ‘‘ Med- 
ical Diagnosis,” the following articles may be mentioned : 
Hardaway, in ‘‘ Pepper’s System of Medicine ;” Harts- 
horne, in ‘‘ Reynolds’s System of Medicine ;”” Thomas, in 
‘*Ziemssen’s Cyclopzedia ;” Cheadle, Shuttleworth, and 
Squire, in the ‘‘ Trans. Internat. Med. Cong.,” 1881 ; 
Griffith, in the N. Y. Medical Record, July 2 and 9, 1887 ; 
Edwards, in the Am. Jour. Med. Sct., 1884; Jones, Bos- 
ton Med. Journ., 1881; Sholl, Med. and Surg. Reporter, 
1882; T. D. Swift, NW. Y. Medical Journal, November 
27, 1886; Harrison, Am. Journ. Obstet., 1885 ; Duck- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Roetheln. 
Roses. 


worth, Erskine, and Gowers, in London Lancet, 1880 ; 
Dukes, ibid., 1881 ; Yonge-Smith, ibid., 1883 and 1886 ; 
Strover and Jaccoud, ibid., 1886; Shuttleworth, Brown, 
Burnie, Davis, Rooke, and Wilson, in Brit. Med. Journal, 
1880 ; Byers and Sadell, ibid., 1881; Lawrence, ibid., 
1882 ; Shackelton and Cullingworth, ibid., 1883; Mc- 
Leod, ibid., 1885 ; and Ryle, ibid., 1886. 
Thomas D, Swift. 


ROHITSCH-SAUERBRUNN, an Austrian spa, lies in 
a well-protected valley, near Poltschach, Steiermark, at 
an elevation of about eight hundred feet above sea-level. 
It contains seven medicinal springs, the waters of two of 
which only, the Moritzquelle and the Tempelbrunnen, 
are used internally. The following is the analysis of the 


Tempelbrunnen. Each litre contains : 
Grammes 

Podium Chloriden.. -eeeveemerraas cae ee Sat OBE 0.094 
MOGMn BUlDNALOMN es anne Semon sie ob aks Tas Set 2.024 
Podiura bicarbOnater seem eto aces oe cee cece ce 1.075 
Oalcnimebicarbonelewesensass cock oaks sck tet 2.226 
Maonesilim-sbicarvonate saemenecintas sitcce «okie ce ciate 1.970 
Ferrous; bicarbonate juss. cenc neeere mee ck oc sie os cele ae. 0.041 
Organicymatterse etc. mee tees bec ce tes ccs s 4a F a «F's 0.025 

PEO GEL eee eter a ce aeRO ao cial cote ake eis, aver eae ne fuss 4.425 


There is a variable amount of free carbonic acid gas. 


The waters of Rohitsch are employed in the treatment 
of chronic catarrhal affections of the respiratory and di- 
gestive systems, corpulence, malarial cachexia, and pas- 
sive congestions of the abdominal viscera. 

The season extends from the 
gel. 3: 


The climate is mild. 
first of May to the middle of September. 


ROSEMARY § (Rosmari- 
nus, U. S. Ph.; Romarin, 
Codex Med.), Rosmarinus 
officinalis Linn.; Order, 
Labiate. Thisisa fragrant, 
evergreen shrub, from two 
to four feet high, with 
numerous grayish-brown 
branches. Twigs square, 
gray, covered with stellate 
hairs. Leaves from one- 
half to one inch or more 
long, thick, leathery, lin- 
ear, blunt, with revolute 
margins, ertire, dark green 
and shining above, covered 
with white stellate hairs 
beneath. Flowers axillary, 
in pairs, half an inch or so 
long, pale lilac ; calyx, two- 
lipped ; corolla also labiate, 
the upper lip bifid, the 
lower of three diverging 
lobes, the middle one of 
which is much the largest 
and deeply concave. Sta- 
mens four, the two upper 
rudimentary. Style long, 
ovary of four, nearly sepa- 
rate, rounded carpels. 
Fruit, four subglobose 
achenes. Rosemary is a 
native of the Mediterranean 
region (Southern Europe, 
Asia Minor, Northern Afri- 
ca, etc.). It is also an old 
and widely cultivated gar- 
den-plant. The pungently 
aromatic leaves are offici- 
nal. 

The principal constituent 
of Rosemary is the essential 
owl, a composite substance ' 
consisting of two or more Fie. 3347.—Rosmarinus Officinalis ; 
hydrocarbons Bud icawaten: flowering branch. (Baillon.) 
roptene. It is ‘‘a colorless or yellowish liquid, having 
the characteristic pungent odor of Rosemary, a warm, 


somewhat camphoraceous taste, and a 
neutral or faintly acid reaction. Sp. 
gr. about 0.900. It is readily soluble 
in alcohol.” 

This plant has the general aromatic 
properties of the rest of the order, but 
from its less agreeable taste is not so 
often given internally 
as the mints proper. al 
Its pleasant odor, on <\QSss 
the other hand, makes { 
it, like Thyme, Patch- 
ouly, etc., a pleasant ad- 
dition to liniments and cosmetics. 
Rosemary leaves are one of the ingre- 
dients of the obsolete Aromatic Wine 
(Vinum Aromaticum, U. 8. Ph.), of 
which they comprise one per cent. 
The oil constitutes one per cent. of 
Soap Liniment, two per mille of Com- Fie. 3848.—Rosmari- 
pound Tincture of Lavender, and nus Oficina lis; 
cight of the officinal Cologne Water. PRR CAT 

ALLIED PLANTS, ETC.—See PEPPERMINT. 


W. P. Bolles. 


ROSES. These beautiful flowers contribute far more 
to man’s pleasure than to his necessities. The -genus 
Rosa gives the name to the great order Rosacew, and is the 
type of one of its divisions. It contains numerous not 
well-defined species of upright, climbing, or sprawling, 
mostly prickly, shrubs, with odd pinnate, conspicuously 
stipulate leaves, and terminal or clustered, showy, sweet- 
scented flowers. The floral envelopes and stamens are 
borne up on the thickened rim of a deep, vase-like, hol- 
low receptacle, whose inner surface is covered with the 
numerous one-ovuled pistils. This receptacle, with its 
enclosed ovaries and crowned by the persistent calyx, 
ripens to a sourish-sweet fruit (rose hips). Calyx mostly 
five-parted ; petals in single varieties mostly five; sta- 
mens very numerous, pistils moderately so. Some ofthe 
more familiar species follow : 

R. lutea Mill. (R. Hglanteria), Eglantine Rose ; Yellow 
Rose, with solitary large, handsome, yellow flowers. 
Southern Europe. 

R. cinnamomea Linn., Cinnamon Rose. 

R. canina Linn., the Dog Rose, orcommon Wild Rose, 
has stiff, compressed, recurved prickles serrate or lobed, 


Fia. 38349.—Dog Rose Hips ; about natural size. (Buillon.) 


reflexed sepals, a rounded, ovoid, scarlet, shining fruit, and 
clustered pink flowers. A common denizen of by-ways 
and hedges in most parts of Europe. The ‘‘ Hips” (Cyn- 
orrhodon, Codex Med.), when fully ripe, and, preferably, 
touched by the frost, make a rather poor but edible kind 
of fruit, which in Southern Europe is made into jams and 
sweet sauces. They contain citric and malic acids and 
their salts, sugar, anda large amount of gum. A confec- 
tion of rose hips is still a little used abroad as a vehicle. 
The galls produced upon this rose were also formerly 
used. Its name is said to have been derived from reputed 
value in dog-bites. ; 

R. rubiginosa Linn., and R. mécrantha Smith, are the 


257 


Roses. 
Rye. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


large and small-flowered sweetbriers easily recognized by 
their very fragrant leaves and stems. ; 

R. Gailica Linn., the Provins or Red Rose has creeping 
rhizomes which send up a colony 
of rather short (two to four feet) 
stems. These are armed with 
numerous short, straight, weak 
prickles, and a 
few longer ones, 
and are covered 
with bristly hairs. 
The leaves are 
also somewhat 
hairy beneath, and blue- 
green in color. The 
flowers grow singly or 
in twos. They have a 
glandular, hairy recep- pet oe 
tacle and calyx, dark-red petals, [gfit// 
and a nearly globular fruit. A 
native of Central Europe, but long under 
cultivation, for medicine as well as ornament. 
The petals, pulled or cut away, just before 
expanding, and dried, are officinal (Rosa Gal- 
lica, U. S. Ph.; Rose Gallice Petala, Br. Ph.; 
Rose rouge ou Rose de Provins, Codex Med.). 
When carefully dried they have a fine pur- 
ple-red color and fine fragrance. They usu- 
ally remain in the same cone-shaped bunches 
in which they were plucked, and unless cut 
away rather high, show whitish or yellowish 
claws. They contain a minute quantity of 
essential oil, some fat, quercitrin, a little gallic and tannic 
acids, and a beautiful coloring matter. As may be in- 
ferred, they have no active properties, and are only used 
for their color or as a vehicle. 

The Pharmacopeia has the following preparations : 
Confection (Confectio Rose)— 


bloom. 


Reds Roses. reii eens fea kae 8 parts 
Sugary see we PS) aR ee el oe eae Ne 64 <“ 
Clarified Honey....: eee ot pati melee 
RogesW ater ayes. Geko eas te 16> 4% 


rubbed and beaten to a smooth mass, suitable for pills ; 
Fluid Extract (Hetractum Rose Fluidum); Honey (Mel 
Rose), strength, +§>; Syrup (Syrupus Rose), strength, -jy. 
It is also employed in making the Pills of Aloes and 
Mastich. Red Rose petals are collected in England, 
France, and Belgium. 

Rosa centifolia Linn., possibly a variety of the above, 
is the parent stock of numerous fragrant, very full-flow- 
ered varieties. It has large, hooked prickles, and droop- 
ing, generally double, pale-colored flowers. <A native of 
the Orient, but cultivated from time immemorial. The 
Moss Rose is one of its almost innumerable forms. Pale, 
Hundred-leaved, or Cabbage Rose petals (Rosa Centifolia, 
U.S. Ph.; Rose Centifolie Petaia, Br. Ph.; Rose a@ cent 
feuilles, Codex Med.; Hlores Rose, Ph. G.), collected and 
carefully dried after the expansion of the flowers, are, 
more or less, heart-shaped or abovate, have a pink color, 
a sweetish, slightly astringent taste, and a delicious rose- 
like odor. When fresh they are a source of Rose Water 
(Aqua Rose, U. S. Ph.); when dry, used for various 
pleasant but unimportant purposes, but mostly as a per- 
fume. . 

R. damascena Mill (Rose de Damas ou des quatre sat- 
sons, Codex Med.). The Damask Rose, another East- 
ern species, has large, hooked prickies and fine sweet 
flowers. It is one of the sources, at least, of the Oil of 
Rose (Oleum Rose, U.S. Ph., Ph. G., etc.). The only 
important constituent of this rose and some others is the 
minute quantity of oil that they contain. This is sep- 
arated by distillation and in great demand for perfumery. 
It contains a hydrocarbon of little odor, and several fra- 
grant stearoptenes that cause the whole oil to congeal at 
a moderately low temperature (50° F.). 

Besides the above, the Tea Rose, R. Jndica, and nu- 
merous others are cultivated for ornament, and several 


238 


Fia. 3350.—The Provins, 
or Red Rose, in full 
(Baillon. ) 


American ones have begun to be. All the roses become 
double in the garden ; most of them hybridize readily. 

‘ ALLIED PLANTS.—The order is one of the largest in 
the natural system, and includes more than one 
thousand species. Its properties are very diverse, 
but tannin is abundant init. The princi- 
pal sub-orders and most useful species are 
as follows: 

Prunee, Al- 
monds, Peaches, 

Plums, etc. (see 
ALMONDS). 

Spiree, Spire- 
as, etc.; Hard- 
hock, Gillenia, 
etc. 

Potentillew, Potentillas, Tor- 
Wey Mentil, Blackberries, Raspber- 


cat Fy ARS ries, Strawberries. 

SNA ARS Poterie, Agrimony, Koosso. 
, RS RY Rosee. 

Ny Me Pomee, Apples, Pears, 


Quinces, etc. 
ALLIED Drucs.—The essen- 
tial oils, also mild astringents. W. P. Bolles. 


ROYAT is a French thermal station in the de- 
partment of Puy-de-Déme, near the railroad station 
of Clermont Ferrand, lying at an elevation of four- 
teen hundred feet above the sea. There are five 
springs. 

The following are the analyses of the two 
which are the richest in saline constituents, given in 
grammes per litre. 


Source Source 
Principale. Saint-Mart. 

Potassium bicarbonate................ 0.48 0.365 
Galcium Ubiearbonates....). cole eee 1.000 0.953 
Magnesium bicarbonate............... 0.677 0.611 
Ferrous bicarbonate ................-- 0.040 0.042 
Manganous bicarbonate .............-. trace trace 
Sodium) bicarbonates-..- sia. sass sa eee 1.849 0.421 
Sodium sulphatet.. eee. ee een wees 0.1838 0.163 
Sodium phoesphaterscs. sense eee 0.018 0.007 
Sodium*arsentate oo 2c en ~s- see ens trace trace 
Sodinm. chlomndemearcec. cere es Alling 1.682 
Silicieacidyen se tee ccna se woot se es 0.156 0.102 
LOLGIS aw tects helene cis sa cee eee 5.586 4,846 


There is a considerable amount of free carbonic acid 
gas. The temperature of the different springs ranges 
from 82° to 95° F. 

The waters of Royat are taken internally, and also 
employed in baths of various kinds. The whey- and 
grape-cures are also used to some extent. The diseases 
in the treatment of which the Royat waters are recom- 
mended are chlorosis and anemia, debility following 
convalescence from acute diseases, vesical catarrh, mus- 
cular rheumatism, and certain forms of eczema. A 
course of treatment lasts from two to four weeks. The 
season extends from June to the middle of Bre ees 

Ly, et, 


RUBINAT-CONDAL. This is the name of a natural 
mineral water recently introduced into this country, 
which, it is claimed, is one of the best of the natural 
saline aperients. The following is given as its composi- 
tion, according to an analysis of Dr. Canudas y Salada. 
One litre contains : 


Grammes. 

Magnesiumesolphatece..2 atc a0 oc sete ete eee 3.172 
Potassium sulphates... 212 os «ides dine taete oe ore 0.228 
Calemmsulphate tere inc co ncdaen ee cee eee 1.887 
Sodinny sulphate Sar; -isieee sss oe case emer te 93.230 
Sodium yohlorides 2.2.45 ice eee tee ee ee nee 1.990 
Silica, alumina, and ferric oxide... 55.0.4 eee 0.036 
TiOSBA ce se thsteic.c ici, Aminiette Melcteln ot hele ieee eee nee 0.017 

VOGAL rc case so mea eiera es Ce TIS Tea en RE 100.560 


The spring from which this water is taken is situated 
in the Spanish Pyrenees, near Cervera, in the province 
of Lerida. As it has been so recently introduced to the 
notice of the medical profession in America, it is not 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


possible to speak with greater precision covcerning the 
merits of the water. LIDS: 


RUE, OIL OF (Oleuwm Rute, U.S. Ph., Br. Ph.; Rue, 
Codex Med. [the flowering plant]). The essential oil of 
Ruta graveolens Linn.; Order, Rutacee. This is a peren- 
nial herbaceous or part- 
ly woody plant, two or D) 
three feet in height. It Aye INO’ sea) 
has pale green, cylindri- £ \ LOA, eg Pe 
cal, branching stems, al- Cees * Ge 
ternate, smooth, ‘(a o aya 
light-green, 
glandular - d ot- 
ted leaves; the @X?e 
lower twice or “oss 
three times pin- #7 
nate, the inter- 
mediate once ortwice 
pinnate, the upper- 
most simple. Divis- 
ions wedge-shaped, 
rounded, or blunt at 
the extremity. Flow- 
ers in a_ terminal 
corymb, with the parts in 
fours or fives; stamens twice 
as many; sepals small, point- 
ed; petals large (one-half 
inch long), rounded, . and 
hooded at the ends, narrow 
below, greenish-yellow. Pis- 
til supported on a thick, 
fleshy disk; style single, 
ovary four- or five-lobed, 
with numerous ovules. 
Fruit a dry, dehiscent cap- 
sule. Rue is a native of 
Southern Europe, the Le- 


vant, etc., and is also culti- 
vated ; it has a strong, dis- 
agreeable odor, and a bitter, 
sharp taste. The oil only is 
officinal here. 

Oil of Rue is obtained from the whole plant by distil- 
lation, the yield being about one-fourth of one per cent. 
It is ‘‘a colorless or greenish-yellow liquid, of a charac- 
teristic aromatic odor, a pungent, bitterish taste, and a 
neutral reaction. 
Specific gravity 
about 0.880. It is 
soluble in an equal 
is \ » le MI Wi I stc\ weight of alcohol” 
SOCAN ME Lee 4 (UrS2 Pho). Oilof 

Rue consists of a 

hydrocarbon and an 

oxygenated portion, 
the latter yielding 
pelargonic acid by 
decomposition. The 
leaves of Rue also 
yield a crystalline, neutral substance called rutin, which 
is found besides in several other plants. It is not active. 

Oil of Rue is one of the more deleterious of the essen- 
tial oils. Like turpentine, tansy, 
juniper, and others, it is exter- 
nally quite irritating, and on this 
account is used in liniments and 
plasters. Given internally, it is 
an anthelmintic, ‘* antispasmodic,” 
and ‘‘emmenagogue,” according 
to the older authorities, and was 
used in amenorrhea, hysteria, and 
epilepsy ; but it is scarcely given 
internally now. Dose from two 
to five drops. 

ALLIED PLANTS. — The genus 
comprises about forty plants of Europe and Asia, none 
of the others of economic importance. The order is a 


Fic, 3351.—Flowering Branch of 
Rue. (Baillon.) 


eo 
Sen: 


F f Ni I % 
f Autlthy 
j i 


Fic. 3852.—Rue, the Flower. (Baillon.) 


Fig. 3353.—Fruit of Rue. 
(Baillon.) 


Roses, 
Rye. 


large one, of mostly tropical plants, nearly all fragrant 
and many of considerable importance in medicine, etc.. 
as the following selections will show: 

Ruta graveolens Linn., Rue. 

Dictamnus albus Linn., Fraxinella. 

Cusparia trifoliata Engl., Angustura. 

Pilocarpus, several species, Jaborandi, Pilocarpine. 

Barosma, several species, Buchu. 

Xanthorylum fraaineum Willd., Prickly Ash. 

Toddalia aculeata Pers., Lopez Root. 

Citrus, several species; Oranges, Lemons, Berga- 
mottes, etc. 

Aegle Marmelos Correa, Bael. 

ALLIED Drues.—Oils of Tansy, Cedar, Juniper, Tur- 
pentine, etc., have physiological properties somewhat 
like that of Rue. W. P. Bolles. 


, RUSCUS ACULEATUS Linn. (Petit Houa ou Fragon 
eprneux, Codex Med.), a singular perennial, half-shrubby, 
liliaceous plant, with minute bract-like leaves and _flat- 


(Baillon.) 


Fie. 3354.—Ruscus Aculeatus ; flowering branch. 


tened leaf-like stems in their axes, looking almost exactly 
like leafy foliage excepting when the little flowers ap- 
pear from the middle of their apparently upper surfaces. 


Its root is laxative, but scarcely used now. 
W. P. Bolles. 


RYE (Seigle, Codex Med.), Secale cereale Linn. (Trite- 
cum cereale Archers) ; Order, Graminew, This important 
grain, standing nearer in some respects to wheat than the 
others, has, like them, been so long in cultivation as to 
have lost its early ancestry, and is not known wild. It 
will grow in colder latitudes than wheat, and on this ac- 
count is the principal breadstuff in some of the northern 
parts of Europe. It is also extensively grown in the 


239 


Rye. 
Sacro-Iliac Disease. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


northern States of this country and in British America. 
Eastern Asia is supposed to be its original home. Rye- 
flour is darker, grayer in color than that of wheat, and 
has a characteristic odor and taste. It is more laxative 


than wheat-flour, and makes a dark-colored, sweetish- 
sour bread (Schwarzbrod) very widely used on the con- 
tinent of Europe, and among the Germans in this country. 
Rye consists of nearly sixty per cent. of starch, ten of 
nitrogenous substances, two of fat, four of sugar (synan- 


<N\ 


Fig. 3355.—Rye. 
same, after removal of the glumes; 6, grain. 


(Baillon. ) 


throse), seven or eight of gum, dextrin, etc., besides ten 
or more of water, and one or two of ash. 

Rye is in no sense a medicine, but it has been with 
some people a favorite poultice material. It is also inter- 
esting as the ‘‘ host” upon which ergot grows. 

ALLIED PLANTS, ETC.—See Starcu. W. P. Bolles. 


SACRO-ILIAC DISEASE. Syn., Sacro-coxitis (Hue- 
ter), Sacrarthrocace, Sacro-coxalgie. The ilio-sacral joint 
resembles the other articulations of the body in its 
anatomical structure, but differs from most of them 
chiefly in the limited amount of motion of which it is 
capable. It may be compared with the intervertebral 
articulations in this respect. Although this joint is 
called upon to support the weight of the trunk and upper 
extremities, in both the standing and sitting postures, it 


240 


1, Inflorescence ; 2, entire plant; 3, spikelets; 4, flower; 5, the 


is, nevertheless, owing to the slight degree of motion 
possible, not so often the seat of traumatic lesions as 
might @ priort be supposed. Yet it is probable that the 
joint more often feels the effect of slight traumatisms 
than is generally believed. The lumbar pains and back- 
ache experienced after long standing, walking, riding in 
a springless wagon over a rough road, or horseback ex- 
ercise, are, in many cases, the result of slight injury, or 
tire, of the ilio-sacral articulation (Chauvel), although 
doubtless muscular strain is also often an important 
factor in their causation. 

The joint is occasionally, though rarely, the seat of an 
acute inflammation, which runs its course rapidly, at- 
tended with high fever and suppuration, and which is 
apt to terminate in the death of the patient from ex- 
haustion. The chronic form is much more often seen, 
though it is nevertheless comparatively rare. Chronic 
sacro-iliac disease is, however, notwithstanding the in- 
frequency of its occurrence, and apart from its 
intrinsic importance, well worthy of careful study 
by reason of its liability to be mistaken for hip 
disease, spondylitis involving the lower segments 
of the spinal column, or other lesions of neigh- 
boring parts. 

The lesions of sacro-iliac disease are similar 
to those accompanying chronic inflammation of 
other joints, for a description of which the reader 
is referred to the article entitled Joints, Chronic 
Diseases of, in the Appendix. There are three 
varieties usually described, viz., the tubercular, 
the puerperal (pyemic), and the gonorrheal or 
urethral. The possible occurrence of a fourth 
form, the syphilitic, may be admitted, but it is, 
at all events, extremely rare. 

The tubercular form, which is by far the 
most common, begins usually as a fungoid syno- 
vitis, the morbid process extending later to the 
cartilage and bone; but occasionally the joint is 
invaded by the extension of a carious or necrotic 
process which had begun in the sacrum or ilium. 

The disease is exceedingly rare in childhood, 
its period of greatest frequency being in early 
adult life. Men are more commonly its subjects 
than are women. In its etiology the tubercular 
form of sacro-iliac disease differs in no essential 
respect from a similar chronic arthritis occurring 
\ elsewhere. Chauvel asserts that the affection 

occurs with comparative frequency in young Cav- 

alry soldiers, and finds its exciting cause in the 

traumatism arising from the unwonted eques- 
trian exercise. The etiology of the puerperal 
and gonorrheeal varieties is sufficiently in- 
dicated by the terms employed to designate 
them. 

The symptoms of sacro-iliac disease are 
often obscure. They resemble closely those of 
Pott’s disease of the lumbo-sacral region, or of 
morbus coxarius. Pain is a nearly constant 
symptom, though it varies much in degree, 
from a heavy, dull ache to an acute, agonizing 
pain, often increased beyond endurance by the 
slightest movement of the inflamed surfaces. 
Like the pain accompanying arthritis of other 
articulations, it is often intermittent and irregular in its 
exacerbations; it is aggravated by standing or sitting, 
but usually, though not always, relieved when the patient 
assumes the recumbent posture ; it is apt, also, to be more 
severe at night than it is when the patient is at rest dur- 
ing the day. In severe cases the pain is increased by 
anything which causes movement of the articulation, 
even by sneezing or by the effort of defecation. Pressure 
over the sacrum, and any movement imparted to the in- 
nominate bone, as by approximation, separation, or 


. twisting of the iliac crests, excites more or less pain; but 


gentle passive movements of the lower, extremities, apart 
from direct upward impulses, usually cause no complaint 
if the pelvis be firmly held so as to prevent all movement 
at the ilio-sacral joint. There may be tenderness on 
pressure over the suspected joint, but this is not always 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Rye. 
Sacro-Lliac Disease. 


present. Sometimes it can be elicited by pressure on the 
anterior surface of the joint by means of the finger in 
the rectum. The pain is sometimes referred directly to 
the articulation affected, but may often be felt in the lum- 
bar region, in the thigh, or even in the knee, and it may at 
times simulate sciatica so closely as to be mistaken for it. 

Swelling is usually present at some stage of the dis- 
ease, though this is not invariably the case. In the 
early stages, before an abscess has appeared, there may 
be a localized swelling in the neighborhood of the artic- 
ulation, and at a later period the entire limb on the 
affected side may become cedematous. It is not rare, 
however, to encounter no appreciable swelling at any 
time during the course of the disease, except such as may 
be due to an abscess. 

The appearance of an abscess is not uncommon, 
though suppuration is no more a necessary accompani- 
ment of tubercular disease of the sacro-iliac joint than it 
is of a similar process occurring in other articulations. It 
is usually not until after the disease has existed for a con- 
siderable length of time that an abscess can be detected. 
The pus may present itself posteriorly over or near the 
articulation, sometimes forming a considerable tumor 
in the buttock, or it may, especially when it comes from 
the anterior portion of the joint, burrow in any direc- 
tion and present itself as a cold abscess at some point 
more or less distant from its source. Thus it may open 
into the rectum, present itself as a tumor of the ischio- 
rectal fossa alongside the anus, appear in the back near 
the spine, or in the groin, or come to the surface on 
either the anterior or the posterior aspect of the thigh. 

The temperature over the diseased articulation is ele- 
vated to a greater or less degree. 

‘Atrophy of the muscles of the corresponding limb is 
invariably present, and usually in a very early stage of 
the disease, becoming more pronounced in proportion to 
the duration of the inflammatory process. The gluteal 
region is flattened, and the muscles are frequently soft to 
the touch and flabby. 

The thigh may appear to be flexed and adducted, but 
in most cases, if not in all, this is not a real displacement, 
but is a consequence of malposition of the pelvis. The 
same is true of the apparent lengthening or shortening of 
the lower extremity, one or other of which, more com- 
monly lengthening, is usually to be observed as a conse- 
quence of the obliquity of the pelvis. Sometimes there 
is a slight degree of outward rotation of the limb, so 
that the foot is turned more or less from the median 
plane of the body. 

Limping is always present, though it may, at the out- 
set of the disease, be intermittent or vary considerably in 
degree. The patient shows a hesitancy in allowing the 
weight of the body to rest on the affected side, and also 
moves the corresponding leg as little as_ possible. 
When it becomes necessary to transfer the weight to this 
side, the foot is placed carefully, the whole sole coming 
in contact with the ground as nearly as may be at the 
same moment, the heel and toe movement being avoided. 
The sound limb is then thrown rapidly forward, the pa- 
tient meanwhile leaning heavily on his cane, and flexing 
the hip and knee slightly, as if to reduce as far as pos- 
sible the force of the concussion. Then, when the body 
rests once more on the sound side, the other foot is raised 
slightly from the floor, and brought slowly and cautious- 
ly forward for a short distance, when it is again im- 
planted evenly on the ground. 

The position of the body when the patient is standing 
is also quite characteristic. | In order to shift the centre 
of gravity as far as possible from the line of the dis- 
eased joint, the body is inclined strongly to the opposite 
side. The position may also afford relief, as has been 
suggested by Sayre, by making the weight of the limb 
on the affected side act as a traction force upon the 
inflamed articulation. This protective attitude may have 
its inconveniences, however, as lateral curvature of the 
spine may be produced as a result of its long continu- 
ance, 

The diagnosis of a well-marked case of sacro-iliac dis- 
ease is comparatively easy, if the points above detailed 


VoL. VI.—16 


be borne in mind ; but in an atypical case the recognition 
of the affection is sometimes exceedingly difficult, and 
mistakes in diagnosis are very easily made, unless the 
case is carefully studied. 

The following table will bring out the differential points 
of sacro-iliac, hip, and spinal disease more clearly than 
could be done by a separate description of the symptoms 


of each one: 


SACRO-ILIAC DISEASE. 


Is a rare disease. 


Occurs usually in 
young adult males. 


Motions of the hip are 
free. 


The spine is not rigid, 
though it is often 
held stiff, as motion 
causes pain at the 
affected joint. 

Position is character- 
istic. Patient stands 
with the body in- 
clined to the sound 
side, 


The limb is apparent- 
ly elongated (some- 
times shortened), and 
there is not infre- 
quently adduction. 


Cautious passive move- 
ments at the hip are 
painless. Severe 
pain is often excited 
by pushing together, 
separating, or twist- 
ing the wings of the 
ilia, or by pressure 
on the sacrum. 

The pain is usually lo- 
calized near the af- 
fected joint, though 
it may be felt in the 
hip, knee, or thigh. 

When a sinus is pres- 
ent, a flexible probe 
passes in the direc- 
tion of the sacro- 
iliac joint. 


Hip DISEASE. 


Is a common disease. 


Occurs usually in child- 
hood and in individ- 
uals of either sex. 

Motion at the hip re- 
stricted in every di- 
rection by reflex 
muscular spasm, 

“x 


The spine 
movable. 


is freely 


Position is not charac- 
teristic, but varies 
with the stage of 
the disease and with 
the position of the 
thigh. 

The character of the 
deformity varies. 
There is real short- 
ening, at least in the 
advanced stages. 


All movements of the 
hip canse pain. Mo- 
tion of the sacro- 
iliac joint excites no 
complaint. 


Pain is usually referred 
to the hip, knee, or 
middle portion of the 
thigh. 


Probe leads in the di- 
rection of the hip- 
joint. 


PoTr’s DISEASE. 


Is not very common in 
the lumbo-sacral re- 
gion, 

Occurs more common- 
ly in children, but is 
not rare in adults, 

Motion at the hip is 
free, except that ex- 
tension and outward 
rotation are limited 
when there is psoas 
contraction. 

The spine is rigid at 
the seat of the lesion. 
In advanced stages 
there is more or less 
kyphosis. 

When loss of substance 
of the vertebral 
bodies has _ taken 
place, there is a for- 
ward inclination of 


the body. E 
The thigh may be 
flexed. Otherwise 


there is no malposi- 
tion. 


Movements of the hip 
painless, Pressure 
or the application of 
a hot sponge some- 
times, though notal- 
ways, causes pain. 


Pain is usuaily located 
in the back, but it 
may radiate down 
one or both thighs. 


Probing seldom aids, 
except in a negative 
way, in thediagnosis, 
as the abscess usu- 
ally cpens «ut a dis- 
tance from the seat 
of the lesion. 


In necrosis of the pelvic bones there may be a sinus 
leading in the direction of the ilio-sacral joint, but in un- 


complicated cases there is no restriction to motion in any 
of the neighboring articulations, and no pain is excited 
by passive movements of these joints. 

Sciatica may usually be easily discriminated by the 
fact that it is an affection of more advanced life than is 
sacro-iliac disease. The position of the patient is not 
characteristic ; there is no deformity, except occasionally 
a slight degree of flexion of the hip and knee ; motion of 
the suspected joints does not uniformly cause pain, and 
it is never restricted by reflex muscular spasm, as is the 
case in arthritis; and there is pain on pressure only over 
the course of the sciatic nerve. 

Psoitis may simulate sacro-iliac disease, but it is more 
often mistaken for disease of the hip, or lower portion of 
the spine. The pain in this affection is increased by ex- 
tension of the thigh, but is relieved by flexion, and all 
movements of the thigh which do not put the psoas 
muscle on the stretch are free. Pressing together, 
separating, and twisting the crests of the ilia, cause no 
pain. In psoitis there is flexion of the thigh, and if the 
body is inclined at all, it is toward the affected side 
rather than away from it. Finally, psoitis is attended 
with much more acute general symptoms than is uncom- 
plicated sacro-iliac disease. | : 

The possibility of neuromimetic joint disease should 
also be borne in mind in the endeavor to arrive at a cor- 
rect diagnosis. Fora general description of the nervous 


241 


Sacro-Lliac Disease, 
Sago. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


mimicry of joint disease the reader is referred to the | which are then carefully dried with gentle heat. Seven 


article on Neuromimesis, in vol. v. of this HANDBOOK. 

Sacro-iliac disease runs a very slow and tedious course, 
being one of the most chronic of all chronic joint dis- 
eases. The patient is more or less incapacitated for any 
kind of work for a considerable length of time, since the 
sitting posture causes almost, if not quite, as much pain 
and inconvenience as does standing or walking. The 
prognosis, as regards life, is about the same as that in 
other forms of chronic joint diseases. Death may occur 
from exhaustion after prolonged suppuration, from renal 
complication, or from tubercular disease of other organs. 
Recovery, usually after a prolonged period of suffer- 
ing, is, however, not uncommon. 

The treatment of sacro-iliac disease, like that of 
other chronic joint affections, consists essentially 
in rest, traction on the inflamed articulation, 
and general tonic and supporting treatment. 
Hutchinson’s method of the treatment of hip 
disease, by means of crutches and a high 
sole on the shoe on the sound side, answers 
better, in the writer’s experience, for sacro-iliac \\ 
disease than it does for the affection for which it 
was originally intended. For patients with sacro- 
iliac disease are older, as a rule, than hip patients ; 
they understand the rationale of the method, and 
they are more careful not to discard the crutches and 
thump the foot down on the ground as soon as the dis- 


\ \ 


ease begins to improve and the exquisite sensibility of | 


the joint has disappeared. In certain cases, especially 
when the pain is very acute, the patient must be confined 
to the bed with a weight and pulley attached to the leg 
by means of a modified Buck’s extension, such as is used 
in the application of an ordinary hip-splint. 
Attention must, of course, be paid to the general 
health, for the patient has, at the best, to undergo a long 
siege ; the disease is a debilitating one, and the sufferer 
must husband his strength to enable him to endure it. 
Of local treatment by means of the injection of iodo- 
form, or of calcium phosphate, as proposed and used by 
Kolischer, the writer is unable to speak from personal 
experience. But such methods, if as efficacious in the 
treatment of hip disease as is claimed, would seem to be 
particularly applicable to the treatment of tubercular 
disease of the ilio-sacral joint. Thomas L. Stedman. 


SAFFRON (Crocus, U.S. Ph., Br. Ph., Ph.G.; Safran, 
Codex Med.). <A perennial, colchicum-like herb, but 
with an inferior ovary. It arises from a flattened, fleshy 
corm, about three centimetres (one inch or more) in 
diameter, having a number of rootlets below and devel- 
oping one or more buds upon its upper surface, which 
become new corms as the first one dies. It is: covered 
with a few brown scales. From one or two of the buds 
a short stem arises, bearing a few long, linear, fleshy, 
shining green leaves. It ends near the surface of the 
ground in one or two flowers. These consist of an infe- 
rior ovary, of three cells, and a large, purple, bell-shaped 


®  perianth, with a very long (ten or fifteen centime- | 


\\ tres), stem-like tube ; divisions, six ; stamens, three. 
\\ This style is very long and slender, colorless ex- 

cepting at the upper end, dividing 
finally into three long, recurved, stig- 
matic branches. Saffron grows wild 
in Southern Europe and the East. It 
is supposed to be a native of the Le- 
vant, but has been so long in cultiva- 
tion that its exact geographical origin 
isin doubt. It is cultivated in several 
warm countries, especially in Spain, 


Fig. 3350.—Ovary of 
the Saffron Plant, 


Entire and in France, and Austria. Large quanti- 
Transverse Section. ties are also raised in different parts of 
(Baillon.) 


Asia for home consumption. Saffron 
of excellent quality is produced in Pennsylvania, but 
scarcely on a commercial scale. 

Commercial saffron consists only of the stigmas, or 
these with as little of the upper end of the style as is 
practicable to get. It is collected by plucking the flow- 
ers as they open and carefully picking out these organs, 


242 


or eight thousand flowers are said to be required for a 
hundred grammes of saffron. French saffron is said to 
be the best. Spanish is the most common. 
DESCRIPTION.—The stigmas are now usually dried 
loosely tangled together, in a way that has given it the 
designation ‘‘ hay saffron ;”’ with a little shaking the in- 
dividual styles can be shaken out without breaking. It 
is dry-feeling, but not brittle, and moderately hygro- 
scopic. The officinal definition is as follows: Stigmas, 
separate, or three, attached to the top of the style, about 


'Fia, 3357.—S affron Plant (one-half natural size) ; also Longitudinal Sec- 


tion of the same, and Style. (Baillon.) 

an inch and a quarter (three centimetres) long, flattish-tu- 
bular, almost thread-like, broader and notched above ; 
orange-brown ; odor strong, peculiar, aromatic; taste 
bitterish and aromatic. When chewed it tinges the saliva 
deep orange-yellow. 

The high price of this product has been the cause of 
many devices, nearly all of them very stupid and easily 
detected, to cheapen it; too much of the styles, which 
are worthless, may be gathered along with it ; it may be 
mixed with stamens; the flowers of Calendula or other 
yellow Composite may be mixed in, or even substituted 
for it; or it may be weighted with water or oil, or colored 
chalk, or it may be partially exhausted. Soaking in 
warm water, examining with a lens, or pressing between 
sheets of blotting-paper will serve to detect these sophis- 
tications. The cheap drug, commonly called in domestic 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sacro-Iliac Disease, 
Sago. 


parlance ‘‘ saffron” in this country, is safflower, Cartha- 
mus tinctorius Linn., order, Composite. It is a favorite 
sudorific in measles, and popularly believed to favor the 
appearance of the eruption. 

The history of saffron has a good deal of interest, 
since it was for centuries one of the most highly prized 
of drugs, a valuable dye, and a pleasant condiment or 
perfume. It has been known since the time of Solomon 
in the East, and almost as long in Asia Minor, Greece, 
and Italy. Its cultivation in Spain dates back seven or 
eight hundred years ; in other parts of Europe from five 
to seven hundred. Its adulteration, almost as old as even 
its production, has always been a subject for govern- 
mental solicitude, and was punished by severe, in some 
countries cruel and barbarous, penalties. People have 
been buried alive and burnt for this crime. The uses of 
saffron also were much more varied, and deemed far 
more important, than we can imagine them now. 

CoMPoOsITION.—Saffron contains about one per cent. of 
volatile oil, heavier than water and not very permanent, 
to which its odor isdue. This oil appears to be vari- 
able both in quantity and properties, and is perhaps 
partly produced by decomposition of the crocin ; Quadrat 
obtained an oil lighter than water ; distilled with a solu- 
tion of salt and potash, more than nine per cent. may be 
obtained (Husemann). It also contains a small amount 
of gum, fat, and wav. The important constituent, how- 
ever, is its coloring matter, Crocin (polychroit), of which 
there is, according to Hager, sixty-five per cent. Itisa 
deliquescent, orange-red, amorphous substance, having 
no odor, but a sweetish taste. Over sulphuric acid it 
can be dried to a bright red powder. Water and diluted 
alcohol dissolve it freely, absolute alcohol but little, 
ether not at all. By treatment with diluted acid it de- 
composes, and glucose and another coloring substance, 
Crocitin (crocin), are produced ; this is a red powder, 
easily soluble in alcohol, but not in water or ether. 

ACTION AND Use.—This is the shortest paragraph in 
the article ; as a medicine it probably has little or no 
value. In large doses, five to fifteen grammes ( 3 j. ad iv.), 
it is said to be abortifacient, in smaller ones emmenagogue 
and narcotic ; but these properties are very uncertain, to 
say the least. In small doses it is moderately carmina- 
tive, but no better than fifty different mints and um- 
bellifers of about one-hundredth its cost. As a coloring 
agent it is superb, and has only recently been superseded 
by the marvellous development of the aniline series of 
dyes. It is still used, especially in Europe, to give color 
and flavor to a number of preparations. The tincture 
(Tinctura Croct, U. 8. Ph.), strength ;';, is officinal. 

ALLIED PLANTs.—Several other species of Crocus have 
strongly colored stigmas, and have been similarly used. 
Gladiolus and Jris, in the same order, are familiar names 
to the florist; the latter genus furnishes two or three 
medicines. See Orris and Fiuac, BLUE. 

ALLIED Drues.—Crocin has been obtained from one 
or two other plants of no botanical connection with cro- 
cus. Carthamus, above-mentioned, resembles saffron 
slightly in color. Annato is another yellow-coloring sub- 
stance, occasionally used in pharmacy, more frequently 
in the dairy. Red rose and cochineal give their superb 
colors to a few mixtures. W. P. Bolles. 


SAGE (Salvia, U. 8. Ph.), Salvia officinalis Linn. ; Or- 
der, Labiate. This is the well-known Garden Sage, a 
half-shrubby perennial, whose stems die down to within 
a foot or so of the ground in the fall, but branch very 
freely and send up numerous herbaceous, squarish, leafy, 
and flowering branches during the summer, twice or 
three times as long. Leaves numerous, those near the 
ground short-petioled, the upper ones nearly or quite ses- 
sile, thick, rugose, bluntly oval or oblanceolate, finely 
serrate. They are slightly pubescent above, often very 
woolly and white beneath. Flowers in a mixed spike, 
with two-lipped, pubescent, bell-shaped calyx, and a con- 
spicuously labiate, blue corolla, with a ring of hairs at 
the base, inside. Upper lip of the corolla concave, 
notched at the apex, the lower three-lobed ; the central 
one much the largest and longest. Perfect stamens two, 


with widely divergent anther-cells, but one of which in 


each stamen is perfect. Ovary four-lobed. Fruit of four 
rc achenes. Sage, like so many others 

Wi of our household mints, is a native 

Wh) of Southern Europe. It has, how- 

D:| ever, been cultivated for centuries, 

Ary Gs and transplanted to all temperate 

i countries. There are a few garden 

ww varieties. The flowers may be pale- 


blue, pink, or white, the leaves nar- 
row, variegated, or curled. : 

The leaves, or leaves and tops, are 
used. Dried Sage leaves have a 
grayish-green color, pubescent sur- 
face, and the peculiarities of shape 
and surface given above; they are 
one or two inches long, have large 
oil-glands upon their surfaces, and 
are very aromatic; taste bitter and 
slightly astringent. 

Sage owes its very characteristic 
odor to less than one per cent. of a 
) limpid greenish essentzal oil, a com- 
posite substance containing a hydro- 
carbon, one or more oxy- 
genated oils, and a camphor 
—in short, resembling the 
oils of mint, patchouly, 
thyme, etc. It also con- 
tains a moderate amount of 
- tannic acid, 
some /7esin, 
gum, bitter 
Wjeatracttve, 
} and common 
plant compo- 
nents. 

Their taste and odor di- 
vide the mints from each 
other more than chemical 

or therapeutic properties. ee 

i Sage resembles the rest of BB 

Fie. 3358. — Salvia the order in its general ac- pyg_ 3359, — 
Officinalis, Sage; tion; it is aromatic, a gas- Flower of the 


= al< 


\ 
ve 


pores branch. tric stimulant, and by rea- Sage Plant. 
(Baillon. ) son of its bitterness also  ‘Paillon.) 
tonic. It is also, what all are not, mildly astringent. 


In large quantities of hot water, like many other mints, 
it is given as a sudorific in the beginning of feverish 
colds, etc. Sage is useful in mouth-washes. It is, how- 
ever, almost entirely a domestic remedy, and even as such 
but little used of late, although formerly in high repute. 
It is one of the ingredients of the aromatic wine (Vinum 
Aromaticum, U. 8. Ph.), an old-fashioned liniment. 
ALLIED PLANTS, ETC.—See PEPPERMINT. 
W. P. Bolles. 


SAGO (Sagou, Codex Med.). 
the stems of several species of 
Palme growing in the Indian 
Archipelago, especially from 
Metroxylon (Sagus) Rumphit 
Mart., M. lave Mart., Sagus 
farinifera Lam., etc. The soft 
pithy stems of these palms, 
just before blossoming, are 
loaded with starch to such an 
extent that upon splitting them 
open it can be scooped out in a 
coarse, moist powder. This is 
then washed over sieves, and 
the cellular tissue thus sepa- 
rated. For European use the 
starch, which has passed 
through these strainers, is 
washed sufficiently, and then, 
while moist and thick, rubbed : , 
through a sieve. By this means it is formed into grains 
of the size of the meshes, which are dried in a hot pan, 


243 


A starch prepared from 


{i 
Fra, 3360.— Fruit of Sago Palm. 
(Baillon. ) 


Sago. 
Saint Moritz. 


and finally polished by friction in bags or rollers. Sago 
varies in appearance according to the details of this 
process. That most common in groceries in the United 
States is ‘‘ Pearl Sago,” in small round granules, about 
as large as white mustard seeds (1 mm. in diameter), 
white and opaque, or somewhat translucent, in places. 
Sago starch is in oblong, sometimes tuberculated, and 
angular granules, with a very excentric hilum, and fre- 
quently with separated protuberances, leaving sharply 
marked facets. 

Sago is simply starch, and no more a medicine than 
arrowroot or tapioca See STARCH. W. P. Bolles. 


SAINT-AMAND is a small city in the Département du 
Nord, France, in which are several mineral springs of 
some reputation. The place is frequented, however, 
chiefly by reason of the mud baths which are there 


given. The following is the composition of the mud : 
Grammes 

AGL) ds MARC cae Hn sae Mink eae cee cpicters BEE 55.000 
Calciumycarbonate sn soa ee eee ee eee 1.569 
Mapnesium Carpomates ince <.ccatucisis= ae cerca ciel oeiere (0.568 
Bron yi er tec oes are a ee ee te Se Brae eat ini teens 1.450 
Sulplwrst3 oA aeeitvis 3 ne wet > Sts DEIN SG at eke oie 0.210 
SUICA posctise sehr were ieiee ae cosas fait plesiotote teres olen 30.400 
Organic matters....:.:... 5 an Sle esas ora levahe teat a(o apetae Sake 8.103 
TOSS SIGS OE Sas cee htitstee Merete ca tiers Sone eee aan e aie 2.700 

OLA archer ecttiols huasiete cee clei re cements 100.000 


The waters of the springs, which are used for drink- 
ing, contain sulphates of calcium, sodium, and magne- 
sium, carbonates of calcium and magnesium, chlorides of 
sodium and magnesium, and silicic acid. No use is 
made of the water for bathing purposes. Saint-Amand 
is recommended chiefly for the relief of chronic and sub- 
acute rheumatic affections, of certain forms of neuralgia, 
and of lameness and disability following sprains or re- 
maining as sequele of fractures and dislocations. <A 
course of treatment here is also said to be of benefit in 
chronic congestive affections of the abdominal and pel- 
vic organs. 135 7 Ee 


SAINT-HONORE is a thermal station in the French 
Pyrénées, lying at an elevation of about 900 feet above 
sea-level. The waters Of the several springs are slightly 
sulphuretted, and contain a large proportion of sodium 
chloride as compared with the other mineral constitu- 
ents. The temperature of the different springs varies 
from 80° to 86° F. 

A course of treatment at Saint-Honoré is recommend- 
ed by writers to those suffering from catarrhal affections 
of any of the mucous membranes, incipient pulmonary 
phthisis, functional disorders of menstruation, and cer- 
tain forms of eczema, lichen, pityriasis, and acne. In 
rheumatic affections baths are sometimes given, with the 
water heated above its natural temperature. 7’ L. S. 


SAINT IGNATIUS’ BEAN (Jgnatia, U. S. Ph.). The 
seed of Strychnos Ignattt Berg, Order Loganiacee. This 
is a large, half-climbing shrub, with very long, slender 
branches, and rather large, oval, pointed, three-nerved 
leaves. The flowers resemble those of S. Nua Vomica, 
and the fruit is a very large (ten to twenty centimetres), 
solid, many-seeded, hard berry. Very little is known in 
detail concerning this plant. Bentley and Trimen, in their 
‘‘ Medicinal Botany,” have been obliged to copy descrip- 
tions and figures from fifty to nearly two hundred years 
old, and there do not appear to be any accessible botani- 
cal specimens. It is even doubted by some whether it 
comes from a Strychnos at all, but the peculiar structure 
and composition of the seeds make this almost certain 
on indirect evidence. The plant grows in the Philippine 
Islands, and has been introduced into Cochin-China. 
The fruit appears to be not uncommon in some Asiatic 
markets. The seed has been known to Europeans since 
1699 (Fliickiger),. 

Saint Ignatius’ Beans are hard, oblong but irregularly 
faceted seeds, two or three centimetres in length, of a 
dull yellowish-gray or blackish color, and corneous text- 
ure; they are normally covered with short, coarse, ap- 
pressed, glistening hairs, but these are usually rubbed off 


244 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


before they reach this country, probably by the friction 
of the long voyage, or carriage. The seed consists 
mostly of perisperm, but contains an oblong embryo, six 
or eight millimetres in length, in a cavity near the centre. 
The seeds have but little odor, and a very bitter taste. 
Composition.—Sitrychnine, to the extent of from one 
to one and a half per cent. ; bructne from one-half to 
three-fourths per cent.; considerable albuminoid mat- 
ters; no starch. These seeds, from chemical, structural, 
and physiological points of view, are qualitatively so ex- 
actly duplicates of Nux Vomica, that the reader is re- 
ferred to that article for further information. An ab- 
stract (Abstractum Ignatie, U. S. Ph.) and a Tincture 
(Tinctura Ignatie, U. 8. Ph.) are to be had at the phar- 
macies, W. P. Bolles. 


SAINT JOHN’S BREAD (Caroube, Codex Med.). The 
fruit of Ceratonta stliqua Linn., order Leguminose, a 
medium-sized ‘‘ Locust” of Southern Europe and the 
Levant, whose English name is derived from the tradi- 
tion that it formed part of the food of The Baptist while 
in the desert. It consists of pods of an oblong-linear, 
curved outline, ten or fifteen centimetres (four to six 
inches) long, two or three broad, and about one (or less). 
thick. They have a dull-glossy brown surface, and a 
sweetish, dry-pulpy texture. The pea-like, but slightly 
albuminous seeds, are imbedded in this pulp. 

St. John’s bread has no medicinal value whatever. It 
forms a poor article of food in Spain, Italy, etc., and is 
also fed to cattle. In this country it is scarcely to be 
met with, excepting at a few shops in the larger cities, 
where it is kept to supply a slight demand of Spanish 
and Italian immigrants. 

ALLIED PLANTS, Etc.—See SENNA, CAssrA FISTULA, 
etc. W. P. Bolles. 


SAINT JOHN’S WORT (Millepertuis, Codex Med.). 
Hypericum perforatum Linn., order Hypericacee. A 
troublesome weed, with a much-branched, herbaceous 
stem, somewhat flattened, from thirty to sixty centime- 
tres high, elliptical-oblong, dotted leaves, acrid juice, 
and numerous rather showy, regular, yellow flowers. 
Sepals five, lanceolate-pointed. Petals five, large, round- 
ed. Stamens numerous, in five bundles. Styles three, 
pod three-celled. 

This and other Hypericums have had in time past con- 
siderable reputation in diarrhea, rheumatism, insanity, 
etc., aS well as in the form of liniments as vulneraries. 
All are at present obsolete, excepting in domestic use. 

W. P. Bolles. 


SAINT LOUIS. The accompanying chart, represent- 
ing the climate of the city of St. Louis, Mo., and obtained 
from the Chief Signal Office at Washington, is here in- 
troduced for convenience of reference. A _ detailed 
explanation of this chart, and of other like charts pub- 
lished in the HANDBOOK, is given in the general article 
on Climate, where also the reader will find suggestions as 
to the best method of using these charts. 

‘St. Louis has one of the most extreme climates to be 
found within the limits of the United States. In illus- 
tration of this fact the reader is referred to the data of 
column J. By comparing the St. Louis and New York 
City charts we learn that although the mean temperature 
in winter at St. Louis is only two and a half degrees 
higher than that of New York, the mean summer tem- 
perature of the former is five and one-third degrees 
higher than that of the latter. The daily range of tem- 
perature is decidedly greater at St. Louis than at New 
York; yet, despite this fact, the day and night figures 
are in summer both of them so high that cooler nights 
are to be found at New York with a relatively low nyc- 
themeral range of temperature. Column K shows us 
that month by month throughout the year the St. Louis 
climate is drier than the climate of New York. Columns 
L, M, and N show that the former is less cloudy, espe- 
cially in summer and autumn, than is the latter. The 
prevalence of south winds throughout the year is a nota- 
ble feature of the St. Louis climate; the blizzards of 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sago. 
Saint Moritz. 


Climate of St. Louis, Mo.—Latitude 38° 38', Longitude 90° 12'.—Period of Observations, Janu 
: 38’, — : f ary 1, 1871, to Decemb 
31, 1883.—Hlevation of Place of Observation above the Sea-level, 485 Jeet. 5 ares 


A 


> 


Men eae 
or 
Mean temperature of months Servet or 


_ at the hours of 


duced from Column A. 


Average mean temperature de- | > 


Cc D E ¥ G Hi 
sce) Slt by 

5 E ges jess 
2 oe) es Diss 
g g Ags |azg 
o ® no | g| 2 5 Bg 
2 & mPa | Peck 
ce a sé Bee | OG S3 
” ~ ° Mao! dan! 
g ge Absolute maximum |Absolute minimum bates Ft Oat F 3 
mS a9 temperature for] temperature for|| , BSa/ 2S I 
go = period. period, Bee aeoR 
“A oy at bal +2 | 5 
RS | 8s Foo. fs5g 
g | Reo8|See Ss 
o (0) pan§ie g no 
ac oo MS ee S Cc ie 
FS S SobG Pores 
S @ SYLE| So wee 
a < CEB hloae 

Highest.| Lowest. | Highest.) Lowest. 
Degrees.| Degrees.| Degrees.| Degrees.| Degrees.| Degrees. 

38.7 22.9 72.0 48.0 eT) —16.0 24 31 
45.5 28.4 73.2 61.0 27.0 —3.0 21 22 
53.5 36.7 82.0 62.0 34.0 8.0 25 26 
65.8 47.5 87.5 78.0 » 43.0 22.0 18 18 
73.4 56.7 93.0 84.0 45.0 32.0 25 25 
83.0 65.2 99.0 90.0 64.0 48.0 16 19 
88.2 70.0 104.0 93.0 70.0 57.0 22 21 
87.4 68.3 106.4 7.0 63.0 55.0 25 22 
79.2 60.0 101.5 85.0 51.0 40.0 25 19 
63.4 51.2 90.0 80.0 42.8 25.0 23 21 
Heid 36.6 82.0 61,0 31.0 5.0 24 23 
43.4 29.0 74.0 53.0 21.0 —17.0 22 24 


TAM. 3P.M. | 11.P.M. Highest.| Lowest. 
Degrees. |Degrees. | Degrees.|| Degrees.|| Degrees.) Degrees. 
January... : 27.8 36.2 Stel SL.7 45.7 ale 
February...) 31.1 41.3 36.0 36.1 43.9 26.0 
March ..... 37.2 49.2 42.9 43.1 53.9 37.8 
April Wears... 48.9 62.2 54.4 55.1 61.3 47.6 
AY Sees se sis 60.6 73.0 64,8 66.1 70.8 59.5 
June... 69.6 81.1 93.4 G47 "9.7 71.9 
J tlyeeee 3 73.7 85.3 WA 78.8 81.7 73.8 
August..... 71.0 84.0 75.7 76.9 82.5 72.8 
September . 61.5 75.7 67.0 68.0 75.3 64.9 
October .... 51.2 65.0 56.4 57.5 62.3 52.0 
November. . 37.7 47.7 42.0 42.4 49.6 31.9 
December .. 30.3 38.4 34.1 34.2 47.9 24.9 
SHEN pea. week aca Agor 54.7 60.1 51.9 
Summer.... AO Nae AoC 76.8 79.5 73.6 
Autumn.,... eres cade sa00 55.9 60.0 50.9 
Winter...... aero see wet 84.0 41.9 26.4 
Nearer vosa | ees Rea erat 55.3 57.5 53.6 
J K L M N 6) Ss 
sits ! by be bi hy =| } bo 
Poe ee leetepas he Ol BR es 
Be | 2 ds | 2 | se | 3 se ik 
S244 ar | 63 | ag H of oS Ps, 
eh Se oe oH o& on & ovs 
om | BB | oy | &s | os, | wo | BS [eas 
oe D RG £S Peay gas) fd Se |£E x. 
go | Sq |-fs | be | Sel fs | &S l[esk 
ae. Ce eo ee h(a pte ha 
January...| 88:0 Deceit LS 8.8 20.1 Zl e ay oss 10.2 
February..| ‘6.2 69.5 10.5 8.5 19.0 3 100e > 8. 10.3 
March..... 74.0 66.0 11.9 EE 19.6 3.04 N. W. | 11.6 
Ayu) gh ee SS 65.5 59.7 11.8 9.4 ieee SraD 8. 10.7 
LAV ee ose: 61.0 64.2 15 9.8 21.3 | 3.86 Ss. 9.7 
June..:.... 51.0 68.2 14.4 8.0 22.4 4.82 bd. 8.9 
Jiihyeescerer 47.0 67.9 12.$ 11.4 24.3 4.36 Ss. "7 
August....| 51.4 66.1 13.2 14.1 27.3 2.56 Ss. v4 
September.! 61.5 64.7 10.9 13.9 24.8 2.55 s. 8.5 
October....| 65.0 64.9 11.8 12.8 PEN a ly Ss. 9.5 
November.| 77.0 67.9 12.2 ed 19.9 2.19 s. 10.6 
December .| 91.0 (2.0 11.2 V2 18.4 | 2.19 Bs 10.2 
Spring..... 85.0 63.3 35.2 26.9 62.1 | 10.25 Ss: 10.7 
Summer. 53.4 67.4 40.5 33.5 74.0 | 11.74 Ss. 8 0 
Autumn. 96.5 65.8 34.9 34.4 69.3 8.12 s. 9.5 
W interes | ol. 0 70.9 33.0 24,5 Deo) 7.48 Ss. 10.2 
Yearseoe 123.4 66.8 | 143.6 | 119.3 | 262.9 | 87.59 Ss. 9.6 


March alone interfering to change the direction from S. 


to N.W. Vee wee 


SAINT MORITZ. The climate of Saint Moritz, con- 
sidered as.a winter health-station, has already been suffi- 
ciently described in the article entitled Engadine. In 
the present article a few words will be said concerning 
the summer climate of this celebrated resort of the High 
Alps, and concerning its valuable mineral springs. The 
wood- cuts on page 246 (Figs. 3361 and 3362), copied 
from Woldemar Kaden’s ‘‘ Baths of St. Moritz,” are pre- 
sented to the reader as illustrations of the descriptive 
passages in the Engadine article, where they would have 
been more properly introduced had they been available 
to the writer when that article was prepared for press. 
These illustrations will be especially interesting to a 
reader of Dr. Yeo’s work on ‘‘ Climate and Health-re- 
sorts,” and if studied.in connection with the lengthy and 
interesting descriptions of scenery therein given, will con- 
vey to the mind a very accurate impression of the topog- 
raphy and scenery of the Upper Engadine. 

In studying the illustrations it should be borne in 
mind that the direction of the Upper Engadine valley is 
from southwest to northeast. 

The view in Fig. 3361 is taken from an elevated point 
on the eastern side of the valley, just south of the St. 
Moritz bathing establishment, and shows the valley as 


seen on looking north from this point. In the foreground 
are seen the Kurhaus, bathing establishments, and hotels 
constituting St. Moritz Bad, or the Baths of St. Moritz. 
Near the centre of the picture is seen the village of St. 
Moritz, built upon the northern slope of the valley, at an 
elevation of some two to three hundred feet above the 
lake of the same name. The mountains which close in 
the view to the north are a portion of the range of the 
Albula and Bindner Alps, the lofty serrated peak seen 
directly in line with the village of St. Moritz and tower- 
ing above all other summits visible in the picture being 
the Piz Kesch (11,211 feet high above sea-level; 5,411 
feet above St. Moritz Lake). 

In Fig. 3362 the view is taken from an elevated point 
on the western side of the valley, just north of the village 
of Campfer; probably from the ‘‘summer restaurant 
known as the Alpina,” mentioned by Dr. Yeo (op. c?t., p. 
192). In this view we are looking up the valley, instead 
of down the valley as in Fig. 3361. The baths of St. 
Moritz are behind us on the left: and not very far dis- 
tant either ; for Dr. Yeo, in describing Campfer, tells us 
that ‘‘it is a convenient abode for those visitors to the 
Baths of St. Moritz who would be at St. Moritz, but not 
of St. Moritz,” being ‘‘as near the Kurhaus and the 
baths as the village of St. Moritz itself.” It isthe village 
of Campfer that is seen in the immediate foreground of 
this picture. The little village standing in the distance 
is that of Silva Plana. The lake in the foreground is 
that of Campfer, the one in the background beyond Silva 
Plana is the lake of Silva Plana. The lake of Sils, the 
village of Sils, and the Maloja we do not see; they are 
hidden behind the mountain-shoulder which rises behind 
Silva Plana; but the great snow-covered alp which 
closes in the view to the southwest is the Piz Margna, 
one of the three Bernina mountains whose slopes are 
said by Dr. A. T. Tucker Wise to abut on the lake of 
Sils and on the eastern side of the Maloja plateau (‘‘ The 
Alpine Winter Cure,” p. 66). The elevation of the Piz 
Margna above sea-level is 10,355 feet. A reader of Dr. 
Yeo’s book will easily recognize another prominent ob- 
ject in this picture, namely, the location of ‘* the restaur- 
ant and summer house called Crest-alta, which is finely 
situated on the top of a wooded promontory which pro- 
jects in the most picturesque manner from the south side 
of the valley into the Campfer lake.” This promontory 
is seen just to the left of the centre in our illustration. 

SumMMER CrimaTE.—The following tables, taken from 
Woldemar Kaden’s interesting pamphlet, will serve 


245 


Saint Moritz. ms ; 
Saint Paul. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


itl 


Fic. 3361.—Baths and Village of St. Moritz, (From *“ The Baths of St. Moritz.” by Woldemar Kaden, ) 


Fic. 3362.—Campfer, near the Baths of St. Moritz, and Piz La Margna, (From ‘** The Baths of St. Moritz,” by Woldemar Kaden.) 


246 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


sufficiently to illustrate the summer climate of Saint 
Moritz: 


TABLE A.—Mean Temperatures of the Summer Months 
and of the Season during the Ten Years 1856-1865, ac- 
cording to Professor O. Brugger. (‘‘ The Baths of Saint 
Moritz.’’) 


| j . 
Mean daily hee oe 
Month. 5aM. 1p.m,|9pP.m.| tempera-| uation o 
ture, tem pera- 
ture. 
JUNG 4s). Minas area 41.57 | 57.27 | 44.74 49.55 15.69 (?)* 
TUulypE te ewe Gee tenes 43.55 | 61,28 | 49,35 52.46 49.67 
ANIGUBER arse si-.5 0 Hoje ages oh 42.98 | 60.62 | 48.70 51.67 49.64 
Heptember Foc.e cece 38.64 | 54,23 | 43.16 45.60 47.48 
Season (June 21st to Sep- 
tember 20th) 2.2. os. 42.31 | 59.43 | 44.07 50.63 49.01 


TaBLE B.—Mean Temperatures of the Summer Months 
and of the Season during the Seven Years 1867-1873 (Dr. 
Husemann, from Candrian’s Daily Observations). (‘* The 
Baths of Saint Moritz.’’) 


Daily  fluc- 


Mean daily | aS f 

Month. 7 aM.|1P.M.|9P.M.| te mpera- ae cai 

five. em pera- 
ture.* 
June ee: ....| 45.95 | 55.61] 44.74] 48.74 43.89 
DULY pee a rereion Het sacaena | 50.79 | 62.43 | 47.57 54 57 45.39 
PGi eee Gln RE Per wae eee 46.92 | 59.50 | 48.11 51.51 45.86 
Septentberc o's. Wes se cs 40.88 | 54.96 | 44.00 46.45 47.33 

Season (June 21st to Sep- | 

tember 20th).<........ 47.31 | 59.77 | 48.30 51.80 45.89 


* Whether the figures in this column represent the mean, or the ex- 
treme daily, fluctuations I do not know.—H. R. 


TABLE C.— Average of the Weather Conditions for the 
Summer Months and the Season during the Fourteen Years 
1860-1873 (Dr. Husemann, from Candrian’s Observations). 
(‘‘ The Baths of Saint Moritz.’’) 


= we | 8 § 5 5 6 
se| be af eb 3 | Ba 
Month. 3 a a qs > e ms a 
Se} et | wo | as ev) sc 

rn Be cs fa Gi = 
PUNCH artes cle tre cetera ee 1G9 a1 2.1 1.4 7.2 | 0.93 | 1.4 
ed UL Ware teesreferctareiais: ere! opereteve ss otarsts in eis 21.9 shal 3,3 Ome Osta leuk 
AMIE UBbier tte te ce steetele siete eerie ® 21.5 9.5 3.38 7.4 | 0.86 | 2.2 
Sepbember con «cj 4oc cristal aes 21.4 8.6 5.4 6. | £36.) 0.8 

Season (June 21st to Septem- 

ber! 20th) ea es tec ea Gamiwes te lOsSaieelA el 57 5 i6 


Mr. Kaden states that July and August are the best 
months for a summer stay at Saint Moritz, and that 
April and May, being the snow-melting months, are the 
very worst season of the year in the Engadine. 

MINERAL WATERS. — There are two chief mineral 
springs at the baths of Saint Moritz, known respectively 
as the ‘‘ Alte-Quelle” and the ‘‘ Paracelsus-Quelle ;” of 
these the latter appears to be a trifle the richer in mineral 
ingredients, but the two are very similar one to the other. 
A very full analysis of the two waters may be found on 
pages 58 and 59 of Mr. Kaden’s pamphlet. Dr. Yeo (op. 
eit., p. 160) also gives an analysis of the Saint Moritz wa- 
ters. He sums up the characteristics of the waters as 
follows: ‘‘ Practically these waters may be regarded as 
containing a small quantity of iron, about three grains 
of the carbonate in a gallon of the stronger source, and a 
considerable amount of carbonate of lime, about eighty 
grains in a gallon, held in solution by an abundance of 
carbonic acid. The presence of this large amount of car- 
bonate of lime in the absence of any appreciable amount 
of aperient saline constituents, interferes somewhat with 
the usefulness of this water in many cases where the use 
of a chalybeate is indicated.” ‘The duration of the course 
of treatment by baths, etc., usually recommended, is 


from three to eight weeks. For full information con- 


cerning the proper use of the waters and the class of mal- 
adies ameliorable by such proper use, as well as the type 
of disease and of constitution indicating the propriety of 
recourse to this ‘‘ high altitude” bathing-station, and the 
class of invalids and type of constitution which should 


/ 


Saint Moritz. 
Saint Paul, 


be forbidden to resort thither, see Dr. Yeo’s book and 
Mr. Kaden’s pamphlet, in both of which works (the 
former especially) these matters are treated ably and at 
very considerable length. For general indications see 
articles ‘‘ Health-resorts” and ‘‘ Mountain Resorts.” 
Huntington Richards. 


SAINT-OLAFSBAD is a health-resort in Sweden, not 
far from the city of Christiania, which is visited to some 
extent by foreigners on account of its iron-spring. This 
water contains 0.114 Gr. of mineral constituents, about 
fifty per cent. of which is ferrous carbonate, in each litre. 
There are various other ‘‘ cures”? made use of, such as 
pine-needle baths, mountain climbing, frictions with peat, 
milk and whey cures, ete. 

The affections for the relief of which Saint-Olafsbad is 
visited are anemia, chronic bronchitis, chronic rheuma- 
tism, debility attending tedious convalescence from acute 
diseases, etc. The place is well protected against the 
north winds, and the climate is more mild than in other 
places in the vicinity. The season for guests lasts from 
about the end of May to the first of September. 

Lidia: 


SAINT PAUL. The accompanying chart, represent- 
ing the climate of the city of Saint Paul, Minn., and ob- 
tained from the Chief Signal Office at Washington, is 
here introduced for convenience of reference. <A de- 
tailed explanation of this chart, and of other like charts 
published in the HANDBOOK, may be found in the gen- 
eral article on Climate ; where also suggestions are made 
as to the best method of using these charts. St. Paul 
and other points in Minnesota were greatly in vogue a 
few years ago as winter resorts for persons in the early 
stage of pulmonary phthisis, and very many such per- 
sons have no doubt been benefited by residence in the 
steady cold of the Minnesota winter ; but, since the some- 
what over-rapid growth of its chief towns has set in, and 
since the discovery of other and. better climates of the 
bracing winter type, the reputation of Minnesota as a 
health-resort has considerably declined. 

A comparison of columns L, M, and N of the St. Paul 
chart with corresponding columns of the New York City 
chart, demonstrates the fact that during the winter and 
summer seasons a less degree of cloudiness prevails at 
the former than at the latter station. During the spring 
season, on the contrary, New York City appears to be 
slightly less cloudy than St. Paul. The spring, fall, and 
winter rainfall at St. Paul is greatly less than at New 
York. Inthe matter of windiness the climates of the two 
places are very much alike in spring, summer, and au- 
tumn ; but in winter the slight difference (in favor of St. 
Paul) existing between the two becomes very considera- 
ble, New York City, according to the figures of column §, 
being nearly twenty-three and two-thirds per cent. more 
windy at that season than is St. Paul. In the matter of 
relative humidity the climates of the two places are in 
winter almost precisely alike, such trifling difference as 
exists being in favor of New York City ; in summer and 
autumn scarcely any difference between the two exists. 
In spring, however, and notably in the two months of 
March and April, the relative humidity at. St. Paul is 
markedly less than at New York City. The absolute 
humidity of St. Paul, during the winter season in par- 
ticular, is less than that of New York City, being at that 
season only half as great. In summer the two places 
differ little in absolute humidity of atmosphere. The 
actual figures for the two places are as follows, assuming 
for convenience of calculation that the mean summer 
temperature of New York is 0.5°, and that.of St. Paul 
0.6° higher than the actual figures, and that in winter 
New York City’s mean temperature is 0.6°, and St. Paul’s 
0.4° higher than shown by the figures of Column AA. 


Mean sum- | Mean sum. |Mean winter! yroan winter 


mer abs. hu-| abs. humid- 
mer temp. midity. ity. | temp. 
New York City.... {2° 5.973 1.537 82° 
Bt. Pant eek 70° 5.586 | 0.823 | 17 


247 


Saint Paul. 
Salicylic Acid. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Climate of Saint Paul, Minn.—Latitude 44° 58', Longitude 93° 3'.—Period of Observations, November 1, 1870, to De- 
cember 31, 1883.—EHlevation of Place of Observation above the Sea-level, 762 feet. 


A | AA B bob Ove D E F G H 
hues aap Y boag hiad 
3 ie g ARE IEPEE 
ed (eg z fo talso ht 
Bs wee he & Bao gaee 
ea 5 2 be ce) psc > 
| 55 See égvaise  § 
| es  Beuahees ceeseee® 
1] one 4 “ ere 5 2 rs 
Mean temperatureof months ||) @9 Mean temperature : = a 5 iB Absolute maximum) | Absolute minimum = ED 5 ® BS 5 
at the hours of Ne ai g for period of ob-| §& a a temperature for|| temperature for||@ g~ g/28 es 
eo servation. ky asks ee period. period. a aga = aye 
OH 8.C Banc} ea Be as Gs 
fg : 5 as 8)a6"8 
oo © o eparpivy > 
ae a tn) eae od begs 
o | 8 3 Swse Sass 
> 1 Pa > Q9ano Pages 
ee |< 4 owed oaad 
TAM. | 8P.M. | 11 P.M. Highest.) Lowest. \| Highest. Lowest. || Highest.| Lowest. 
Degrees. | Degrees. | Degrees. || Degrees.|| Degrees. Degrees.| Degrees.| Degrees. || Degrees. | Degrees.| | Degrees, | Degrees. 
January....| 8.8 UW BS 12.4 Rey Weer ebue tel 0.8 24.3 4.8 49.0 23.0 —11,.0 —31.0 27 26 
February...; 12.8 24.7 17.8 18.4 31.8 629° i -220"4 9.4 59.0 24.0 5.0 —32.0 21 3 
March tain a1 22.6 34.7 28.3 28.5 44.3 Pe On Pelemclae 22.2 68.0 46.0 21.0 —22.5 20 30 
ADIN teow | 93%.9 51.8 43.7 44.4 50.9 36.9 58.3 36.9 82.0 63.0 30.0 7.0 19 21 
May ie cceny 53.1 66.1 57.2 | 58.8 63.8 52.2 68.7 48.3 94.0 75.0 40.0 24.0 24 25 
Abitsbnodante 61.5 73.7 65.1 66.7 43.0 | 63:8 78.1 ate) 94.0 85.0 | $2.0 39.0 17 20 
JULY tee eek 65.9 79.6 69.9 eS A eo} 74.6 66.6 82.8 62.7 100.6 91.0 57.0 46.0 26 21 
August..... 63.5 17.8 68.0 feeO Se 42.9 66.1 82.0 61.5 98.0 §8.0 54.0 43.0 ai 24 
September... 52.2 66.2 57.0 | 58.4 64.1 GBM Ns CEE 50.7 94.0 76.0 41.0 30.0 23 19 
October..... 41.9 53.5 45.3 46.9 heeo6z9 a2 D0 i) r.6 41.0 7.0 67.0 32.5 15.0 22 19 
November.. 26.4 34.8 29.3 eis VAN 39.6 22.2 | 40.2 23.8 72.0 47.5 15.0 —24.5 20 24 
December .. 15.2 22.8 18.1 fot setts! 33.6 Seer ily eS.2 12.2 56.0 36.0 10.0 —39.0 at 30 
Spring et ec.f wee tenet Moseees viene te | 43.9 47.1 SOA, gcc sene me ae ehhh tee GREY Magenta Cis ae 
SOULE CI a= nie esters aunote.| lie cacone | 69.4 71.3 (Care APs |) Roane SAP doses.) jl” aencos ASN Macsane. eater 
ATTN Feet Bee ote cic emma Miecis ¢ Siotln |e avers inte je a5eL0 siege o. 6 5 os eee acon Wl oreo. HEC ad Snooe al) Goans Ber old ericnn ye 1k Bec 
Winter...... Me Bisa pian gacic, Hill G datigos 16.6 || . 29.2 Se a ippemaccre | Ole ompsso NNN Geecwl, uh epoods voi Sw hate ee oe 4 
YVear:t). 2328; ee ee 43.7 48.2 BOS 8 p's ns sieve. cally ee sie. e eeu a motets een Onl emretme pile, son! |N iste ardor lh ts pheetaty 
| | | eye 
J'K LF mM! N Oo | F_ S_4 the composition of the waters, after analyses made by 
at ae fut as bg Filhol and Byasson. In 1,000 parts of water there are of 
| | pan oO 2 
23) 4 ny FS ot Es f Vises ig 3a Source Source 
SE iy ac = be E 8 | Sc P| m8 | os des Bains. de Hontalade. 
Se BS) ae) Ae ae 3 eee | PA Sodium eiphate.+ 47. aemen 0.0400 0.0213 
SE | Bo | ek] oF | ox i BS | oF 5 Calcium ‘sulphate. ..0 ia. -2 teers eee ee 0.0572 
Ase aa | oo | fee ep rt ae Meg ee Magnesium sulphate! ... ) We os eee 0.0087 
}gsi1 8 | 33 | oy Bie 5 on ie g Sodium sulphides, iva. a: it nee 0.0218 0.0197 
aes 4 a SE A aia Sodium hyposulphite., sieccs- ave ees ee 0.0028 
Eo (Be Tip, RMP Rn caer db) VACA OA Ba teres AB Sodium ichloride..g7.4 8; Acasa Sa ee 0.0695 0.0600 
| | Inches.| From Miles. Sodiumsilica tessa eee eee See 0.0704 0.0896 
January....; 80.0; 72.1 | 18.0; 8.@ | 21.0 1.07 | N.W. 7.8 Calcium silicate... .cc eee eee nee 0.0062 0.0076 
poorer y is] ae a 4S | ee an Of | an ae Magnesium silicate...........0....... O00ST > Sin a 
ee ane aes 9. Ae “ 20. . cons : Aluminiumasilicates seme set eee 0.0070 
Aprils eee 75.0 | 60.38 | 12.0° S528] 2052) 2209 NW 9.6 P| aoe See Bite go VETS co Re PM Bony OM CL tine 215 
May wie. 20.0 60.5 14.2 | 8:8 23.0 8.72 8.E. 8:6 Oreaniceumatterac.mevscs.se oe eee see 0.0820 0.0215 
UNE res D. 68.0 | 15.% Py de ray. : Hi. : oa 
lUnY ss taeties | 54.0 | 69.9 | 15.8} 10.6 | 26.4 | 8.22 | S.E. 7.2 LOtAl so... see os oe ae tests 0.2500 0.2884 
August..... hOl0- ae pele) teh 5 25.3 3.83 | S.E. 7.3 res ;. ° 
September.! 64.0 | 70.7 | 18.8) 91 | 22.9 | 8.26 | S.E. 8.2 There are traces of iodine and boracic acid. The 
S pamene cael Ih aR lata h eet eet cas ith eee waters issue at a temperature of 94° and 71° F., respect- 
December. .| 95.0 |) 74:8 | 12.8.) ° 8.8 | 21.6°|° 1.28 ) NW. 1 75 ively. 
Spring's... 116.5 | 63.3 | 98.2| 25.3 | 63.5 | 7.45 | NW. 95 The indications for a course of treatment at Saint- 
Summer... 61.0 | 69.9 | 45.8 | 29.3 | 5.1 | 12.18 S.H. ee Sauveur are stated to be catarrh of the bladder, gravel, 
ee ee te See tee Mk ees ee ney gastralgia, chronic diarrhcea, menstrual disturbances, 
Near Sos: 139.0 69.1 1159.9 | 106.2 | 266.1 | 29.9% | SH. 8.4 certain uterine affections, pulmonary phthisis, and irri- 


It is in the matter of temperature that we find the chief 
difference between the climates of the two places. The 
mean temperature of November at St. Paul is the same 
as that of January at New York City ; while the mean 
temperature of the four months, December, January, 
February, and March is at New York 32.8° F., at St. 
Paul only 19.6° F. 

Steady cold in winter, involving exemption from thaws, 
is the chief cause of the popularity formerly enjoyed by 
Minnesota as a resort for phthisical patients, and is the 
leading factor in its climate (combined with relative 
windlessness and cloudlessness, and its inland location, 
involving freedom from the perpetual changes from land 
to sea air, and from sea air to land air, common along 
the Atlantic coast), which renders the truly and purely 
continental climate of that State more favorable to weak 
lungs than is the climate of any of the larger seaboard 
cities of the Northern United States. Reig i % 


SAINT-SAUVEUR is a little hamlet in the Départe- 
ment des Hautes-Pyrénées, France, lying at an elevation 
of 2,500 feet above the sea. The valley in which the 
village lies is exposed to the north and south winds, but 
the climate is nevertheless equable and mild. There are 
two principal springs—the Source des Bains or des 
Dames, and the Source de Hontalade. The following is 


248 


table conditions of the nervous system. The therapeutic 
means employed are baths, both general and local, 
douches, and the internal use of the water. The season 
extends from about the first of June to the middle of 
September. A single course of treatment generally oc- 
cupies about four weeks. 7 S. 


SALEP, Codex Med. (Tudera Salep, Ph. G.). The corms 
of several European and Asiatic Orchidaceous plants, es- 
pecially of Orchis mascula Linn., O. Moris Linn., 0, 
militaris Linn., O. varvegata Linn., etc., dried by means 
of artificial heat. It is in the form of small round, oval, 
or irregular tubers of a yellowish color and rather trans- 
lucent texture. Salep is tough and hard to pulverize ; 
it has a mucilaginous taste and very little odor ; consists 
of a small quantity of starch and a good deal of bassorin- 
like gum, with no more active ingredients, and is simply 
a not very nutritious food, devoid of physiological or 
therapeutic value. 

ALLIED PLANTS.—See VANILLA. 

ALLIED DrRuGs.—See TRAGACANTH ; STARCH. 

W. P. Bolles. 


SALICYLIC ACID AND SALICYLATES. Salicylic 
acid, chemically ortho-orybenzoic acid, HC;H;QOs, takes its 
name from the principle salicin, found in willow-bark, 
from which substance it is possible to make salicylic 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Saint Paul. 


acid by fusion with potassic hydrate. Salicylic acid in 
the condition of the ethereal salt, methyl salicylate, con- 
stitutes about ninety per cent. of oil of gaultheria 
(wintergreen), and occurs also in other plants. Salicylic 
acid can be made from oil of gaultheria, but at present 
almost all the acid used in medicine is made by the pro- 
cess of Kolbe, from carbolic acid. The principle of this 
process consists in the forcing upon the molecule of car- 
bolic acid a molecule of carbon dioxide, an addition 
which just converts one molecule of the phenol intg one 
of salicylic acid. By the process, carbolic acid and a 
concentrated solution of soda are first evaporated to dry- 
ness, and over the product, heated, a stream of dry car- 
bon dioxide is made to pass. As a result, one half of the 
phenol used is converted into salicylic acid in condition 
of sodic salicylate, which salt, on decomposition by treat- 
ment of its aqueous solution with hydrochloric acid, 
yields salicylic acid under its own form. Kolbe’s pro- 
cess, by reason of its cheapness, has practically super- 
seded all others for the procurement of salicylic acid. 
Salicylic acid is officinal in the U. §8. Pharmacopceia 
under the title Actdum Salicylicum, Salicylic Acid. It 
presents itself as ‘‘ fine, white, light, prismatic, needle- 
shaped crystals, permanent in the air, free from odor of 
carbolic acid, but sometimes having a slight aromatic 
odor, of a sweetish and slightly acrid taste, and an acid 
reaction. Soluble in 450 parts of water, and in 2.5 parts 
of alcohol at 15° C, (59° F.); in 14 parts of boiling water ; 
very soluble in boiling alcohol; also soluble in 2 parts 
of ether, in 2 parts of absolute alcohol, in 3.5 parts of 
amylic alcohol, and in 80 parts of chloroform. When 
heated to about 175° C. (847° F.) the crystals melt, and 
at about 200° C. (892° F.) they begin to sublime; at a 
higher temperature they are volatilized and decomposed 
with odor of carbolic acid. The aqueous solution is 
colored intensely violet-red by test-solution of ferric 
chloride” [one part of ferric chloride dissolved in ten 
parts of distilled water] (U.S. Ph.). Although salicylic 
acid is but feebly soluble in cold water, it dissolves freely 
in many saline solutions. Thus the pharmacopceial 
solution of acetate of ammonia will dissolve twenty-five 
per cent. of salicylic acid ; a twelve and a half per cent. 
aqueous solution of potassic acetate will dissolve twelve 
_ and a half per cent. of the acid ; a twelve and a half per 
cent. solution of potassic citrate in equal volumes of 
glycerin and water will dissolve six per cent. All of 
these solutions possess the sharp stinging taste of the un- 
combined acid. A serviceable and permanent solution of 
the acid, and one that instead of being sharp to the taste 
has a pure bitter flavor only, can be made as follows: 
Dissolve two parts of borax in twelve of glycerin by the 
aid of heat ; add one part of salicylic acid, continue the 
heat, and stir until the acid dissolves. Almost all solu- 
tions of salicylic acid, either immediately or after a 
while, turn of a reddish or of a smoky color resembling 
that of solutions of carbolic acid. 

Salicylic acid, taken into the mouth, has not much 
taste, proper, but speedily and quite suddenly after the 
tasting a sharp stinging seizes the throat, often severe 
enough to bring tears to the eyes. Similarly, a little of 
the dry acid snuffed up the nostrils will sting quite 
strongly. The acid brings sharp pain to cuts and abra- 
sions, but, swallowed, is much less irritant to the stom- 
ach than its effects on the throat would lead to suppose. 
Large doses, so taken, may upset digestion and cause 
a strong sensation of heat, and even actual burning 
pain, but no serious or lasting results follow. The acid 
is rapidly absorbed from the stomach into the circulation, 
presumably in saline combination, and thereupon exerts 
the peculiar influence characteristic of the salicylates (see 
Salicylates, below). 

Salicylic acid was at first used as an internal medicine 
for the procurement of the therapeutic effects of the 
salicylates; but now, and very properly, salicylates 
themselves, because of their freedom from the locally 
irritant action of the uncombined acid, have superseded 
the acid for this purpose. The present medicinal appli- 
cation of the acid is for local purposes as a deodorant, 
detergent, or so-called antiseptic—purposes which sali- 


cylic acid fulfils by reason of its possession of a fairly 
potent germ-sterilizing faculty. (See Salicylic Acid in 
article Germicides.) For general local use, the solution 
of the acid in a glycerin solution of borax is convenient, 
this solution bearing any necessary dilution with either 
water or alcohol without precipitation. A. dilution rep- 
resenting a two per cent. solution of acid is one very 
commonly employed. For other salicylic preparations 
for local use, see Salicylic Acid in article Antiseptics. 

SALICYLATES.—In saline combination, whether with 
metallic or ethereal bases, the local pungency of free 
salicylic acid disappears while yet the faculty for consti- 
tutional action remains. As already said, it is probable 
that the acid, when taken as an internal medicine, enters 
the circulation only after conversion into a salicylate, so 
that, as a matter of fact, what is commonly called the 
constitutional action of salicylic acid is, so far as we 
know, the action of a salicylate. The constitutional ef- 
fects in question are as follows: After a full dose a non- 
pyrexial subject experiences, in about fifteen minutes, a 
moderate reddening of the face with a sense of fulness of 
the head, or perhaps even a pronounced headache, and 
with a buzzing or roaring in the ears precisely similar to 
what occurs in cinchonism, Almost simultaneously free 
perspiration begins, and, according to dose, there is more 
or less tendency to a reduction of pulse-rate, of respiration- 
rate, and of body-temperature. Tests for salicylic acid 
will reveal the presence of the substance in the urine, the 
saliva, and the sweat. The urine will furthermore be dis- 
colored, appearing brown by reflected, and green by trans- 
mitted, light. It will also contain a something that will 
reduce copper salts in copper test-solutions (Brunton). 
In overdoses, salicylates readily irritate the kidneys, set- 
ting up albuminuria ; may derange the cerebral faculties, 
causing hallucinations and delirium; and may danger- 
ously or even fatally depress the functions of heart and 
lungs, determining collapse or death by failure of respi- 
ration. These several untoward effects vary a great deal 
in readiness of occurrence, and, according to Squibb, in 
‘‘a very large proportion” of instances are determined, 
not by the salicylic acid, but by a contaminating acid 
very commonly present in market samples of salicylic 
acid, and hence in salicylates derived therefrom. The 
medicinally valuable constitutional effects of salicylates 
do not appear in experimentation with a subject in health. 
They consist, in general, in a reduction of fever-tempera- 
tures, and, in particular, in an abatement of pains in 
fibrous tissues, notably the pain of affected parts in acute 
articular rheumatism ; and in an occasionally seen abate- 
ment of the glycosuria in saccharine diabetes. The anti- 
pyretic power of salicylates is second to none, in all the 
three elements of quickness, degree, and duration of re- 
duction of temperature. For a full antipyretic effect, 
however, considerable dosage is necessary—considerable 
enough to cause disagreeable sweating, ténnitus aurium, 
depression of pulse and respiration-rate, and, every now 
and then, actual toxic symptoms. The antirheumatic 
faculty of salicylates is unapproached by any other known 
medicine, so that, as is well known, salicylates constitute 
a standard set of medicines for the treatment of acute 
rheumatism. Various opinions have been held concern- 
ing the efficacy of salicylates to accomplish more in this 
disease than the obvious reduction of temperature and 
abatement of pain. Some maintain that these effects are 
all that can properly be ascribed to the medicine ; while 
others consider statistics to show for salicylate treatment 
a shortening of the duration of the rheumatic attack and 
a lessening of the frequency of cardiac complications. 
The antidiabetic power of salicylates, as is the case with 
the same faculty shown by other medicines, is very vari- 
ably manifest in different cases of glycosuria. Some- 
times the effect is n¢/, while in other cases the sugar may, 
for a while at least, totally disappear from the urine as 
the direct result of salicylate treatment—the diet remain- 
ing as before during the period of the observation. For 
decided results full dosage is necessary, and full doses 
are often exceedingly well borne in diabetes, the subject 
hardly experiencing any obvious derangement from the 
medicine. 


249 


Salicylic Acid. 
Salivation. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


The salicylates in common medical use for the purpose 
of salicylate medication are the salicylates, respectively, 
of sodium, lithiwm, and methyi—the last named in the 
shape of the volatile ot of gaultherta, which consists of 
ninety per cent. of methyl salicylate. The salicylates, 
respectively, of physostigmine, quinine, and other alka- 
loids, are used for the sake of the medicinal action of the 
respective bases only. 

Sodice Salicylate, 2NaC;H;03.H2O. The salt. is offici- 
nal in the United States Pharmacopeeia under the title 
Sodii Salicylas, Salicylate of Sodium. It is thus de- 
scribed : ‘‘ Small, white, crystalline plates, or a crystal- 
line powder, permanent in the air, odorless, having a 
sweetish, saline, and mildly alkaline taste, and a feebly 
acid reaction. Soluble in 1.5 parts of water, and in 6 
parts of alcohol at 15° C, (59° F.); very soluble in boil- 
ing water and in boiling alcohol. When heated, the salt 
gives off inflammable vapors, and leaves an alkaline resi- 
due amounting to between thirty and thirty-one per cent. 
of the original weight, which effervesces with acids, and 
imparts to a non-luminous flame an intense yellow color, 
not appearing more than transiently red when observed 
through a blue glass. On supersaturating the aqueous 
solution with sulphuric acid, a bulky, white precipitate 
is obtained, which is soluble in boiling water, from 
which it crystallizes on cooling ; also soluble in ether, 
and striking an intense violet color with ferric salts ” 
(U.S. Ph.). Sodic salicylate is the most commonly used 
salicylate, and is a very important medicine. It is easily 
made 7 solution by mixing salicylic acid and a sodic 
carbonate in the presence of water, whereupon sodic sa- 
licylate results, and remains in solution, and carbon di- 
oxide gas escapes in effervescence. From this solution 
the salt can be obtained by evaporation to dryness, care- 
fully conducted. Extemporaneous preparation of the 
medicine 27 solution being easy, Squibb points out an 
advantage of such extemporaneous making of the salt in 
all cases where the prescriber or the dispenser may not 
be certain of the purity of the market article. The point 
is that the purity of a given sample of sodic salicylate is 
not easy of establishment except by an elaborate chemi- 
cal analysis, whereas a good sample of salicylic acid is 
immediately recognizable by the simple fact of its crys- 
talline condition. Hence, in making one’s own sodic 
salicylate from a selected well-crystallized sample of 
salicylic acid, purity is assured. And in the instance of 
this salt purity is important, since, as above said, there 
is probably good reason to lay many of the untoward 
effects of salicylates to the door of the contaminating 
acid of salicylic acid. Squibb recommends the follow- 
ing formula for the preparation of a solution of sodic 
salicylate of a strength convenient for use as a medicine: 
‘Take of salicylic acid, well crystallized, 437 grains = 
28.32 grammes ; bicarbonate of sodium, 270 grains = 
17.5 grammes ; water, free from iron, a sufficient quan- 
tity. Put the acid into a vessel of the capacity of a pint, 
add 4 fluidounces = 120 c.c. of water, stir well together, 
and then add the bicarbonate of sodium in portions with 
stirring, until the whole is added and the effervescence 
is finished. Filter the solution, and wash the filter 
through with water until the filtered solution measures 
6 fluidounces, or 180 e¢.c. This solution contains 10 
grains (= 0.65 grammes) of the medicinal salicylate of 
sodium in each fluidrachm (= 3.75 c.c.).. If made from 
good materials, the solution before filtration is of a pale, 
amber color, but as most ordinary filtering paper con- 
tains traces of iron, the filtered solution is often of a 
deeper tint.” The proportions of the ingredients for this 
solution are estimated so that the solution shall be neu- 
tral, but, ‘‘ owing to the varying proportions of hygro- 
metric moisture in the materials,” the neutrality may 
not always be absolute. According to Squibb, a well- 
made sample of sodic salicylate, prepared by use of a 
well-crystallized sample of acid, is always, when evap- 
orated to dryness, ewhite, and is free from all odor of car- 
bolic acid, unless it have been shut up for a long while in 
a bottle. Even then, however, the odor should be but 
very faint—only perceptible on close examination, and 
should disappear upon exposure of the sample to air, 


250 


Solutions of sodic salicylate of good quality should have 
none of the carbolic acid smell. 

Sodic salicylate is used almost exclusively as an inter- 
nal medicine, being commonly held to be lacking in the 
germ-sterilizing faculty which gives salicylic acid, as 
such, its applicability as a local antiseptic. For the pur- 
poses of internal salicylate-medication, as set forth above, 
the salt is thoroughly effective, and, if made from a well 
crystallized and therefore fairly pure sample.of salicylic 
acid,. rarely produces untoward effects in reasonable 
doses. So large a quantity as 5.00 Gm. (about seventy- 
seven grains) has been given at a single dose in rheuma- 
tism without producing serious derangement, but the 
ordinary dosage for an antipyretic or antirheumatic ef- 
fect does not exceed 1.30 Gm. (twenty grains) repeated 
every two hours, for three or four doses, or until a dis- 
tinct impression is produced, followed by doses of half 
the quantity every hour or two thereafter, as long as the 
influence of the medicine may be required. In diabetes, 
doses of 1.30 Gm. (twenty grains) three or four times 
daily may be required, and can often be borne without 
derangement of the stomach or an unpleasant degree of 
ringing in the ears. The medicine is readily enough 
taken in simple aqueous solution, but if the faint, mawk- 
ish taste of the salt be objected to, the addition of twenty 


_ per cent. of glycerin and the flavoring with a drop or 


two of oil of gaultheria will render the mixture perfectly 
palatable. 

Lithic Salicylate, 2LiC;H;O3.H.O. The salt is offici- 
nal in the United States Pharmacopeeia under the title 
Lithti Salicylas, Salicylate of Lithium. It is thus de- 
scribed : ‘‘ A white powder, deliquescent on exposure to 
air, odorless or nearly so, having a sweetish taste, and a 
faintly acid reaction. Very soluble in water and in al- 
cohol. When strongly heated, the salt chars, emits in- 
flammable vapors, and finally leaves a black residue 
having an alkaline reaction, and imparting a crimson 
color to a non-luminous flame. On supersaturating the 
dilute aqueous solution with hydrochloric acid, a bulky, 
white precipitate is obtained, which is soluble in boiling 
water, from which it crystallizes on cooling ; also solu- 
ble in ether ; and producing an intense violet color with 
ferric salts” (U. 8. Ph.). The effects of this salt are 
similar to those of sodic salicylate, with the possible 
super-addition of medicinal virtues, in rheumatic or 
gouty cases, derived from the basic element. The dose 
is similar to that of the sodic salt. 

Methylic Salicylate, as already said, is used only as it 
occurs as the main ingredient of the volatile oil of gaul- 
theria. See Wintergreen. Hdward Curtis. 


SALIES-DE-BEARN is situated in a well-protected 
valley in the Département des Basses-Pyrénées, France. 
There are several springs here, all strongly saline, the 
most important of which is the Source du Baillat. The 
following is the composition of this water, according to 
the analysis of Henry. One litre contains: 


Grammes 

Sodium chloridene haces). share tk ets eae ota sere bipewielas 216.020 
Potassium chioride whine cent woe cnc ciciuee oe nore 2.080 
Sodium sulphate ) 
Magnesium sulphate t ES, Glee See otha la ce rele ee 9.750 
Calcium sulphate 
Potassium sulphate J 
Magnesium and calcium bicarbonate nes Se etd 5.500 
Ferrous oxide, organic matter 
SUICAANG SUMING, wcoetiocaee + sete ia= were cele eatin eee ae 1.056 

TT OLA eee olers wereiais mei Oo ice oretsia siete teeters 234.406 


There are traces also of iodine and bromine, 


The waters are used externally and internally in the 
treatment of so-called scrofulous affections of the glands, 
bones, and articular structures, of subacute and chronic 
rheumatism, and of anemia following hemorrhage, or 
induced by long-continued suppuration. Ea 


SALINS is a small village in the Département du Jura, 
France, lying at an elevation of about a thousand feet 
above sea-level. The climate is subject to considerable 
changes of temperature, the days often being quite warm 
while the mornings and evenings are cool. There are 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


several mineral springs, the most important of which is 
known as the Puits 4 Muire (Grotto A). The following 
is the analysis made by Réveil. One litre contains: 


Grammes. 

SOGiMUMEHCHIOTIGS ase. e Sel ceriacce en Sieee ohne keene 22.74516 
IMatnIGsItinn GHIOTIGGI ewe cs ve cis ciece niet ce totus 0.87018 
‘Potasnimncnloridere. cease ts cceeek oft, pee ae 0.25652 
POTASSIUM DIOTDIUG Ase mc leik le retain teauie coo nen 0.03065 
Walotum sal phates week on ccc cae oh ok arte oe ee 1.41667 
POCASSIUT TAU PIRLe secs scs fcs cea teetccnee eo. 0.68080 

Bsc Tien Lares eter ate ciate © re ochre tate wie tle aiccret baees 25.99993 


There are traces also of sodium iodide and of calcium and magnesium 
carbonates. M 


When employed for bathing purposes this water is 
sometimes strengthened by the addition of a brine con- 
taining about 320 Gm. of saline constituents to the litre. 

The waters are used internally and, in the form of 
baths, douches, and local compresses, externally. Like 
other waters of this group, they are employed chiefly in 
the treatment of rheumatic troubles, anzemia, and the so- 
called scrofulous affections. i Sd Pk 


SALIVATION. The term salivation is used to denote 
a superabundant secretion and flow of saliva, This use 
of the word has been objected to on the ground that sali- 
vation should properly signify a physiological act, in an- 
alogy, perhaps, with such words as urination, defecation, 
lactation, and the like. But the Latin word saldvatio is 
derived from the transitive verb salivo (from saliva), which 
means to salivate, to produce an excessive flow of saliva. 
The synonym ptyalism would, perhaps, be less liable to 
ambiguous construction. The term sialorrhea, while in- 
dicating an abnormal flow, does not necessarily imply 
abnormal secretion. It often happens that saliva accu- 
mulates in the mouth or drools from the lips, through 
failure in the act of deglutition, even when not produced 
in abnormal quantity. Thus in sleep, especially in cer- 
tain conditions of debility, and when the head is in a de- 
pendent position, the saliva may escape from the mouth 
because the muscles or nerves of deglutition are inactive, 
as it does habitually from a similar cause in the case of 
imbeciles. Similarly, when, in consequence of inflamma- 
tion of the throat, as in acute tonsillitis, the act of swal- 
lowing is instinctively avoided or rendered impossible 

through tumefaction of the parts, the saliva often ap- 
pears to be in excess; but this is due rather to passive 
accumulation than to any excess of secretion from reflex 
irritation. 
_ As to the exact amount of secretion necessary to con- 
stitute a superabundance, it is difficult to speak definitely. 
Normally, the quantity of the secretion varies from two 
to three pints in the twenty-four hours. In salivation it 
is often increased to from three to four pints, and may 
reach six or eight pints or more in the day. In the 
simplest cases it may only be sufficient to cause moderate 
discomfort from the frequent necessity of swallowing or 
spitting; in the most aggravated cases, on the other 
hand, salivation becomes a fatal malady, partly through 
the prolonged and excessive drain upon the economy by 
the loss of the solids contained in the salivary discharge, 
and partly through the intensity of the concomitant sto- 
matitis and the interference with nutrition consequent 
upon the inability to swallow the necessary food. 

In addition to the increase in quantity, there is also 
more or less alteration in the character of the secretion. 
The proportion of water may be either increased or di- 
minished—the latter more particularly in inflammatory 
conditions, when the solid ingredients are augmented. 
The saliva is then cloudy in appearance, and often con- 
tains gray or blackish flocculi. In certain nervous forms 
of salivation albumen may be present in the secretion. 
‘The ptyaline is usually diminished in quantity. The re- 
action is commonly neutral or alkaline, and but rarely 
acid ; in the latter case the acidity is said to be due to the 
buccal mucus. In cases accompanied with stomatitis 
the salivation is attended with a fetid and characteristic 
odor. 

The association of stomatitis with salivation, while 
very common, is by no means necessary. Very often 


Salicylic Acid. 
Salivation. 


= 


the buccal inflammation is the primary and more essen- 
tial disease, the ptyalism being secondary to it and the 
result of irritation reflected from the mucous membrane 
of the mouth to the salivary glands. In other cases both 
the ptyalism and the stomatitis are more or less the di- 
rect effects of a common cause. But there is no evidence 
that ptyalism, as such, can be the cause of stomatitis. 

A very common cause of salivation is a reflex irritation 
of the glands, which has its starting-point in the buccal 
mucous membrane. The irritation is conveyed by the 
centripetal nerves to the medulla, and thence transmitted 
through the secretory filaments of the chorda tympani to 
the salivary glands. This irritation may be excited by 
the'so-called ‘‘ topical” sialagogues—strong acids and al- 
kalies, ethereal substances and the various masticatories, 
such as pyrethrum, horseradish, ginger, mezereon, to- 
bacco, cubebs, and the like. Again, the irritation may 
proceed from the teeth, as in dentition or dental caries. 
Erythematous stomatitis, aphthee, buccal ulceration, ul- 
cero-membranous stomatitis, gangrene, and cancer of the 
mouth are likewise all attended with salivation in greater 
or less degree. In the mercurial and scorbutic forms of 
salivation, gingivitis or more extensive inflammation is 
an almost invariable accompaniment, and the latter com- 
monly precedes the ptyalism. In many of these cases, 
however, when the flux first appears, the swelling and 
redness of the mucous membrane are concealed by thick- 
ening and opacity of the epithelium, so that the presence 
of the stomatitis might easily be overlooked. So far as 
the scorbutic form is concerned, the sialorrheea is doubt- 
less dependent solely upon the buccal inflammation. 

Again, irritation may be transmitted to the salivary 
glands in a similar manner from regions more remote 
than the mouth. Nausea is commonly attended with ab- 
normal flow of saliva, as are various forms of disease of 
the stomach, or even the presence of food, the irritation 
being communicated to the medulla through the vagus 
and thence to the salivary glands. Frerichs found that 
the saliva was secreted abundantly so soon as food was 
introduced into the stomach through a gastric fistula. It 
is said also that irritation of the splanchnic nerve, whether 
by means of an electric current or through intestinal dis- 
ease, may produce salivation. Ptyalism may be asso- 
ciated with the presence of intestinal worms. 

The salivation that sometimes occurs as a symptom of 
pregnancy has been attributed directly to irritation of 
the uterine nerves, but not improbably it is the nausea 
that usually attends this condition, and the consequent 
irritation of the pneumogastric, which is the more direct 
cause of the ptyalism. According to Dewees, in all 
pregnant women there is more or less excess in the secre- 
tion of saliva. When the salivation is marked the sali- 
vary glands are usually swollen and tender, and there is a 
certain degree of swelling and congestion of the buccal 
mucous membrane. The gums, however, do not become 
sore, spongy, or ulcerated, and there is no fetor from the 
mouth. The amount of saliva secreted varies, but may 
reach as high as three or four quarts in the twenty-four 
hours (Tanner). The affection generally begins at an 
early period of gestation, coincidently with the period of 
the so-called ‘‘ morning sickness,” disappearing generally 
by the end of the third month; though it may persist 
during the entire course of pregnancy, and, in some 
rare instances, for one or two months after parturition. 
It is stated that menstrual troubles also may give rise to 
ptyalism. 

A ‘‘nervous” form of salivation may be the result 
either of transitory impressions on the sensorium or of 
neuropathic conditions of the nerves or nerve-centres. 
Of the former a common example is the so-called ‘‘ water- 
ing of the mouth,” at the sight or suggestion of certain 
kinds of food. ‘‘Frothing” of the mouth, another form 
of sialorrhcea, may be the result of mental emotion. 
Mental disease (acute mania, melancholia, hypochondria) 
may also be accompanied with ptyalism. The same 
affection may occur as a symptom of facial neuralgia, or 
of disease of the medulla, brain, or spinal cord. It is 
observed in connection with certain forms of partial or 
general paralysis, and with progressive muscular atrophy; 


251 


Salivation. 
Salivation. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, 


also in hystero-epilepsy and in rabies... In some of these 
cases it is possible that a condition of atony of the sub- 
maxillary ganglion may account for the salivation. Ac- 
cording to Claude Bernard, this ganglion has a moderating 
or inhibiting action upon the secretory function of the 
salivary glands, and when its influence is withdrawn, the 
secretory filaments of the chorda are free to act without 
restraint. 

Sometimes salivation, occurring in connection with cer- 
tain fevers, has the character of a ‘‘ critical” flux. Ithas 
been observed in pneumonia, typhoid fever, dysentery, 
and other acute febrile diseases. This form, however, is 
rare. 

It remains to speak of the ptyalism that is the result of 
the systemic or toxic action of certain medicaments, 
These, in contradistinction to the sialagogues that owe 
their effect solely to topical irritation of the buccal mu- 
cous membrane, are known as “‘ general” or “‘ remote ” 
sialagogues. Such are jaborandi, physostigma, musca- 
rin (obtained from bitter orange), tobacco, mercury and 
its compounds, the compounds of iodine, gold, and cop- 
per, and also the so-called nauseants. The last-named 
doubtless produce this effect upon the salivary glands re- 
flexly, through the gastric division of the vagus. With 
regard to the others, the mode of action has been too lit- 
tle studied to justify positive conclusions, It is quite 
possible that in some instances the effect is due to a toxic 
irritation of the medulla, whence the stimulus is con- 
veyed to the salivary glands through the chorda tympani. 
Many of these drugs are eliminated with the saliva, and 
in some this elimination is attended with stomatitis. In 
the latter case the ptyalism may be secondary to the buc- 
cal affection. Jaborandi, which salivates within half an 
hour, and sometimes by the end of two minutes, causes 
no inflammation of the mucous membrane of the mouth, 
and doubtless acts directly upon the salivary glands. 
That it does not act through the nerves has been demon- 
strated by experiment. Salivation occurs after injecting 
pilocarpine into the blood, even when the nerves supply- 
ing the salivary glands have been previously divided. 
The same is said to be true of muscarin, physostigmine, 
and nicotine. Gold does not cause stomatitis, it is said, 
and it probably acts in a similar manner to the above. 


On the other hand, the salivation from mercury and cop- 


per is almost invariably accompanied with more or less 
inflammation of the mouth. 

Of all forms of salivation, the one most frequently ob- 
served is that which occurs as a toxic manifestation of 
the constitutional action of mercury. That the stoma- 
titis, which so commonly attends this form, plays a very 
important part in the etiology of the ptyalism, does not 
admit of doubt. As to the question whether it is the 
sole cause of the latter—whether without the stomatitis 
there would be no ptyalism, a number of well-authenti- 
cated cases, in which salivation occurred without any 
signs whatever of buccal inflammation, give a pretty defi- 
nite answer. Hallopeau mentions a case observed by 
Fournier, in which salivation was produced by mercurial 
inunctions without the gums showing the least trace of 
inflammation. Similar cases have been observed by 
Fournier and others. Von Mering several times saw 
salivation produced in cats in five minutes after a hypo- 
dermic mercurial injection. 

The opinion has been held that mercurial salivation is 
a dynamic effect of the mercury acting upon the general 
system, while others have maintained that it was due to 
an impression produced upon the sympathetic ganglia. 
The most rational explanation, however, is that it is the 
direct effect of the mercury contained in, and eliminated 
by, the saliva. That mercury is eliminated by the saliva 
there can no longer be any room for doubt. It has been 
verified repeatedly, and Bernatski has even succeeded in 
finding the metal in the saliva coming directly from 
Steno’s duct. Doubtless both the ptyalism and the 
stomatitis may be due to the same irritating cause con- 
tained in the saliva, although the former would naturally 
be aggravated by the existence of the latter. All the 
facts seem to point to the presence of a corrosive poison 
in the secretion. 


252 


According to Ricord, the starting-point of this form of 
stomatitis is an area of inflammation just behind the last 
molar tooth, on the side on which the patient habitual- 
ly sleeps, and this observation has also been repeatedly 
verified by Fournier. The natural inference is that the 
trouble begins where the saliva collects, and where the 
poison would therefore become concentrated. The well- 
known influence of the teeth in the production of mer- 
curial gingivitis has an important bearing here. Eden- 
tulous individuals, such as infants and toothless old 
men, do not have inflammation of the gums when mer- 
curialized. It would seem, therefore, that it is the col- 
lection and concentration of the poisoned: saliva about 
the teeth that excites inflammation in the gums. Itisa 
noteworthy fact, true as well of those who are exposed 
to the action of mercury by the nature of their occupa- 
tion as of those who take it medicinally, that when par- 
ticular attention is paid to the teeth, when they are often 
and carefully brushed, the individual most frequently 
escapes mercurial stomatitis. Indeed, it is a matter of 
every-day experience that patients undergoing mercurial 
treatment who are careful to keep the teeth clean, rarely 
show any oral effects whatever. Hutchinson says,! with 
regard to the so-called ‘‘mercurial teeth,” that ‘‘ the 
effects produced by mercury concern chiefly the enamel, 
although when severe, they affect the dentine also. The 
enamel is usually deficient, and the surface of the teeth 
is in varying degrees rugged, pitted, and dirty. The in- 
cisors and canines are usually affected, and not infre- 
quently we see the enamel deficient on them all, below a 
line which crosses them at the same level. The appear- 
ance produced is much as if a line had been stretched 
horizontally across these teeth at about their middle.” 
‘‘The first molars” are ‘‘ almost invariably affected ” 
also. These appearances point pretty clearly to a cor- 
rosive effect, to which the teeth were subjected at an 
early age through the administration of mercury. The 
‘‘line” of defective enamel mentioned corresponded, 
doubtless, in early childhood to the line of the gums, 
and to the part where the secretions and impurities of 
the mouth would be most apt to collect. Furthermore, 
it should be noted that of all modes of administration, 
that which brings the mercurial in direct contact with 
the mouth is most likely to cause stomatitis. Overbeck 
attributed the peculiar liability of calomel to produce 
salivation to the fact that, of all preparations, it was most 
apt to leave traces of the dose in the buccal cavity, where 
it would act topically after solution in the salivary fluid. 
In this connection we recall the observation of John 
Hunter, that every mercurial, when held long in the 
mouth, becomes sapid, showing that a solution takes 
place. 

The inference seems unavoidable that the mercurial 
stomatitis, and to a certain extent also the ptyalism, are 
due to the elimination of the mercurial, which becomes 
corrosive immediately upon its escape from its organic 
connections. While circulating in the fluids of the body 
it is in intimate combination with the albumen, forming 
an albuminoid compound which almost assumes the 
character of the homogeneous substances of the body. 
But at the moment of elimination a noxious inorganic 
chemical substance is set free to work its deleterious ef- 
fects. To account for the severity of these effects it 
must be remembered that there is a continual irrigation 
of the parts with the solution, and not a single applica- 
tion. And, furthermore, this solution will become more 
concentrated where the secretions are apt to collect, 7.e., 
at the borders of the teeth. 

Of the conditions which are favorable to mercurial 
salivation, the most important depend upon the mode in 
which the mercury is introduced into the system. Gen- 
erally speaking, those methods by which the drug is most 
rapidly introduced and absorbed are most likely to cause 
salivation. It is stated that it is oftenest observed after 
inunctions, fumigations, and the administration of calo- 
mel. It has been erroneously claimed that it was com- 
paratively infrequent among workers in mercury. But, 
according to Kussmaul, though seldom so severe among 
them as when the drug is given therapeutically, it is 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Salivation. 
Salivation. 


nevertheless always the most common of the symptoms 
of hydrargyrism. In the professional form of mercu- 
rialism the amount of mercury received into the economy 
is much smaller than when it is administered as a drug, 
and it is introduced more gradually. Hence acute toxic 
manifestations, such as ptyalism and stomatitis, are not 
often severe, while the constitutional disturbances are 
commonly more marked than in patients who are mer- 
curialized therapeutically. 

The dose necessary to produce mercurial salivation 
varies according to individual predisposition. Some in- 
dividuals are singularly susceptible. Ricord speaks of a 
patient in whom one grain of calomel was sufficient to 
cause salivation. Trousseau saw a violent case follow a 
single vaginal injection of a solution of corrosive subli- 
mate 3 parts in 5,000 parts of warm water. Breschet 
observed a similar effect in a woman the morning after 
the vaginal portion of the cervix had been cauterized 
with the acid nitrate of mercury. Gubler saw severe 
stomatitis result from a single mercurial friction to the 
abdomen of a woman suffering with puerperal peritonitis. 
Christison reported cases in which salivation followed, 
in one instance the administration of two grains of calo- 
mel, and in another the inunction of two drachms of mer- 
curial ointment. On the other hand, cases are met with 
where prolonged exhibition of mercury in considerable 
doses fails to produce the slightest effect in the mouth. 
Hallopeau refers to a case in which a patient, who had 
been treated for months with mercurial inunctions with- 
out salivation, afterward had a stomatitis in consequence 
of a single local application of mercurial ointment for 
pediculi pubis. Asarule, women are more susceptible 
than men, and pregnant women are especially liable to 
it. Exposure to cold, when the system is under the in- 
fluence of mercury, will often provoke or precipitate an 
attack of salivation. The influence of disease of, or 
neglect in cleansing, the teeth has already been referred 
to. The fact that a patient has previously been salivated 
appears to render the person more susceptible to a sub- 
sequent attack, perhaps for the reason that a certain 
amount of mercury still lingers in the system. Under 
certain provocations this residual mercury may give rise 
to ptyalism long after the use of mercury has been 
stopped. Kussmaul cites the case of a woman who had 
a sudden attack of salivation, without stomatitis, in con- 
nection with a severe frontal headache. The woman was 
pregnant, and her condition may have had something to 
do with the causation of the salivary flux ; but it was dis- 
covered that at this time both the saliva and the urine 
contained mercury, though it was known that shortly 
before the attack the drug was not present. The patient 
had been a worker in quicksilver four years before, and 
had suffered severely during her employment from mer- 
curialism with stomatitis. Other observers also have 
testified to the fact that salivation may occur at long in- 
tervals after exposure to mercury, whether profession- 
ally or medicinally ; sometimes after exposure to cold ; 
occasionally after the administration of certain drugs 
(especially the iodide of potassium), in connection with 
commencing gestation or with some nervous affection. 

Thanks to the more conservative and rational treat- 
ment of syphilis now generally pursued, mercurial sali- 
vation is far from being the common malady it was in 
former times. Instead of being regarded as a necessary 
accompaniment of the cure in every case of syphilis, it 
has now, among the best practitioners, become an accident 
of exceptional occurrence. How important was the role 
that salivation formerly played in the treatment of syph- 
ilis appears from the following aphorisms of Boerhaave : 

‘1468. To procure it, drench the patients for several 
days with large quantities of ptisan. 

‘1469. Next give a small dose of calomel every two 
hours. . 

‘©1470. When the breath begins to be fetid, the gums 
are painful, the teeth seem to grow longer, examine 
whether it be proper to continue, to stop, or to check the 
symptoms, : 

‘©1471. A salivation of three or four pounds a day is 
enough. 


‘1472. If less, it must be excited by mercury. 

‘1473. If more abundant, it must be restrained by 
emollient clysters, purges, sudorifics. 

‘1476. This treatment should be kept up till the symp- 
toms have entirely ceased, usually thirty-six days. ~ 

“1477. Afterward, for thirty-six days more, give only 
very moderate doses of mercury, to maintain a slight 
salivation.” 

When a patient is about to be salivated with mercury 
the first thing noticed usually is a sense of dryness and a 
disagreeable metallic taste in the mouth. If the teeth 
are clashed together the patient is aware of a little tender- 
ness. The gums have a grayish appearance, or are slight- 
ly reddened and swollen, and if pressed upon a little pus 
wells up between their border and the teeth. There is 
emitted from the mouth a more or less fetid odor. Soon 
the gums begin to recede from the teeth, and when the 
tongue touches the latter it seems to the patient as though 
they were elongated. The tenderness increases and is 
accompanied with some pain in the jaws. Meantime the 
saliva increases in quantity, collects in the mouth, and, 
bécause of its disagreeable taste, the patient is often im- 
pelled to spit. The inflammation increases and extends 
to the lips, cheeks, and tongue. Their surfaces are cov- 
ered with a whitish or yellowish coating, and exhibit the 
prints of the teeth. The saliva becomes more copious, 
and, if the case is severe, dribbles from the mouth. The 
mucous membrane becomes ulcerated, and the ulcers are 
covered with pseudo-membrane. The ulceration extends 
superficially rather thanin depth. The teeth become loose. 
The mouth is kept continually open, with the swollen 
tongue protruding, and over the lips and chin flows a con- 
stant stream of stringy saliva, sometimes tinged with 
blood. The quantity may become enormous. The stench 
becomes horrible, tainting the air of the whole apartment 
in which the patient is. The condition of the patient, if 
the malady is not arrested, grows more and more distress- 
ing. The teeth drop out; the swelling and pain, which 
may extend to the face and neck, continue to augment 
till the patient can neither masticate nor swallow ; speech 
becomes impossible, and even respiration may be greatly 
impaired. Sometimes deep gangrenous ulcers form and 
the mucous membrane separates in large sloughs. Oc- 
casionally there is suppuration of the parotid or cervical 
glands; sometimes phlegmon of the cheeks or roof of the 
mouth occurs, or there is gangrenous inflammation of the 
tongue; finally cicatricial deformities may result, unless 
the patient, worn out by the intensity of the disease and 
the impairment of nutrition, sinks into a fatal collapse. 
Cases of such intensity as this are fortunately very rare. 
The recovery in most severe cases is slow. The swelling 
gradually diminishes, the ulcers slowly heal, and the teeth 
regain their solidity. For a long time, however, the mu- 
cous membrane of the mouth remains vulnerable, and 
slight irritations, such as may arise from the use of sharp 
or pungent articles of food and the like, will suttice to 
reawaken the stomatitis and produce again some degree 
of sialorrhcea with more or less fetor of the breath. 

The first indication for treatment in all cases of sali- 
vation is to remove, if possible, the offending cause. If 
the ptyalism be the result of a reflex irritation originat- 
ing in the buccal cavity, in the stomach, or in regions 
still more remote, the surest way to relieve the secondary 
affection is to allay the primary irritation. Where this 
is impracticable, as, for example, in pregnancy, we may 
avail ourselves of certain drugs, such as belladonna or 
duboisia, which have a controlling influence over the 
salivary secretion. In other cases the offending cause is 
located in the salivary glands or contained in the saliva. 
In salivation from mercury the ptyalism is doubtless 
partly due to the direct action of a corrosive mercurial 
upon the salivary glands, but chiefly to the stomatitis 
which is the effect of the same corrosive poison in the 
mouth. 5 

As already intimated, mercurial salivation is at the 
present time regarded as an exceptional occurrence In 
the treatment of syphilis, and is usually the result either 
of neglect of proper precautions, or of an idiosyncrasy on 
the part of the patient. If the mercury is judiciously 


253 


Salivation. 
San Antonio. 


‘ 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


administered, the teeth properly attended to, and expo- 
sure to sudden changes of temperature avoided, the pa- 
tient will rarely complain of ptyalism or stomatitis, ex- 
cept in their incipient stages. 

So soon as signs appear indicating that the gums are 
‘‘touched,” the mercury should be suspended. Unfor- 
tunately there are cases in which this does not suffice to 
arrest the progress of the malady. The mercury accu- 
mulated in the system continues for some time to be 
eliminated in the saliva in sufficient quantity to maintain 
or augment the local irritation. Therefore, when the 
latter does not quickly subside, measures should be taken 
both to hasten elimination and to divert it to other 
emunctory channels. At the beginning, a brisk purge is 
to be given, followed by a series of hot baths and the 
administration of diuretics. 'To the same end iodine or 
the iodide of potassium may be given, bearing in mind, 
however, that the first effect of these remedies, some- 
times, is to aggravate the trouble, though they are after- 
ward beueficial in limiting its duration. The use of 
iodine to arrest salivation was first recommended by 
Knod. It is given in doses of ten centigrammes (one and 
a half grain) per day, gradually increased to twice that 
amount, as in the following formula : 


BO ie, Be wee to eee ete caaions 0.25 (gr. iijss.). 
PB ICODO A sae cane acs ee ee 8.00 (3 ij.). 
Dissolve and add cinnamon 

WALD ches stain avers Bees wosar are . 80.00 ( 3 ijss.). 
LID DIO SVT Diet cisctag ase vicie cee 16.00 (3 ij.). 


M. Dose, two to four teaspoonfuls. 


To check the flow of saliva one one-hundredth of a grain 
of atropia may be injected hypodermically, and repeated 
according to the effect. The inflammation of the mouth 
must be combated by astringent or disinfectant washes, 
and by the local and internal use of the chlorate of pot- 
ash. Mouth-washes of borax, alum, or tannin in honey 
or glycerine and water (seven or eight grains to the 
ounce), or tincture of myrrh (3 ij.-iv.) in water or infu- 
sion of cinchona (3 iv.), serve a good purpose. The chlo- 
rate of potash may be used as a mouth-wash, 
dissolved in cold tea or in infusion of flaxseed, 
to which a small portion of dilute hydrocyanic 
acid or spirits of chlo- sesgang,. 
roform may be added. “S8&s 
It should also be ad- 
ministered internally 
in doses of two or 


( 0 


three grains every 
hour ortwo. Should 
ulceration or gan- 


grene supervene, 
mouth- washes con- 
taining carbolic acid, 
Labarraque’s solu- 
tion, or the perman- 
ganate of potash are re- 
quired. 

Edward Bennet Bronson. 


1 Tilustrations of Clinical Surgery, 
p. 54. London, 1878. 


SALIX (U. 8. Ph., Saule 
blanc, Codex Med.). Wil .3* 
low ; ‘‘The bark of Salix 
alba Linn. and of other species 
of Salix.” SALIcrn (Salicinum, 
U. 8. Ph.), a crystalline, bitter, 
neutral substance, obtained from 
the bark of various species of 
Salix. 

Salix alba Linn., the white 
willow, is a large tree with, 
when old, often a very thick, 
irregular trunk, dividing near 
the ground into several great limbs ; branches numerous, 
ascending, rather close; twigs slender, brittle, with a 
light yellow or yellow-green bark, and white, rather brit- 
tle, soft wood; young shoots, buds, and the under sur- 


254 


Fic. 3863.—Salix Alba; Stami- 
nate Branch. (Baillon.) 


face of the leaves silky ; leaves numerous, alternate, with 
minute stipules and short petioles ; blade lanceolate, nar- 
; : row, and very acute at the 
apex, white beneath, bor- 

g der finely serrate ; flowers 

h ~early, dicecious, in slen- 

7 der, weak spikes, each 
Ag flower in the axil of a 

/ small bract; staminate 
fy flowers consist of two sta- 
jae mens, the pistillate of one 
one-celled, many-ovuled 
ovary; fruit dehiscent ; 
two-valved, seeds silky. 
This willow has a very 
wide natural range, cover- 
ing most of the temperate belt 
of the Old World; it has been 
also introduced into North Am- 
erica, where it is firmly natural- 
ized. The bark of the small 
branches is officinal, and is col- 
lected with that of some other 
willows of similar appearance 
and properties. 

Willow bark is ‘‘in frag- 
ments or quills, from  one- 
twenty-fifth to one-twelfth of 
an inch (one to two millimetres) 
thick, smooth; outer surface 
somewhat glossy, brownish or 
yellowish, more or less finely 
warty; under the corky layer 
green; inner surface brownish- 
white, smooth, the fibres sepa- 
rating in thin layers; inodor- 
ous ; bitter, and astringent.” Willow is an old tonic and 
febrifuge, formerly official abroad, but dropped from 
most pharmacopeceias since the easy 
preparation of salicin, which in a 
great measure took its place ; neither 
is much used at present. 

Composition.—The bitter, crystal- 
line, neutral principle, salicin, is the 
characteristic derivative of all the 
willows. It is easily prepared by ex- 
hausting the bark with water, pre- 
cipitating tannin, etc., with litharge, 
evaporating and crystallizing out the 
salicin, which is then purified by re- 
solution and the same process again. 
Salicin is colorless, odorless, but very 
bitter; it crystallizes in scales and 
needles ; is permanent in the air; melts 
at 198° C. (388.4° F.); dissolves in twenty-eight parts of 
water and thirty of alcohol ; sublimes and is entirely dis- 
sipated by heat; with concentrated sul- 
phuric acid it forms a red solution. It 
is a glucoside; treated with diluted sul- 
phuric or hydrochloric acid, or with a 
powerful galvanic current, it is decom- 
posed, and saligenin and glucose are 
formed ; by other methods of handling 
many interesting derivatives have been 
obtained ; salicylous and salicylic acids, 
saliretin, helicin, helicoidin, etc. It has 
also been formed synthetically. 

AcTIon AND Use.—As salicin is the 
only active principle, whatever value this 
bark has is due to it. Salicin itself, it 
must be confessed, is far from an energetic 
remedy—between two and three ounces 
have been taken with no marked effect. 
It appears to be decomposed in the blood 
Fia. 3366.—Salix into saligenine, salicylic acid, etc., and is 

iaattty eliminated from the kidneys as one or 

; more of these products. Salicin has un- 
doubted antipyretic power, although less than quinine 
or salicylic acid, its antiperiodic action is much less than 


Fic. 3364.—Salix Alba, Pistil- 
late Branch. (Baillon.) 


Fig. 3865.—Salix Alba, 
Fruit. (Paillon.) 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Salivation. 
San Antonio. 


that of either of them; as a remedy in rheumatism, sali- 
cin has also been obliged to yield to the more useful sali- 
cylic acid. Asa tonic, in small doses, it is occasionally 
used, but is far inferior to gentian or quinine. Four or 
five grams(3j. ad 3 jss.) may be given as a dose, and re- 
peated every three hours; as a tonic one or two deci- 
grams (gr. jss. ad ilj.) is sufficient. 

ALLIED PLANTS.—The genus comprises a hundred and 
sixty species ; from twenty or more this substance has 
been obtained. The allied genus Populus has some sali- 
cin-yielding species, and others containing populin, which 
latter can be made to yield salicin itself by decomposi- 
tion. The order, in its narrow sense, contains but these 
two genera. 

ALLIED DruGcs.—A number of plants in different or- 
ders yield also a little salicin, but not enough to make it 
their characteristic principle. The various tonics, of 
which Gentian, Columbo, Cinchona, etc., are examples, 
are also related, and the latter is doubly so as an anti- 
periodic. Other glucosides of mild or tonic qualities are 
hesperidin, from orange peel; phloridzin, from apple 
bark ; arbutin, from several Hricacew; esculin, from 
the horse-chestnuts, etc. W. P. Bolles. 


SALOL. Under the titles salol and salicylate of phenol, 
there has been recently proposed, for medicinal use, a 
body compounded of salicylic acid and carbolic acid 
(phenol), representing in its composition sixty per cent. 
of salicylic acid and forty per cent. of carbolic. Salol is 
a white crystalline powder, melting at 48° C. (110° F.) 
into a colorless, oily fluid. It is nearly insoluble in water, 
but dissolves in alcohol, ether, and fixed oils. From its 
insolubility in aqueous fluids it is practically tasteless in 
powder, but it has a faint aromatic smell. 

Salol has been proposed as a substitute for the com- 
monly used salicylate salts, on the grounds that it is 
equally, at least, effective as a medicine, while at the 
same time, in medicinal doses, it is much less deranging 
to digestion on the one hand, and less productive of con- 
stitutional toxic effects on the other. It is said of this 
substance that it is insoluble in the fluids present in the 
stomach—whence the lack of gastric derangement in its 
employment—but suffers solution by chemical decompo- 
_ sition in the small intestine through the action of the 
pancreatic juice, resolving into salicylic acid and car- 
bolic acid (phenol). Constitutionally, so far as reported, 
salol, in ordinary dosage, has produced little disturbance 
beyond an occasional and trifling ringing intheears. In 
experimenting, however, with a dosage exceeding 6.00 
Gm. (about a drachm and a half) distributed over the 
twenty-four hours, toxic symptoms have been observed. 
Salol, taken internally, imparts to the urine of the sub- 
ject the peculiar coloration seen after ingestion of car- 
bolic acid, a phenomenon that may persist for several 
days after discontinuance of the medicine. The average 
medicinal dose of salol for an antirheumatic or anti- 
pyretic effect is 2.00 Gm. (about thirty grains), given 
twice, or possibly thrice, daily. A dosage reaching 8.00 
Gm. (about two drachms), in the course of a day, was fol- 
lowed, in one instance, by severe vomiting, gastralgia, 
and tinnitus. Salol may be taken dry upon the tongue, 
in powder, the dose to be washed down with a little 
water, or may be conveniently administered in pill-form. 

Hdward Curtis. 


SALT SULPHUR SPRINGS. Location and Post-office, 
Salt Sulphur Springs, Monroe County, W. Va. 

Accrss.—By the Chesapeake & Ohio Railway to Fort 
Spring, two hundred and forty-four miles west from 
Richmond, Va., thence by stage fifteen miles south to the 
springs. Stages meet the C. & O, Railway trains at Fort 
Spring. 

THERAPEUTIC PROPERTIES.—The name Salt Sulphur 
would imply the presence of an appreciable amount of 
sodium chloride. This is not the case, so that the name 
is not appropriate. They are rather alkaline sulphur wa- 
ters, purgative and alterative. Taken internally or em- 
ployed as baths, they are effective in chronic diseases of 
the digestive organs, bladder, liver, and kidneys, and I 


am informed of their utility in chronic neuralgias. The 
iodine spring is indicated in syphilitic and scrofulous dis- 
orders. 

ANALYSIS.—One pint contains: 


Old Spring, Iodine Spring, 


49° F. to 56° F. 561g° F, 
Prof. W. B. Rogers, D. Stewart, M.D, 
Grains. * Grains. 
Carbonate of potassa ............ ...... 0.291 
Carbonate Of soda... sence ee. eee 1.350 
Carbonate of magnesia .......... 0.414 0.875 
Carbonate of lime... ........ 62. 1.283 4.125 
Chloride of sodium.............. 0.197 0.188 
Chloride of magnesium.......... 0.083 0.085 
Chioride of calctum,........2.-. 0.007 0.070 
Sulphateofsodas aon oe eke oe 2.195 3.000 
Sulphate of magnesia.........., 2.276 2.500 
Sulpbateof limes... 0 ..006 282. 10.613 8.500 
Peroxideiobarons. 22. eee 0.012 0.1383 
EGdINer As ae nets ieee trace. 0.079 
IBYOMTINES, A eaeke cistsie’s cee Ree ee 0.081 
Silicic Acideoeir aan. oe eee ed ee 0.220 
ANUINING SAP on act oh ck ced ae, 0.0238 
Earthy phosphates (soda and 
Lithia: event cs eeeptics th ire ee trace. 0.091 
Organic matter (with sulphur)... 1.155 = «...., 
Motalass saves dss cae’ 18.%85 21.561 
Gases. Cub. in Cub. in 
Carbonicl acidic eee ee 1.66 4.32 
Sulphuretted hydrogen.......... 0.43 2.39 


This resort, possessing the Iodine, Salt Sulphur, and 
Sweet Sulphur Springs, is beautifully situated in a val- 
ley north of Peter’s Mountains, Alleghany range, on the 
banks of Indian Creek, at an elevation of 2,000 feet above 
sea-level. The surrounding views of mountains and hills 
are charming, and the climate is delightful. The hotel 
buildings are built principally of brick and stone, the 
largest containing seventy-two rooms, with wide piazzas, 
and surrounded by a beautiful lawn. An elegant ball- 


‘room, a billiard-room, tennis courts, bowling alleys, etc., 


furnish amusement for the guests. Gopal 


SALZUNGEN is a spa in Sachsen-Meiningen, Thiirin- 
gen, lying in the valley of the Werra, at an altitude of 
about 820 feet above the level of the sea. There are sev- 
eral salt-wells here, the composition of one of which, the 
Bernhardsbrunnen, is as follows. 

One litre contains : 


Grammes., 

Sodiumchloride ae 40.0 sara. cL cee eee 260.76419 
Potassitumpechlorideywer neds cae: ee es 0.32566 
Magnesium chlorides: s S28.6.. eee ae 0.20179 
Calcium chloride eern8 (eercnk chee ee 0.78266 
Magnesium brontid cir. secs arse ae ee 0.01218 
Sodium sul phatensrae: ake aie cae ee ee ee 1.25679 
Calciumysulighatess.-mp oe succes aoc Paha he Coke OF 3.340138 
Mapnesiine sulphate ce ays. eect cee ae oe 0.19408 
Calcium. cCarbonatemsar ae ecces. ce eee ae ee 0.05199 
IM a ONeSTU IR CArb OME Le mnie atta renee ae eae 0.00188 
Herrous CAT Doreteyeenmcntats set ie oe tii noes 0.01318 
Silicic: acid eee ah ete et eens ees oh oe ae ae 6.00259 
DOtaleew ta ecreretesih stones aaicc scares dhe eles 266.94712 


There are also traces of iodine, lithium, aluminium, 
and manganese. There is some carbonic acid gas. When 
employed internally, the water is usually diluted with 
milk or whey. Baths, douches, local compresses, and 
inhalations are made use of. 

These waters are employed in the treatment of catarrhal 
troubles of the respiratory mucous membranes, anzemia, 
and scrofulous affections of the joints, bones, glands, and 
skin. 

The season extends from the middle of May to October. 
A. course of treatment lasts from two to three weeks. 

By TRS 


SAN ANTONIO. The accompanying chart, obtained 
from the Chief Signal Office, represents the climate of 
the city of San Antonio, Tex., a town of twenty thousand 
inhabitants, lying at an elevation of six hundred and fifty- 
six feet above sea-level, and situated two hundred and 
forty-five miles to the north of Brownsville, and one 
hundred and thirty miles from the coast of the Gulf of 
Mexico. Its climate may be regarded as typical of that 
of the inland and moderately elevated portion of Southern 


255 


San Antonio. 
Sandefjord. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Climate of San Antonio, Tex.—Latitude 29° 28'; Longitude 98° 22'.—Period of Observations, March 1, 1877, to June 15, 
1883.—EHlevation of Place of Observation above the Sea-level, 656 feet. 


A AA B C D E FE G H 
1 o o bBLadlmadag 
as] 
3 Boe ECPEILEEE 
= ~~ 
rs : § Fa Ko RS Ao RS 
pa & & sg o 3 odo 3 
ea g g Bas Qi) me 5 
s] 5 g z . is ory g g 
Be =3 he SAEs aes 
o ° = + r ini oH io) ° 
Mean temperature Ses Pay Absolute maximum Absolute minimum ||\S 224 og 
cee ee haces ate es for period of ob-|| ¢ Ey as, temperature for| temperature for| #2353) 4 Pa 5 
2 || servation. BS ly period. period. 2 nH} 2 9 g 
$F as = Be} Segelaaak 
ea ae a= BESS GSEs 
a | Bo, Alas rt | 
ie ea Se 43 = Be | ea) 
a5 s ss CHES VobS 
5 5 5 Sbee Suse 
S > > DPaBS|D RS 
< < < Oa Bala aad 
7 A.M. 3 P.M. 11 P.M. Highest. | Lowest. Highest. | Lowest. | Highest.| Lowest. 
| Degrees. Degrees. | Degrees. || Degrees.|| Degrees.| Degrees.|| Degrees. Degrees,| Degrees. | Degrees. | Degrees.| Degrees. 

January....| 45.4 58.8 51.8 51.8 61. 43.4 61.4 41.1 80.0 75.0 38.0 14.0 26 27 

February... 48.8 63.1 55.2 55.7 60.7 53.0 66.0 44.9 88.0 77.0 36.0 17.0 18 20 

March ..... | 57.1 72.3 63.3 64.2 70.2 60.7 5.3 53.8 92.0 83.0 41.0 7.0 18 26 

Atpril <0. 26 | 68.1 79.0 68.8 70.3 1.2 68.4 82.0 59.5 96.0 87.0 47.0 36.0 15 20 

May. sacri. | 69.6 84.4 74.5 76.1 79.9 13.5 87.1 66.5 104:0 93.0 61.0 49.0 22 24 

ORE, a ich | 5.6 90.2 80.6 82.1 84.5 79.8 92.4 "3.0 103.0 97.0 68.0 53.0 14 28 

July. t0.53 i ewud 91.7 82.5 83.5 87.3 81.6 95.7 73.7 104.0 98.0 71.0 58.0 19 24 

August.....| 75.2 90.6 80.9 82.2 85.0 78.7 93.4 72.2 108.0 95.0 69.0 60.0 20 28 

September... 70.3 86.6 75.9 77.6 80.3 74.4 89.2 67.7 100.0 93.0 59.0 53.0 22 22 

October ....| 63.6 79.3 68.8 70.5 2.7 65.1 81.3 60.8 99.0 87.0 46.0 41.0 22 21 

November..| 51.8 66.2 56.7 58.2 65.4 48.6 68.7 47.9 88.0 75.0 32.0 21.0 25 23 

December..| 47.4 61.2 52.8 53.8 59.0 49.0 64.0 43.4 82.0 75.0 32.0 10.0 28 | 88 

Soritig Riss itd lacey tate Meee: 70.2 73.8 68.8 i hea. al Dia werte ot YEA le « aeagsleh as a cn Ramee ot as tenes ¥ 

SULIMAEL yi) ioe sen el iat len crereiely meet ste.s 82.6 84.3 S152. ailisaceas ooh | reseies, UM vee sas cmmm Maneler stron MMi emtsta\soe stoner incteige'om | [reersttere eave 

VQoaocvesee ie Meaaos || capace. | aga 68.7 71.7 C52 We ORS We ies dart Mes este Mh Mss arm ste chee ane Mere ote lcim mn temetela:s eta itebeiare 

Winters! Ja laucdee | aessaseeeed Bae ae 53.7 58.8 AO A eae ese La ke toig oh Jeai'e Sens AU nahin SG? en Ee sees: wes 

Vicar yo. 2s0hs (bse cotes MIM a mic eee 68.8 71.2 ei Wye) | Rha tee J ocetsee | teeeet | sees | seetee [cette [T eeeeee Be sie 

J |K| L y Oo . : 
: eu i s Santalum album Linn., order Santalacer, is a small 
as | os > iy Se | q & me East Indian tree, whose fragrant wood has made it a 
ae eS oe a4 | BS eee Pe highly esteemed plant from the most remote time. It 
Saye dg aS | #3 | 3 "4 Sa has a slender habit, with opposite branches, and smooth, 
wi | 83 Oi apogee of | #8 | ocd light-green, opposite, lanceolate leaves; inflorescence 
ee | “E as | go | ae oo ag cate small, close, pyramidal, paniculate cymes; flowers 
a8 3 2 23 SH 2 eS ere minute, perfect ; the perianth is single, bell-shaped, four- 

Clea) MM . 

a |S = a rahe) 4 ay <4 or five-lobed, at first yellow, afterward purplish ; sta- 
ne | nh mens opposite, arising from the throat of the corolla, 

January....| 66.0 | 72.3] 8.2 | 10.0 | 18.2 | 1.50 | N. 48 and separated by a series of alternate scales ; pistil one, 

February... 71.0 | 87.6 Ee Bauer te pose piece tat 5.6 ovary one-celled, with central placentze and three or four 

Bear sstes| Dee EY roel Gee elegans ae ae naked, pendulous ovules; fruit one-seeded, about as 

May «1.1... 55.0 68.8 oe 6. i a8 8.25 SE. 4.8 large as acurrant. This tree is a native of India, and of 

July. 2222) | 46:0 | @2.6 | 13:9 938 | 3:7 | 398 | SE 46 some of the islands of the Indian Archipelago. It is also 

August.....| 48.0 | 67.0 | 17.7 B52 ae 2509 ets Ovens. Er 3.8 ultivated, the property of th vernment or protected 

September..| 47.0 | 69.0 12.4 11.3 ont 5.05 S.E. 4.2 ‘ 2 1 re ie ioe : leg : ° her ey 

October ....| 58.0 | 69.7 | 10.2 | 12:5 | .92°7 | 2:73 | SE 4°93 y the authorities, in most localities ; in others it has been 

November..| 67.0 | 69.3} 11.0 10.0 21.0 1.93 N. 4.9 exterminated. 

December..| 72.0 | 69.5 | 9.5 9. 19. 04 é 4.8 ; 

aN 3 Ue a = CoLLECTION.—The logs are felled, cut into short 

Spring...... 77.0 | 66.3 | 87.2 | 25.8 |- 68.0 | 8.30 | S.E. 4.9 £ : 

Pee 4 Meno | 30k Cocco sae a ee aH lengths, and then left on the ground for several months, 

Autumn “9.0 | 69.3 | 33.6 | 38.8 |. 67.4 | 9.76 | S.E. 44 while the white ants gnaw away the alburnum, or white 

Winter...... 78.0 | 69.8 | 23.9 | 29.8 | 58.2 | 5.40 | N. 5.1 i ; . : 

Neat Acc, 98:0 | 67.8 | 145.1 | 113.4 | 25815 | 92.55 | SE. | 4:7 outside zone, and leave the valuable heart-wood perfectly 
cleaned. This is then cut and made into various articles 
of cabinet work or convenience, the chips and coarser 

Texas. What this climate is may be seen fairly well | portions being put into the still for the extraction of the 


from a study of the chart (an explanation of which will 
be found on pages 189-191 of vol. ii.). The reader’s at- 
tention is especially called to the general mildness of 
temperature during the winter season, which, so far as 
shown by the figures of Column AA, is seen to be nearly 
as warm as the autumn at New York City. Columns E, 
F, and J show, however, a great range of possible ex- 
tremes at San Antonio, and Table F, in the article entitled 
Colorado Springs (vol. ii., p. 238), shows that the average 
daily range of temperature is thirty-three per cent. higher 
at San Antonio than at- New York City. Asarule the 
atmosphere is remarkably still at San Antonio, and in 
this respect this station even surpasses that of Little 
Rock, Ark.; but San Antonio is a Texan town, and 
Texas, with its ill-famed ‘‘northers,” is that part of the 
United States which is most liable to great and very sud- 
den falls of temperature upon the supervention in winter 
of a northerly wind. Column K shows us that the San 
Antonio climate is moderately dry ; column O, that the 
winter rainfall is very light. Hf, fi. 


SANDAL WOOD, OIL OF (Olewm Santali, U. 8. Ph.; 


Br. Ph.; Santal citrin, Codex Med.; yellow (or white) 
sandal wood). 


256 


oil. A considerable amount of the wood is exported to 
England and Germany, where a high grade of oil is dis- 
tilled. The root is also dug up and used. 

This is a compact, heavy, porous wood, of pleasant 
aromatic odor, pungent, astringent taste, and yellowish- 
brown, variegated color. The oi, of which it contains 
from one to three per cent., isa thickish, pale yellow 
liquid of agreeable, aromatic odor, pungent, spicy taste, 
neutral reaction, and specific gravity of 0.945. 

As a perfume, etc., but not generally as a medicine, 
sandal wood has been used for more than a thousand 
years. It was known in Europe some eight hundred 
years ago, and it has always been a costly perfume. Its 
modern employment in gonorrhea, etc., is not more 
than a generation old. 

Of the different trade varieties, that from the East 
Indies is most highly prized, that of the West Indies 
and South America the least. There may not be so very 
much difference in their medical properties. 

AcTION AND UsE.—Sandal wood oil resembles copaiba 
in many respects, as well as the terebinthinous oils in 
general. It is readily absorbed and pretty promptly 
eliminated, appearing both in the urine and in the exha- 
lation from the lungs. It is slightly astringent, and fre- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


San Antonio, 
Sandefjord, 


quently followed by discomfort in the stomach and dry- 
ness of the throat ; occasionally it causes vomiting and 
colic. Disagreeable eructations and its taste are com- 
plained of by some patients, but on the whole it is less 
unpleasant than copaiba. Its elimination by the kidneys, 
which is sometimes accompanied by a feeling of tension 
there, changes the odor of the urine, and causes it to 
become cloudy with acid, in the same way as co- 
paiba; alcohol, by clearing up this cloudiness, 
fwhich is caused by a resinous precipitate, will dis- 
tinguish it from albumen. 
ucts in the urine exert a beneficial action upon 
vesical, and especially gonorrhceal, inflamma- 
‘tions, equal to, if not better than, that of co- a 
paiba or cubebs, for which it is an efficient (fg 
and rather more elegant substitute. It is es- 
pecially serviceable in recent acute cases 
with considerable discharge. 

ADMINISTRATION.—This is simple 
enough. Dropped upon sugar, or 
shaken with mucilage, it can be 
easily taken by those who do not 
mind its disagreeable taste, but 
probably more than nine-tenths 
of it is given in gelatine cap- 
sules, where it is often mixed 
with copaiba or cubebs. Dose, 
from five to twenty drops 
—ten is a good average— 
four or five times a day. 

It should be continued F 
a week or so after the S244 
symptoms have disap- of} “i 
peared. 

ALLIED PLANTS. 
—There are eight 
known species of 
Santalum, all close- 
ly related. They 
are inhabitants of 
India, Australia, 
and of many of the 
Pacific Islands; all 
are fragrant, 
and _ perhaps 
others than 8. 
album may con- 
tribute to the 

ield of East 

ndian sandal 
wood. 8S. Yast 
Seem, of the 
Fiji Islands, S. 
Freycinetia- 
num Gaudich, 
and S. Pyruy- 
lartum Gray, 
of the Sand- 
wich Islands, 
and several 
species in Aus- 


4 
A. O77 
ths bry 


Wa Ye, a 
fp) Re f 


/ 


tralia, furnish Ge A; 
both wood and GY Fi iyjuk 
* “YY iy yy 
oil. The order jlttttleddll 
isarather small 
one, compris- 


ing some two 
hundred spe- 
cies, mostly 
shrubs or trees, and often root-parasites. The source of 
West Indian and South American ‘‘ Oil of Sandai” is 
not known. It resembles in its odor and taste the Kast 
Indian oil, but is cruder and less agreeable. It is very 
much cheaper, and is the kind usually dispensed for medi- 
cine, the other being reserved for perfumery. 

ALLIED Droues. —From a medical point of view Co- 
PAIBA and CuBEsBs are most nearly related to the subject 
of this article. As an astringent of the intestinal and 
urinary mucous membranes it may be compared with 


Vou. VI.—17 


A 
The sandal wood prod- = 


Fic. 336%7.—Flowering Branch of Sandal Wood Tree, about Natural Size, (Baillon. ) 


Vey. 


AY 
‘ 


TURPENTINE, to which it is inferior; as an alterative to 
bronchial secretion, for which purpose it is sometimes 
given, GRINDELIA is superior ; in cystitis, etc., it is com- 
parable with the balsams, as well as Bucuu, Uva Urst, 
etc. The red saunders, or red sandal wood, resembles this 
product only in name. 

W. P. Bolles. 
ay 


SANDARAC (Sandaraque, Codex Med.) A 


a 


BN very brittle resin obtained in tears in North- 
PPh “OG ern Africa from Callitris quadrivalvis Vent. 
Vd (2 (Thuja articulata Shaw), a member of the 
5 \ £2 Cypress division of the order Conifere, 


Sandarac exudes spontaneously from 
S the trunk and branches, and dries 
( in rounded or irregular drops 
averaging the size of small peas, 
but sometimes larger and 
long. The tears are dull on 
the surface and covered with 
a white powder produced by 
attrition. Fracture glassy, 
interior transparent. Upon 
being chewed the tears crum- 
ble to a fine powder in the 
mouth, while Mastic, which 
closely resembles it in ap- 
pearance, softens. Powdered 
Sandarac, which is non-adhe- 
sive and white, with a pleas- 
ant resinous odor, and a re- 
sinous and_ bitter taste, 
bejeceash he 
‘*Pounce,” and 
was formerly 
used to rub 
over the sur- 
face of paper 
where an eras- 
ure had been 
made, to pre- 


vent the ink 

from running 

when it was 

written over 
Wee again. Sanda- 
2. TR G rac 1s not used 
» LEN at present in 


medicine. This 
resin is a com- 
pound one, con- 
sisting of at 
least two, hav- 
ing different 
degrees of solu- 
bility in alco- 
hol, ether, etc. 
Asie bl Rep 
Puants, ETc. 
—See TURPEN- 
TINE. 
W. P. Bolles. 


SANDE - 
FJORD is a 
Norwegian 
healt h-resort, 
pleasantly situ- 
ated on a fjord 
at a short distance from the sea. In addition to the 
sea-bathing, therapeutic use is made of the several min- 
eral springs here found. Sea-mud, containing sulphur, 
iron, and common salt, is used in the form of baths, 
poultices, and as a local application applied with fric- 
tion. 

Sandefjord enjoys considerable reputation as a resort 
for those suffering from chronic rheumatism, neuralgia, 
nervous prostration, chronic joint diseases and other so- 
called scrofulous affections. The season extends over 


257 


>. 


Sandefjord. 
San Francisco, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the months of June, July, and August. A course of 
treatment occupies the usual time of three or four weeks. 

The following is the composition of the three principal 
springs, computed in grammes per litre : 


} 


Ba bo ela 

ges Ed @ op 

Hed bh a8 2 ) asi rm 

ont - 2 | mM cS 18 us a Fes 

Bee | B83 gOS 

qp09 | 2a gas 

oh ee Wi ABA 

Sodium ‘chloride FL. Ny. -Gaea me ee eee eee 3.9066 | 16.3877 
Lithium chloride 302. 2ssjccseice ane eee trace). | aan eee 
Calciumecnloride ie o...4.0 60s ae ee ee O22) > Sie 
botassinm chloridety~ 002 cee cee in ieee oe OL0632 5 eee ae 
Povassium wromiders Ja) l 4) see eee tee 020005) area. - 
Maenesium chlonidesc.c-0. seaesee eee O01 87 a acres 2.2149 
Macnesinmubromidens .nr ei eens a) meee | ees 0.0639 
Calcium sulpaate. nee eee 0.7582 0.0248 0.5821 
Macnesium sulphate).ces: onsets I O.46B00 Ot ss tersee ep ees 
Sodium jsulphate 2275 4) ee eee een. OAL aor Oieoeee rae ee 
Potassium sulphates wet ianna eee 0,03881°- |" seeee 0.5282 
Herrous Sulphate osm os oe oe er CD Rie tie. IN. Gerry 6 
Ferric sulphate. ste ccsmre eee ee ne 1:0542 4) (Saen 5 he a eee 
Aluminium! sulphateg=2..- eee eee oe 0.8467 0.0009 0.0068 
Caleiani carbonater c.ccvcwe ceo ce te cline eatote 0.0832 0.5446 
Macnesium. carbonates dan cme se ae cll seer 0.1806 0.6814 
Berrous.carponatert. 5 oes a nea tase: cleats 0.0016 0.04166 
Manganous carbonate................. RAS, AIR Aare oe 0.0080 
Dilicic Acid Fishes ee Oe Sete 0.0642 0.0167 0.0274 
Organic matters eee meee eee OL0010 55 | aeeee 0.2271 
Total takctain re: een ee es 3.6117 4.4002 21.8187 


The composition of the sea-mud, used for bathing and 
local applications, is as follows. In 1,000 parts there are 
of: 


Clay ‘and sand 2. teenies ces cc See eeiaee 728.0 
g Organicumatters so Si sageaes cies s tlocig ane as coe ee 99.2 
Sodium (chloride Siva: csicee cee cack coe eee ene 41.8 
Sulphuric acids i.e Gas sea cist ele ee ee eee 20.5 
Potassimmit) ede ee eee pee eee ee eee 7.8 
Ma pinvesiinr Ys... cracls ascii cue 5) Seectensl oer ee tere ee rakiove 11.3 
TPOD 2 3 oe oe vues coe Ba oe De ee ele Soe RO EC seioe ces 41.5 
Callens co's s je kee Stic seuss AEE So Ee eee ee eee 13.1 
AMIN a TAOS: Soins See orate eee eR en aes eee re 12.5 
Silica ese i. cays one tats eae Tee eccienetios wate heels sints 13.9 
TLiO88° og Sacks ded ee eee ksiete cee OReeT is: ein ee oth weet ete 0.4 
Yes Piers A 
SAN DIEGO. [For a detailed explanation of the ac- 


companying chart and suggestions as to the best method 
of using it, see the general article on Climate. | 

The city of San Diego, California, lies upon the slop- 
ing northeast shore of a land-locked bay five and a half 
miles long, twenty square miles in area, and twenty-three 
feet deep on its bar at low water, constituting a harbor 
which, by competent authority, has been pronounced to 
be, ‘‘ with the single exception of San Francisco, perhaps 
the best from Callao to Puget Sound” (General Emory, 
of U. S. Engineers, quoted by a writer in the New York 
Times of May 9, 1886). The town is the most southerly 
of any in California, lying in the extreme southwestern 
corner of the State, only fifteen miles distant from the 
Mexican border, ‘and its latitude is almost precisely the 
same as that of Yuma, Arizona, from which it is distant 
about one hundred and fifty miles in a westerly direc- 
tion. From San Francisco it is distant nearly five 
hundred miles in a direction 8.E. by 8. The popu- 
lation in 1880 was less than three thousand; it is now 
(1887) estimated at about seven thousand. The slope 
of the hill upon which the town is built is three hun- 
dred feet to the mile; hence the natural facilities for 
drainage must be good. Concerning the soil, I possess 
no information save that the writer in the New York 


Times, already cited, states that ‘‘ there is little mud and - 


the ground dries in a few hours after the heaviest rain.” 
The water-supply of the town was formerly deficient, but 
Dr. Chamberlain, in a paper read before the New York 
Academy of Medicine in October, 1886, says of this defect 
that it is one which he believes is soon to be remedied. 
There are good hotels at San Diego, As may be seen 
from the chart opposite, the winter climate of San Diego, 
so far aS mean temperature is concerned, is about the 
same as that of Los Angeles, but the daily range is 
much less than at Los Angeles, and a decidedly greater 


258 


equability of temperature throughout the year is found 
at San Diego, on the coast, than at Los Angeles, among 
the hills and seventeen miles back from the coast. San 
Diego has a less rainfall, but a more cloudy sky and 
markedly more humid atmosphere than has Los Angeles. 
In point of windiness the two places are almost precisely 
alike in winter; very similar, indeed, throughout the 
year. In regard to the frequency of occurrence of fogs 
at San Diego, I find two contradictory statements: that 
of the writer in Appleton’s ‘‘ Handbook of Winter Re- 
sorts” (1886-1887), who says of San Diego that ‘‘ there is 
no fog, as in Santa Barbara and more northern latitudes, 
and very little moisture in the air,” and that of Dr. 
Chamberlain (loc. cit.), who tells us that the local climate’ 
of San Diego is ‘‘ unsurpassed in the matter of tempera- 
ture,” but is damp; for while the ‘‘ rains are few,” the 
‘‘fogs are frequent.” Dr. Chamberlain also speaks of 
the fogs at Santa Barbara. Dr. H.S. Orme, president of 


the California State Board of Health, in his interesting 


pamphlet entitled ‘‘ The Climatology and Diseases of 
Southern California,” tells us that ‘‘ from the time of the 
first rains the belt of country next the coast is bathed in 
an atmosphere which is tolerably moist,” and that ‘‘at a 
distance of a few miles inland the relative humidity in- 
creases, not because there is more moisture, but because 
the temperature is apt to range lower.” In this belt, he 
tells us, ‘‘ the fogs are heaviest and the deposition of dew 
is greatest ;’’ while beyond it, ‘‘as the distance from the 
coast increases, the relative humidity decreases until, at 
the crest which separates the Pacific slope from the Great 
Basin the air throughout the year is dry, pure, and in- 
vigorating.” The limits of the belt of country character- 
ized by an especially frequent occurrence of fogs, and by 
greater relative humidity than elsewhere throughout the 
Southern California region, cannot be very accurately de- 
fined ; but to the seaward it is in general bounded and 
defined by a line drawn parallel to and at a distance of 
five miles back from the coast. Probably it is only close 
to its seaward border that this district is damper than the 
coast belt itself. Its inland border I can by no means 
determine, for while Dr. Lindley (see his paper quoted 
in article Los Angeles and Pasadena) speaks of an ele- 
vation of one thousand feet as the inland limit of the re- 
gion wherein fogs ‘sometimes come in from the sea,” 
and the atmosphere ‘‘ during the winter months is some- 
what moist,” we see from the chart of Los Angeles, a 
point only seventeen miles back from the sea, and 283 
feet above its level, that the relative humidity in winter 
is decidedly less than in summer ; while a comparison of 
column J in the Los Angeles chart with the same col- 
umn in the San Diego chart shows that, month by month 
throughout the entire year, the relative humidity of Los 


_ Angeles is very markedly less than that of San Diego, a 


place not lying within this belt of especially great hu- 
midity, frequent fogs, and heavy dewfall, but upon the 
coast which, according to Dr. Orme, is drier and less 
liable to fogs than this belt, beginning ‘‘ at a distance of 
a few miles inland.” 

The paramount importance of a careful study of each 
‘‘climat de localité” in Southern California has already 
been urged in the article on Los Angeles and Pasadena, 
is well recognized by all authorities on this subject whom 
I have consulted, and is probably exemplified before the 
eyes of the reader who has followed us through what 
has just been said respecting the somewhat misty limits 
of this belt of winter dampness and spring fogs. 

A brief and necessarily general discussion of the clim- 
ate of Southern California taken as a whole, and of its 
undoubtedly great adaptation to the purpose of a health 
region for the resort of phthisical and other invalids dur- 
ing the winter season, or during the entire year, has al- 
ready been presented in the article entitled ‘‘ Los Angeles 
and Pasadena.” To what is said in that article, and in 
particular at its close (page 582 of vol. iv.), I have noth- 
ing to add, merely repeating here, in slightly different 
form, what I have said before, viz., that for many in- 
valids Southern California is not only a good winter resi- 
dence, but is a health-giving and health-restoring home 
for residence all the year round; and this in no small 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sandefjord. 
San Francisco, 


Olimate of San Diego, Cal.—Latitude 32° 43', 


Longitude 117° 10'.—Period of Observations, November 1, 1871, to De- 


A [AA ie 


cember 31, 1883.—Hlevation of Place of Observation above Sea-level, 49 Jeet. 


2 | 


? B C D DD E F 
' Y 2 bay 2 | by ure 
s Bo PHOS gos | g65 
24 ee ey Seg.| S885 
B'_g x a, Oo - woe | oo ae 
& oq PAH! hag 
o I 5 = mo ies | mo ep 
25 (83 | 23 | 3E ogee | ogee 
Soa atagn ¢ t ae Slog : ‘4 we | GD 
Meant { iS) ean temperature || ¢ ga - ||Absolute maximum | Absolute minimum || os °38.| S¢0a 
op eeeateotmpnths S5 for period of ob- || By Be aS temperature for | temperature for || 4 ae A) & a 
a5 servation. = ga” | ee period. period. 2OBL | S508 
oo q5 | 55 | &s Ga2n| gao¢g 
| Sis a" | 3" | ms aees| Fegs 
o Fe A'S Borg | 8§o%eq 
os on op a? Paad | epsex 
ao | as Sobek | SoBe 
: Pete ere a SaeH| $uge 
< ee 2s GaSe) GAbw 
7 AM. 3 P.M. 11 P.M. De- || Highest. | Lowest. || De- | De- | De- || Highest.| Lowest. | Highest. | Lowest. 
Degrees. | Degrees. | Degrees. | grees.|| Degrees, | Degrees, \grees, |grees, |prees,|| Degrees.| Degrees. | Degrees. | Degrees, 
January ...| 48.0 60.4 52.6 || 58.6 || 57.4 50.4 || 61.8 | 44.5 | 17.3 78.0 64.0 44.0 32.0 22 24 
February ..| 49.1 60.3 53.5 54.3 || 57.9 50.8 || 61.6 | 46.3 | 15.3 || 82.6 63.0 45.0 35.0 25 17 
March ..... 50.8 61.3 54.9 55.6 || 58.9 52.1 || 62.8 | 49.0 | 18.8 99.9 63.0 || 48.0 38.0 27 19 
April... ;..s. 52.5 63.6 57.0 57.7 || 60.8 56.0 || 65.8 | 51.2 | 14.1 87.0 67.0 51.0 39.0 18 20 
eee ee 56.6 66.2 60.0 60.9 || 62.6 60.0 || 68.5. | 55.3 | 13.5 94.0 68.0 52.0 45.4 23 21 
June.:.\a.. 60.5 69.6 63.2 64.4 || 66.6 62.7 FTL B81) 12.8 94.0 73.0 || 58.0 51.0 17 21 
False... dea: 63.5 72.2 65.6 67.1 68.7 63.4. || 73.5 | 61.9 | 11.6 || 86.0 73.0 62.0 54.0 26 24 
August... 65.0 eRe 67.4 68.7 Fg) 65.8 74.9 | 63.1 | 11.8 || 86.0 78.0 || 64.0 54.0 27 26 
September.| 62.7 eee 65.6 66.8 69.7 63.1 74.5 | 60.4 | 14:1 || 101.0 73.0 59.0 49.5 26 17 
October ....| 58.1 69.1 61.4 62.8 || 67.2 61.2 70.2 | 55.0 | 15.2 92.0 12.5 53.0 44.0) 20 16 
November..| 52.5 65.7 56.6 58.2 60.6 56.2 || 66.8 | 48.7 | 18.1 85.0 75.0 50.0 33.0 22 23 
December..| 50.0 62.7 54.1 55.6 57.5 58.3 || 64.5 | 49.0 | 15.5 82.0 68.0 44.0 82.0 24 15 
rey TMI 2 Le Ny Sion cai ee lee a Rel, ae 58.0 || 59.2 86.44 ||"). laren On ee iia Eh A 
SUI OTe welenercer tm | eetostaeee siete thax 66.7 68.1 64.1 ; He Opi aueeteieas) iil MMvaee NS ill |Meracas rte ik care se 
MU UM ont tosene a [sc soer) lth es ss ns 62.6 65.1 60.2 Ube tl eka i) genset “NM Gator fea imeceeee 
Ld a den 9 Ayes ae ds aR 545 57.4 52.2) || PeOUN Mec sae sy | Pacer cA Ops tee 
Vedra Bers ar ANN fy ae n steam ocd | 60.4 62.1 | 58.5 ET |e seis ee Ge ef eee a 
J K L MI N oO R Ss . ; 
bp rss ates pacts 1 During the year 1880 the thermometer at San Diego rose 
2.2 S B | ss camila se By | to 90° F. only six times, while at Los Angeles this tem- 
emake &, | 86 | Be 4 ad | 82 perature was reached fourteen times (Dr. Orme, op. cit.). 
g3 BB Er ES FE 4 aE ey The general healthfulness of Southern California has 
es BE ae ae s ibe oS been alluded to in the account of Los Angeles (vol. iv.), 
= fal rt a= . 
Go| a 28 ao aeg| @ #8 a5 and a table printed on pages 10 and 11 of Dr. Orme’s 
cel é 2 pe | S38 | © ef | gs | pamphlet, which shows the prevalence at each of twenty- 
ms PN cu ee poy ie Oe es ee four towns of the diseases occurring throughout this 
Taeheaih Brom i aries. caeale in the yea oe owen the fact that San 
January ...| 46.0} 71.2 | 11.2 | 11.3 | 22.5 | 1.85 | NE. | 5.1 lego compared very tavorably with any of the other 
February ../ 47.6 | 74.8 | 11.3 | 9:0 | 20.3 | 2:07 | NW. | 6.0 points specified. For phthisical invalids it is probably 
ee a ya al to ae esos HL ea not quite so suitable a winter residence as are Pasadena 
May... 35: | 48.6 | %8.0 | 12.1 SH OO te 86 We.) 6.7 and other inland points. Huntington Richards. 
JUNE. os. | 43.0 3.8 15.2 6.7 21.9 0.05 Ww. 6.3 
lye | $2, 76. A 2 ‘ 0) : i 
Sewtember..| 3 | wed | as9 | tz | one | oe | Nw. | Si SAN FRANCISCO. The chart on next page, ob- 
October rae 48.0 i15 12:6 12:8 25.4 0. 49 NW. Bu pe aa ie ee Bia Office, in Nig nee sg 
ovember..| 47. 6. ‘ : 23. G00 oN We | Ssh resents the climatic conditions prevailing at the city o 
ae ele ih cea ee ay Soo ee Ot San Francisco, Cal. (For a detailed explanation of the 
Spring een 61.0 | - 73.6 36.7 26.9 63.6 1.91 WwW. 6.6 chart and suggestions as to the best meth j j 
Summer..../ 68.0 | 75.8 |° 48.2 | 24.3 | 72.5 | 0.30 | W. 6.2 ve J] Clos fable L - 189 ae eo Uane 1 
ie al Os | Be | Bo aes | aa | Ree | SE | rece uaay be the ndveniagen of 
inter .....| 8 70. 33.7 : 2 é : d } Yr meg ages j > clims 
Near: on. DEVO Sth asslie trash 7B hog We 15.9 Pua NE Tila ia Cate ACW ana e ee 0 eae tet eninate 
| at San Francisco when compared with that found at 


degree by reason of the very considerable varieties of cli- 
mate which are therein to be found comprised within a 
-comparatively limited area of territory. 

In conclusion, and as emphasizing the equability of the 
climate of San Diego, the place now under our special 
consideration, and, as illustrating its immunity from even 
occasional extremes of heat and of cold, I quote the fol- 
lowing data, derived from Appleton’s ‘‘ Handbook of 
Winter Resorts,” from Dr. Orme’s pamphlet, and from 
the letter to the New York Times of May 9, 1886, already 
quoted above. During the ten years 1876 to 1885 the 
mercury at San Diego rose above 80° F. on only one hun- 
dred and twenty days (¢.e., on an average but twelve 
times in each year); and it went above 95° F. on only six 
days. During the same period it fell below 40° F. on 
only ninety-three days, an average of but nine days in 
each winter ; and on no day did it remain below 40° F. 
more than two or three hours, and this between midnight 
and daylight. It fell below 35° F. on six occasions only 
throughout the whole period of ten years, and never once 
fell below 32° F, Says the Times correspondent, com- 
menting upon these figures: ‘‘ There is therefore no such 
difference between summer and winter, or between day 
and night, as to prevent one from wearing the same cloth- 
ing and, sleeping under the same cover all the year round.” 


places of corresponding latitude in the eastern and cen- 
tral portions of the United States, it is very much less 
mild than that found at points lying further south in the 
same State, and particularly at such as lie to the south of 
the Tehachipi and Santa Ynez mountain ranges, in. 
what is known as Southern California. As for the sum- 
mer climate, it is by very common consent pronounced 
to be exceptionally disagreeable ; and is by no means 
suited to the benefit of invalids affected with any form 
of pulmonary disease. 

The situation of San Francisco, at the mouth of a gap 
through which the cool air lying over the surface of the 
Pacific is sucked up to supply the place of the heated air 
radiated from the great inland basin comprising the Sac- 
ramento and San Joaquin Valleys, is the cause of its pe- 
culiar, and to most persons very disagreeable, summer 
climate. The hotter it is at this season in the interior, * 
the colder and more windy will it be in San Francisco, a 


fact which is well corroborated by the data in the accom- 


panying chart. The windiness of the summer season, 
as compared with other parts of the year, is plainly to be 
seen in the data of Column 8. The direction of the pre- 
vailing wind at this season, the high relative humidity of 
July, August, and September, the low absolute and aver- 
age daily maxima, and the small mean daily range of 
July and August as compared with those of June and 


259 


San Francisco. 


Sanitary Inspectn, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Climate of San Francisco, Cal.—Latitude 87° 48', Longitude 122° 26'.—Period of Observations, March 8, 1871, to De- 
cember 31, 1883.—Hlevation of Place of Observation above the Sea-level, 13 feet. 


A AA B c |p |DD E F G H 
n . pb St oe 1 ; 
$ Apa ay get gees | E96 
2d 2 3 ey i es ES _ ss 
4 be ra = | om Ss | So "Zs 
B S 5, 5. fis neg o ws 2 2 
gE | SI sl rae a Ras g 
ee 9 a0 2 4 Absolute maximum ||Absolute minimum ia: BS eS bes 
Mean temperature of months go Bee eer oe 55 | EE on temperature for temperature for Pas a 
at the hours of F 5 servation. Eo nee | Ea period: period BS se le S me 
: zeae Ee es0e | be 
(oP) | ro] AO aS 
© © i) fo | ‘ac BAEb | peee 
of on & | eo QRES mee 
SS es) 3 ° RZoss Cords 
mB = ta as ahs | 596% 
w ) © (ag S ws Es casa 
> > > | S38 Seso] Sau9 
< < <q | ae maa | Saak 
7 AM. 3 P.M. 11 P.M. || De- Highest. Lowest. || De- | De- | De- || Highest. ; Lowest. || Highest. | Lowest. 
Degrees. | Degrees. | Degrees. ||grees. || Degrees. | Degrees. | |grees. |grees. grees.|) Degrees. | Degrees. || Degrees. | Degrees, | 
January....| 47.8 58.1 50.1 |! 50.3 54.6 46.5 54.5 | 45.9 | 8.6 69.0 58.0 || 46.0 36.0 || 24 30 
February...| 48.6 55.1 51.9 51.8 55.7 47.9 57.9 | 46.5 | 11.4 10.5 61.0 47.0 55.0 ty R28 24 
areb..c.ce 49.8 57.4 52.9 53.3 57.0 48.9 59.5 | 48.7 | 10.8 77.0 62.0 || 48.0 29:0° hipaa St 19 
APL ore. 50.5 59.0 53.4 54.3 57.1 52.3 60.6 | 49.% | 10.9 || 81.0 63.0 48.0 40.0 || 25 20 
Mayo... 5. 52.1 61.4 55.2 56.2 57.5 54.3 || 68.8 | 51.7 | 12.1 86.0 71.0 50.0 45.0 || 22 15 
TUNG Se Wak 54.3 64.0 57.3 58.5 61.7 56.0 65.0 | 58.4 | 11.6 || 95.2 67.0 52.5 48.0 || 28 13 
Jt eee Gieas 54.6 63.1 56.8 58.1 59.9 56.6 64.8 | 54.2 | 10.6 83.0 66.0 53.0 19,0) he 2Y 20 
August ..... 55.0 63.5 57.2 58.5 59.7 57.6 64.7 | 58.9 | 10.8 89.0 69.0 54.0 50.0 17 17 
September..) 55.7 65.4 58.4 59.8 || 62.1 58.3 67.0 | 54.5 | 12.5 92.0 69.0 58.0 50.0 25 22 
October..... 55.2 64.2 58.5 59.3 61.8 55.9 65.0 | 58.5 | 11.5 84.0 72.0 52.0 45.0 || 23 18 
November..| 52.2 59.0 55.7 55.6 57.9 52.5 60.1 | 58.0} 7.1 78.0 64.0 50.0 41.0 29 23 
December..| 48.8 53.9 52.1 51.6 53.2 49.4 55.9 | 44.8 | 11.1 68.0 59.0 44.0 34.0 || 18 22 
Springs. iced aeeeche y Woden den ben 54.6 || 56.8 52.9 Sana! RED: TY FRIED Oh Poa estan nates om Bee: | PP meriedyl ed og, 5 
SUMMEN Ico meceen Malemenest 58.3 |; 60.2 Eyal at LER OR |e Soares te tetaeetes ASSAD S) Mamet sanee 1) (oesbogae Scie 
SUE SCRE PE ieecdn lace Nl a cetisc sae | ner a8 ‘ bee ae cessed Ml aimed see | attest ce isieteetaall eae ciate Sor 
ATLECE Fo. Sccail)) Gaste storey iin Mectocetotedl ua ee aees 51.2 || : on S78 MPA roe AN RUA oan lin AGG Rh ado sce tai Wisobieae (po soctddc 
Wearic. ae Pech i cade ei hear tea 55.6 57.3 54.2 Sec OEM Wil oeciectels Geis saan estamce” ANMiee + 2 pcre, ah Wacoor 
Sid KA Gaal Meek ow ra) R Ss : ; 
te ee oe en ON cen ea SC See eee ik noon ; but when the sun has reached the zenith the wind 
tes | & 5 es 1 Be ss d be rapidly increases, coming down in gusts from the hills 
BE | ae] ge |e g Eg $3 which separate the city from the ocean,* and often bring- 
ga BP ES Re | ay 2 | ae =. | ing with it clouds of mist. But the dampness is never 
os | oz ex| g8 | on 2 | se eg sufficient to prevent the elevation of clouds of sand and 
&e | oc | 8s) £° | gan = | e2< | dust which sport through the streets in the most livel 
go| § |83) Ss | eee) gz fe al Tl falls nuddeniy rand lorie barons 
gs | 3 > PO | BY > RS bao | manner. 1e mercury falls suddenly, and long before 
a =| < qo°- Ay oe : ECs , 
ee eke “ eb See ME 4 Pld EPA, Be re _ | sunset fixes itself within a few degrees of 50°, where it 
Inches. From remains pertinaciously till next morning, often not mov- 
Forbert 355 re 1033 06 19:9 305 W. ce ing a hair’s breadth fortwelve hours. . . . The mist 
March ne 55.0 2.8 Hy ‘ 11.8 aes 2.88 W. 83 often increases toward evening, and when the wind falls 
Drilveeeeees F : b 2. : : : ; es A : 
May 41.0 | 72.0 | 102| 15.0 | 25:2 | om | w. | 13 | Yemains all night in the shape of a heavy fog. Some- 
June........ 41.2 3.8 He 2.6 | 3.8 (ah BW. ee times, when the sun has been shining brightly, the mist 
August.....| 39:0 | 80:0 | 144} 9'7 | 341 | 0101 | Siw: | 19:1 | Comes in from the ocean in one great wave and suddenly 
September..| 42.0 | 77.5 | 13.1) 12.4 | 25.5 | 0.15 | 8.W. 9.9 submerges the landscape. In short, there is no conceiv- 
October.....| 39.0 (ea | 11.4 15.4 26.8 1.18 Ss. W. %.8 - bl d * t f ° 1 d t ] d f d hi 
November..| 37.0 | 71:1 | 914| 15:0 | 24:4 | 2:70 | N.w. | 61 | able admixture of wind, dust,{ cloud, fog, and sunshine 
December..| 34.0 | 76.0 | 9.6 | 18.2 | 22.7 | 4.72 N. 6.4 | that is not constantly on hand during the summer at San 
Spring...... 47.0 | 2.0 | 92.9) 30.2 | 1 | 5.99 | We | 101 Francisco.” 
ummer.... : (KG il. 30. gt : 3.W. , i r . . 
Autumn 2/30 | a6 | 389 | 28 | wea | sas | Siw. | ao | , Lhis fog, we are told by Mr. Blodget, does not blow 
Winter... 86.5 | 74.0 | 295 | 84.7 | 64.2 | 18.77 N. 7.0 | in from the sea, but is formed on the spot by contact of 
Neat Nines 61.2! 74.8 '187.6 | 146.7 | 984.3 | 28.32 S.W. 9.4 


the cold sea-air with the naturally warmer land-air. 
The sea-breeze in summer is a more or less cold breeze, 
he tells us, all the way down the coast as far as the ex- 
tremity of the peninsula of Lower California, at Cape St. 
Lucas ; but at San Francisco its coldness is most marked, 
because the indraught of air at that point is vastly’ 
stronger than elsewhere, for reasons which will be found 
fully explained in his work, and which have been al- 
ready briefly referred to in this article. 

San Rafael, a town of some three thousand inhabi- 
tants (population in 1880, 2,276) lying twelve miles north 
of San Francisco, about three miles from the shore of 
San Pablo Bay (a subdivision of the great gulf compris- 
ing San Francisco, San Pablo, and Suisun Bays, which 
is entered through the Golden Gate), is a place much 
better sheltered from the direct influence of the sea- 
winds than is San Francisco, and on this account pos- 
sesses a much more agreeable climate. ‘‘ The scenery 
about San Rafael and in the approaches to it is extremely 
fine . . . and the air is pure and bracing, and, 
though. hardly warm enough for consumptives in ad- 
vanced stages of the disease, is admirably adapted for 


September, all point in the same direction, and receive 
their full explanation in the following passages, which 
are taken from Blodget’s ‘‘ Climatology of the United 
States,” and are quoted by the author of that work from 
the writings of Dr. Gibbons, of San Francisco. The 
first of these passages discusses the increase in the force 
and frequency of the sea-winds during the summer sea- 
son. 

‘‘ Whatever may be the direction of the wind in the 
forenoon in the spring, summer, and autumn months, it 
almost invariably works around to the west in the after- 
noon. So constant is this phenomenon that in the seven 
months from April to October, inclusive, there were but 
three days on which it failed to do so, and these were 
rainy. ‘The sea-winds are moderate until May, when 
they begin to give trouble. In June they increase in 
force, reaching their greatest violence at the beginning 
of July. In August they decline in force, but not in 
constancy ; in September they continue steady, though 
moderate ; and_in October they lose their annoying quali- 
ties, and become gentle and agreeable.” 

What these ‘“‘ annoying qualities” are will appear from 
the second passage quoted from Dr. Gibbons, wherein he 
describes the course of a summer day at San Francisco : 

‘The sun shines forth with genial warmth, the mer- 
cury rising generally from 50° at sunrise, to 60° or 65° at 


* Blodget’s Climatology was published in 1857. Dr. Gibbons’s meteoro- 
logical observations at San Francisco covered the period of sixteen 
months, from December, 1850, through March, 1852, 

+ The dust is less troublesome now than at the time when this account 
was written, more than thirty years ago, the streets of the city being 
kept carefully watered. 


a ee 
Dee Ss SS ee eS SS eee 


260 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


San Francisco, 
Sanitary Inspeec’n, 


such as are in the preliminary stages, and only need a 
dry and tonic climate inviting to an out-door life” (Ap- 
pleton’s ‘‘ Handbook of Winter Resorts,” 1886-87). The 
hills which lie close about San Rafael on its western as- 
pect, that is, on the side toward the ocean, are quite high 
(1,500 feet according to a writer in the New York Daily 
Graphic of January 22, 1885), and, moreover, the dis- 
tance -in a direct line to the sea-coast is, in a southwest- 
erly direction ten miles, in a westerly direction twenty 
miles. I have no data to illustrate the superiority of San 
Rafael over San Francisco in point of climate. Monte- 
rey, a small town lying directly upon the Pacific coast, 
at the southern extremity of the Bay of Monterey, and 


Monterey Temperature and Rainfall. 


at a distance of about one hundred miles from San Fran- 
cisco in a SSE. direction, has acquired some reputation 
during late years as a pleasure and health-resort, and a 
large hotel has been built there by the Southern Pacific 
Railway. Through the kindness of Dr. C. B. Currier, 
of San Francisco, I received, some two years ago, a 
printed table showing the absolute monthly maximum 
and minimum temperatures, the mean daily temperature, 
and the total rainfall for each of the fifty-four months, 
July, 1880, to December, 1884, inclusive. The observa- 
tions of which these data are the record were taken at the 
HN just mentioned ; the hours of observation I do not 
now. 


AA B T V E ¥F 1) 

Month as 3 PP aie (le Le aR tes pS os FE Absolute maximum | Absolute minimum ea of 

3 3 a f p ure, 3 ar 8 as temperature, temperature. Sees 

455 qm | 288 qs 

Highest. | Lowest. Highest. | Lowest. | Highest. | Lowest 

JARUATY q clea slave cus sie tcte ne cee ce aibiere 49.55 53.67 46.75 63.33 35.41 70.00 57.00 | 45.00 27.00 2.38 
MEDITIALYE co evpeenr. islea eek set cee. 52.30 56.28 50.60 69.33 37.66 82.00 58.66 52.00 28. 00 3.03 
ERECT To's cn Ohinaike's's ees eo 8 oo0.c.0e be 55.41 56.82 54.29 70.383 45.16 84.00 60.66 49.66 40.00 4.73 
PANEL aretetete a clot heseic'eieieinie Ze ss e'a see 58.45 62.26 56.83 67,58 50.41 71.00 63.33 58.00 45.00 2.03 
WER Vcmeisten acer iin ot v0.0 © fol e-tace ee 60.73 62.74 59.68 74,75 53.33 87.00 66.00 58.00 50.00 - 0.42 
SUNG ree ate ointitacie Aaioave 6° a eGiaweis 63.13 64.92 61.13 72.83 58.41 87.00 67.00 62.66 55.00 0.52 
JOIN FS Unniberac bac Sh Ucar eane tare 64.21 66.42 61.01 73.63 59.02 84.00 67.50 63.33 53.00 0.00 
PSPS eRe eicercte tae wis hts te. aioli 62.89 64.85 61.09 70.99 56.59 77.00 66.66 61.33 50.00 0.01 
BepremlDereem staves sacs cee eo ae 61.46 63.26 57.52 74.06 53.73 85.60 66.66 60.00 44.00 0.11 
Octoberwee apace ss heise ceteces canes 57.17 bY 54.39 68.53 47.40 77.00 60.66 55.00 37.00 1.19 
INDVEMDERT reas sas Bieincien takes 51.79 52.58 51.13 64.79 40 73 71.00 58.66 46.00 82.00 0.82 
OCEM DEL M c kis ecisis: se eecicees ets 52.16 53.87 50.81 - 64.26 40.80 73.00 58,33 49.33 80.00 2.99 


From this table, sent by Dr. Currier, I have deduced 
by calculation the data standing in columns AA, T, V, 
and O of the chart herewith presented ; the figures in the 
remaining columns (B, E, and F) are copied directly 
from the table, but are differently arranged. The col- 
umns of this chart may be compared with corresponding 
columns of the San Francisco chart (and of other Signal 
Office charts), but in doing so the reader should bear in 
‘mind that the period of observations at Monterey was a 
very short one, the hours of observation perhaps different 
from those adopted by the Signal Service, and the method 
of taking maximum and minimum observations unknown 
tome. A careful study of the chart not only shows that 
Monterey possesses a mild winter and a cool summer cli- 
mate, but also reveals facts which bear out the observations 
made by Mr. Blodget, to the effect that the peculiarity al- 
ready noticed in the summer climate of San Francisco ex- 
ists also at other points upon the coast, but that it is very 
much less marked at places lying to the south of San 
Francisco than it is at San Francisco itself. Columns T 
and V by no means correspond to columns C and D of 
the Signal Office charts ; the former give the average of 
monthly, the latter of dazly, maxima and minima. 

Huntington Richards. 


SANICLE, Codex Med., Sanicula europea Linn., order 
Umbellifere. A small European perennial with palmate 
orreniform, five-lobed leaves, unisexual flowers, and 
ovoid spiny fruits. It contains tannin, bitter extractive, 
and resin. Sanicle is a household herb of Europe, and 
used both internally and externally in numerous condi- 
tions. It probably has no value. W. P. Bolles. 


SANITARY INSPECTION, PRINCIPLES OF. This 
is a comprehensive subject, as it relates to inquiries into 
all influences affecting or tending to affect injuriously 
the health of a locality. It involves a knowledge of the 
importance of perfect purity and cleanliness of air, water, 
food, and soil as the fundamental and paramount condi- 
tions of health, and seeks to discover and guard against 
or counteract those influences which are liable to render 
impure these essentials to the maintenance of healthy 
life. It is through this important public service that the 
local health authority is kept informed of those condi- 


* Observations of five years. For the other months the observations covered only four years. 


tions which tend to endanger the health of the inhabitants, 
and that knowledge is obtained with regard to the sani- 
tary state of the people, and the preventable causes of 
sickness and death, which forms the basis of all intelli- 
gent and efficient sanitary legislation and administration. 

Sanitary inspection is not restricted in its objects sim- 
ply to the collection of information which is indispensable 
to the application of the provisions of the public health 
laws ; it also includes the execution of the provisions of 
such laws whenever the circumstances of the case may 
justify and require it. An executive service is the nat- 
ural and necessary complement of an inspection service, 
inasmuch as the purpose of the latter, in detecting all 
such influences as are injurious to the public health, is 
to suggest and make possible the proper steps for their 
removal. 

The causes of disease with which public hygiene is con- 
cerned, such as affect the mode of life of masses of popu- 
lation, operate through a great variety of channels, and 
their discovery and removal require the exercise of knowl- 


| edge affecting the various conditions under which people 


live, whether in the city, town, or hamlet. Such knowl- 
edge relates to the natural and acquired features of the 
locality, its meteorological peculiarities, and the social 
and sanitary state of. its population ; the character of the 
soil, ground-water, wells, and springs; the water-sup- 
ply ; plans of drainage and sewerage ; the distribution of 
buildings and of open spaces, whether paved or unpaved ; 
the sanitary arrangements of houses, especially those of 
the poorer classes; the management of burial-grounds 
and the arrangements for the burial of the dead; the nat- 
ure of manufacturing and other industrial establish- 
ments ; the housing of the poor, and the facilities afforded 
for bathing, washing, etc. ; the conduct of slaughter- 
houses and all establishments where food-supplies are 
prepared ; the examination of foods with respect to their 
wholesomeness ; the sanitary inspection of schools and 
school children ; the regulations for cleansing the public 
ways and markets, and for the removal and disposal of 
domestic and trade refuse ; the examination of persons 
and houses with the object of restricting or suppressing 
contagious or infectious diseases of local origin, and of 
vessels and passenger-trains in order to prevent the in- 
troduction of such diseases from without. 


261 


Sanitary 
Inspection. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


While the intelligent exercise of the functions of the 
sanitary inspector requires a familiarity with these vari- 
ous subjects, a high degree of efficiency is more surely 
attained by a division of labor according to special 
branches of inquiry, a plan which yields the advantages 
of more matured experience and greater precision of 
knowledge. Besides the ordinary nuisance inspectors 
and inspectors of quarantine, it is becoming more and 
more customary to appoint officers fitted for particular 
lines of work by special education and training. In or- 
der to prevent the sale of adulterated and unwholesome 
foods and drugs, it is necessary to have officers who, in 
addition to other qualifications, shall possess a knowledge 
of chemical analysis and microscopical examination. The 
sanitary inspection of school buildings and the supervi- 
sion of the heaith of the children are wisely entrusted to 
men who have had a medical training. The sanitary su- 
pervision of house-drainage and plumbing required under 
the laws recently established in many American cities, 
imposes upon the local health boards the duty of employ- 
ing experts skilled in the technics of this art. The ex- 
amination of immigrants and travellers, with the object 
of preventing the introduction and spread of dangerous 
communicable diseases, is another special branch of sani- 
tary inspection which none but a medical officer is quali- 
fied to conduct. 

QUALIFICATIONS OF SANITARY INSPECTORS.—FEfficient 
sanitary inspection depends primarily upon an adequate 
knowledge of the various subjects relating to hygiene 
and public health, and the officers employed in it should 
be fitted for the work by special and sufficient education. 
As many of these subjects relate to diseases, their causes, 
mode of propagation, and the means of their suppression, 
a medical knowledge becomes an essential qualification 
of at least a portion of the force employed as sanitary 
inspectors by a board of health. Under the English 
health laws the officer of health, whose duties are largely 
those of an inspecting officer, must be qualified by law 
to practise medicine or surgery, though such qualifica- 
tion is not made necessary in the case of inspectors of 
nuisances, 

Intelligent sanitary inspection rests upon a knowledge 
of the following subjects : 

1. The principles of chemistry, particularly with re- 
gard to the methods of analysis (including microscopical 
investigation). Such knowledge is indispensable in 
forming accurate judgment as to impurities of air and 
water, injurious impregnations of the soil, harmful ad- 
mixtures in food, and also in the proper use of disinfect- 
ants. An acquaintance with chemical physics, includ- 
ing the chief phenomena of light, heat, and electricity, is 
also advantageous. 

2. Natural philosophy, which should embrace a thor- 
ough knowledge of the principles of pneumatics, hydro- 
statics, and hydraulics, with special reference to venti- 
lation, water-supply, drainage, construction of dwellings, 
and sanitary engineering in general. The laws of nat- 
ural philosophy will be of great aid in tracing nuisances, 
in determining questions of ventilation and of over- 
crowding, and in studying atmospheric changes; and, 
in conjunction with chemistry, will be of the greatest 
service in the investigation of industries and trades al- 
leged to be prejudicial to health, and in devising meas- 
ures for the abatement of the evils associated with them. 

3. A knowledge of the laws relating to public health. 

4. The, sanitary construction and arrangements of 
dwellings, including soil, structure, materials, internal 
decoration, lighting, ventilation and warming, water- 
supply, house and soil drainage, and disposal of refuse. 

5. A knowledge of the effects of overcrowding, vitiat- 
ed air, impure water, bad or insufficient food, unhealthy 
occupations, and of the diseases they produce ; the char- 
acter of nuisances injurious to health, the disposal of 
sewage, and the effects of soil, season, and climate 
upon the health of localities. 

6. A knowledge of the causes, propagation, and pre- 
vention of contagious and infectious diseases. In addi- 
tion to a familiarity with the above subjects, there should 
be the further qualifications of methodical and industri- 


262 


ous habits, competent powers of observation, sound 
judgment, and conscientiousness in the investigation and 
statement of facts. 

It may be objected that the qualifications outlined 
above are too comprehensive, and that the knowledge 
deemed essential for the performance of the duties of 
sanitary inspector is such as should only be required of 
a professional expert. But it should be remembered 
that sanitary inspection is pre-eminently the service by 
which information is obtained of the numerous and vari- 
ous conditions which operate against the health of a 
locality, and constitutes a large and important part of 
the work of sanitary government. In order to recognize 
and intelligently investigate these conditions, and advise 
as to the means of their amelioration or removal, a com- 
prehensive knowledge of the principles and laws of 
science involved in their consideration is indispensable. 
Efficient sanitary inspection requires skilled or expert 
labor, which can only be secured by special knowledge 
and experience. 

SANITARY SuRVEyY.—A systematic sanitary survey of 
a locality isthe true basis of measures for its sanitary 
improvement. Such a survey embraces an investigation 
of the natural and artificial or acquired conditions affect- 
ing the health of the inhabitants in the district. 

The natural conditions affecting the health of a district 
comprise the geological and topographical characteristics 
of the locality, the climate, water-supply, etc. The 
causes of many of the most common diseases arise from 
conditions connected with the earth’s surface and under- 
lying structure, as well as with the soil polluted by the 
act of man. The influence exerted upon human health 
by the drainage of a locality, by the moisture in the soil, 
the ground-water, and telluric emanations, has long been 
recognized, but the exact effects of these conditions can- 
not be rightly understood without a knowledge of the 
physical characteristics of the soil, studied in their rela- 
tions to the records of diseases in their geographical dis- 
tribution and local history. These two series of facts, 
studied side by side, lead to the interpretation of the laws 
governing the relations of the earth’s features to health 
and disease. Detailed and exact records of the configu- 
ration of the earth’s surface and its underlying structure, 
illustrated so far as possible by means of maps and dia- 
grams, form the basis of correct knowledge of sanitary 
geography and local hygienic history. It is only by the 
aid of these facts that the health of a town or district and 
the records of prevalent diseases can receive their proper 
explanation. 

The influences of climatic conditions upon health are 
also to be investigated in connection with the natural 
local conditions. The daily temperature and rainfall, 
the force and direction of the wind, the barometric press- 
ure, degree of humidity, etc., should be subjects of care- 
ful observation and record. In many places these data 
can now be obtained from the Signal Service Bureau of 
the Government. In districts where such observations 
are not recorded, arrangements should be made for ob- 
taining the necessary information. The meteorological 
fluctuations exert a powerful influence on health and 
disease, and though they are beyond the control of man, 
a knowledge of their effects will be most useful in the 
investigation of other local conditions more amenable to 
human effort, and in assigning to them their proper share 
of hurtful influence. 

The quantity and quality of the water-supply of a dis- 
trict depend mainly on its geographical and topograph- 
ical characteristics, which must be studied in their rela- 
tions to this important fact. The quality of water is 
necessarily affected by the character of the soil through 
which it flows and by the surface upon which it is col- 
lected. A water may become so thoroughly impregnated 
with mineral or vegetable matters contained in the soil, or 
with organic matter upon its surface, as to be unfit for 
domestic use. A wholesome water may become polluted 
by the transmission of impurities through the porous 
structure of the ground. In locating wells the physical 
characteristics of the soil should be taken into considera- 
tion with reference to the risks of pollution of the supply. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sanitary 


Soil moisture and the state of the ground-water play an 
important role in the causation of disease. These natu- 
ral characteristics of the soil depend on certain combi- 
nations of geological and topographical structure, which 
must be investigated in every locality before improve- 
ments necessary to secure healthfulness can be intelli- 
gently undertaken. Before drying and aerating the soil 
one must have a knowledge of its natural drainage and 
physical conditions. No plans of artificial drainage or 
of sewerage can be satisfactorily accomplished without a 
thorough comprehension of the natural drainage system 
of the district. 

The acquired conditions affecting health relate to the 
habitations of the population, the water-supply, the drain- 
age and sewerage, removal of refuse matters, public ways 
and places, gas and lighting, slaughter-houses and abat- 
toirs, markets, food-supplies, manufactures and trades, 
public school buildings, hospitals and public charities, 
police and prisons, fire establishments, cemeteries and 
burial, the arrest of contagious and infectious diseases, 
etc. <A series of questions upon these and other subjects 
relating to municipal sanitation have been framed by the 
National Board of Health to serve as a guide in making a 
systematic sanitary survey of a district, and their practi- 
cal use is exemplified by surveys taken of several cities 
and detailed in the reports of that Board for the year 
1879, to which reference should be made. The annual 
volumes of the American Public Health Association also 
contain valuable information upon the same subject. 

SaniTARY [nspecTiION oF Hapirations.—The health 
authority should, so far as practicable, have a full knowl- 
edge of the general sanitary condition of every house in 
the district which it controls. The acquisition of such 
information is of necessity a laborious undertaking, re- 
quiring painstaking and systematic search, and a consid- 
erable outlay of money ; but when the record of facts is 
once completed its benefits will be continuous. A brief 
description of every house, showing the structure of the 
building, the facilities for ventilation, the drainage ar- 
rangements, its connection with the sewer, the nature of 
the water-supply, the conditions of the soil, health of oc- 
cupants, number and causes of deaths that have occurred 

in it, and other pertinent information, should form a per- 
manent record, and this record should be kept up by re- 
cording any changes noted upon subsequent examination. 
The complete sanitary history of every locality thus ob- 
tained will be useful for reference, and will serve as a 
guide to the discovery of unhealthy premises and the 
causes of their insanitary conditions, and lead to the em- 
ployment of measures of improvement. By reference to 
the records the condition of each house at once becomes 
known, and the effort to determine the exciting cause of 
any disease therein existing will be greatly facilitated. 

It is the right of everyone proposing to buy or rent a 
house to have a knowledge of its sanitary history. Such 
information is generally obtained with the greatest diffi- 
culty, because no sanitary survey has ever been made. 
With this as a basis the local sanitary authority ought to 
be able, for a small fee, to furnish to anyone proposing 
to occupy a house a copy of the health history of the 
house, certiffted from the records. 

The tabulated forms to be used for a sanitary inspec- 
tion of houses will vary slightly according as the district 
is urban or rural. The form presented below is a modi- 
fication of the schedule of questions proposed and used 
by the National Board of Health, and differs in several 
respects from that given in the next article. The head- 
ings should be printed in tabular form, on paper of con- 
venient size and shape, arranged in the style of a tablet. 


SANITARY INSPECTION OF HOUSES AND PREMISES. 


De tW ALG. sas ls , Street...... PIN Oisashenstels 


Z 
p 
B 
oO 
n 
° 
rh 
e) 
fe) 
ie) 
i=) 
se} 
— 
i) 
bar) 
i) 
= 
= 
° 
Fh 
° 
= 
=) 
@ 
a) 


Site of house, wet or dry...... 

Age of house...... ; material...... ; number of stories...... 
Number of living-rooms...... ; of sleeping-rooms...... 

. Cellars and basement..... 

. Sinks, drains, and cesspools...... 

Privies or water-closets, location and condition,,,,,, 


$O 23D OTB 9 20 


. 


Inspection, 

LOR Yard ser nee 

11. Hogs or other animals...... pELOWISN tenes ; number...... ; where 
Kepeies.. 

12. Public nuisances on or near premises...... 

13. Number of families in house...... 3; names of heads of families 
Re eee ; number of persons in each family, specifying number of whites 
and blacks...... ; total number of occupants...... 

14. Sickness now in house...... ; what diseases...... 

15, Sickness during past year...... ; what diseases...... ; number of 
cases...... 

16. Deaths during past year...... ; what diseases...... 

17. Persons vaccinated...... 3 persons not vaccinated...... 


18. Water-supply, whence derived, sources of contamination 
19. Sanitary needs and estimated cost 
20. Additional observations...... 

Certified as correct, 


ae aeee 


eee e eter essen 


Scot et, gigs oxid ng eA tea ~ 
Inspector. 


Upon the other side of the blank may be printed direc- 
tions for the guidance of the inspector. 


Directions: 1 and 2. Give the exact and full name of the owner and 
occupier of the premises. Give the street and number, and describe the 
location so that it cannot be mistaken. 

3. Give dimensions of sheds, privies, stables, etc., with their relations 
to living-rooms. 

4. State whether site is above, below, or upon same level as adjoining 
land. Conditions of the soil, whether damp, wet, or dry or ‘‘made- 
ground,” 

6. Note how ventilation is secured. 

7%. Examine cellars very carefully, and describe their condition, parti- 
cularly with regard to dampness, amount and kind of filth, ventilation, 
drains, etc. State whether used for living purposes. 

8. Is there any offensive smell from the sinks? Are the drains water- 
tight, clogged, or uncovered? Are there any traps to prevent drain-air 
from coming into the rooms? Are there sewer-connections, intercepting- 
trap, soil-pipe ventilation? Are the cesspools tightly covered, clean, and 
ventilated? Do the cesspouls leak into the cellar or into the well? 

9. Privies and vaults. Describe their condition particularly. Are they 
full, foul, leaky, or overflowing? Are they shallow or deep, water-tight 
or leaking, connected with the sewer, trapped, ventilated, ete. ? 

10. Describe the kind and amount of all heaps of filth about the prem- 
ises, and the general condition of the yard, area, etc. 

12. Public nuisances, as sewers, badly paved and drained streets, gut- 
ters, etc., stables, manufactories. 

13, Note overcrowding and social condition of the inmates, 

14, 15, 16, and 1%. Inquire particularly. 

18. State whether, in addition to the supply from the public water 
mains, water is used from a well or cistern ; whether it is called good or 
bad; whether any filth probably drains into the well. 

19, State what is necessary to be done to remove nuisances, and im- 
prove the sanitary condition of the premises, and the approximate cost of 
such improvements. 


The duty of collecting information upon the subjects 
embraced in a sanitary inspection should be performed 
with great discretion, so that, while nothing necessary to 
be known shall escape observation, the service shall not 
excite opposition by its obtrusiveness and unnecessarily 
inquisitorial character. It must be remembered that in 
most cases these examinations can only be carried out by 
the sufferance of the people; but by tact and politeness 
it is possible in nearly all instances to obtain all the in- 
formation desired. 

Upon the completion of a general house-to-house in- 
spection, the returns—containing a record of sanitary 
facts—-should be tabulated, paged, indexed, and grouped 
by wards or districts in such a manner as to make in- 
stant reference to the original inspection of every house 
and locality possible. From these data sanitary ward- 
maps may be compiled, indicating by color the special 
insanitary features of a district ; as, for example, in- 
sufficient or defective drainage, polluted or suspicious 
water-supply, unhealthy habitations, public nuisances, 
centres of excessive mortality, prevalence of epidemic 
disease, etc., these subjects being so arranged that ready 
reference can be made to the original records of inspec- 
tion for a full description and sanitary history of any 
house or locality. 

The frequency with which a systematic inspection of 
a district should be made must necessarily vary accord- 
ing to the extent and character of the district and other 
circumstances. It would be a useless task and a waste 
of time and money to inspect localities containing the 
best residences and a population of the better class, as 
frequently as streets and houses in poor neighborhoods, 
particularly such districts as are notoriously unhealthy. 
The latter, of course, will require most vigilant watch- 
ing. At the same time, no part of a town, however fav- 
orable its sanitary reputation, should be exempt from 


263 


Sanitary 
Inspection, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


periodical visits, as it is only by universal and rigid 
scrutiny that a full record of facts favorable or other- 
wise to the public health can be satisfactorily obtained. 
Whenever made, these inspections should be thorough 
and systematic, so that the data secured shall represent 
the actual state of every part of the district. 

SANITARY INSPECTION OF THE WATER-SUPPLY.—An 
abundant supply of wholesome water is an essential to 
the health and comfort of man. An insufficient quantity 
leads to impurities of all kinds, and an impure quality is 
a frequent cause of disease. Experience has taught us 
that a community will be unhealthy in proportion as the 


supply of water is scanty and the quality bad, other | 


things, of course, being equal. In providing a supply, it 
is to be presumed that the water commissioners have 
given due consideration to the quality of the water, the 
quantity required, and the risks of pollution, both as re- 
gards the source of supply and the mode of distribution. 
But this fact does not relieve the health authorities from 
the duty of vigilant inspection of the source, storage, and 
distribution of the water used for domestic purposes, in 
order to discover any permanent, temporary, or acci- 
dental cause of contamination. It is pertinent to such an 
inquiry to ascertain all facts connected with the source 
from which the supply is derived. If from a river or 
stream, whether the drainage from towns, villages, and 
factories, or other polluting matters flow into it above the 
point at which the water is taken ; whether the gathering 
grounds are cultivated lands, enriched with night-soil or 
other excrement, and whether the territory from which 
the water is drained is sufficiently populated to seriously 
affect the quality of the latter ; whether the supply is am- 
ple for general and domestic purposes, and is distributed 
to every house ; whether impurities of storage are care- 
fully guarded against, and the processes of filtration and 
purification are successfully conducted; whether the 
channels of distribution are protected from all risk of 
pollution, and whether the supply is always constant and 
the pressure in the mains sufficiently strong to insure 
delivery at the top of the house, if necessary, and also to 
prevent regurgitation. 

These and other questions relating to the character of 
the supply should not be overlooked, but the services of 
the sanitary inspector will be more constantly required 
in searching for the sources of pollution to which water 
may be exposed after it has been brought into the town 
and into the houses. It will be necessary to inquire into 
the situation, construction, and condition of cisterns and 
tanks, the means of separation of cisterns used for do- 
mestic supply from those supplying water for the closets, 
the situation of the overflow-pipes, and the relation be- 
tween the service-pipes and the water-closets, the object 
being the prevention of any influx of foul air or foul 
matter into the service-pipes, and the consequent contam- 
ination of the supply. 

The color, taste, and smell of water will generally in- 
dicate the presence of impurity, but, if this evidence is 
not satisfactory, more exact information should be ob- 
tained by chemical analysis. The inspector should not 
be required to make such an analysis, but he can care- 
fully procure samples of the water to be submitted to a 
chemist who is expert in this branch of investigation. 

In rural districts and in towns where the supply is col- 
lected or obtained on the premises, it is important that 
the state of every well and other source of water used 
by the inhabitants should be fully known. Rain-water 
stored in cisterns and well-water are liable to contami- 
nation from many sources. If the collecting surface is 
defiled, impurities will be washed into the cistern by the 
first fall of rain. Rain-water collected in the neighbor- 
hood of inhabited places is liable to contain gaseous and 
solid impurities washed from the air. Inspection should 
be made, from time to time, of the interior of cisterns, in 
order to see that impurities are not collecting, that no 
leaks exist, and that the overflow-pipes are properly ar- 
ranged. <A leaky condition of a cistern may lead to con- 
tamination of the water by influx of deleterious matter 
from the soil, aided by a favorable state of the surface of 
the ground. Rain-water may take up lead from the lin- 


264 


ing of the cistern and from lead pipes, and zinc from 
zinc roofs. 

The situation and construction of wells, with reference 
to their liability to contamination from surface washings, 
oozings from: drains or cesspools, and other sources of 
filth, will require the most careful investigation. When- 
ever cesspools or drains, whether open or closed, or ac- 
cumulations of filth, are near a well and the soil about 
it is wet and filth-sodden, there will be a presumption 
of contamination. When suspicions arise, samples of 
the water should be taken for examination. Under cer- 
tain circumstances, however, the evidence may be such 
as to warrant the closing, cleansing, or repairing of wells 
without resort to proof of impurity by chemical exami- 
nation. When well-water is used it is advisable to inquire 
into the condition of the soil, which more or less influ- 
ences the quality of the ground-water from which shal- 
low wells are supplied. In districts where the soil is 
made use of as a reservoir for excremental matters de- 
posited in cesspools and privy-vaults, or is exposed to 
defilement by leakage from disjointed or ‘broken drains, 
badly constructed sewers, or leaky gas mains, or where 
filth is stored upon the surface of the ground, the entire 
water-bearing stratum in time becomes polluted, and the 
water of wells is rendered impure. On this account sur- 
face and shallow-well waters in thickly populated places 
are always to be regarded with the greatest suspicion. 
Shallow wells, even in rural districts, are often horribly 
polluted by sewage, and by animal matters of the most 
disgusting origin. 

Public drinking-fountains should not escape notice, as 
they are sometimes improperly arranged, as, for example, 
in connection with drinking-troughs for horses. Cis- 
terns for the public supply of ice-water may be permitted 
to become unclean by the accumulation of deposits, or 
the water may be rendered unwholesome by the inju- 
dicious use of impure ice. 

Public baths should be kept under strict sanitary super- 
vision. Not only should the supply of water be main- 
tained in a fresh condition, but the regulations prescrib- 
ing the proper use of the baths should be rigorously 
enforced. 

SANITARY INSPECTION OF DRAINAGE AND SEWERAGE. 
—The drainage and sewerage of a town bear important re- 
lations to the public health, and therefore properly come 
under the notice of the sanitary inspector. Nuisances aris- 
ing from insufficient surface drainage, from dampness of 
the sites of habitations, and from badly planned and man- 
aged sewerage-works, frequently engage the attention of 
the health officials. It may not devolve upon these offi- 
cers to suggest special schemes for the construction and 
improvement of public works, but it is a part of their 
duties to notice gross defects so far as they tend to exert 
an injurious influence upon the public health, and to 
urge the adoption of means for their remedy. 

It may be necessary in some localities to have a system 
of deep drainage to facilitate the movement of the 
ground-water, and thus make both air and ground drier. 
A moist soil exerts an injurious influence upon health, 
it having been shown upon reliable evidence to be favor- 
able to the production of lung diseases, rheumatic and 
catarrhal affections, and to be connected in some way 
with the development of typhoid fever and cholera. 
The drainage of swamps, areas of made-land, and places 
saturated with water, near or in inhabited districts, will 
be followed by the best results to the public health. 

Surface drainage should be free and unobstructed, so 
as to promptly carry off the greatest amount of rainfall, 
and prevent the overflow of cellars or the intrusion of 
soil-water. 

Nuisances are often caused by the disposal of slop- 
waters upon the surface of the ground or by wayside 
channels. Slop-waters or house-waters are in fact a con- 
densed form of sewage, as they contain not only the 
cooking-water and water used for washing the person, 
clothing, and house, but almost invariably some portion 
of urine. Such matter is not fit to be discharged over 
the surface of the ground, as it must of necessity become 
offensive and cause a nuisance by decomposition and 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sanitary 
Inspection, 


soakage into the soil. If it cannot be disposed of upon 
the premises, it must be carried from the house in pipes 
to a proper outfall. 

Sooner or later, every town must be provided with a 
system of sewers to prevent the collection of filth in and 
about habitations and frequented places, and to protect 
the air and soil from pollution. While aiming to carry 
out this object, the sewers themselves must not be per- 
mitted to become reservoirs of filth, which, by stagna- 
' tion and decomposition, may give rise to a nuisance only 
less offensive and dangerous than that which it is in- 
tended to prevent. 
well constructed, and permit of a rapid, continuous, and 
complete flow of the sewage to the outfall without leak- 
age by the way. They should allow no deposit to take 
place, and should be thoroughly ventilated. With these 
conditions maintained, it is scarcely possible for a sewer 
to become offensive or in any way dangerous to the 
public health. Ventilation may be effected by having 
numerous openings into the streets, protected by grat- 
ings, and by leaving the sewer-inlets untrapped. In this 
way a free interchange between the sewer-air and the 
atmosphere is secured. The openings will relieve press- 
ure upon the house-drains, and if these latter should be 
left unguarded the danger from the admission of sewer- 
air will be greatly diminished by the free dilution of the 
latter with atmospheric air. 

The escape of evil odors from untrapped sewer-inlets 
is not a valid objection to the disuse of the trap, but 
rather an indication that the sewer does not properly 
perform its mission, which should lead to the remedy of 
the fault and not to its concealment. With the condi- 
tions giving rise to the nuisance unremedied, it is far 
safer to permit the escape of sewer-air upon the streets 
than to subject the inhabitants of houses having connec- 
tion with the sewer to risk by closing the manholes and 
using traps upon the inlets, and thus increasing pressure 
and preventing the diluting effect of the outside air. 

Extrinsic flushing will be required when the force of 
the current of sewage is not sufficient to produce a 
scouring effect. The cleansing and disinfection of sew- 
ers are occasionally required to improve their condition, 
but at best they are only temporary expedients, Sewers 
which accumulate deposits and are commonly foul, and 
which constantly require cleaning out and disinfection, 
are radically wrong in construction and should be recon- 
structed without delay. 

When sewers are properly constructed and managed 
and have free ventilation, the air which they contain 
differs but slightly from the outside air; but as these 
conditions cannot always be insured, it is a wise plan to 
have the house-drain disconnected from the sewer by 
means of an efficient trap, and the system of house-pipes 
thoroughly ventilated. The disposal of sewage should 
take place without causing a nuisance in relation either 
toair or to water. This is a subject of serious considera- 
tion in the planning and management of the outfalls of 
sewers. The sewage of a town should never be dis- 
charged into a stream at or near a point from which the 
water-supply is obtained, or which, from its small vol- 
ume of water, is incapable of diluting the liquid refuse 
sufficiently to prevent serious pollution, without first un- 
dergoing a proper degree of purification. Purification 
of sewer-water may be effected by precipitation at the 
outfall by chemical agents, by irrigation, and by inter- 
mittent filtration. If properly managed, any one of 
these methods may be applied with satisfactory results. 

In small towns and villages it may not be practicable 
to provide a general system of sewers, and hence the dis- 
posal of refuse matters, such as excreta and house-wa- 
ters, must be effected by other methods. As the choice 
of these plans is more or less directly under the control 
of the householder, being only exceptionally restricted 
by local regulations, a variety of methods will be encoun- 
tered in every locality, including even the large cities. 
For the disposal of excreta the cesspool or privy-vault, 
or some one of the dry methods, is resorted to; but the 
house-slops are not so readily gotten rid of. In towns 
the open gutter is commonly used for this object, while 


It is essential that sewers shall be 


in villages and in the country the slops are thrown upon 
the ground. ‘These plans for disposing of refuse matters 
are everywhere among the chief sources of nuisances, 
and will constantly claim the attention of the inspector. 

Privies of the accumulative sort, with their respective 
soakings and exhalations, whereby air, soil, and water 
are polluted, are a very common means of spreading 
some of the most fatal of diseases, of which typhoid fe- 
ver may be taken asa type. The utmost watchfulness 
should be exercised to reduce these nuisances, which 
exist in all populous places throughout the country, to 
the lowest degree of dangerousness. Privy-pits and 
cesspools, if at all permitted, should be made to conform 
to the most stringent regulations both as to their con- 
struction and management. They should not be located 
too near the house or the water-well; they should be 
constructed of unabsorbent materials, and should be per- 
fectly water-tight, so as to prevent the leakage of filth 
into the soil, building, or water ; they should be of 
small capacity, so as to preclude the accumulation of 
matter, and they should be regularly and methodically 
cleaned at short intervals, so as not to allow the putre- 
faction of excrement. Their use should not be per- 
mitted for anything but excreta. 

To meet sanitary requirements, improved systems have 
been devised to take the place of the filthy storage-pits, 
so universally condemned. These are principally the 
pail-system and the so-called dry systems. The simple 
pail-system, much used in England, but not yet system- 
atically adopted in the United States, consists in the re- 
moval of excremental matter at short intervals, before it 
has become offensive. As a means to this end, movable 
receptacles are used which systematically, at short inter- 
vals, are to be changed, clean for the dirty, by the scav- 
enger ; and which, in order to prevent offence in this 
process, are provided with tight-fitting lids to be applied 
to the foul pails under removal. The excrement is re- 
moved daily without admixture, except with the ordi- 
nary kitchen refuse, and is transported outside the town. 

The dry system is adapted to towns and villages and 
to single cottages. It consists in the admixture of dried 
earth, coal ashes, or other dried refuse, with the excre- 
ment in sufficient quantity to absorb and reduce it to an 
inodorous form. All slops and sink-water and other ex- 
traneous matter must be carefully excluded. The recep- 
tacles should be made of impervious materials, and the 
closet should be located either out-of-doors, or in an iso- 
lated part of the building, or in an apartment projecting 
from the house, where the necessary ventilation can be 
secured. The dry systems form a convenient, economi- 
cal, and efficient substitute for water-closets where the 
latter cannot be made use of, but they must be vigilantly 
superintended, and in some cases actually managed by 


‘the local authority. 


It is essential that privies of all kinds, particularly 
those located in poor neighborhoods, shall be under con- 
stant supervision, in order to prevent the violation of the 
laws and regulations pertaining to their construction and 
management, But this supervision should not be con- 
fined to the privy contrivances and the methods of their 
cleansing, but should also extend to the ultimate disposal 
of the matter, whieh is a most important part of the 
management of refuse removal. 

Nuisances incident to the improper disposal of liquid 
house-wastes are of frequent occurrence. In towns and 
villages, the house-slops are either thrown upon the 
ground near the house, where they are partly absorbed 
and in time load the soil with impurities; or they are 
carried away in open or in closed channels to some dis- 
tant part of the premises, where they gradually soak into 
the ground ; or they are discharged into the roadside or 
street-gutter, causing a nuisance of a most offensive char- 
acter. Sometimes the entire sewage of the house is col- 
lected in cesspools provided with porous walls, with the 
obiect of allowing the fluid parts to drain away, the solid 
matter being removed only after long accumulation. In 
the absence of sewers, these nuisances may be avoided 
by providing tight cesspools with sufficient capacity for 
oné or two days’ collection, from which the sewage may 


265 


Sanitary 
Inspection. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


be distributed to the land near by through pipes under 
the surface of the ground. This is the plan of subirriga- 
tion, which is very convenient for the disposal of the 
sewage of separate houses or groups of houses, where 
land is available. 

Subsurface irrigation may be used for the disposal of 
slops alone, or for slops mixed with the efflux of water- 
closets. It is necessary, however, to provide a means 
for intercepting all solid and fatty matters, which should 
not be discharged into the drain-tiles, as they would in 
time clog up the pipes and render the system inopera- 
tive. Solid excrement may be disposed of in a cleanly 
and inodorous manner by the use of the earth-closet, only 
the slop-water being allowed to flow away in the subsoil 
drains. 

The success of this plan depends on the property of 
the soil of destroying organic matter, by the aid of the 
oxygen contained in its pores, and, to some extent, upon 
the action of the rootlets of grass and plants. The sup- 
ply must be intermittent, and in order to secure this ac- 
tion a flush-tank is provided, which automatically dis- 
charges its contents through all the ramifications of the 
drain-tiles. When water-closet wastes are disposed of at 
the same time, an intercepting chamber should be placed 
between the house and the tank to collect the solid mat- 
ter, which should be removed at frequent intervals and 
applied to the land. 

The occupants of rural premises will generally be able 
to satisfactorily dispose of their own refuse matters upon 
their own premises, without any detriment to themselves 
or to their neighbors. But when human beings are gath- 
ered together on small areas, the disposal of refuse can- 
not be secured without method. The obligation to de- 
signate the correct system of disposal and to supervise 
its management, so that no avoidable nuisance shall be 
created, rests upon the sanitary authority. 

Frequent inspections will be required in order to pre- 
vent nuisances from arising through neglect in the dis- 
posal of dry house-refuse, such as ashes, dust, and garb- 
age, and through improper disposal of trade-refuse and 
the refuse of domestic animals. Provision must be made 
for the frequent and regular removal of these matters, 
and, at the same time, regulations must be enforced 
which shall prescribe that house-refuse, while awaiting 
removal, shall be so cared for and managed as not to 
cause a nuisance on the premises. Every facility should 
be afforded the householder for promptly getting rid of 
his refuse, so that no excuse can be offered for the ac- 
cumulation of offensive matters upon his premises. 

Faults in house-drainage and plumbing are a frequent 
and formidable danger to the public health. Until with- 
in recent years, this fact has been very imperfectly re- 
cognized by architects and builders, and by the public 
generally, and too much trust has been placed in artisans, 
who have been permitted to proceed in their work with- 
out any carefully wrought plan or expert supervision, 
and also without their qualifications first having been 
thoroughly ascertained. Asa result of various deficien- 
cies, and prominently that of neglect of competent sani- 
tary supervision, it frequently happens that the evils a 
modern system of house-drainage is intended to avert, 
are made worse by careless planning and execution of 
the drainage arrangements within the dwelling. Owing 
to the absence of skilled guidance, and frequently through 
want of conscientious execution, defects in house-drain- 
age of the most flagrant character are constantly encount- 
ered, even in the better class of houses. Buta greater 
familiarity on the part of the public with the correct 
principles of house-drainage, and supervision of the work 
by boards of health, will tend to lessen abuses, which are 
responsible for a large quantity of preventable disease. 
In many places laws regulating house-drainage have been 
enacted, and entrusted for their execution to the local 
sanitary authority. Under these laws, rules and regula- 
tions are prescribed for the registration of plumbers and 
for the guidance of artisans in drawing their plans and 
specifications. In large cities the plans, when approved, 
are executed under the supervision of trained officers 
especially appointed for the purpose ; but in small towns 


266 


the work of supervision may be advantageously combined 
with the duties of general sanitary inspector. The laws 
and regulations in force in Boston, New York, Phila- 
delphia, and Washington may be cited as examples of 
the methods adopted for conducting this important branch 
of house sanitation. The object of these laws is to place 
the drainage arrangements of houses under skilled sur- 
veillance, so that their planning, construction, and man- 
agement shall conform to standard principles. 

The essential conditions of house-drainage are: That 
the receptacles shall be constructed of such material 
and in such manner as to be impervious to fluids, and 
easily permit of cleansing and of being kept clean in all 
their parts. That the pipes and drains shall be of sound 
and durable material, and so constructed and laid as to 
be gas-tight throughout, and to secure a continuous and 
complete removal of whatever enters them without leak- 
age by the way, or without the formation of deposits or 
incrustations. That the system shall be so planned and 
arranged that neither the air of the house nor the drink- 
ing-water can in any wise be polluted by the escape into 
the house of air from the sewer or from the drain. Upon 
these fundamental principles are based the rules and 
regulations governing the technics of construction, which 
should be formulated for the guidance of the architect, 
builder, and artisan. The law should require that the 
plans and specifications of the drainage arrangements of 
every proposed dwelling, and of old houses undergoing 
alterations, should be submitted for approval to a compe- 
tent official or board of experts, and that the essential 
details of such plans should be carried out under skilled 
supervision. The effect of such a requirement would be 
to avoid errors in design and construction in new build- 
ings, and to gradually improve the drainage arrange- 
ments of old structures. 

As the best systems of house-drainage are liable to de- 
rangement which may escape the notice of the house- 
holder, provision should also be made for the periodical 
inspection of the drainage-works of every dwelling, in 
order to guard the occupants against the evil conse- 
quences of deficiencies of which they may have no 
knowledge. 

In many places no systematic regulation and supervi- 
sion of house-drainage is ever attempted, the authorities 
having to depend for knowledge of existing defects upon 
complaints made in special cases, upon the results of in- 
vestigation of the localized causes of disease, or upon 
discoveries made during a casual house-inspection. This 
information relates to a small number of the actual de- 
fects, the greater number escaping detection in the ab- 
sence of methodical inquiry.. Where no such laws exist, 
the sanitary authorities may do much toward effecting a 
reform in the present objectionable methods by adopting 
and promulgating regulations similar to those in force in 
the cities already mentioned, for public information, for 
the instruction of their inspectors, and to serve as a guide 
in all work which they are called upon to perform. 
Thousands of houses are annually built in a manner 
dangerous to the health of the occupants, because the 
builders are ignorant of the conditions to be observed to 
make them healthy, and they fall into the errors which 
might have been avoided had they the knowledge of the 
correct principles of construction, or had the authorities 
required their application. 

SANITARY INSPECTION OF PUBLIC WAYS AND PLACES. 
—The sanitary importance of thorough cleanliness of 
public ways and places cannot be over-estimated. The 
deposit and retention of refuse matters upon the surface 
of streets may give rise to dangerous pollution of air and 
soil. This is apparent when the composition of the filth 
of badly-kept streets is inquired into. In addition to the 
inorganic detritus of the road, it consists of the dung 
and urine of horses, and sometimes of other animals, of 
vegetable matter from trees, of refuse from houses— 
kitchen garbage and house-slops—containing animal and 
vegetable matter, and, in poor neighborhoods, there ‘is 
sometimes an admixture of human excrement, both solid 
and liquid. This mixture of animal and vegetable sub- 
stances, when converted into dust, fills the atmosphere 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sanitary 
Inspection. 


with disgusting particles, or when wetted by rain and 
exposed to heat, soon decomposes and develops effluvia 
which must be detrimental to health, especially in crowd- 
ed and ill-ventilated localities. Unless the pavement is 
composed of impervious materials, liquid matters upon 
its surface will penetrate into and pollute the soil. 
These results are due to imperfect drainage, to a bad 
system of scavenging and refuse-removal, and very ma- 
terially to badly constructed pavements. 

Surface cleansing cannot be made efficient without the 
provision of suitable pavements—such as will prevent 
the retention of filth and its imbibition by the soil. It is 
especially important that this provision should be ex- 
tended to all small streets, courts, and alleyways, and to 
the surface areas in all crowded and badly ventilated 
places, as in such localities the open spaces are likely to 
be used as common depositories for all kinds of refuse 
matter, including human excrement. 

The construction of public roadways and the conserv- 
ancy of the surface area of towns are commonly en- 
trusted to a commission or board of public works, but 
the delegation of these powers to a co-ordinate branch of 
government does not relieve the sanitary authorities of 
the duty of closely scrutinizing the work, and noting de- 
ficiencies which tend to injure the public health, and of 
urging the proper remedies. 

Under certain circumstances the application of disin- 
fectants to the street surface and gutters will be required, 
but this precaution will rarely be necessary when proper 
care is exercised in the construction and cleansing of the 
pavements. The utmost care will be required in pre- 
venting public urinals from becoming nuisances of an 
offensive character. These conveniences should be 
washed out daily, and otherwise carefully managed un- 
der the vigilant eye of an inspector. 

The relation of gas and lighting to the public health 
is a subject demanding careful investigation. Adequate 
lighting of the public streets and places is not only essen- 
tial to public convenience and order, but is a means of 
restraining the perpetrating of nuisances which are apt 
to be committed under the protection of darkness. Gas 
should be maintained of a specific illuminating power 
and purity. Impurities in gas not only diminish its il- 
luminating power, but tend to injure health by deterio- 
rating the air in the rooms where it is used. The escape 
of gas from defective joints, or from flaws in the street 
pipes, has often been attended with disastrous results. 
The escaping gas may pass through the foundations of 
houses and poison the air within. This accident is not 
uncommon in the winter season, when the air in the 
ground surrounding the house is apt to be drawn into 
the basement by the aspirating power of the heated air 
within the building. Gas may also prove injurious by 
fouling the water of wells. Another danger is from ex- 
plosion in sewers, and in cellars and cesspools connected 
with sewers by drains, the gas escaping into the sewers 
and thence being conveyed upon private premises through 
badly constructed house-drains and untrapped inlets. 

The location of gas-works, with respect to the influ- 
ence on the health of the neighborhood of vapors escap- 
ing during the process of gas-production, and also with 
respect to the manner of disposal of refuse matters from 
gas-working, will occasionally require a careful investi- 
gation. 

The sale of illuminating oils should be restricted to 
such qualities as are known to be free from explosive- 
ness. The law should make provision for ascertaining 
the grade of petroleum exposed for sale, and should pro- 
hibit the sale of this article at retail when its ‘‘ flashing- 
point” is below 100° F. The routine work of testing 
oils and burning fluids is properly delegated. to special 
officers, but the sanitary government should interest it- 
self in procuring the adoption of laws which will avert 
accidents and prevent the loss of life. . 

SANITARY .INSPECTION OF SLAUGHTER-HOUSES AND 
ABATTOIRS.—By mismanagement slaughter-houses may 
become a nuisance to the neighborhood, or their con- 
dition may be such as to affect the wholesomeness of 
the meat prepared for the market. Wherever located 


these establishments will always require careful super- 
vision, as from the nature of the business nuisances are 
readily created by putrescent effluvia, or by filthy soak- 
age or outflow. Particular attention should be directed 
to the location and construction of the buildings, to the 
means of water-supply, drainage, and ventilation, to the 
provision of suitable receptacles for the refuse and its 
prompt removal, to the means of preventing filthy soak- 
age of liquid refuse within or about the buildings, and 
to the maintenance of cleanliness throughout the estab- 
lishment and in every process of the business. By-laws 
prescribing rules embodying these essential points should 
be adopted, and their observance enforced by vigilant 
inspection. 

Slaughtering is most commonly done in private estab- 
lishments, which are seldom constructed, equipped, or 
managed in strict conformity to sanitary principles. 
Many of these establishments are extemporized out of 
buildings constructed for other purposes, and are totally 
unsuited for the slaughtering of cattle. As they are gen- 
erally located in densely populated parts of the town, 
their deficiencies and mismanagement have the widest 
scope for exerting a pernicious influence. By placing 
these establishments under the control of the board of 
health, and requiring a permit to engage in the business, 
conditioned upon proper location and construction of 
buildings and good management, a great reform can be 
effected in a business which is too often conducted in a 
slovenly manner, to the detriment of the public health. 

The concentration of the business of slaughtering cattle 
in well-appointed and well-conducted public slaughter- 
houses, or abattoirs, where abundant water, good drain- 
age, thorough ventilation, ample means of cleanliness, 
and perfect facilities for the work are provided, and 
where every branch of the business is conducted under 
constant official observation, is strongly to be advised, as 
a measure highly advantageous in its economic and hy- 
gienic results. The adoption of this practice is gradu- 
ally being extended as its benefits become understood 
and appreciated. 

The fact that typhoid fever, scarlet fever, and some 
other diseases have been spread through the agency of 
milk, makes it imperative that cow-houses, dairies, and 
milk dépéts should be managed under the provisions of 
salutary laws and systematically inspected, in order to 
insure the enforcement of such provisions. 

SANITARY INSPECTION OF MARKETS.— All markets 
should be placed under the control of the sanitary gov- 
ernment. The construction and management of the build- 
ings should be such as to insure ample light, free ventila- 
tion, perfect drainage, prompt removal of refuse matters, 
and thorough cleanliness. Supervision should also be 
extended to the immediate neighborhood, including the 
streets and passage-ways, with the view of preventing any 
avoidable nuisance. The provision of smooth and im- 
pervious pavements is necessary, in order to facilitate 
cleansing and prevent the retention and imbibition of filth. 

SANITARY INSPECTION OF Foop Suppuiies.—The su- 
pervision of the food supplies of the people is one of the 
most important obligations of a municipality. While 
the price and the quality, in a measure, must be left to 
the ordinary operations of trade, the law must take cog- 
nizance of and prevent adulterations, and the manufact- 
ure and sale of any articles intended for human con- 
sumption that are injurious to health. In order to effect 
this object the law should clearly define the offence of 
adulteration in all its various forms, and also designate 
the kind of food which is unwholesome and the circum- 
stances which render it so, and direct the course to be 
pursued in condemning, and withdrawing from_ the 
market, and disposing of, any diseased, or unsound, or 
unwholesome food, or food unfit for the use of man, It 
should also embrace provisions for its own thorough and 
complete execution. 

The organization necessary for carrying into effect 
such regulations, as well as many other important meas- 
ures connected with the preservation of the public health, 
already exists in many States in the form of a State board 
of health. Vesting ‘such authority in a central board 


267 


Sanitary 
Inspection, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


should. not abrogate nor conflict with the regulations of 
local boards for the inspection of food-supphes, such as 
meat, fish, game, vegetables, and other perishable ar- 
ticles which require daily supervision ; but, on the con- 
trary, would furnish a means of co-operation in effecting 
a common purpose. 

While the main object of legislation against adultera- 
tion is the protection of the public health, it yields a 
further advantage by its economic results. This fact is 
prominently displayed under the operations of the Massa- 
chusetts food-inspection law. Of articles liable to adul- 
teration, such as milk, butter, spices, vinegar, cream of 
tartar, and some drugs, consumed in that State in 1884, 
of the value of $15,000,000, five per cent., or $750,000 
were saved to consumers through the services of inspec- 
tors of food. 

Most European countries are well provided with laws, 
both general and municipal, for regulating the manufact- 
ure and sale of articles of food, but, beyond enacting a law 
prohibiting the importation of damaged and adulterated 
tea, and regulating the sale of oleomargarine, the United 
States Government has done little to insure the purity of 
food. Most of the States have statutes relating to special 
articles of food, some of which have a purely commer- 
cial object, while others are intended for the protection of 
the public health. Massachusetts, New York, and New 
Jersey have recently adopted stringent measures for the 
prevention of the sophistication of food and drugs, which 
have already been productive of good results. These 
laws have been ingrafted upon those of the State boards 
of health. One of their objects is the protection of trade 
by preventing falsifications which may or may not be in- 
jurious to health ; but the vital purpose is to take cogni- 
zance of adulterations which are deleterious, and to pre- 
vent the sale of such articles of food. 

Violations of the law are detected by the employment 
of inspectors and analysts, and its provisions enforced by 
notification and warnings, or by prosecution and penal- 
ties, and in some cases by the confiscation of condemned 
articles. The same officer may act in the dual capacity 
of inspector and analyst. 

In order to promote the objects of food-inspection 
public test-offices, properly equipped with all necessary 
appliances, should be opened for the examination of all 
articles submitted by the inspectors, and also by the peo- 
ple. Such an office has been established in Paris, where 
all articles of food, beverages, etc., are analyzed and 
tested by experts, who also perform the duties of inspec- 
tors of markets and among the tradesmen. For a nom- 
inal sum, and in some cases gratuitously, anyone can as- 
certain the composition of any suspected article of food. 
Articles of domestic use, clothing, colored toys, wall- 
papers, etc., are also examined in order to detect any 
poisonous ingredients that may be present. 

Adulteration has been practised in a great variety of 
foods, beverages, and drugs; but the practice is com- 
monly restricted to a limited number of articles. The 
principal articles liable to adulteration are milk, butter, 
cheese, spices, vinegar, sugar, ground coffee, tea, oils for 
consumption, cream of tartar, spirits, and various sorts of 
drugs, and to these special attention should be directed. 

The examination of meats, fruits, and vegetables, and 
other perishable articles, should be made with great fre- 
quency, as the stock is ever changing. 

Animals should be examined immediately before kill- 
ing, and again before the meat is exposed for sale. The 
concentration of the business of slaughtering in public 
slaughter-houses or abattoirs will make efficient inspec- 
tion practicable. 

In order to facilitate the labors of the inspector, the 
law should describe the kind of food which is unwhole- 
some, or the circumstances which render it so; but with 
the best care as to details, much will have to be left to 
the discretion of the officer who makes the examination. 
Study and practice will enable him to successfully dis- 
criminate in most cases coming under his observation. 
Occasionally it will be necessary to refer suspicious ar- 
ticles to the public analyst for the application of chem- 
ical or microscopical tests. 


268 


It is the practice, in the city of London, to condemn the 
flesh of animals infected with certain parasites, as ¢tri- 
china in pork, the cysticerct in pork, beef, and mutton, 
and flukes, which infest the livers of animals; and of 
animals suffering from fever or acute inflammatory dis- 
eases, as rinderpest, pleuro-pneumonia, and the fever of 
parturition; and of animals wasted by lingering sick- 
ness, such as phthisis ; and of animals which have died 
from accident or from natural causes; and also all meat 
that is tainted with physic, or that is sufficiently decom- 
posed to be discolored or have a putrid smell. 

The flesh of animals which have been exhausted, ex- 
cited, or tortured before death, has frequently proved 
to be unwholesome. 

Sausages are liable to become poisonous on account of 
a modified putrefaction which occurs in this variety of 
food when kept fora length of time. The poisonous 
effects have generally been traced to sausages which are 
mouldy and soft in the interior, and which emit a strong- 
smelling odor. Other kinds of animal food, when ina 
decayed or mouldy condition, may occasionally produce 
similar results. 

Fish, poultry, and game must be examined for signs 
of decomposition. 

Fruit and vegetables must be objected to mainly on 
account of advanced decomposition. Mouldy food of all 
kinds is dangerous, and should be condemned. 

The testing of canned goods for poisonous substances, 
and the examination of milk, butter, cheese, coffee, tea, 
sugar, cocoa, flour, bread, vinegar, drugs, etc., is mostly 
work to be performed in the laboratory, the duty of the 
inspector being chiefly confined to procuring samples of 
suspected articles for analysis. 

The officers selected for the responsible service of food- 
inspection should possess special attainments and un- 
doubted honesty, and in order to secure proficiency they 
should be required to devote their entire time and ener- 
gies to the work. 

SANITARY INSPECTION OF MANUFACTURES AND 
TRADES.—Noxious or offensive trades and manufactures 
require supervision in order to protect the health of em- 
ployees and prevent the processes from becoming a nui- 
sance, or injurious to the health both of the work-people 
and the public generally. The law should not only make 
it imperative that the ordinary conditions of health shall 
be observed; it should go a step further, and restrict 
labor at certain ages, and regulate the hours of work. 

The workshops should be well lighted, thoroughly ven- 
tilated, and, when necessary, provision should be made 
for the prompt removal of dust-particles. The speedy 
removal of deleterious refuse matters and the observ- 
ance of extreme cleanliness should be enjoined, and all 
overcrowding prevented. 

Trades which produce offensive effluvia, dust, or acrid 
vapors, are apt to cause nuisances which are injurious to 
health, or which may simply annoy or inconvenience the 
public. Nuisances of the latter description are subjects 
for action at common law. When the public health is 
imperilled the sanitary authorities are bound to interfere. 

The workers at certain trades are liable to suffer in 
their health from the inhalation of solid or gaseous sub- 
stances produced by the processes, unless efficient safe- 
guards are provided. The dust in cotton and woollen 
mills, metallic vapors, filings and grindings, and solid 
particles of various kinds, when inhaled, are highly in- 
jurious. Certain gases and fumes and fetid substances 
also have an injurious effect, if breathed in confined 
apartments. 

The public also are to be protected from annoyance 
and from injury to health resulting from the improper 
conduct of dangerous, noxious, or offensive trades. The 
businesses apt to create nuisances are very numerous, as 
will be seen by a reference to the classification adopted 
by the French Government in 1866, which may be profit- 
ably consulted. It is not expected that the inspector 
shall be familiar with all the details of the various trades 
therein specified, but he should have a general knowledge 
of the sources and effects of the offensive effluvia and 
outflow produced by certain well-known processes of 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sanitary 
Inspection. 


manufacture, so that when complaint is made he will be 
able to intelligently investigate these offences and sug- 
gest the best means for their remedy. To perform this 
oftentimes perplexing duty it is necessary that the in- 
spector shall possess good powers of observation, a thor- 
ough acquaintance with practical chemistry, and famili- 
arity and experimental knowledge with regard to the 
uses of various mechanical contrivances and the modes 
of testing their efficiency. It is only by close personal ob- 
servation and careful investigation that reliabie informa- 
tion can be obtained upon which to base the suggestions 
of remedies. Suggestions should not be made without 
extreme caution, and in no case unless there is a strong 
probability of a successful result. In some few special 
cases it may be necessary to employ the services of an 
expert who has greater familiarity with the questions at 
issue. 

With proper precautions, offensive trades and manu- 
factures can be conducted without causing a nuisance. 
Whenever advantageous and practicable, foul refuse 
matters should be utilized ; but if this cannot be done, 
other means should be employed for their disposal with- 
out causing a nuisance by contaminating either air, soil, 
or water. Foul matters awaiting disposal should be 
stored in closed tanks or receptacles. Suitable recepta- 
cles with tightly-fitting covers should also be used for 
removing such matters. Dangerous or offensive gases 
or vapors should be intercepted and rendered harmless 
and inoffensive by the use of proper condensers, or scrub- 
bers, or of absorbents, or by combustion in the furnace- 
fires. A combination of these various means may often 
be advantageously adopted. All offensive processes, such 
as fat-rendering, bone-boiling, etc., should be conducted 
in steam-tight tanks, and the vapors given off should be 
passed through condensers, and such fetid matters as 
may not be removed should be consumed in the furnace- 
fires. 

The inspection of mines, and the storage and sale of 
explosive and poisonous substances, etc., are generally 
regulated by State laws, and do not require the special 
attention of the sanitary inspector. | 

SANITARY INSPECTION OF PusLic ScHoois.—The san- 
itary supervision of schools is an essential part of the 
administration of every well-ordered system of public 
education. The object of such supervision is the protec- 
tion and preservation of the health of the children b 
securing proper sanitary arrangements of the school 
buildings, the observance of the laws of health, the en- 
forcement of regulations for the prevention of the spread 
of contagious or infectious diseases, and by practical in- 
struction in the plain rules of hygiene. 

The surroundings in which the child passes the first 
years of its life should conduce to its healthy develop- 
ment-and not impede it, as is so often the case in a 
large number of our schools. The aim of modern educa- 
tion should be to foster the physical as well as the intel- 
lectual and moral development of the child, not only for 
the advantages of health itself, but also for the sake of 
establishing a sound physical basis, without which true 
progress in the culture of the intellect is impeded or pre- 
vented. 

When the State assumes the responsibility of educat- 
ing the children, it also obligates itself to carefully guard 
their health, both physical and mental. This obligation 
is due to the public who entrust the care and training of 
their children to others during a large portion of their 
lives. The State should not be content simply to ‘‘ hold 
physical childhood unharmed while mental childhood is 
getting its schooling ;” it should strive to promote physi- 
cal health and vigor as an indispensable accompaniment 
to intellectual training, in order to make public educa- 
tion an important measure of public economy as well as 
a powerful moral agency. 

As a means of promoting these objects, the aid of sani- 
tary and medical science must be invoked in the adapta- 
tion of the school buildings for healthful occupancy, in 
supervising the hygiene of the premises and the hygienic 
care of the children, in preventing the spread of conta- 
gious or infectious diseases, in regulating the programme 


of studies, and in imparting practical notions of hygiene 
and sanitary law. ' 

The selection of the site, the construction, heating 
lighting, ventilation, water-supply, and drainage of the 
school buildings, and the details of arrangement and 
management of the buildings and appurtenances, must be 
in conformity with the principles of sanitary science. 
The arrangement and adaptation of light and of the 
school desks and seats, according to the requirements of 
hygiene and the special needs of the children, are most 
important considerations. Mental application should be 
carefully proportioned to the capacity of the child; it 
should be neither too taxing nor too prolonged, and 
should be alternated with recesses and physical exercise 
in the fresh air. 

The best-constructed buildings may be rendered un- 
healthy, and the most perfect sanitary appliances and 
arrangements may become inoperative, by the neglect of 
those in charge. Hence it is necessary that the sanitary 
supervision of the buildings‘and appurtenances shall be 
entrusted to qualified officers, who shall be responsible 
for everything pertaining to the hygienic management 
of the institutions. 

Sanitary supervision is an effectual means of prevent- 
ing the spread of contagious diseases in, and by means 
of, schools. The medical inspector, aided by the teach- 
ers (who should be instructed how to recognize the pre- 
monitory symptoms of contagious diseases), will take 
advantage of early information of the appearance of sus- 
picious symptoms in any child, by sending the child 
home at once for his further observation, and treatment 
if necessary. If the disease be infectious, any other chil- 
dren in the family, though well, must not be permitted 
to attend school until the cure is complete and all dan- 
ger from infection has passed. 

No child should be allowed to enter the public schools 
who has not been vaccinated. The medical inspector 
should determine the evidence of satisfactory vaccina- 
tion. 

A close observation of the children will enable the in- 
spector to determine whether any injury to health is 
liable to happen, by reason of constitutional disease or 
weakness, from the course of study or discipline, and 
advise such modification as the case may require. Chil- 
dren predisposed to consumption, scrofula, lymphatic 
disease, anemia, etc., should be the objects of the great- 
est solicitude of both teacher and physician while under 
their care. 

Besides the provision of favorable surroundings, fresh 
air, light, proper temperature, etc., special attention 
Should be given to the personal hygiene of the children, 
to their clothing, proper cleanliness, exercise, and the 
regulation of studies, so as not to overtax and fatigue 
the organs of the child. 

The medical inspector should have a ready faculty for 
teaching, as his position will enable him to speak with 
authority and effect, and to utilize the many opportuni- 
ties afforded for instructing the children in the elemen- 
tary principles of hygiene, by means of examples com- 
ing under their own personal observation. He should 
describe to them the dangers from the use of alcoholic 
drinks and tobacco, the ill effects of want of ventilation 
and uncleanliness, the reasons for isolating infectious 
diseases and for the practice of vaccination, the improper 
use of clothing, either too warm or too thin, the effects 
of improper attitudes, the causes of near-sightedness, 
ete. Occasional instruction of this kind will be most 
serviceable in impressing the lessons in hygiene which 
should form a part of the regular course of instruction, 
and in diffusing throughout the community a knowledge 
of sanitary laws. 

Systematic records should be kept, with the use of 
suitable blanks, of the results of medical inspection, 
which should be summarized and presented, with deduc- 
tions and recommendations, monthly or oftener, if nec- 
essary, to the board of health or the body having sanitary 
jurisdiction over the schools, and to the superintendent 
of public instruction. These blanks will provide for a 
complete descriptive list, including medical observations 


269 


Sanitary 
Inspection. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


of each pupil who enters the school, upon which list en- 
tries may be made from time to time, at least once in 
each year, There should also be kept a record of dis- 
eases, accidents, and indisposition occurring at school 
during the month, with particular notice of cases of 
contagious diseases, and statistical information with re- 
gard to the premises, embracing notes on the cleanliness 
of rooms, school furniture, heating and ventilation, ther- 
mometric records, lighting, condition of water-closets, 
urinals, yards, dressing-rooms, etc. Reports should also 
be made of sanitation and hygienic improvements pro- 
posed, and of the matters of personal hygiene which 
have been the subjects of familiar instruction. 

A most complete system of medical inspection of pub- 
lic schools was inaugurated in the city of Brussels, Bel- 
gium, in 1874, and has been in successful operation ever 
since. The thirty-three public schools of that city are 
subject to regular medical inspection, performed by five 
medical officers, who devote their whole time to this 
work. They have the entire sanitary supervision of the 
schools and buildings, and the watchcare over the health 
of the children, and, under special circumstances, the 
treatment of cases of sickness. 

The service includes within its scope a consideration 
of faults in construction, heating, ventilation, lighting, 
size of class-rooms, seats, desks, windows, etc.; the tem- 
perature and daily condition of the air and the causes 
tending to vitiate it; physical exercise, swimming les- 
sons, and instructive excursions ; the care of the eyes, 
ears, teeth, skin, and body ; accurate records of condi- 
tions of health determined by physical examination, and 
the adaptation of studies and discipline to the capacity 
of the child ; careful training of children under the nor- 
mal standard of health, and measures for preventing the 
spread of contagious or infectious diseases, including 
vaccination and revaccination ; and proper sanitary in- 
struction, so that the schools shall be the means of dif- 
fusing among the people a knowledge of the laws of 
health. 

SANITARY INSPECTION OF HOSPITALS AND PUBLIC 
CHARITIES.—The government of hospitals and public 
charities is generally entrusted to boards of directors, va- 
riously constituted, which are responsible for its proper 
administration. Efficient sanitary management is a pri- 
mary consideration, and in securing this object valuable 
aid is derived from the counsel of the medical officers, 
who, by education and special facilities for observation, 
know best the wants, the necessities, and the failings of 
the institutions with which they are connected, and are 
therefore competent to speak with authoritative advice 
on questions pertaining to their sanitation. 

Independent of these provisions for responsible gov- 
ernment, the State or local authority should have the as- 
surance of the faithful and efficient administration of its 
delegated powers which .periodical investigations will 
afford, and, among other things, should take cognizance 
of the sanitary condition of these institutions, either 
through the State or local health boards, according as 
they fall under the jurisdiction of the one or the other. 

Sanitary inspections should be made periodically, and 
the results recorded for future reference and use. The 
primary surveys will necessarily embrace a large num- 
ber of inquiries, many of which, if satisfactorily an- 
swered, need not be made again ; the subsequent inspec- 
tions being confined to conditions liable to variation, and 
which depend on various contingencies. Much of the 
information required, such as details of construction, 
cubic air-space, plans of drainage, ventilation and heat- 
ing, statistical data, ete., will be available from reliable 
records preserved by the institutions, so that the inqui- 
ries will be directed more especially to the adaptation of 
the buildings to their uses, the efficiency of the sanitary 
arrangements, the salubrity of locality, the sanitary con- 
dition and management of the buildings and premises, 
and the management of contagious diseases. 

The special points to be inquired into are: The loca- 
tion, nature of the soil, area of grounds, drainage ar- 
rangements, materials of construction of buildings, num- 
ber of stories, floor plans, number and size of wards, 


270 


floor-room per bed in wards, cubic space per bed, mode 
of heating and ventilation, position of water-closets, uri- 
nals, etc., and their ventilation, provisions against fire, 
fire-escapes, amount and quality of food, water-supply, 
overcrowding, prevalence of hospital zymotic diseases, 
as erysipelas, pyeemia, etc., contagious diseases and their 
management, disinfection, presence of endemic influence, 
hygiene of the buildings and premises, and rules, reg- 
ulations, and statistics on sanitary subjects. 

The results of inspection should be recorded in proper 
form for use in furthering the ultimate objects of the in- 
vestigation. 

SANITARY INSPECTION OF POLICE AND PRISONS.— 
Oversight in all matters of concern to health in these de- 
partments should be exercised by the proper sanitary au- 
thorities. The station-houses of the police department 
will require occasional inspection, in order to insure the 
application of necessary hygienic measures. The build- 
ings should be expressly adapted to their uses, and all 
necessary appointments should be made for the health 
and comfort of the officers, and for the decency, conveni- 
ence, and cleanliness of the prisoners. The air-space 
per head for the average occupancy of the cells should 
conform to a standard. Special attention should be 
given to the ventilation, heating, privy arrangements, 
and cleanliness of the cells, and also to the facilities for 
personal cleanliness. : 

Arrangements should be made for prompt surgical and 
medical attendance, at all hours, upon cases of injury or 
sickness, and for the immediate examination of suspected 
cases of contagious or infectious diseases brought in from 
the street, so that persons suffering from dangerous com- 
municable diseases may be transferred to the proper hos- 
pital, and the cleansing, disinfection, and fumigation of 
the apartments executed with despatch. 

An ambulance system in connection with the police 
department, for conveying the sick and injured to hospi- 
tal should be organized and conducted under medical 
supervision. The regular and systematic instruction of 
the police force in the manner of rendering first aid to 
the sick and wounded is a humane requirement, which 
should be carried out under competent medical direc- 
tion, 

The sanitary inspection of prisons should be carried 
out upon the general plan suggested for hospitals and 
public charities. Special attention should be directed to 
the cubic air-space per head of occupancy of the cells, to 
the ventilation, heating, and privy arrangements of the 
apartments, to the cleanliness of the prisoners, and to 
the means at hand for checking the spread of contagious 
diseases. Every well-ordered prison should have an iso- 
lated building or apartment for the treatment of these 
diseases, to which all cases at their inception should be 
removed, if they cannot be at once transferred to the 
town hospital for contagious or infectious diseases. 

The medical inspection of houses of prostitution, in aid 
of the suppression of one of the worst forms of human 
disease, must be conducted under the provisions of special 
laws upon the subject. 

SANITARY INSPECTION OF FIRE ESTABLISHMENTS,— 
Fire establishments should be included among the insti- 
tutions subjected to sanitary supervision. The hygienic 
condition of the premises, water-closet accommodations, 
facilities for bathing, and the manner of berthing and 
subsisting of the men are the chief points of inquiry. 

Medical attendance should be provided for the sick 
and disabled. Suitable apparatus for the rescue of life 
endangered by fire should be distributed over the town, 
and be under the immediate control of the fire or police 
department. The inquiry should also be extended to the 
provisions made for the erection of fire-escapes, and for 
the inspection of illuminating oils, and the storage of ex- 
plosives. 

SANITARY INSPECTION OF CEMETERIES AND BURIAL. 
—The disposal of the dead without injury to the living 
is a question of the greatest interest to a community. 
Cremation, a process by which bodies can be rapidly, 
completely, and inoffensively disposed of, solves the 
problem to the satisfaction of hygienic laws, but the 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sanitary 
Inspection. 


practice is in its incipiency. The common mode of burial 
by interment requires the strictest sanitary regulation. 
The location of burial-grounds should be determined 
only after the most careful inquiry into the sanitary 
features of the question, and a full consideration of the 
future, as well as the present, needs of the community. 
Intramural interment, being in conflict with the laws of 
health, should be interdicted. 

In locating cemeteries the site, character of the soil, 
facilities for drainage, direction of the ground-water, and 
distance from inhabited places are prominent considera- 
tions. The site should be elevated, so as to afford good 
ventilation and ample drainage; and it should be well 
planted with shrubs and trees, in order that the roots 
may absorb and utilize the products of decomposition. 
The soil should be dry, and the ground-water never per- 
mitted to rise into the graves or vaults. When necessary, 
artificial drainage should be employed to prevent the ac- 
cumulation of water in the soil. The drainage should 
not be allowed to flow into any water-course from which 
drinking-water is obtained; nor should the flow of the 
ground-water be toward inhabited places which depend 
on wells for their water-supply. When there is a choice, 
a loose, marly soil should be selected, as it permits of 
the free movement of air and water, conditions which 
are essential to speedy decomposition. Gravelly soils are 
not so good, but they are preferable to stiff clays, which 
tend to retard the process of decay. 

The decomposition of bodies takes place by putrefaction 
with the evolution of effluvia. The products of decom- 
position are arrested or changed by the earth. Under cer- 
tain conditions the volatile substances generated by putre- 
faction may escape into the air, and hence the air over 
graveyards is liable to contamination. Saponification 
may take place when the earth about bodies is dense, and 
becomes saturated with the products of decomposition. 

The time required. for the decay of bodies varies ac- 
cording to the nature of the soil, the access of air, press- 
ure, etc. Ordinarily, in a loose, marly soil the process 
may be completed in three or four years, but in other 
soils of a less favorable character it may be very slow, 
thirty or more years being required for effecting a com- 
plete disintegration. Before interfering with an old 
graveyard a sufficient time should be allowed to elapse, 
after the discontinuance of all interments, to insure the 
complete destruction of the remains. Deep burial is to 
be preferred, and not more than one body should be 
placed in a single grave. The earth should come in con- 
tact with the coffin, in order to hasten decomposition. 
The use of strong outer cases is objectionable, as it pro- 
longs the process of decay. 

The vicinity of cemeteries is not considered salubrious, 
owing to the danger of contamination of the air and wa- 
ter, and the escape of effluvia from frequent disturbance 
of the soil saturated with the products of putrefaction. 
Most foreign governments prescribe the least distance al- 
lowable between graveyards and dwellings; but in the 
United States there is no general regulation on the sub- 
ject. Under ordinary circumstances the distance should 
be at least five hundred feet. 

It is customary among the poor to keep the bodies of 
their deceased friends for days in the same room in 
which the family live and sleep. Such a practice cannot 
be otherwise than detrimental to health. In order to 
avoid the necessity for such detention, mortuaries should 
be provided in every city and town, where, in these cases, 
all corpses could be removed at a reasonable time after 
death has taken place. Burial should not be delayed 
for more than three or four days, and in hot weather and 
in all cases of infectious disease the interment should 
promptly take place. Another advantage of mortuaries 
is the means they afford of lessening the expenses of the 
funeral, a point of great significance to those in humble 
life. ; 
No interment should be permitted without a permit 
from the board of health, issued over a certificate of 
death from an authorized person ; nor should any grave 
be disturbed, nor any body be removed into or out of any 
place, without official authorization. 


~ rooms, 


Special care is required in the management of the bod- 
ies of those who have died of contagious or infectious 
diseases. In such cases public funerals should be abso- 
lutely prohibited, and the interment should take place 
without needless delay. 

Vigilant inspection is essential to the efficient adminis- 
tration of the laws and regulations pertaining to ceme- 
teries and burial. This duty may be imposed upon the 
sanitary inspector, or an officer specially appointed by 
the board of health, which body should have the power 
to make rules for the proper disposal of the dead. 

SANITARY INSPECTION IN CASES OF CONTAGIOUS OR 
INFECTIOUS DIsEASES.—The prompt notification of cases 
of dangerous communicable disease is a duty generally 
imposed by law upon the medical attendant, and its neg- 
lect is made punishable by fine. The object of notifica- 
tion is to secure the advantages of prompt investigation 
of the origin and causes of diseases liable to become epi- 
demic, the discovery of the means by which they are 
spread, and the application of measures of prevention. 

In all cases in which the disease can be spread, either 
directly or indirectly, from one person to another, the iso- 
lation of the patient and the disinfection or destruction 
of the infectious material are of primary importance. 
Isolation may be accomplished by removing the sick at 
the earliest possible moment from the house, or, in some 
cases, by the removal of the well, if accomplished -at the 
outbreak of the disease. In order to carry out the former 
object it is necessary to have hospitals exclusively for 
the treatment of these cases, and special conveyances for 
the transportation of the patients. In crowded houses 
the removal of the sick is the only possible way of check- 
ing the spread of the disease, and therefore every town 
should have the means of isolation. 

The arrest of the spread of the disease is further to be 
attempted by thorough ventilation and cleanliness of the 
sick-room, the prompt disinfection of excreta, the disin- 
fection of bedding, clothing, and all articles in the sick- 
room before their removal, and, after the recovery or 
death of the patient, the disinfection of the clothing, 
house, cesspool, etc. Disinfecting chambers 
should be provided by the town authorities for the im- 
mediate purification, by heat or other means, of all soiled 
clothing, bedding, and other infected articles that cannot 
be properly treated at home. 

Small-pox is prevented by vaccination. Some diseases, 
such as typhoid fever and scarlet fever, may be propa- 
gated by the agency of contaminated water, or milk, or 
other food. Epidemics have originated in this way. 
The origin of the disease is therefore to be inquired into, 
in order that measures may be intelligently employed for 
checking its spread. 

During the prevalence of an epidemic unusual meas- 
ures may be required for the public safety, such as 
house-to-house inspection for detecting concealed cases 
of disease and insuring their proper management, the pla- 
carding of houses of the sick for preventing intercourse 
with them, the speedy interment of the dead, the purifi- 
cation of houses and premises by the public disinfector, 
the erection of temporary hospitals, and the publication 
of information for the use of the people in dealing with 
the emergency. The prompt recognition of the first 
cases of disease is of the greatest importance, as upon it 
will often depend the possibility of preventing its spread. 

MARITIME AND INLAND QUARANTINE INSPECTION.— 
For the object of preventing the introduction of conta- 
gious or pestilential diseases from one country to another, 
quarantine stations have been established at the ports of 
all civilized nations, where vessels infected or suspected 
of infection are subjected to sanitary inspection, in order 
to determine whether such vessels shall be admitted to 
free pratique or be detained for observation, disinfec- 
tion, and the application of necessary prophylactic meas- 
ures. For the same purpose the restriction of inter- 
course by land with places infected with dangerous 
communicable diseases is sometimes a necessity. Abso- 
lute isolation, or suspension of all communication with 
the infected place, is impracticable and unnecessary, since 
the risk of introducing disease from infected places can 


271 


Sanitary Inspee’n. 
Sanitary Inspectors. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


be greatly diminished, if not prevented, without stopping 
or retarding to any considerable extent commercial inter- 
course, by establishing a system of sanitary inspection of 
passenger trains, boats, and vehicles conveying persons 
or goods from such places. In foreign countries the in- 
spection service is conducted by the national govern- 
ment. In this country, in the absence of a national 
health bureau, it would be best to have such a service 
organized under the State boards of health, and practised 
on the frontier, on the lines of travel from the seaboard 
to the West, and in the vicinity of the infected locality. 
By concerted action between the State authorities, and 
with the co-operation of the National Government, the 
means necessary for restricting or suppressing epidemic 
disease can be most effectually carried out. Such action 
would be a guarantee of protection to the public health, 
which would prevent panic and demoralization, and dis- 
astrous obstructions of commerce and the stoppage of 
trade and travel. 

The efforts made to protect the Mississippi Valley 
against yellow fever, and the West and Northwest against 
small-pox, by a system of sanitary inspection maintained 
by the National Government, and carried out along the 
lines of travel without embarrassing commerce or travel, 
have been attended with the best results, and prove the 
value of this service. The stream of immigration which 
pours into the great Northwest direct from the seaports 
of the country has made advisable, during the preva- 
lence of dangerous infectious diseases at the ports of 
embarkation, the establishment of inspection stations at 
the railway centres along the lines of travel, for the ex- 
amination of immigrants who may have developed the 
infection after leaving the seaboard, and for the inspec- 
tion of baggage and the vaccination of the unprotected. 

The inspectors employed for this duty should derive 
their authority from the National or State Governments, 
and, in order to facilitate their labors, they should seek 
the co-operation of local boards of health and of the rail- 
way and transportation officers. Provision should be 
made for the isolation, care, and treatment of the sick, 
and for the detention and isolation of suspected cases ; 
for the ready use of disinfectants, the cleansing and dis- 
infection of cars and boats, and for the disinfection of 
the clothing and baggage of the passengers. If the dis- 
ease is small-pox, all unprotected persons who have been 
exposed to the contagion should be vaccinated ; if they 
refuse to be vaccinated, they should be turned back, un- 
less exempted for good or sufficient reason. ‘The exam- 
ination should include all parts of each vessel and train, 
and each passenger and all baggage, etc. 

It is important to know the place from which the pas- 
sengers have come, and the destination of any persons 
suspected of conveying or harboring a dangerous com- 
municable disease. All bedding, wearing apparel, or 
other articles liable to contain infection, arriving from 
suspected places, should be unpacked and disinfected 
before being allowed to proceed. When practicable, 
special provision should be made for the disinfection of 
clothing in cars while on the route. 

The sanitary condition of the cars should be inquired 
into, and the quality of the drinking-water and the ice 
used in it closely scrutinized. If from any cause it is 
unsatisfactory, the fact should be noted, and steps taken 
for its immediate improvement. The inspecting officers 
should make frequent reports to the authorities under 
which they act, and should communicate to local and 
State health-boards any facts coming within their knowl- 
edge which may be of advantage in preserving the pub- 
lic health. Publicity should be given to the objects and 
requirements of the service, in order to enlist co-opera- 
tion and prevent needless attempts to evade the law. 

The sanitary inspector, in whatever line of duty em- 
ployed, should form the habit of taking accurate notes 
of the particulars of his examinations, and of the action 
taken in each case. These notes will form the basis of 
more permanent records, and of reports which he will be 
required to make, from time to time, to the sanitary au- 
thorities. The notes should be terse but clear, and they 
should embody a condensed statement of pertinent ob- 


272 


servations and recommendations. In order to systema- 
tize and render less onerous the work of record-keeping, 
printed forms containing the subjects of inquiry should 
be made use of. These forms, with the observations 
legibly written in ink, if bound, paged, and indexed— 
a plan advised in making a sanitary survey of a town— 
will make a valuable record for future reference. 
William H. Ford. 


SANITARY INSPECTORS, DUTIES OF. Sanitary in- 
spections or examinations have, until within the last few 
years, been made by members of the medical profession in 
their capacity either of family physician, or of local health- 
officer, and in every case have had for their object the 
study of all possible conditions affecting the health of 
the individual, the household, or the community which 
the physician was called upon to investigate. 

The opinion, however, is rapidly gaining ground that 
there are engineering problems involved.in preventive 
medicine worthy the attention of the best talent; and 
with the growth of this opinion a new department in 
the engineering science, called ‘‘ sanitary engineering,” 
has sprung into existence. As a result the requirements 
of the position of inspector have greatly increased, and 
now involve special study and training. 

The inspector, to be properly qualified, must have a 
thorough knowledge of medicine, so far as it relates to 
the exciting causes of the zymotic or preventable dis- 
eases ; of engineering, so far as it relates to water-supply, 
sewerage, and the drainage of land; of chemistry, to en- 
able him to determine correctly the characteristics of 
drinking-water ; of plumbing, and of the principles of 
ventilation. If, in addition to these qualifications, is 
added a mind not hasty in forming opinions, the result of 
the examination will usually be a solution of the problem. 

The inspector should provide himself with a note-book 
in which he should record all facts learned by questions 
and by observation, together with sketches of the location 
and arrangement of the buildings, their water-supply, 
plumbing, drainage, etc. He should never trust his 
memory, but enter every little item, no matter how seem- 
ingly unimportant. Besides this, the inspector can much 
more readily grasp the case and be able to make an in- 
telligent report, by paying attention to small matters. 
When making an inspection, time should not be taken 
into consideration. Whatis required is an absolute mas- 

tery of the facts. Besides 
the note-book it is well to 
carry a hammer, cold- 

chisel, screw-driver, a 

small monkey-wrench, 
an ounce-bottle of oil 
of peppermint, about 
two feet of #-inch 
rubber tubing, a 

small funnel, and 
a wet and dry 


pong 


fe 


Fra. 3868.—Portable Electric Lamp and Battery, for by ti 
use in sanitary inspections. 2 


bulb hygrometer such as is used by the Coast Survey. 
These can be fitted compactly into a small box, so as to 
be readily portable. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, S@uitary Enspeen. 


Sanitary Inspectors, 


The preceding sketch (Fig. 3368) represents a one- 
candle power electric lamp and battery, arranged to be 
strapped around thewaist. It is exceedingly convenient, 
and is free from the objections of candles or wax-tapers. 
It can also be lowered into a cesspool, drain, or other place 
difficult of access, and is not affected by draughts of air, 
the great enemy of naked lights. The only hinderance 
to the general adoption of this lamp is its cost. 

There are three lines of investigation in every inspec- 
tion: 1, The occupants of the house or the inhabitants of 
the town ; 2, the surroundings ; 3, the house proper. 

I]. Tok PERSONAL.—This is, perhaps, the most trouble- 
some part of the inspection, owing to reticence on the 
part of the people when questioned as to their mode of 
living. This may be dispensed with if there is no dis- 
ease in the house or locality at the time of the inspection. 
Usually, however, under our existing boards of health, 
the only time when thorough inspections in small com- 
munities and villages are made, is during or after an out- 
break of one of the preventable diseases. In such cases 
the first point to be learned is the date of the first appear- 
ance of the disease in the community ; then each case 
should be marked on a map of the village or town, with 
the age of the person and the date of the appearance of 
the first symptoms. If possible, the family physicians 
should be consulted, and the history of the cases, together 
with any hereditary or constitutional complications of the 
patients, be obtained. In the case of the first person taken 
ill, if the beginning of the period of incubation of the 
disease corresponds in time with the residence of the pa- 
tient at some other place than that at which the disease 
made its appearance, it is safe to assume that the specific 
germ was taken into the system at that place. When the 
cause of the disease in sporadic cases has been traced in 
this way to some remote place, a complete inspection of 
the premises is, of course, unnecessary, but it would be 
well to examine them for any sanitary defects that might 
lower the vitality and check the convalescence of the pa- 
tient, or might convert the locality into a centre of con- 
tagium. When disease is found among school-children, 
or among persons who are confined to their places of 
business, the store, counting-house, or school should be 
thoroughly examined. 

II. THE Surrounpines.—This line of inquiry com- 
prises the geology of the district, the water-supply, dis- 
posal of excreta, etc. In cities where the natural water- 
courses have been subverted by the grading of streets and 
filing in of ground, the character of the soil has very 
little effect on the salubrity of the dwellings ; but in the 
country it is quite the reverse, and the presence of sand 
or gravel, clay or rock, very often determines whether a 
locality shall be healthy or the reverse. Sand or gravel 
is the best foundation on which to build, but even this is 
unhealthy if it exists in the form of a bed superimposed 
on a depression of clay, or as a thin covering of the rock 
beneath. 

Dampness of soil is now recognized as the prime factor 
in the production of pulmonary troubles, as well as a 
necessary attendant of malaria. The remedy is the un- 
der-drainage of the land with porous tiles, and the in- 
spector should recommend such work to be done in every 
case. ‘‘Situations at the base of hills are particularly 
unhealthy, as the ground-water, coming from the higher 
lands, is checked in its flow by the sudden change in the 
grade and forced to the surface,” making the upper layer 
of the soil extremely moist. The health of a community 
is very often affected by the presence of streams, ponds, 
and marshes. Streams are dammed up and overflow 
large tracts of land, which are at times laid bare by the 
subsidence of the water ; while the surfaces of ponds and 
marshes are constantly fluctuating, alternately covering 
and laying bare large areas of mud. Malarial diseases 
are the certain result of this condition of things ; but 
they as certainly decrease as drainage is instituted and 
the water-level made unvarying. 

The loss of sunlight, the want of free circulation of 
air, and the odor of decaying vegetation given off in the 
autumn by the dead leaves that accumulate about a house 
that is densely shaded by trees, all conduce to make it 


Vou. VI.—18 


damp and unhealthy. A thorough pruning of the trees 
nearest the house should in these cases be recommended. 

The dangers to health from without the house that are 
most frequently met with in cities are: 

1. Badly Built and Filthy Streets. Whatever material 
admits of depressions or cracks, in which surface wash- 
ings can accumulate and from which they can leach out 
into the earth below, should be rejected .as unfit for the 
purpose. Surface water from the yards in the rear, and 
from imperfect roadways and gutters in front, saturates 
the ground about the houses, and presents conditions fa- 
vorable to the development of pulmonary diseases. The 
writer has learned, through a long series of observations, 
that ninety per cent. of the cellars in the city of New 
York are damp, if not actually wet, a condition largely 
due to this percolation from the surrounding ground, 

2. Defective privy-vaults, fouling the air and saturating 
the ground. 

3. Offensive Trades. 
proper heads. 

Water for domestic use is obtained either from the reg- 
ular town-supply or from wells and springs. In the first 
case, it is natural to infer that sufficient care has been 
taken in the choice of a source and in the protection of 
the gathering grounds to prevent the contamination of the 
water. It often happens, however, that towns along the 
banks of streams are obliged to take water that has been 
fouled by the discharge of sewage or manufacturing 
waste from some town above them on the same stream. 
Although the water of streams thus polluted becomes 
again fit for drinking by the oxidation of its impurities, 
it is still a mooted question at just what distance below 
the point of contamination so desirable a result is 
reached. 

Too much attention cannot be bestowed on the wells 
of a district, and great care should be taken in examining 
their location and surroundings, and the influence of the 
geological formation on the purity of the water. 

In making the examination of the water there are three 
points that should receive special attention : 

‘*ist. To what extent it is contaminated. 

‘¢9d. The causes that have led to this result, or that 
may produce it in the future. 

“*3d. The tracing of connection between the use of 
contaminated water and cases of disease that usually 
have their origin in such use, viz., typhoid fever, diph- 
theria, etc.” 

It sometimes happens that the food has more to do 
with an outbreak of fever than have plumbing and drain- 
age. For instance : ‘‘ Milk has so often been the carrier of 
contagium that everything which in any way could affect 
it should be carefully examined; the dairy from which 
it comes, the cows, the milk-cans, and the water they are 
washed in, should all receive attention. Then, again, the 
ice may be the cause of the trouble. Impure water in 
freezing does not make pure ice, and hence the pond or 
other sources from which it is taken should be examined 
for any possible cause of contamination.” 

‘““The only protection for a well that is deemed neces- 
sary by the majority of farmers and the like, is to raise 
the top by banking the earth above the level of the sur- 
rounding ground.” This does not in any way affect the 
quality of the water, as the well draws its supply from 
under ground, in the manner illustrated in the article on 
Soil. 

‘‘ Oftentimes wells are found without curb of any kind, 
and receiving the surface drainage from barns, pigsties, 
and out-buildings. Wells are sometimes dug under a 
house, or, having been formerly outside the kitchen door, 
have been brought under the roof of an ‘extension,’ per- 
haps with the pump in the kitchen. This arrangement 
is sure to lead to contamiration of the water, as decay is 
going on in every conceivable form at their very mouths, 
and, being closely shut in, there is no chance for ventila- 
tion. When the well is near the back door, the slops 
that are certain to be thrown out on the ground will find 
their way into it.” 

These are some of the dangers of contamination of 
well-water from surface washings ; but those that threat- 


These will be treated under the 


273 


Sanitary Inspectors: REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sanitary Inspectors. 


en the purity of the water from beneath the ground are 
even greater. 

If a well is in a depression or below the level of barns, 
houses, privies, and the like, even if they be a hundred 
feet or more distant, its water should be looked on with 
distrust and a sample should be taken for analysis. 

It sometimes happens, as illustrated in the article on 
Soil, that although the top of a well is at a greater ele- 
vation than a neighboring source of contamination, its 
bottom is far below, and is constantly receiving infiltra- 
tions of decomposing matter. These statements go to 
show that, in making a sanitary examination of a local- 
ity, no dependence should be placed on wells unless 
they have been proved, by absence of improper sur- 
roundings, by the geological formation of the ground in 
which they are dug, and lastly by a chemical analysis, to 
contain water fit for domestic purposes. 

Privy-vaults are so common that they need no descrip- 
tion. They are nasty, unnecessary, and extremely dan- 
gerous to health. The inspector should set his face 
against them and condemn them without mercy. 

The proper substitute for the privy-vault, in any given 
instance, depends on a variety of conditions. If the town 
is provided with sewers, the premises should be con- 
nected with them. Country houses without running 
water might with advantage adopt the dry-earth system. 
If, however, the building is a large one, with hot and 
cold water supplied throughout—such as country resi- 
dences, hotels, public institutions, and the like—the 
proper method of sewage-disposal is a matter requiring 
careful consideration, and the services of an engineer fa- 
miliar with the construction of sewage-works should be 
obtained. If the town or village under examination is 
provided with a public water-supply, but no sewers, 
every argument should be brought to bear to induce the 
prompt introduction of a comprehensive sewerage sys- 
tem. 

‘“‘ Next to the privy-vault, the pig-sty, as it is usually 
met with in the country, is one of the most offensive and 
dangerous nuisances that will be found. These pens are 
sometimes quite near the house for convenience sake ; the 
excrementitious and liquid filth is always allowed to soak 
into the ground. ‘The floor is dug out every year and 
used as a fertilizer, leaving a pit from one to six feet 
deep. Some of these pits have water standing in them 
during hot weather, and have fetid mud in them all the 
time.” In hot weather they become very offensive, and, 
when in populous districts, should be moved without 
delay. 

Ill. Tue Hovusre.—Less attention is given to the dis- 
posal of household dirt than to any of the other questions 
bearing on the health of the occupants, and yet it should 
be recognized by the inspector as an important factor. 
Charles Slagg says: ‘‘ One must consider that there are 
two kinds of dirt—the one mineral and inoffensive, the 
other refuse organic matter. We do not feel defiled 
by contact with the one, but contact with the other is 
abhorrent, and there ought to be in every household a 
sufficient quantity of water to wash it off frequently. 
Those who suffer the dirt which is caused by the per- 
spiration of the body to linger underneath the clothes, 
out of sight, are essentially dirty. We cannot all be rich, 
but we can all be clean.” The dust that accumulates on 
the walls, floors, and furniture of a house is composed of 
organic and inorganic matter, and would, if sprinkled on 
the wounds of patients in the surgical wards of hospitals, 
produce conditions extremely dangerous to life. The 
cellar should be as clean as the parlor; and yet fully 
ninety per cent. are so dirty and littered with rubbish 
that one cannot go into them without soiling his clothes. 
The front door-step may be taken as a criterion of the 
character of the inmates of the house. As it is clean or 
dirty, so will be its owners. ‘‘The average American 
house has its ‘company room,’ in which the chance 
visitor is ushered. Here everything is in order, from the 
gilt frame about the French picture to the velvet carpet 
on the floor. Go to the kitchen, and you will find the 
week’s wash on the floor, the garbage-pail standing on 
the hearthstone, the remains of several meals on the 


274 


table, and cockroaches crawling over everything.” Go to 
the bedrooms and examine those receptacles of rubbish, 
the closets under the basins ; notice the rolls of hair, the 
burnt matches, and dirty brushes lying on the bureau ; 
open the closet-doors and speculate on the time that has 
elapsed since those clothes have been aired. All these 
things are sure indications of the habits of life of the oc- 
cupants, and the experienced inspector notes them as 
carefully as he would the syphoning of a trap. 

The questions to be investigated inside the house are : 

A. The character of the air. 

B. The mode of heating. 

C. Means of ventilation. 

D. Plumbing and drainage. 

A. The Character of the Air.—The material of the out- 
side walls (whether wood or stone) should be noted ; and 
the rain-leaders and roofs should also be examined, for, 
if leaky, they are fruitful sources of moisture. The 
cellar also plays.a very important part in the salubrity of 
a house. Being below the level of the ground it acts 
like a cesspool, receiving and holding surface-water that 
finds its way into it from the surrounding ground; and 
hence it is that cellars are usually damp, except in cer- 
tain cases where great care has been taken, by concreting 
or asphalting the floors and walls, and by a system of 
underdrains, to keep the water out. Every house for 
at least eight months of the year resembles a chimney. 
The air inside, being warmer than that outside, is con- 
stantly rising and producing a vacuum that must be filled 
from somewhere. Windows and doors, and even brick 
or wooden walls, leak air; but this vacuum is partly 
filled by air drawn from the ground around the house. 
Ground-air has always more or less decaying matter in 
it, and has been known to carry contagium. Care should 
therefore be taken to prevent the cellar from drawing its 
supply of air from the surrounding ground, by the open- 
ing of windows and doors and the sustaining of good 
ventilation. 

The cellars in country houses, as usually found, are 
very objectionable. ‘‘ They very seldom extend under the 
entire house, and are, as arule, reached by a steep flight 
of steps from the outside. In many instances the door 
is the only opening for light and air, the result of which 
arrangement is that the walls become damp, the beams 
rot, and the atmosphere is heavy with moisture. In 
these cellars will be found vegetables, apples, and sundry 
other household goods stored for winter use.”” The decay 
of these things makes the air foul, and more or less af- 
fects the atmosphere of the house, as explained above. 

Another source of nuisance in the country is the air- 
space that is often left under a house. Refuse of all 
kinds—dead animals, etc.—collect here, and being diffi- 
cult to reach, will never be removed. ‘‘ When the cold 
weather comes on, these houses are banked with earth, 
saw-dust, leaves, manure—whichever is most available. 
The surface of the surrounding ground is frozen, and 
thus hermetically sealed. It follows that any sweating of 
the earth, or movements of air or gases in the soil, must 
work up under the unfrozen part beneath the house. 
As the temperature is always above freezing-point, 
some decomposition goes on all the time; these gases 
mingle with the others, and all winter they rush through 
the cracks in the floor into the living-rooms above. Fort- 
unately, most of this class of houses have been rocked 
by the wind, shrunk or warped by sun and rain, until 
the entrance of pure air from without balances in most 
cases the vitiated air within.” The effect of cellar-air on 
the atmosphere of a building should be further deter- 
mined by the use of a wet and dry hygrometer. The 
instrument should be set in turn out of doors and on 
each floor, including the cellar. The readings should be 
taken not less than fifteen minutes after setting, as this is 
the minimum time in which the columns of mercury will 
come to rest. 

B. The Mode of Heating the Building.—With the me- 
chanical details of steam and hot-water heating the in-: 
spector will have nothing to do further than to note the 
ability of the apparatus to keep the building at a uniform 
temperature of 70° F. The air-supply to these apparatus, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, S2nitary Inspectors. 


Sanitary Inspectors. 


if heating by indirect radiation, as well as that to the or- 
dinary hot-air furnace, is of the greatest importance, and 
the position of the inlet and the condition of the flues 
should be carefully examined. ‘‘ Cracks or openings in 
the ducts, or the position of the air-inlet near the drain- 
opening or other source of contamination, will allow foul 
air to pass into the heating chamber and be distributed 
through the house.” The air-tight stoves so often met 
with in country houses are an abomination. The air in 
the room is heated and reheated, and breathed over and 
over again until the vitality of the system is so lowered 
that a person who has been subjected to the bad air for 
some time experiences a severe chill when passing into 
purer, fresher air. 

Dr. D. F. Lincoln, in the New York State Health 
Board Report for 1882, makes some extremely good sug- 
gestions for the turning of these stoves into ventilating 
apparatus, and the inspector would do well to familiarize 
himself with them. Dampers in the smoke-flues of both 


nth | i | 


iy | 
Hi Ih 
| / i 


i ‘Ml 


Fie. 38869. 


hot-air furnaces and stoves are a source of great annoy- 
ance. When the fire is too hot, these dampers are closed 
and the carbonic acid gas arising from the combustion 
of the coal forces its way into the rooms, sometimes to 
suffocation. There ought to be no dampers of this kind, 
as it is quite possible to regulate the fire by the doors, if 
the furnace is properly constructed. When the owner 
will not dispense with them, there should be a small 
leak-hole cut in the disk to allow the noxious gases to 
pass up the chimney. 

C. Means of Ventilation.—Doors and windows are the 
sole reliance in this direction in most buildings. The air 
of houses would be very much improved if a good-sized 
opening, properly protected by louvers, was made in the 
roof. This would allow the constantly ascending warm 
and vitiated air of the building to pass out at the roof 
and be replaced by pure, fresh air. The skylights over 
stairways and light shafts in city houses will usually be 


found closed tight. The inspector should recommend 
them to be raised a couple of inches for the above-men- 
tioned reasons. No part of the house needs ventilating 
more than the water-closets, and yet in many cases they 
will be found in the middle of the house, far from any 
window. The foul odor must of necessity pass out into 
the rooms and taint the air. Persons who are accus- 
tomed to living in city houses do not notice this odor, 
but it is very perceptible to those whose lungs are usually 
filled with the pure air of the country. The inspector 
should look well to this matter of ventilation. When 
water-closets are very much shut in, he should recom- 
mend the carrying of a ventilating-tube from the closet 
to some point outside the house ; and the heating of the 
air contained in it by a gas jet, or a similar method, which 
will create an outward current of air at all times. This 
will prevent the foul air from passing out into the house 
by creating a strong counter-current. 

In the examination of school-houses, dormitories, and 
the like, it will be necessary to test the character of the 
air with respect to the 
presence of carbonic 
acid, in order to ascer- 
tain the efficiency of ven- 
tilation. A convenient 
method, and one given 
by Dr. John T., Billings, 
is to take ‘six well- 
stoppered bottles con- 
taining, respectively, 
450, 350, 300, 250, 200, 
100 c.c., a glass tube 
or pipette, graduated to 
contain exactly 15 c.c. 
to a given mark, and a 
bottle of perfectly clear 
and transparent lime- 
water.” The bottles are 
filled with the atmos- 
phere to be examined 
‘by. means of one of 
the smaller hand-ball 
syringes, taking care 
that none of your own 
breath is pumped in; 
add to the smallest bot- 
tle, by means of the pi- 
pette, 15 ctm. of the lime- 
water, put in the cork, 
and shake the _ bottle. 
If turbidity appears the 
amount of the carbonic 
acid will be at least 16 
parts in 10,000.” Tur- 
bidity’ in the. 200, ee: 
bottle would indicate 12 
parts ; in the 250 c.c. bottle, 10 parts ; in the 300 c.c. bot- 
tle, 8 parts; in the 850 c.c. bottle, 7 parts; and in the 
450 c.c. bottle less than 6 parts. 

Another simple method, and one devised by the writer, 
depends on the characteristic action of phenolphthalein, 
one of the aniline colors, which in an alkaline solution 
is a brilliant crimson, but in an acid solution is a dull 
yellow. The method is thus described in the Sanitary 
Hingineer : 

Fig. 3369 shows the apparatus enclosed in a box. It con- 
sists of two graduated glass flasks, Fig. 3370, set in a re- 
volving frame, and connected by a glass tube furnished 
with a stop-cock. The tubes connect with the three-way 
cock, which allows air to enter one or the other of the 
flasks at pleasure. The U-shaped glass, Fig. 33871, has 
eight bulbs blown on one of the legs to insure the per- 
fect absorption of the carbonic acid by the baryta-water. 

To use the apparatus, fill the upper flask to the zero 
mark with water (this may readily be done by attaching 
the end of the flexible tube to a faucet); pour into the 
absorption-tube, through the funnel, from 12 to 15 ctm. 
of baryta-water containing 3.425 milligrammes of baryta 
(BaO), which will absorb one-half a cubic centimetre of 


275 


Fig. 38870. 


Sanitary Inspectors. poppRENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sanitary Inspectors. 


carbonic acid gas ; turn a three-way cock so as to connect 
the upper flask with the absorption-tube ; turn the stop- 
cock so that the water will pass from the upper into the 
lower flask ; aspirate slowly till the color disappears ; shut 
the stop-cock, and read on the graduated flask the num- 
ber of cubic centimetres of water run out, and hence the 


| 
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we a q 


Tavwiit i HO it 


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it 


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) 


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HAN 
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Fia. 3871. 


amount of air passed through the baryta-water. If 1,000 
c.c. of water have been used, the proportion of car bonic 
acid is 5 parts in 10,000. As air changes its volume under 
varying pressures and temperatures, “corrections must be 
made for these in order to obtain absolutely correct results. 
Should it be necessary to pass more air through the bar- 
yta solution than is contained in one flask, turn the stop- 
cock, close the air-hole in the flask containing the water, 
revolve the aspirator, open the air-hole in the empty flask, 
reverse the three-way cock, and proceed as before. 

D. Plumbing and Drainage.—The defects in this 
work that may be encountered are almost without num- 
ber. A list of such defects that have been encountered 
by a firm of English engineers, has been slightly altered 
to meet American practice, and is given here as being a 
concise statement of the experience of the writer: ce 1. 
Common brick sewers with flat bottoms, under or near 
houses. 2. Earthen pipe-drains, either broken or with 
leaky joints, laid under the cellar floor, saturating the 
earth with sewage. 3. Pipe-drains, cither earthen or 
iron, laid under houses without sufficient fall, or with 
the fall the wrong way. 4. Drains, both earthen and 
iron, without running traps, admitting air from sewer 
and cesspool to the pipes in the house. 5. Drains with- 
out a free current of air moving constantly through 
them. 6. Rat-burrows from built drains or sewers un- 
dermining flags and floors, and admitting foul air to the 
house. % Rat-burrows worked along perfect pipe- 
drains from street sewers and into houses. 8. Defective 
connections between soil and waste pipes, and sewers 
admitting foul air to houses. 9. Soil or waste-pipes with- 
out. any or sufficient ventilation. 10. Defective water- 
closet apparatus. 11. Water-closet cisterns with over- 
flows joined to waste-pipe or drain. 12. Safes under 
closets or basins, connected to soil-pipe or drain. 18. 
Two or more fixtures with unventilated traps on the 
same line of pipe, siphoning each other when used. 14. 
Sink overflow-pipes joined to soil-pipes, untrapped or 
with trap liable to siphon. 15, Overflows from basins 


276 


or baths connected with waste-pipe on sewer side of 
trap. 16. Water-supplies to sinks taken from water- 
closets or other contaminated cisterns, and used by care- 
less servants for drinking purposes. 17. House cisterns 
and tanks with overflows direct into soil-pipes or drains. 
18. Traps of every description without ample ventilation 
to prevent them from siphoning. 19. Scullery sinks 
connected directly with drains, admitting foul air to 
houses, not only through traps, but through joints of 
brickwork all around, as shown by the smoke test. 20. 
Bell-trap with loose covers on scullery sink connected 
with drains. 21. Gullies or traps in sculleries, laundries, 
larders, refrigerators, etc., leading to drains usually dry 
and untrapped. 22. Rain-leaders used as ventilators to 
drains, delivering foul air to bedroom windows, or under 
eaves or roofs. 23. Ashpits near larders and pantries ; 
ashpits liable to soak moisture through house-walls. 24. 
Defects of drainage and rat-burrows from neighbors’ 
houses. 25. Water-cisterns in areas near ashpits or 
sculleries, and with overflows directly to drain. 26. 
Wash-basins in dressing- oo connected directly in any 
way to drains or soil-pipes. Cisterns of all kinds in 
houses with overflow Ber it to drains. 28. Cesspool 
near houses, and cesspools or defective drains near walls. 
29. Neighbors’ drains crossing under houses, or joining 
drains.” 

The plumbing system of a building may be likened to 
a tree, the house-drain being the trunk, and the waste- 
pipes with the fixtures at their extremities representing 
the branches. The inspector will find it best to begin 
his examination in the cellar and work gradually to the 
roof, making sketches of each floor, and the arrange- 
ment and connections of all the pipes in the house. Un- 
fortunately, it is too often the case that the pipes are hid- 
den in walls and partitions, and cannot be got at without 
great inconvenience to the occupants ; and yet it is neces- 
sary, for a thorough and intelligent examination, that the 
entire length of piping should be exposed to view. To 
overcome this difficulty, and also to detect the pin-holes 
or air-holes which often occur in pipes, and which it is 
impossible to see with the naked eye, two tests, the pep- 
permint and the smoke, may be employed. 

To make the peppermint test, two persons are re- 
quired, one to handle the oil and the other to search for 
traces of it through the house. <A pailful of boiling 
water is poured in the top of the soil-pipe, if it extends 
above the roof ; or if not, into the highest fixture in the 
building. About one ounce of oil of peppermint (or 
any other pungent volatile substance) is next mixed thor- 
oughly with about a gallon of boiling water and sent 
down the pipe, followed immediately by another pailful 
of boiling water. By heating the pipe at first, and then 
breaking up the oil into minute globules, the oil is, to a 
certain extent, volatilized and carried into every part of 
the system. When the end of the pipe on the roof is 
protected by a return bend, the rubber tube and funnel 
previously mentioned can be used to advantage for si- 
phoning the water and oil into the pipe. When it is 
necessary to pour the oil down from the highest fixture, 
the person using it should shut himself in the closet, 
and remain there until the inspector has made his search 
for traces of the odor. Too much care cannot be taken 
in making this test, and at least ten minutes should be 
allowed between the time of pouring in the oil and be- 
ginning the search, in order to give time for the _penetra- 
tion of the odor to every part of the system of piping. 

Quite a novel apparatus has been recently invented by 
John T, Phelan, of Cambridge, Mass., for making the 
peppermint test. It is an admirable contrivance for in- 
troducing the oil into the plumbing of a building whose 
pipes are not Oe above the roof. ‘The device 
represented in Fig. 3372 consists of two pipes, A and B, 
connected together by a joint, C, in which joint are 
two openings, @ and ), which extend downward and are 
separated by a partition, ce. The joint C, is provided 
with an extension, d, on which is a flange, f. At the ex- 
tremity of the pipe ‘Aisa cock, D, and at the extremity 
of the pipe B is a cock, £, and attached at right angles 
to the pipe B is a pipe, B which is provided with a cock, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, S22it@ry Inspectors. 


Sanitary Inspectors, 


G. To the end of the pipe /’is attached in any suitable 
manner an elastic bag of rubber, H. Under the joint C, 
and at right angles to the same, is a U-shaped bar, J, 
which is attached by its extremities to the pipes on each 
side of the joint C, and in the lower part of this bar is an 
adjustable support, A, for a flask, Z, which contains the 
oilof peppermint or other equivalent substance the vapor 
of which is to be forced into the soil-pipe. The support 
is adjusted by a set-screw, g. The extension d of the 
joint 5 extends into the flask, and between the mouth 
of the flask and the flange f is placed a rubber washer, 
h, by means of which a tight joint is effected when the 
mouth of the flask is forced against the flange jf by the 
set-screw g. In the extension d of the joint are two per- 
forations, each of which is in connection, respectively, 


WISTLLILL LAD 


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Jey eee 
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FS 


Ks 


LULLLAPLEDAAS LA 


Ga 


\ pd eee 
3 — ka 
YZ, 


ort ON 


Fia. 3372, 


with one of the openings in the joint. A tube, 7, extend- 
ing into the liquid in the flask, may be connected with 
the perforation which is connected with the pipe B. 

““The mode of operation of the apparatus is as follows : 
The soil-pipe is first closed at the top and bottom and at 
all other openings, and the pipe A is then attached toa 
suitable opening made in the soil-pipe, or is otherwise 
connected with the same. The cock D is then closed, 
and the cocks # and G are opened. .Air is then blown 
into the elastic bag H, through the pipes B and F, until 
it is expanded to any desired extent. The cock # is then 
closed and the cock D opened, when, by the contraction 
of the elastic bag H, a current of air is forced from the 
same, and, passing through the opening a, pipe /, open- 
ing b, and pipe A, carries the vapor of the volatile sub- 
stance contained in the flask Z into the soil-pipe C.” 

The accompanying cut (Fig. 3373) shows the apparatus 
used for making the smoke-test. It consists essentially of 
a fan, a, and a furnace, 0, in which any substance that will 
make a good smoke (straw-paper, tobacco-stems, etc.) is 
placed. All openings in the pipes, with the exception of 


those on the roof, are closed, an opening is made at as 
low a point as possible on the house-drain, and the tube 
c is inserted in it and carefully luted. The blast is now 
turned on, and the furnace 
kept well filled with com- 
bustibles till the smoke 
begins to pour out of the 
pipes on the roof. These 
openings are then carefully 
closed, and the blast is kept 
up until the inspector has 
made his tour. This is a 


very good test, as thesmoke E th 


is easily seen and its origin 
quickly traced. The ma-c 
chine, however, is rather 
cumbersome for general 
use, and it is to be hoped that a modification will be de- 
vised before long. 

Another form of smoke-test consists in the use of a 
““smoke rocket” (Fig. 3874), which resembles a Roman 
candle; being the same 
length and perhaps three 
times as thick. The rocket 
is placed at the foot of the 
drain, or just inside the in- 
tercepting trap, and when 
lighted gives off a large 
volume of smoke, which 
gradually diffuses itself 
through the pipes and es- 
capes at any open joint or 
other defect. Although it 
burns for some fifteen minutes, the rocket is not as satis- 
factory as the blower, as the smoke can be forced to 
every part of the system of pipes by the latter, while the 
former is dependent for diffusion on the currents of air 
in the pipes. These, as we have seen, may often be down 
in one pipe and up in another, when the system is some- 
what complex. 

A recent form of drain-tester is the ‘‘ drain grenade,” 
made in London (Fig. 3375). ‘‘ It consists of a cylindrical 


a 
aa —— wk 
te WM egy nyu 


Fie. 33%3 


l] Open ready 
for use. 


Fic. 3374.—Smoke Rocket. 


Fig. 3875.—Actual Size of Drain Grenade, 


vessel, made either of gelatine or thin glass, about two and 
a half inches long by three-eighths of an inch in diameter. 
It is charged with either peppermint, assafcetida, or a spe- 
cial pungent compound. The ‘grenade’ is thrown down 
the drain to be tested, due care being taken in the case of 
the glass one that it shall have sufficient fall to break, 
whereby the content is, of course, released. In the case 
of the gelatine ‘ grenade’ the filling is, of course, released 
as soon as the gelatine is dissolved. A little hot water is 
thrown down the drain after the ‘ grenade,’ in order to 
flush it through.” 

When the house-drain is laid under the cellar floor, the 
smoke and peppermint tests will not detect defects. In 
such cases the following test should be made: ‘‘ Select 
some inlet where you would have a pressure from a head 
of from two to six feet ; plug up all the openings whose 
outlets are below that level, and also plug up the connec- 
tion into the manhole or other outlet from the house- 
drain to the main sewer. The whole system of under- 
ground pipes can then be filled with water up to a certain 
level, care being taken that the outlet at the manhole is 
perfectly stopped with pugged clay or other means, If 
the water remains up to the original level, and does not 
sink or disappear, it is proof there is no leakage from the 
pipes. The pipes should be filled under the eye of the 
inspector, so that no tricks may be played ; for instance, 
in the case of new houses where the drains have just 
been covered in, the inspector should know approxi- 
mately what quantity of water is required, and should not 
be content to find the pipes already filled for him, or he 


277 


Sanitary Inspectors. poerRENCE HANDBOOK OF THE MEDICAL SCIENCES. 


San Pellegrino. 


might discover, perhaps, that a false plug had been put 
in the first length of pipe and the water prevented from 
passing beyond the first joint. By seeing the removal of 
the plug from the manhole, such a trick as this might be 
detected, as the quantity of water used would then show 
itself if the gradient be known; but the better way is to 
calculate the cubic contents of the given length of drain- 
pipes, and measure the number of gallons put in. 

When the pipes in the upper floors of a building are 
so laid that they cannot be reached, and it is desirable to 
know their exact whereabouts and connections, the work 
is one of great difficulty. The following suggestions 
may, however, aid the inspector: To the run of a pipe, 
allow water to run from the fixtures that are supposed 
to be located on it, and then go into the closets on the 
floor below and listen.. The trickling sound of water 
will fix the location. Where several pipes are close to- 
gether, and only one can be seen, the running of hot 
water from the various fixtures above, in turn, will usu- 
ally serve to separate them. To test whether safe-wastes 
are connected to the waste-pipes from their several fixt- 
ures, or are carried by a separate pipe to the cellar, as 
they should be, pour water through one of the strainers 
and look for it on the cellar-floor. When itis uncertain 
whether bath and basin wastes connect with the trap of 
the adjacent water-closet, or discharge directly into the 
soil-pipe, cut off the water from the closet; or in the 
case of a pan-closet, take the bolt out of the lever ard 
drop the pan. The surface of the water in the trap is 
thus exposed, and by running water in the various fixt- 
ures the mode of connection can readily be seen. 

To test the efficiency of trap-seals, two methods are 
employed: First, by the production of a partial vacuum 
on the sewer side, which destroys the atmospheric equi- 
librium and forces the water out of the trap, except in 
cases where the weight of water in the trap’ is greater 
than the pressure of the atmosphere. 'To make this test, 
all the fixtures above and on the same line of piping are 
filled with water, and discharged as nearly as possible at 
the same time. The characteristic gurgle will announce 
the siphoning. Second, the fixture is filled with water, 
and all rotary currents are checked; the plug is then 
gently raised and the contents allowed to rush out. 
Traps siphoned in this way are siphoned by the momen- 
tum of the water. The gurgle is not always a sure in- 
dication of the breaking of the water-seal, but the mere 
fact of a trap being sensitive should be sufficient to con- 
demn it. 

The following schedules are given here as suggestions 
for use in sanitary inspections, and by means of which 
the sanitary value of a house may be estimated. The 
first was prepared by Dr. William K. Newton, health- 
officer of Paterson, N. J., and is designed for coun- 
try and suburban work. It has been in use for two 
years, and has proved of great value. The second sched- 
ule was prepared by the writer for the use of the New 
York ‘Tenement House Commission, and is applicable to 
large cities. ‘The use of similar schedules will be found 
of great value in tabulating and arranging sanitary statis- 
tics, and the writer, from personal experience, strongly 
recommends their adoption by boards of health. 


SOHEDULE FOR THE SANITARY SURVEY OF A HOUSE. 
(The inspector will cross out all but the correct words, and will fill in 


spaces. ) 
Dates ack tctee ee ere eee 
Malai beats Saris Rites Street, wNumberss25.. eee 

Street runs N., H.,.S., W. Width .;.. feet. Grade........ 

Pavement.—Cobble, block, Macadam, Telford, none....... 

Gutters.—Paved, curbed, smooth...... 

Sewer.—Material, brick, pipe...... PISO a SENS s shapes ; depth 
below surface....feet; fall....inches to....foot; runs into........ 
Streetisewen. CONGLUION Wa -F arene eeu ace ce ealet ok wea 

Conditionsor ebrece and entiersom 2. nee. nese. cs fee oe Aen cer eee 
"" Shade-trees.—How far from house........; prevents sun exposure ? 


Ase oe Be Site of House, 

o ateters feet above the sea-level. 

Soil.—Grayel, sand, clay, loam, rock, made ground, filled in with 
be eiahs ; site of swamp, old water-course, pond, damp, dry. Was site 
drained before building?......; how?... .. ; is surrounding land high- 


278 


Diagram of Lot. 


$$ 


w,—well. 

c.—cistern. 
p.—privy. 
c.p.—cesspool. 
c.b.—catch-basin. 
arotate drain. 


*quoay 


Width of alley, if any...... 
Yard.—Paved, flagged, cemented, drained, clean, slops, garbage. 
Privy-vault.—Stone, brick, board, none, water-tight, connected with 


sewer, supplied with water, clean; how near living-rooms...... 
Water-closet.—Style, clean...... 
Cesspool.—Stone, brick, tight, leaching, connected with sewer...... 
Water-supply.—City, well...... ; depth of...... sicisterni a... 
Distance of well from source of pollution...... 
Analysis of water. 
a House. 
Owner...... : 
Agent je... 


Tenement.—Private, boarding-house...... 

House faces N., H., S., W. ; sun exposure, good, bad ; 1-, 2-, 3-, 4-story ; 
number of rooms...... 

Construction.—Brick, stone, wood; sheathed before clapboarding 


Bie bare ; fire-SLOpeeeac 
Roof.—Tin, shingle, slate, tar, gable, flat, French, leaky...... ; sceut- 
tleseren.. ; fire-escapes ..... 
Size of house...... : size Of lot. ..... ; ratio of unoccupied space...... 
Back-building, distance from house...... 
Cellar.—Foundation, stone, brick; how laid.:....; asphalted or ce- 
mented... ... ; damp course...... ; depth below sidewalk...... 
Floor.—Cemented, asphalted, stone, board...... srdry, «damp... 
Water-closet.—Condition...... 
Windows 2" 2a Is room used for sleeping-room, living-room, shop ? 
Ventilation of house...... 
Tilumination.—Window-space...... 
Rooms not connected with external air...... 
Heating.—Fireplace, stove, furnace, steam; has furnace an air-box ? 
_ Plumbing.—Is house connected with sewer or cesspool ?...... ; angle 
of connection with sewer...... 
House-drain-—Lead, iron, earthenware; size..... all eee ; calked 
joints, cement joints; how fixed in cellar; under ground or exposed 
Main trap....- : inlet for fresh air...... 
Soil-pipe.—Iron, lead...... SIZ L Merete “eIO\NCE Sse ; angle of connec- 
tion with house-drains,.. ..; extend above roof...... 
Does ventilating-pipe run into soil-pipe?...... 
Traps under fixtures...... ; traps vented...... 
Water-closets.—Number...... ; pan, hopper, plunger, siphon...... 5 


Population of house...... 

Number under five years of age...... 

Number of families...... 

Number to each family...... 

Number of rooms to each family...... 

Diseases reported.—Scarlet fever, diphtheria, typhoid fever, dysen- 
tery, diarrhoeal diseases...... 

Deaths...... 


SCHEDULE FOR SANITARY SURVEY OF CiTy HOUSE. 
File Nos: edocs 


Inspector...... = ETOUBGm secre SeINO: Of Stories... .... ; Material...... ; 
Built about how long...... ; Single or double...... ; No. of families on 
HOOL Meee an ©), '00\-) a ; Address se... ; Is name posted?...... ; Du- 
ties of housekeeper...... ; Soil (sand, clay, rock, or made ground)...... 5 
Street, how paved...... ; Condition... -. 2 Size Of lob yee. ; Per cent. 
of lot covered...... ; House fronts...... ; In good or bad repair... .. ; 
Width of areas, front...... cereal. eee ; Alley, width...... ; Distance 
between front and rear houses......; Adjoining nuisances...... ; Any 
stable in building...... ; Any animals or fowls kept in house...... 

Cellar.—Depth below sidewalk...... ; Height of ceiling...... ; How 
sedi. ; Condition...... ; How floored...... ; Are walls damp?...... : 
No. and size of windows...... ; Location of...... ; Are they kept closed ? 
Braete sit ; How occupied or used...... 

House.—Stairs, width...... ; Condition......: Width of well-hole 
< a 3 ; Fire-escapes......; How located. .....; Are windows obstructed ? 

Halls.—Are they kept clean?...... 5) DY Whom) aes ; Have walls 
settled? .....; Condition of plaster and ceiling..... ; How is roof 
reached fa jaeae ; Is roof-door locked ?...... ; Are hallways obstructed ? 


Roof.—Material...... + Condition. ... 2 HOW, USeG to. ; Flat or 
sloping...... ; Are chimneys in good repair?...... ; Skylights tight or 
Openerer. ; Form of opening...... 


Yard.—How paved. ... ; Size.... .; Isitcleanly?...... ; Is light 
obscured by clothes hung to dry?...... ; Privy-vault, material...... ; 
No. of seats...... ; How connected with sewer...... ; Condition...... ; 
How ventilated...... se tOW: TUN ere ; School sink, size and condition 
BS erick: ; Distance from nearest window......; Any complaint of odors ? 
.... -; Water-closets, kind ..... ; Location...... ; Condition...... : How 
flushed see. 4< SWPOLNIKS fn woe al rAppediaan. A ; Are all traps ventilated ? 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 


Sanitary Inspectors, 
‘San Pellegrino, 


Water-supply.—In yard, rooms, or halls...... ; How high does water located’? iw, + SILOS ha « ; End where?...... ; Is bottom open ?......; 
rise by day?...... ; Is water wasting from fixtures ?...... Pompe... , | Are they used improperly ?...... ; Size of windows opening into....__: 
Condition...... ; Hydrant, condition...... ; How wasted ?...... > Tanks Are there side windows therefrom into courts or outer air?, ....; Are 
on roof, SIZOle wes 3 Overflow discharges...... E p transom windows into hall kept open?.. ... ; Bedrooms, how lighted 

Heating and Lighting.—Stove...... ; Damper in pipe?...... ; Does and ventilated ?...... ; Are there any transom windows over doors be- 
chimney smoke?...... ; Is coal-gas noticed ?...... ; Light shafts, how tween rooms?........ 

4 cop ae 
Seleade 
S, ote ve 
£ 2 indole 
Size. Material. Location. | Condition. | i | 43 How connected. Opening where. a ve es 
AEP ae B3/a2! "6 
ais eeles|23 
= -— S Lamed 3 Si cw 
House Drain. csi... 5... 
Sol?Pipesee. cee etd | 
Waste. Pines cr ccc ciclo. +.c sre 
Rain) Weader tise ects. s-e's 
REMARKS, 
Soe ae r Bs ag 
: Poe eae [= ,) £6 | 8e P d ig |3 oo 
re eke g ol ae o9 a¢d a= fo) | |o © a} 
$ ee lS Sater ig © Se ae Be lacie. fg ISOS] aw 
5 ul Stlnwexineeie Sew seats ma = g |2 S| e244 Be lee Git ‘ 
be AS) eh iy hae A Oo | o's =. eeic# q 3.8 © > he 
3 ag ht ESE TF opal aoe bo Sea | Sc 5 eS |i 5 4 + Ee = 
2 3 ES, (Sp) GSy i) o a Se | BS 3) ae @lg 2 |o# = ® 
cel Gt tie, at adie ho Ve et O86 Z oD jo. |o a 4e} Oo al 
| ca ar | — 
FLOOR 
b Ne crete ren See ree | 
Bae cients eles eters stele 
CRE II She 58 is 
Deiat ociae baa coke | 
Total, . 
PLOOHMIMOR EEN MiT ira lo. (ict Meee) i | OEE 
DES is a 2 eC re 
Di henna A sees | 
CoRR cn teee. cris © 
Dinars sede on stab se | 
Total, | 
FLOOR Riser! ink | rey 
Adama stacias. args toy 
Les aonb ca eee 
Sf a Ben Boece eee | 
D.. Niiahe clit ewes 0%) Sls whee | | 
5 Total, | 
FLOOR | | +3 
DN ri ate AE, dean Ae 
Bi Cheese sinas shoes 
Ce Matte aie eee Sec 
Dy Woes, « eae eiese sere: | 
Total, 
FLOOR ar | | 
US. Cio Geta Sa ence | 
Bade sie a ow eens | | 
Cree eta nisnteserais | | 
1 8) cer Pinan | 
Total, | 
FLOOR E 
ARE ASCE scree oleate 
Biasiniek eee tee 
(oes eh Aq Ane pene 
1D Ae aA Sapo os 
Total, 

Summary.—Total ocecupants...... ; Adults..... 3 Ghveren ite es fle. per litre. The climate is mild, and the air is delightfully 

of beggars recorded? ..... ; No. of saloons on block front...... ; Any ure and invigorating. The indications for the employ- 

i 8 : bE Meet, ; Any sleeping in Pp 8 e: L JO1 

Hay aaa rae! ek ae Reet ot ment of these waters are said to be chronic inflammatory 


Frederick N. Owen. 


SAN PELLEGRINO is a thermal station near Bergamo, 
in Lombardy, Italy, lying at an elevation of about four- 
teen hundred feet above the sea. The water of the springs 
issues at a temperature of 81° F., and contains 1.6 Gm. 
of saline constituents in a litre. The solids are chiefly 
chlorides and sulphates, with 0.022 Gm. of sodium iodide 


troubles of the liver, spleen, intestinal tract, bladder, and 
female sexual organs, gout, syphilis, and the so-called 
scrofulous diseases of the joints, glands, and skin. San 
Pellegrino is a favorite summer resort for families in 
which there are delicate ‘‘scrofulous” children. The 
waters are employed medicinally both internally and in 
the form of baths. 
Teds 


279 


Santa Barbara. 
Santa Barbara. 


SANTA BARBARA. The town of Santa Barbara, 
Cal., lies in a valley among the foothills of the Santa 
Ynez Mountains, close to the shore of the Pacific Ocean. 
The main street of the town runs down to the beach, but 
its thickly settled portion lies about a mile back from the 
beach and at an elevation of from twenty to one hundred 
feet above sea-level. The latitude of Santa Barbara is 
34° 28’ N. ; two degrees farther south than Algiers ; less 
than two degrees farther north than Madeira. The 
mildness of its winter climate is, however, due only in 
part to the comparatively low latitude, being chiefly de- 
pendent upon its situation on the western rather than the 
eastern coast of the North American Continent, and also 
in great measure upon the trend of the coast-line at this 
point, and to the protection against northerly winds af- 
forded by the Santa Ynez range of mountains. From 
Point Concepcion to Carpenteria, a distance of about 
sixty miles, the California coast-line runs nearly due east 
and west, a chain of the Coast Range Mountains, bear- 
ing the name of the Santa Ynez Range, running parallel 
to the coast-line, its chief peaks lying some twenty miles 
back from the shore and rising to an elevation of three 
or four thousand feet above sea-level. In fact, we have 
along this part of the California coast a counterpart of 
the Genoese Riviera; less extensive by half than the lat- 
‘ter and backed by mountains less elevated and farther re- 
moved from the coast-line, so that the term ‘‘ cornice ” 
(La Cornice), which is applied to the Genoese Riviera, 
would hardly be applicable to this far wider Riviera, or 
coast country, of California. Protection alone gives to 
the Cornice a mildness of winter climate to which by its 
latitude it is not entitled ; less perfect shelter against 
northerly winds along the California Riviera is but an 
adjunct of low latitude and proximity to the warm water 
of the Pacific in causing the swpertor mildness of its win- 
ter climate. 

Santa Barbara is the largest town in this part of Califor- 
nia (population, about five thousand), and as it is beauti- 
fully located, and is one of the most attractive places—per- 
haps the most attractive place—in all Southern California, 
it is doubtless destined to increase greatly in size so soon 
as the chief obstacle to such growth, lack of direct rail- 
road communication, is removed. The water-supply is 
‘‘abundant and excellent” (Dr. W. M. Chamberlain in 
New York Medical Record, October 80, 1886); of the 
drainage [ find no specific mention. There are excellent 
hotels, and we are told by a recent writer on Southern 
California (Wolfred Nelson, C.M., M.D., in the Planet 
of January 15, 1884) that living expenses are moderate. 
Many of those who resort to Santa Barbara very wisely 
follow the plan of living in their own cottages rather 
than at either of the large hotels; boarding-houses also 
exist for such as prefer them. Dr. Nelson speaks of still 
a fourth method of living which is adopted by some per- 
sons, viz., the renting of furnished rooms near a hotel 
and taking one’s meals at the hotel. Riding is the most 
popular form of amusement at Santa Barbara; fishing, 
hunting, boating, and bathing are also in vogue; and the 
beach is not only a good one for this latter form of 
recreation, but is so hard as to be likewise available for 
riding and driving. As to bathing, it may be practised 
at all seasons of the year, as the sea-water is never very 
cold; but the season proper begins in May. The mean 
temperature of the sea-water for each month of the year 
is given by Dr. Nelson, on the authority of Mr. John P. 
Stearns, as follows: 


January ....60° April ....... 619 JULY Pee ee 64° October..... 68° 
February, ...61°° Mays... ..:; 61° August ..... 65° November. .. 61° 
March? oc. 7 Glos Funes see 620° September ..66° December... .60° 


This would give a mean for the five months, Novem- 
ber to March, of 60.6°, a temperature 3.5° higher than the 
mean surface-temperature of the Mediterranean during 
the same season at Cannes, as quoted by Dr. Sparks from 
a paper of Dr. Tripe’s (see Sparks’s ‘‘ Riviera,” p. 7). 

CuIMATE.—The chief objections to the Santa Barbara 
climate appear to be that it is less dry than that of inland 
and higher-lying stations in Southern California, is liable 
to fogs, and is rather exceptionally windy—exceptionally, 


280 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


that is, for a South California station. Dr. H. S. Orme, 
president of the California State Board of Health, speaks 
of the land- and sea-breezes as ‘‘ nearly always to be 
found ” along the coast of this part of the State, and as be- 
ing ‘‘ very noticeable at Santa Barbara, Santa Monica, and 
San Pedro; perhaps less so at San Diego” (‘‘ The Clima- 
tology and Diseases of Southern California”). 

I have no data showing the force of the winds at Santa 
Barbara, but at San Diego we see, from column § of the 
chart published under that heading, that the mean ve- 
locity of the wind is remarkably small. From column 
K of the accompanying chart it would appear that Santa 
Barbara possesses a drier atmosphere than San Diego; 
yet hardly so dry as to warrant the assumption that it is 
what can be rightly termed a dry place, and Dr. W. M. 
Chamberlain (doc. cit.) evidently regards it as very infe- 
rior in this respect to the inland California resorts, ‘‘ Like 
San Diego,” he tells us, ‘‘it is very damp, as the moss- 
covered roofs and lichen-encrusted fences indicate. More 
than San Diego it is windy, for it lies in a trough be- 
tween the hills opening to the southeast and northwest ; 
up this valley the fogs roll in the early hours of the day, 
and whatever winds there may be are compressed and 
accelerated to an unusual force.” In other respects, the 
Santa Barbara climate appears to be all but ideally per- 
fect—warm, sunny, and equable ; and, lest what has just 
been said concerning its liability to fogs and comparative 
liability to winds should produce an unduly dark impres- 
sion of its claims as a health-resort, I introduce the fol- 
lowing passage, quoted from Appleton’s ‘‘ Handbook of 
Winter Resorts” (1886-87). The ‘‘only serious draw- 
back” to the climate of Santa Barbara, according to the 
writer in this guide-book, is the fog which ‘‘ sometimes 
comes in from the sea.” Such a fog occurs, on the aver- 
age, perhaps twice a week between May and September, 
he tells us, but he adds that these fogs ‘‘ disperse at nine 
in the morning, and the succeeding weather is delight- 
ful.” * ‘Mr. Nordhoff,” he says, ‘‘expresses the opin- 
ion that there were but ‘five days, either in Santa Bar- 
bara or San Diego, in December, January, and February 
of this year (1871), in which the tenderest invalid could 
not pass the greater part of the day out of doors with 
pleasure and profit. In Santa Barbara there were not a 
dozen days during the whole winter in which a baby I 
know did not play on the sea-beach.’”’ 

The following ‘‘record of the weather at Santa Bar- 
bara for one year, kept by , an invalid with ad- 
vanced pulmonary disease,” is quoted from Dr. Nelson’s 
paper already cited.{ According to the observations of 
the gentleman in question, made during a leap year (366 
days), there were ‘‘ 310 pleasant days, so that an invalid 
could be out of doors five or six hours with safety and 
comfort ; 29 cloudy days, upon over twenty of which an 
invalid could be out of doors; 12 showery days, upon 
seven of which an invalid could be out an hour at a time 
several times on each day ; 10 windy days, confining the 
invalid to the house all day ; and 5 rainy days, also con- 
fining the invalid to the house during the whole of that 
time.” 

Santa Barbara not being a station of the United States 
Signal Service, I am obliged to rely on the reported ob- 
servations of various volunteer observers for the data 
quoted in this article and presented in the accompanying 
chart. All the figures of the chart are either copied from 
or calculated from those given in Dr. Nelson’s article. 
The headings of the various columns of the chart suffi- 
ciently indicate the value of the data in each as an index 
of the habitual weather, or climate, of Santa Barbara. 
One of Dr. Nelson’s tables shows the temperature ob- 
served at 7 A.M., 2 P.M., and 9 P.m. of every day during 
the year 1879, and the average daily temperature at the 
hours specified during each month of that year, the ob- 
servations having been taken by Dr. L. N. Dimmick. 
Another of Dr. Nelson’s tables gives the highest, lowest, 


* How frequently these morning fogs occur during the months between 
September and May we are not told. 

+ Dr. Nelson gives the name of the gentleman who kept this record, 
which name I omit, not having asked permission to publish it in the 
HANDBOOK, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Santa Barbara. 
Santa Barbara. 


* Calculations made according to the Smithsonian formula \% (7 A.M. + 
2P.M. + 9P.M. + 9P.M 


** Figures evidently calculated according to the formula 4 (7A.M. + 2 


P.M. + 9 P.M.). Deduced from Dr. N.’s figures. 
tt Winter of 1877-78. t Winter of 1874-75. 


and average temperatures for each month and year from 
January 1, 1871, to December 31, 1879. A correspond- 
ence which exists between the maximum and minimum 
temperatures of the year 1879 in this table, and the figures 
of Dr. Dimmick in the table first mentioned, shows that 


7 9 P.M. 
the averages are derived by the formula 4%+??-+°?™: 


and that the maxima and minima are such as were noted 
at the regular tri-daily hours of observation ; not such as 
would have been recorded from self-registering instru- 
ments. Hence I assume that the same is true of the 
averages and the maximum and minimum figures of 
each of the other eight years, 1871-78. The figures of 
Column K, showing the mean relative humidity for one 
year, are quoted by Dr. Nelson on the authority of Dr. 
J. B. Shaw, M.R.C.S., of Santa Barbara. Those of 
Column O and of Column OO are based on a table pre- 
sented by Dr. Nelson, which is quoted from records of 
Drs. Shaw and Tebbetts. This table shows the actual 
total rainfall of each month and of each year from Jan- 
uary, 1867, through December, 1878. <A careful exami- 
nation of the table reveals the fact that, in the course of 
this period of twelve years, there occurred three winter 
droughts, viz., in December, January, and February of 


AAt| B | BBt BBB 4 Vv E KF 
UJ mn mn + 4 
o [as] o 3 3 
i = . #) 3 3 
wae @ 5 5 
- “eg | ag 4 E 
pan fee ates) q 3 so 
° val oft ri ~ 
5 con > b>! : 
ore ©: al ad at Absolute maxi- | Absolut ini- 
Mean temperature during the|| 25 84 £2 ieee pec aed piety Be | 3 mum tempera- mum tempera- 
year 1879 at the hours of eq Bb a of vara 1871279, oe R - a ture at 2P.M., ture at 7 A.M. 
BS | gf | && bales a has i Sea el al 1871-79. or 9 P.M., 1871- 
eo | as | os ehh | ay 79. 
Bs Be ae Om On 
Be S + & 3s e 2 
¢ s os} 
Sek ares eae 
S = a < < 
7AM. 2 P.M. 9 P.M. De- De- De- Highest. | Lowest. De- De- ||Highest.| Lowest. | Highest. | Lowest. 
Degrees. | Degrees.| Degrees. || grees. | grees. | grees. || Degrees.| Degrees.|| grees. | grees. || Degrees. | Degrees.) Degrees. /Degrees. 
JAMUANY, <achoes yess ss 46 60 46 49.5. | 51.00 | 58.08 || 56.00 50.37 78.1 | 89.5 83 67 42 38 
Pebruary) saci 508% Bt 63 BS 57.5 | 57.00 | 54.69 || 59.00 52.01 72.4 | 41.5 79 67 46 39 
Marelivadan.. Miata. 55 68 56 58.7 | 60.00 | 57.26 || 60.00 53.61 75.4 | 45.7 89 69 48 44 
Aprihi see 58 68 59 61.0 | 62.00 | 58.69 || 62.00 50.00 80.1 | 47.0 86 in 50 41 
Mays aerate thst 61 70 59 62.2 | 64.00 | 63.57 || 66.10 62.00 88.6 | 52.0 95 re B4 50 
Sung ke ie ieee: 64 3 59 63.7 | 65.00 | 66.43 || 69.00 63.56 86.6 | 56.2 102 76 58 54 
Sulpiseaeerrn. ated: vo 64 16 61 65.2 | 67.00 | 68.14 || 70.00 65.44 84.2 | 58.6 89 80 61 58 
ADRUBE A Srchecoiaes 93 4s 63 i 63 66.5 | 68.00 | 68.23 || 69.53 66.00 87.5 | 59.1 98 52 61 7 
September ............ 60 5 61 64.2 | 65.00 | 66.04 || 67.00 65.00 85.4 | 56.3 94 83 58 54 
OCLOpeR EO. cis. 56 64 57 58.5 | 62.00 | 63.30. || 65.00 61.36 88.3 | 50.4 100 2 55 46 
November.........00.. 49 65 51 54.0 | 55.00 | 59.17 || 60.70 55.00 79.3 | 45.6 82 16 51 40 
December .........00.. 47 59 50 51.5 | 52.00] 54.27 || 59.86 52.00 72.7 | 40.0 79 68 43 33 
Gripes he. atten, OM Te slices tes gees OOLC saad 59.84 || 62.00 SOD geer eh eee cies taaeeaha Itasca itt oo oe Neca 
SiS DL aces iat nH etal GRR Me os aa ee ar 67.60 || 69.00 BESS) Ol same tit Se Oem hac eee Ie ccs aan Vireee faces 
AUN er eet MRED 5. etieties fo dake Ea eee 62.83 || 63.80 GOTOG VON a mame lie kaso getae- so La ae on | ¢ 22 hela nee 
Wtior Mr ee ti mae y alo Fee. a De, tes) nae RN MMT MG ipa dS Sale tC SF Ne Se fe eee tay meray! GAS Ue 
creer mmr tree ele...) | iasde.. 59.3 | 61.45 | 61.35 || 62.50 GOST CE cee ame, ie. tale ad et Ie ls ARO Iee Oed 
ice oO oo 
p ie each of the three winter seasons, 1869-70, 1870-71, and 
As | ae 1875-76. During the first of these three the total rainfall 
o2 Ho ° ° : 
es | £2 | Monthly, seasonal, | was but 4.35 inches; during the second it was only 5.75 
‘Ba ce and annual ex- . : 4 eet ‘ : J 
S> | .-.| tremesofrainfall inches ; and during the third it was only 3.85 inches. In 
HH | ote | 1867-78 (twelve | the case of this last winter season, the excessively small 
da | ees |. rere). | rainfall of D ry, and Feb 
Belles s, total rainfall o ecember, January, an ebruary was 
S < no doubt, in great measure, compensated by the very ex- 
—- ca pe Pane ceptionally heavy rainfall of the preceding November 
1gnest. owest. “| a . 1 
ehea lt aches fi labhon (November, 1875), which was no less than 6.53 inches. 
January co. eae eee oe Bee re 14.84 0.25 But in neither of the other two cases of winter drought 
ene Beara eicabincicleasiys gmeiseian eis ie at ee He do we find any compensation. The combined rainfall of 
Ape Ge, APM Rt tee, Sel Teach: OT 0.88 2.44 0.00 October and November, 1869, was only 0.95 inch, while 
ey se teeeeee Steen eee en ee er eens eeee neers 2 Ae hee 03 during the nine months of March, April, May, June, 
aly; eeeweee  HNeedeisences| 12 0.00 0:00 | 0.00 July, August, September, October, and November, 1870, 
rea een settee eee esate teen nee nee ey ane Deng eke ee the total rainfall amounted to only 3.72 inches. In other 
OeDber ha anor RA gicks |) TO 0.31 1.91 | 0.00 words, a winter drought (4.35 inches of rain) was pre- 
) ‘ : . . 
UW Deaalte SCRE en any Pec are on Pipa (a npes iti ie ceded by a rainfall of only 0.95 inch in two months, and 
cig is followed by a rainfall of only 3.72 inches in nine months. 
Saat a a ee ee geet Way Nae The winter drought of 1870-71 (5.75 inches of rain) was 
AMOUMMN os sseeeeeseeeseeereeeeeese tee 69.3 | 1.63 | 6.58 0.90 preceded by a rainfall of 1.81 inch in October and No- 
Year III coats’ 15:6? | S683 | tuo | “vember, 1870, followed by nine months, March to No- 


vember, 1871, having a total rainfall of 4.04 inches. 
From March 1, 1869, to December 1, 1871—a period of 
thirty-three months—the total rainfall was only 21.44 
inches. On the other hand, in the single month of De- 
cember, 1871, there fell 6.56 inches of rain ; and in Jan- 
uary, 1874, there fell 14.84 inches! These facts abun- 
dantly establish the truth of what is said concerning the 
irregularity of the winter rains of California in Blodget’s 
‘*Climatology of the United States.” ‘‘They are some- 
times much later or much earlier than their average,” he 
tells us, ‘‘and sometimes in great excess as well as in great 
deficiency.” As tothe rainlessness of the summer season, 
that is a never-failing phenomenon, as may be seen from 
the data set down in Column OO. The most extreme 
case of summer rainlessness recorded in Dr. Nelson’s 
table was that occurring in 1872, when between March 
1st and December 1st—a period of nine months—there 
fell only 0.05 inch of rain. 

It is not possible to establish any accurate comparison 
between the climate of Santa Barbara and that of San 
Diego or of Los Angeles, based upon the data of the 
charts for these places, because of the different hours of 
observation adopted at Santa Barbara, and the shortness 
of the period of observations upon which some of the 
data are based. In Dr. Orme’s pamphlet we find a brief 
table (op. cit., p. 7) giving the mean summer and winter 
temperatures of each of these three places for a period 
of four years ; from which it would appear that, both in 
winter and in summer, Santa Barbara is the warmest of 


281 


Santa Barbara. 
Saratoga Springs. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the three. Column F of the chart presented in the pres- 
ent article, shows an absence of frost and of very low 
temperatures at Santa Barbara throughout nine success- 
ive winters. But neither this column nor column E can 
fairly be compared with corresponding columns of the 
San Diego and Los Angeles charts, because in these lat- 
ter self-registering instruments supplied the data; in the 
former such does not appear to have been the case. Dr. 
Nelson gives an interesting and practically useful table, 
showing throughout the course of seven years the num- 
ber of days on which the mercury was observed to fall 
below 48° (probably either at 7 A.M. or 9 P.M.), and the 
number of days on which it was observed to rise above 
83° (probably at 2 p.m.). This table is presented below. 


1873. | 1874. | 1875. | 1876. | 1877. | 1878. | 1879. 
IBCLOW Aso ee eee eee Fi 9 4 AiG 15 23 13 
MADOVE! GBC vce oon ce 1 6 22 4 


10 8 15 


Average below 43° F., 12 days ; above 83° F., 94 days. 

The figure 13 in the year 1879 is very likely a misprint, 
for on referring to his table for 1879, based on Dr. Dim- 
mick’s observations, we find that the 7 A.M. observations 
of January in that year gave a temperature of 41° F. on 
two occasions, of 40° F. on three occasions, of 39° F. on 
two occasions, and of 88° F. on one occasion ; in Febru- 
ary of that year we find three 7 A.M. minima under 48° 
F. (viz., 42° F., 40° F., and 89° F.); in November two 
such minima (42° F. on two occasions) ; and in Decem- 
ber of the same year, 7.¢., the first month of the following 
winter season, seven such (viz., 42° F. on two occasions, 
38° F. on one occasion, 87° F. once, 85° F. once, and 33° 
F. twice). That is, we get the figure 20 instead of the 
figure 13 representing the total number of days having a 
minimum under 43° F, As tothe figure 15, showing 
the number of days, in 1879, having a maximum at 2 
P.M. above 83° F., a careful examination of Dr. Dim- 
mick’s figures verifies its accuracy. The actual figures 
for the fifteen days in question were as follows: March, 
89° F. once, 84° F. once; May, 92° F. once; June, 97° F. 
once, 95° F. once, 90° F. once; August, 85° F. once, 
84° F. once ; September, 86° F. once; October, 90° F. 
twice, 89° F. once, 88° F. once, 87° F. once, and 86° F. 
once, 

We have now presented all the data at our command 
which are likely to help the reader toward an accurate 
understanding of the Santa Barbara climate, at least so 


far as it has been possible to do so within the just limits 
of the present article ; and the sum and substance of all 
recorded observations appears to be a demonstration of 
the fact that Santa Barbara possesses a winter climate as 
mild in temperature as any in Southern California, per- 
haps the mildest of all; and that it has (like all other 
stations lying to the west of the Coast Range Mountains) 
a very moderate degree of heat in summer, with cool 
nights, and with temperatures, even at mid-day, which 
are usually much below those found at that season in the 
eastern and central portions of the United States. Fogs 
and winds are the chief blemishes in its winter climate, 
and it is at that season unsuited for residence by those 
having a tendency to rheumatism, and is less suitable for 
most phthisical patients than are the inland stations. 

The upper part of the town is the best for residence by 
those desiring to avoid dampness, and at El] Montecito, a 
suburb two or three miles to the east, there is said to be 
better shelter against the sea-breeze than at Santa Barbara 
itself. 

THE Osat VALLEY.—About thirty miles east of Santa 
Barbara is the Valley of the Ojai, which, according to 
Dr. Orme (op. cit.), is sheltered from ocean winds and 
fogs. The little town of Nordhoff in this valley has an 
elevation above sea-level of about 1,500 feet, and stands 
fifteen miles back from the coast. The Ojai Valley is a 
resort which seems likely to become one of the most 
popular in Southern California. ~ Interesting views. of 
Santa Barbara, and rather attractive (although far less 
instructive) views taken in the Ojai Valley, may be found 
in Harper’s New Monthly Magazine for November, 1887. 

Huntington Richards. 


SANTA FE. [For a detailed explanation of the ac- 
companying chart and suggestions as to the best method 
of using it see article ‘‘ Climate,” vol. ii., pp. 189-191. ] 
Santa Fé, the capital of New Mexico, and the largest town 
in that Territory, lies at an elevation of seven thousand 
feet above sea-level, upon the western slope of the Rocky 
Mountains, the eastern slope of the Valley of the Rio 
Grande, and, roughly speaking, at a point equi-distant 
from the crest of the mountain chain and the river. The 
little river Santa Fé, one of the chief branches of the 
Rio Grande among those running into the latter from 
the east, bisects the town. The distance from Santa Fé 
to the Rio Grande in a ‘‘ bee line” is about seventeen 
miles ; in a southwesterly direction to the point of junc- 
tion between the Santa Fé River and the Rio Grande, it 


Climate of Sante Fé, N. Mex.—Latitude 35° 41’, Longitude 106° 10'.—Pertod of Observations, December 1, 1871, to June 
15, 1883.—Hievation of Place of Observation above the Sea-level, 7,055 feet. 


A B 


= 
> 


® 
as} 
2, 
Ba 
ge 
2.5 
§ 9° 
Mean temperature of months go Mean temperature 
at the hours of a g for period of ob- 
ae servation. 
OH 
=fee) 
o 
or 
gc 
oO 
> 
_ 
| 7 AM. 3 P.M 11 P.M. || Highest.| Lowest. 
Degrees. | Degrees. | Degrees. || Degrees.) Degrees.) Degrees. 
ganuary....| 21,1 36.2 26.9 28.0 b Meero aac 
February...| 24.7 40.5 381.0 82.0 | 87.0 24,2 
March...... 30.3 49.6 38.5 39.4 We 2475 32.4 
ACO YT Peis ee 36.2 55.8 44.3 45.4 | 51.2 Ait: 
i, ee ee 46.7 66.3 54.8 55.9 | 60.0 52.0 
dine re... 56.6 76.0 63.6 65.4 || 68.6 62.2 
PUL ese 60.4 GTA 66.2 68lOe e708 64.0 
MUS Stic. at | 988.2 75.1 64.5 65.9 1. 168.2 64.3 
September..| 49.8 69.7 57.5 59.0 62.5 56.8 
October..... 40.4 60.1 47.8 49.4 52.8 45.7 
November.. 29.2 45.8 34.9 36.6 42.7 29.6 
December .. 23.3 39.5 28.7 30.5 33.0 26.4 
| 
floaters, eas He asioaoe i asada. || eceriac 46.9 | 51.8 44.2 
SQMMIOr, FI Cees scte | leiswte vel | renee ue 66.4 68.2 65.2 
AACE. ea icicte aot til mae atte WHE Ol eats 48.3 50.8 44.0 
Wanter.. Go iets do's ala sis ay S coil ees caities 30.1 32.8 27.2 
VORP Cee, ool wrerteete | Feereasleme [5 ea grote ft!) 50.2 45.4 


Cc D E F G H 
o © Sia gi mddo 
Pa 4 a 
B 3 Bg Ss/S8S8 

Sasha So 

Pe Fs Be” Aiton & 
o vo 
J 5, Beg sies sa 
= = SeP Sacha 
Be & ||Absolute maximum] |Absolute miniraum||° 2g 8|° 235 
9 8, 5 a temperature for|| temperature for||3 5° 5 Se°R 
tale c= period, period. Bo aR Oo ag 
as 5S Eada sca k 

+ he BERS See 
: © a Ba g » f 

softs po ea ier 

g e goFe goes 
2 g SMES SHES 
< < Sane oad 

Highest.; Lowest. |} Highest.; Lowest. 

Degrees.| Degrees. || Degrees. | Degrees. || Degrees. | Degrees. 
89.5 15.0 76.0 46.0 6.8 —13.0 18 ° 
44.9 20.7 75.0 48.0 19.0 —3.0 28 23 
54.8 28.3 82.0 66.0 25.0 Zero 81 31 
58.0 34.3 84.0 7.0 23.0 11.0 24 24 
71.3 43.0 890). 975.0 34.0 24.0 24 28 
81.0 51.3 92.0 85.0 53.0 33.0 21 22 
83.2 56.5 95.5 86.0 53.0 46.0 22 29 
80.7 Dok 97.0 $1.0 | 53.0 40.0 17 29 
74.5 46.6 90.0 74.0 42.0 27.0 28 25 
63.5 ities! 85.0 69.0 29.0 16.0 25 27 
49.4 24.6 77.0 56.0 25.0 —11.0 24 27 
41.5 17.0 65.0 52.0 10.0 —13.0 18 18 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


3|Kiu| m|wn oO R S 
oot to 5 i oa ‘ Pe 
25 a 4 g| oe 5 = 3 ‘og 
g aI £ ° ta - 5 e So a 3.8 5 g 
S92 /32)acg| gt | ke 5 aoe pa. 
we | SS Bs u Ss Far ous ea 
| OF OF Se £3 oH © Be Yo) ots 
Po ae |] ae a YS ai oo aq ES 
aedis do | oo | OR! £ Fo a 
doje |2 | 2° |ee3| £ |) gF | 38 
: ays ce ar ar 2 
Inches.| From 
January..../ 89.0 | 51.7 | 11.2) 15.8 | 26.5 | 0.52 N. 6.9 
February ..| 78.0 | 54.0 | 12.5 ins 23.8 0.64 N. ee! 
March...... 82.0 | 42.9 | 13.8 1255 26.3 0.51 S.W. 8.1 
A DTT eke 73.0 | 35.0 | 14.7 Hb 26.2 0.57 S.W. 8.8 
Maya cnces 69.07 1630-4 |- 15.2 12.4 27.6 0.85 |E.&S.W. 8.5 
June, ......} 59.0 | 30.5 | 18.9 13.7 27.6 114 S.W. 7.5 
dhyana ce 49.5 | 46.5 | 18.4 Gl 25.5 3.41 E. 6.7 
August..... 57.0 | 50.9 | 18.0 WES al 3.01 EK. 6.1 
September.| 63.0 | 48.5 | 12.7 14.9 27.6 E25 E. 5.9 
October....| 69.0. | 41.9 9.9 18.8 28.7 1.02 EK. 6.6 
November..| 88.0 | 49.2 | 10.9 15.4 26.3 0.91 N. 6.5 
December..! 78.0 | 50.7 | 10.8 | 15.6 26.4 0.65 N. 6.3 
Spring .....| SOO 36.1 || 43.7 36.4 86.1 1.93 S.W. 8.5 
Summer ...| 64.0 | 42.6 | 50.3 28.3 78.6 7.56 EK. 6.8 
Autumn ...!101.0 | 44.9 | 33.5 49.1 82.6 3.18 EK. 6.3 
Winter..... 89.0) 52.1 | 34.5 42.2 76.7 1.81 N. 6.8 
Year): ee. 110.0 |! 43.9 1162.0 | 156.0 318.0 14.48 E. tee 


is about twenty-three miles. The main chain of the 
Rocky Mountains near Santa Fé attains a very consider- 
able elevation, and less than thirty miles to the northeast 
of the town are peaks between twelve and thirteen thou- 
sand feet high. Santa Fé does not lie in a valley, but 
upon a great plateau ; ‘“‘in a wide plain surrounded by 
mountains,” are the words used to describe its location by 
the writer in the ‘‘ Encyclopedia Britannica ;” while the 
authors of an army circular, quoted by Dr. W. Thornton 
Parker in his interesting pamphlet ‘‘ Concerning the Cli- 
mate of New Mexico,” say that the town is ‘‘ pleasantly 
situated on an extensive plateau,” etc. We are told by 
the authors just cited, that although ‘‘large pines and 
cedars are found on the hills toward the mountains 
: the country for miles about Santa Fé is,” never- 
theless; ‘‘ destitute of trees,” 7.e., of trees of any consid- 
erable size, although ‘‘ stunted cedars and pines are very 
common.” They add that ‘‘this want of vegetation de- 
tracts much from the natural beauties of the town and 
vicinity.” Of the water-supply they say: ‘‘ The river 
water is very extensively used for drinking purposes, and 
is excellent ; good water, but a little impregnated with 
lime, may be obtained by wells at a depth of from ten to 
forty feet.” Of the matter of drainage they remark that 
although ‘“‘ the natural drainage of Santa Fé is excellent, 
ind is materially assisted by an extensive system of ace- 
quias or canals around the town, still little attention is 
paid to the subject, and many of the narrow streets and 
lanes of the city are excessively filthy.” The soil about 
Santa Fé they describe as ‘‘ dry, light, and sandy, and 
yet very fruitful.” 

I shall attempt no discussion in this place of the claims 
of Santa Fé as a health-resort. The reader desirous of 
particular information on this point is referred to Dr. 
Parker’s pamphiet just mentioned. A general discussion 
of the climate of New Mexico, considered from a sanitary 
point of view, may be found in the article entitled New 
Mexico, and in particular toward the close of that arti- 
cle, vol. v., p. 182. In Dr. J. Hilgard Tyndale’s papers 
on ‘‘ The Climate of New Mexico” (see boston Med. and 
Surg. Journal, 1888, vol. i., pp. 265 and 818) may be 
found various tables and data illustrative of the climate 
of Santa Fé; but the figures presented in the accom- 
panying chart, together with such as stand in Tables A, 
B, F, and H in the New Mexico article (of which Table F 
is quoted from Dr. Tyndale), and the data given in the 
table on page 238 of vol. ii. of this REFERENCE HAND- 
BOOK, will doubtless suffice to convey an abundantly ac- 
curate idea of the local climate of this town. i, i. 


SARANAC LAKE. Saranac Lake lies in the north- 
west portion of the Adirondack region of New York 
State, at an elevation of 1,539 feet above the sea-level. 
Having at command no special climatic data for this 
resort, and having no comment to make upon its claims 
as a health-station other than what may be found un- 


Santa Barbara, 
Saratoga Springs. 


der the title Adirondacks, in vol. i. of the HANDBOOK, 
the writer will confine himself in this article to a brief 
mention of the institution known as the ‘ Adiron- 
dack Cottage Sanitarium,” which was established near 
Saranac Lake three or four years ago. This institu- 
tion, intended for such phthisical patients as, in the 
opinion of its medical staff, would be likely to derive 
benefit from a sojourn in the Adirondack country, pro- 
vides good accommodations and medical supervision, at 
the exceedingly moderate price of five dollars a week, 
being supported chiefly by voluntary contributions, and 
with the object of providing a chance for climatic treat- 
ment to persons in moderate or reduced circumstances. 
The plan wisely adopted in building this institution is 
the cottage plan, each cottage accommodating from two 
to four persons, and intended for use simply as a dor- 
mitory ; the dining-room, general “ sitting-room,” kitch- 
en, etc., being in the main building, about which the cot- 
tages are grouped. This main building is described as ‘‘ a 
quaint, irregular, red cottage, with unexpected corners, 
delightfully original and ample windows, a deep piazza, 
and a range of offices and store-rooms at the rear.” 
(‘The Adirondacks as a Health-resort,” by Joseph W. 
Stickler, M.S8., M.D.) The custodian’s apartments and 
four bedrooms for patients are on the second floor of this 
building. 

The site for this institution was admirably well chosen, 
being a shelf-like plateau ‘‘on the shoulder of ‘a hill 
which overhangs the valley of the Saranac River,”—a 
“natural terrace on the spur of the hill, with a steep de- 
scent of about one hundred feet to the Saranac River in 
front, and an equally sharp and still higher rise to the 
crest of the ridge in the rear.” (Op. cit.) The exposure is 
toward the southeast. The little plateau commands a fine 
view of the higher peaks of the Adirondacks, some fif- 
teen miles distant toward the east and southeast. The 
steep wooded hill-side behind the terrace protects it 
from the storm-bearing winds of the region. The soil is 
sandy ; the natural drainage facilities are of course excel- 
lent. It is much to be desired that similar institutions 
should be established at other leading sanatoria of the 
United States. 


SARATOGA SPRINGS. Location and Post-office, Sara- 
toga Springs, Saratoga County, New York. 

AccEess.—To Albany, N. Y., by the various railroads 
centring there, thence to the springs by the Saratoga & 
Champlain Division of the Delaware & Hudson Canal 
Company’s Railroad, extending from Albany north to 
Montreal, Canada. 

THERAPEUTIC PROPERTIES.—The characteristic ingre- 
dients of the waters of this famous resort are common 
salt and alkaline carbonates. They are therefore classed 
as alkaline-saline. The proportion of contained carbonic- 
acid gas is unusually great, and the waters in great meas- 
ure owe their popularity to their sparkling appearance 
and agreeable taste. Altogether there are about thirty 
springs, six of them spouting. The High Rock, Con- 
gress, Washington, Hathorn, Geyser, Empire, and Star 
springs can be taken as types of the Saratoga waters. 

Some are cathartic, some contain iron, sulphur, and 
iodine. The tonic and cathartic properties of these wa- 
ters have made them the most popular in America of all 
adapted to the treatment of catarrhal diseases of the di- 
gestive and urinary organs, gall-stones, urinary calculi, 
jaundice, torpid liver, ete. 

Saratoga is situated in the northeastern part of New 
York State, thirty-two miles north of Albany.. Its per- 
manent population is about ten thousand, but this num- 
ber during the ‘‘season”’ is quadrupled. The streets are 
wide, well graded, and bordered by large elm-trees. Ho- 
tels and boarding-houses abound, and there are many 
handsome residences. Probably nowhere in the world 
are there caravansaries constructed upon such a scale as 
to size and comfort. The attractions at Saratoga are 
few besides the interest connected with observing the 
ever Changing multitude of fashionable visitors, and lis- 
tening to the fine music provided at the leading hotels 
and in Congress Park. 


é 283 


Saratoga Springs. 
Sarcoma. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


ANALYsIs.—One gallon contains : 


Champion | Colum- | Gongress,| Crystal. | Empire. | Eureka. | Excelsior.| Geyser. | Hathorn.| High 
| spouting. bian. /Prof. C. F.| Prof. C. F. |Prof. C. F./R. L. Al-/R. L. Al-|Prof. C. F, Prof. C. F. Rock. 
Prof. C. F.| Prof. E. | Ghandler.|) Chandler. | Chandler.| len, M.D. | len, M.D. | Chandler.| Chandler. |Prof. C. F. 
Chandler.| Emmons. | Chandler. 
Grains. Grains Grains, Grains. Grains. Grains. Grains. Grains. Grains. Grains. 
Bicarbonate of lithia.............. C24 eee ee 4.761 4.326 2.080 Wi GS oe eee 7.004 200, lee ee 
Bicarbonate of soda.............-- 17.624 15.40 10.775 10.064 9.022 S!750 aes ee wAsooe 17.685 34.888 
Bicarbonate of magnesia .......... 193.912 46.71 121.757 75.161 42.953 29340 FAY eos 149.343 130.555 54.924 
Bicarbonate of lime............ -» > PHOAV EUS Eb pas ear 143.899 101.881 109.656 A1 G21 Tile ee es 170.392 147.226 131.789 
Bicarbonate of strontia ........... OCS 25 tees cee trace trace tracesy i Mist cele ee 0.425 trace trace 
Bicarbonate of baryta............. 2083 MR eck or 0.928 0.726 0, OF 0 re terete an nee ee 2.014 0.972 trace 
BICaArHDONALG OILON eho. eae O64 ti eee ee 0.340 2.038 0793 Sh) ee ee cet mee eet core 0.979 0.853 ° 1.478 
Oarbonaterton mew cee ck <cee) social baie mer 6800) Ge wie ee iit we cece ee ane ahs Seem ere 77.000 Brewis. oe All. everest Tamm Ieee stele tees 
Garbonate:olaron yer. eo. ke ne ete he rl ae eee Gott Manse ard MaDe. etilin Gace ea 3.000 B25; nek pei |e oe cee ot Creer 
Carbonate of magmesiay fej 05's!) OSA aie ic eee eel tocar str Oe dec ate rot Ue cette an Pade tect 32,880) lcs eet Cue mets cen lee breereiee 
Carbonate-of Oda. ee i3. aioe te ce > Pilly revatio Hebe g ie ate Pe en tke ec Sem |) tema ata s (oO baal) fo ereeret mtn | et enete ee LOCOS ee on : E inp ee, Ol atte eee 
@hloride‘of sodium... cen veuee 702.239 267.00 400.444 328.468 506.630 166.811 370.642 562.08 478.722 390.127 
Ghioride!of potassium... 7.3.26... A446 ol 0 Ber. cts 8.049 8.327 4: 202 78 1 aa eereee Wl mesieaees. fio 24.684 82.859 8.497 
OChiloride’of magnesium :2%.6.6..58 50. lad irk een] Re EAE Se Ty AUS oc ci clan 00 Mucccwaire Cicatercll at Nm Mena a ie sor uiag Nees SCO kad Lc ae ee ee 
CO) sV erm hroy merece) 1204s eS Ser he a ie A a Se i sac WN porenny lee st cek. IP kseke yt pig sse oe he cer eel Poe 
Ohloride of lithium 3). Sos es hoe ic Re Meee oe ayes Pe ere ET Hp Nee scat ote Taal! areca 0h a eae | ea) Re Mees Al ee pct 
Sulphate of potassa.. ...........- 05252 sree 0.889 2.158 269 Oe nn diaries 28d 0.318 | trace 1.608 
Sulphate Of Masnesialvec class we.ce cll heres Heel eee tec, © (Mme ete tet reuman laMeratetetore, Mea EeMartayela cere 2.146 Tol Beene mall oe a Were ok aad Meteors 
Sulphate of Boda :.b 0 dacs cece wcekladd | Wystee cee amid la beste: coke) LOL daie ee’ ctene all SOc a tercy ete saue MME sc teues ae as Oia tot cere SQ Soe cote, lr ieee ce ah mettre 
Sulphate of strombiagy 25 20 cco mk ose tl Sota ee ok ee orto cn er he i | aaa tones hres or (re ne noe EXYACE™ Ell ites. Wl atisaclee GaMILa Sistine 
peje § 6) ft; 0 cian Mil ba6)> eae re PRM ire gener Mere ee MC ee ee aes tio rade Os dinars il aabdoels, | Godlee | saben Fi resstabehl| | Matias oO ees 
Phosphate ofisodayyivse. oeieeste ee OO103 eee 0.016 0.009 OLU28 CIT | ee saroe an meets ee trace OS OL Ole mae 
Phosphate. of Times. 0. s-f.c5.s clersce cM Saree Sar Ab uherewtee ) E Ua en setehen WL, (ies oo ots MIM MDUNEtere crete cM Cay cen) So a ee ee oe ee trace 
Biborate ofisoda so see een. an eee tEACE) Tce ee trace trace trace) uh sb eee ieee trace TYACOW UNGMAE S os 
Bromideoft sodiumu. eae 3:5 (ON Mae ee 8.559 0.414 0.206, 21a ee er aes 2.212 3.644 0.731 
Bromide of potaselwm yo cesiscre es Hs eee IN ete ee eeSTemn lecP deceisecce rem en nieSTO ct 20 een Poe 1.566 LFACCS Bi Ouitcee ah eile merecaeke Seemel ware eRe 
Jodiderof sodium sey see eee tee 022340 ret 0.188 0.066 0.006 4.666 4,235 ().248 0.115 0.086 
Fluoride of c#leiumir. pees eee pagevetey Vill)” aa kt ke trace trace ALTACE, hl hed. Je. eee! meres trace trace trace 
Fluoride of lithium, .5 62/20 03.62 a5 | Sea geews Ul See cee Od eee Se etise U| Tipcteceiesecell aces ee ric anita coerce) ane Erg tee O 
Hydriodatetor soda hens ssecetit all meee Psi eo ne Poe cies Pry wl eeepc inks car Et el el hae Las, NI else f 
Alumina Ces qadeh Meee ee Ler weer cees OLB pence trace 0.805 0.418 Oi 2571 Cain tee ape trace 0.258 1.223 
Silicate of potasea fey seas casicis lates ec ML pect MMB WD ae ctor lice cus ro os ret O00) Shot eee ee eae Bln, eee 
Silicate Of BOM 1.5 saicre chi eceareee cha BEh Meets el eee oT aac olathe s Sean Garda re coe maieccs: tc enn meu ete faye UM see AQOU |e cRe eat Clk Win. heme eee mele 
Silica f/tavike oot lee eee ite ete 0.699 2.05 0.840 3.213 1.458 O:5 82) Miers 0.665 0.700 2.260 
Organic imattermiieen seen one ee tTAce: Wile cew ste TieaeeAt Te ee trace traces 3 04.52 2. Cling eee trace trace WW ne. 
totes) a nr ik A ane aaa ll abeeae ee eer fe Bieta ae ik Carre oe ol Suck Wl Mies Ase We oagand! bof eoce sc 
BOracic ACid 07.22 un8 wee oe cence el Loren ceteel ae no tarrete byes Wi eee ead GW inmates ile emp etas WMA seen Bi” MN Uaioe pine) Malt ay eas opts CR eames 
MOtala ye cee re eee 1195.582 407.30 700.895 537.156 680.436 258.365 514.746 991.546 820.844 627.561 
Gas Cub. in. | Cub. in. | Cuh. in. Cub. in. Cub. in. | Cub. in. | Cub. in. | Cub, in. Cub. in. | Oub. in. 
Oarbonic:acid. = Set eeeecm ances 465.458 272.060 | 392.289 317.452 344.669 239.000 250.000 454.082 375.747 409.458 
Kissingen.| Pavilion. Red. (Saratoga A.| Seltzer, Star. Union. United | Vichy. Washing- 
J. R. Nich- Prof. C. F.|Prof. J. H.|J. G. Phole,| Prof. C. F.|Prof. C. F.|Prof. C, F.|_ States. | Prof. ¢.F.|_ ton. — 
ols & Co. | Chandler.) Appleton. M.D. Chandler.| Chandler.) Chandler.|Prof. C. F.. Chandler, J- R. Chil- 
Chandler. ton. 
Grains. Grains. Grains. Grains, Grains. Grains Grains. Grains. Grains. Grains. 
Bicarbonate of Lithia va): sees 5.129 9.486 () 1042) PATE 08 SS Salt os Pete yee ee 2.605 4.847 . T(60 ane 
Bicarbonate of soda..............- 67.617 3.764 15.327 6.752 29.428 12.662 17.010 4.666 82.873 8.474 
Bicarbonate of magnesia .......... %0.470 16.267 | 42.413 20.480 40.339 61.912 109.685 72.883 41.503 65.973 
Bicarbonate of lime ............... 40.260 120.169 101.256 56.852 89.869 124.459 96.703 93.119 95.522 84.096 
Bicarbonate of strontia ........... trace trace sp Seae ee Milter se ets ols trace Pavceer trace 0.018 trace, oases 
Bicarbonate of baryta............. 0.992 OSS ae ete AP eerste tpg Pore lh We me gene 1.703 0.909 0593 S|" Se 
iBicarpouate-ol tron ess ene 1.557 2: DO ilpereerce 1.724 1.703 1.2138 0.269 0.714 0.052 3.800 
Ontoride orsodiuins + -eor cue sence. 238.500 459.903 83.530 565.300 234.291 378.962 458.299 141.872 128.689 182.733 
Chloride of potassium............. 16.980 7.660 6.857 0.857 1.385 9.229 8.733 8.624 TALS ieee 
Chloride of marnesium teh ge. cos hie toe |e. ee ea ene eee trace: 2) CC. LER Sorin OR Re NEP ter Fela ROR all ee ore tat 0.680 
Chiorvide oficalcium Fs. 7.c sesceecell| bem ceteec | Meeeie se en ee one EYACOE | sli Pes Renee “efi Oke eles taal Reta c coe POR ID tnre eee eel lee eens 0.203 
OhloridevoL bthivim |. :Gee fees cose catches, eects or aned I tna ete en mm 0562 clans ARCA aes Shah an ia soe Oconee gee || eee ee 
Sulphate of potassa ..........--00 trace 2032 Cale geek 0.370 0.557 5.400 OLS ub ene cies LTACET br luber eee 
Stilphate- of maanesia. leit... <sciiup ea eee) le eres | een ee O:2B8 eral ieee eee 2 RS PE ae ails canes haem |e eee Oke (oe ae eee 0.051 
Sulphate OfisOd ase yen Maan tire cece ly od ieee et Late ae ee tee QD BOO ie Mcaee RG Ran ap ters. 20 emi eed eet a ator Bic ie Ty meet oe me ete 
Sulphate of strontia 3 G/.650 ccc cee] ace esis, |) flys Stasie oth tere pete set iM se ites ie esa im NImeee eet EU cre Cote me eR eee | | 
Sulphate ofiimertrecti. cs case ae ios ec lde eee sc Bla ane cee cee er OFAES Co ii ciate ces cy I Mens btate Cee MI ie eo aya Me Mama cheers acl alco cre fae ae et emt 
Phosphate/Omsoda, cavecvsaceiase ly. wee eas 0.007 TLACe Th 4.s | th ee mee stectoce Vt ers e e. ares 0.026 0.016. traces |e 
Phosphate. om limesc.c ccsarecie.s.< 6 nv lie oie tes oe allt Eder g traces fll) be. e trace TraGe Fig ea Vee eR ae ae ol | eee ee ee ee ee 
IBIDOTALG OF BOM mere hecho teleiiealer diamines ave Loy: 6 i oy Ue nhs ik oeoee Ub =paaeds trace trace trace.” tiga. 
Bromide Of sodium): 22.5. cco. cos 1.800 O98C ES Pre ee an) eee 0.630 6.565 1,307 0.844 O: 990s ere cane 
Bromide of potassium 16 A. see] See stead TY tee IR ecteine e tim | mete te eee 0.474 
Todideiofcounine epee eee oes 0.042 0.071. ie eee 0.0381 20.000 0.039 0.047 trace 2.243 
Fluoride of calcium ,............./. GEACE s-S8 ASS 5 I Bees, eee ee trace?) || (ieecct. trace trace tracey) Beene. 
Eimoride of dithiinm yee c cen cit ce |e ee ce trace bg pers cl eli ale She en p eo tre Dun Revert eter dill Se ayeceneemicr a | Ameer set a 
Mytiriodate of 6008 so. Saisie se eccle o'c 2 Since ll esis ceva. > ip bivohepe cia oll ntti aes Seatposts ot Ree te ec eee re 
ALUMINA Ce, aath citos staieees cece trace 0.3829 2.100 * 0.880 OSTA Bie Manes se 0.824 0.094 0.473 trace 
Silicate of POtASBA 7. 6 siss'eisievels.edies os), “isterut alee ct soahbr fh cS od cereale eetepe tee MRT: Mine Pet ern wh Oty nti (ura eres Fe a | a ger Or | 
Sica terorsoda sekiincs ate sicwse esc brews eee Mere rar! fey st) | aagke MeN oete aie oouuae| cake Wt ya gelsts’ “MS esaeise 
Siljcn Maceo. heen Net eee ook 1.280 3.155 3.250 2a ee 2.561 1.288 2.653 3.184 DATOS Nil ae ete 
OLranicaMaLLerine acta cece: tokeis trace trace ')) Si cU.F 0 Re Pee een nmerereyetares alll Sirona reeee trace trace UWACOT EH ceria 
MILICIG: BOLdae 12, By eee wie sicvectevs Chicabolitl mee shire. esumecuen iene habe arne ans LAGOA earth e enters & Bacal ete cra eee, Ree 1.500 
BOraGicracld eS aare slaslee nee eee Ce ol dee oc bine tmhll ieeeleieca sce Tl ca htc -5 Reale ee ERACON Eph Wie serail ul Sc ciseaten sain |i enue teeter ore tenee co am | en camer 
LOCAL UE Sethe wth. let cite: 444.627 687.275 255.680 656.911 401.680 615.685 701.174 381.8387 367.326 350.227 
__ Gas Cub, in. | Cub. in. | Cub. in. | Cub. in. | Cub. in. | Cub. in. | Cub. in. | Cub, in. | Cub. in. | Cub. in. 
OCarbonic'acid so. wean ede ee acces 432.634 EP AACN hg Gay fae 212.000 824.080 407.550 384.969 245.784 383.071 363.770 


284 


* Alumina and sesquioxide of iron. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, — 


Saratoga Springs. 
Sarcoma. 


The High Rock is the oldest spring, its medicinal qual- 
ities having been known to the Indians, and by them 
shown to the whites as early as 1585. Derick Scowton 
built the first log-cabin here in 1778, and in 1784 General 
Schuyler erected the first frame-house and made cther 
improvements toward rendering the place more accessi- 
ble and providing for visitors. 

The season extends from the middle of June to Sep- 
tember. During July and August the weather is apt to 
be excessively hot. Yet the air is pure and is generally 
acknowledged to be tonic. Shade-trees on the streets, in 
the park, and in the extensive and attractive courtyards 
of the leading hotels, in a great measure temper the at- 
mosphere and compensate for the absence of a cooler 
climate. Geo. B. Fowler. 


SARCOMA. In defining the various tumors of which 
we have treated in this work, it was possible to compare 
them with some normal tissue, either in the character or 
in the arrangement of the cellular elements. We come 
now to the consideration of a tumor most forms of which 
do not agree, either in structure or in the character and 
arrangement of the cells, with any of the tissues of the 
adult body. The sarcoma has most similarity in struct- 
ure to the connective tissue, and its affinity to this is 
still more clearly shown by the fact that it always origi- 
nates in this tissue. ‘The chief difference between the 
sarcoma and the other connective-tissue tumors is that 
the connective tissue which forms the type of the sar- 
coma is represented, not by the adult, but by the em- 
bryonic form of this tissue. The different varieties of 
sarcoma may be said in a general way to represent the 
different phases which the embryonic connective tissue 
passes through in the course of development. This dif- 
ference between the embryonic and the adult connective 
tissue is chiefly found in the greater abundance of cells 
in comparison to the formed material, the intercellular 
substance; and a similar difference exists between the 
sarcoma and the fibroma. In the fibroma we have a tu- 
mor composed of a tissue which in nowise differs from 
the adult connective tissue, and which cannot be distin- 
guished from it, macro- or microscopically. The same 
-is true of the osteoma and chondroma. The tumors are 
typical. The sarcoma may not differ from the fibroma, 
save in the number of its cells, nor from the osteoma or 
chondroma, save in the fact that the bone or cartilage in 
the tumor is atypical, as compared with the adult tissues, 
and resembles that formed in the first stages of the evolu- 
tion of the skeleton. We may have different species of 
sarcoma, which are more unlike each other than two tu- 
mors of wholly different names. 

The tumors which are now included under the term 
sarcoma were formerly known under a great variety of 
names. The name sarcoma is a very old one, and was 
used to describe all manner of fleshy growths (cdpé, flesh). 
Galen described under this name fleshy polypi of the na- 
sal cavity, and afterward all sorts of fleshy growths ; 
and later. authors used the term to describe all growths 
which had the appearance and consistency of muscular 
tissue. Still later the conception was extended until, at 
the beginning of the present century, it came to include 
every sort of tumor which had not a cystic struct- 
ure, or was not extremely hard, or had not an especial 
tendency toward ulceration. The influence of Abernethy 
was felt in this ; he proposed to make a very large group 
of tumors, which received the general name sarcoma, 
and which was further subdivided, according to general 
appearances and clinical course, into a number of species. 
Only the cystic tumors, the exostoses, and cancers were 
left out. As soon, however, as the tumors began to be 
studied histologically, those for whose tissue a type could 
be found in some one of the adult tissues were separated 
from what had been known generally as sarcomas, and 
an attempt was made to abolish this name. Still, it was 
found that many tumors did not agree exactly with the 
forms of connective tissue, though they were evidently 
derived from it. Lebert, in France, designated the most 
common of the sarcomas, and the one most frequently 
taken as a type of the tumor, the spindle-cell sarcoma, 


fibro-plastic tumor. Robin separated from the general 
group certain tumors which, though having much anal- 
ogy with the fibro-plastic tumors, yet in their structure 
more nearly approached that of the embryonic tissues, 
and to these he gave the name embryo-plastic. In Eng- 
land, Paget, studying the tumors more from a clinical 
than a histological stand-point, found certain tumors 
which, though similar in appearance to the fibromas, dif- 
fered from these by their greater malignity, as shown by 
a tendency to return after removal. To these he gave 
the name of recurrent fibroid. Paget named other tu- 
mors, from the similarity of their structure to the marrow 
of bones, myeloid tumors. We owe to Virchow the first 
scientific classification of these tumors; and his views, 
as expressed in his ‘‘ Geschwiilste”’ (1864), have since 
then undergone but slight modifications. 

We will first consider the sarcoma as a single tumor, 
then under separate heads the various varieties. The 
sarcoma, in general, is distinguished from all other tu- 
mors by the abundance of its cells; and the diagnosis of 
the particular species is in great part made from the 
character of these cells. In the case of the simple tu- 
mors of the histoid group, as the fibroma, myxoma, etc., 
the diagnosis is made, not so much from the character 
of the cells as from the tissue which they produce, In 
the carcinoma and other tumors of the epithelial type, 
the diagnosis is made, not only from the character-of the 
cells but by their grouping. The great strength of Vir- 
chow’s description of the sarcoma lies in his comparison 
of the tumor to embryonic tissue. JBillroth does not 
agree with him in this, hut considers the sarcoma-tissue 
as most similar to embryonic muscular tissue. This ap- 
plies especially to that variety of sarcoma which is com- 
posed of spindle-cells. The type of the sarcoma-tissue 
may also be found in the adult tissues, in some patholog- 
ical conditions. The tissue covering the floor of an ul- 
cer, the granulation-tissue wherever found, is similar to 
the tissue of some of the sarcomas. This granulation- 
tissue passes through the same steps in the formation of 
connective tissue as does the embryonic tissue. In its 
earliest form it is composed almost entirely of cells which 
present some differences of form, and whose general 
character is represented by a round cell about the size of 
a leucocyte, with a relatively large nucleus. Not infre- 
quently large protoplasmic masses, containing many nu- 
clei, may be found in this tissue. The blood-vessels are 
peculiar in that, in many cases, they appear to represent 
nothing but channels surrounded by cells, and are alto- 
gether lacking in a supporting meshwork of connective 
tissue. Granulation-tissue varies in some degree in the 
various tissues in which it arises; that coming from the 
marrow of bones, as in cases of fracture, etc., is similar 
to the embryonic marrow. We may have represented 
by it not only the general type of the sarcoma, but also 
some of its distinct species. The difference between the 
sarcoma and the inflammatory granulation-tissue is to be 
found, not in the histological character of each but in the 
termination to which each tends. When the granulation- 
tissue is produced in consequence of a wound or a chronic 
disease of the bone or articulation, it never passes beyond 
a certain point of growth, tends to the production of a 
typical tissue, and ceases to be when the conditions which 
favored its development no longer exist. In all cases a 
tendency to, or a beginning production of, a typical 
formed tissue can be seen in some part of the granula- 
tions. In the sarcoma, on the other hand, there is no 
such tendency to the production of tissue, but the cells 
simply increase in numbers. The character of the cells 
of a sarcoma is but slightly influenced by its seat ; every 
variety of cell may be found in tumors arising from the 
subcutaneous cellular tissue. 

The close connection of the sarcoma with the typical 
connective-tissue tumors is further shown by the forma- 
tion of mixed forms with these. In a fibroma the whole 
tumor, or certain parts of it, may contain more cells 
than can be regarded as typical for fibrous tissue; In 
other words, it approaches the type of connective tissue 
found in the embryo. This connection with sarcoma 1s 
expressed by the compound name fibro-sarcoma, myxo- 


285 


Sarcoma. 
Sarcoma, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


sarcoma, etc. Virchow says that a tumor may also rep- 
resent a mixed form between the sarcoma and carcino- 
ma, in which certain parts are sarcomatous and others 
carcinomatous. Such tumors he has named sarcoma 
carcinomatosum, and he ascribes to them the malignity of 
both the sarcoma and the carcinoma. He does not think 
that in such cases the tissue of the sarcoma passes over 
into that of the carcinoma, but that they both develop 
simultaneously from the same tissue, growing like two 
branches of the same stem. When we regard the carci- 
noma as a pure epithelial tumor, and the sarcoma as a 
connective-tissue tumor, such combined forms must seem 
extremely improbable, and the tumors in which such a 
combination appears to exist will be found, on careful 
examination, to be either carcinomas with a stroma very 
rich in cells, or sarcomas in which the arrangement of 
the cellular elements resembles somewhat the alveolar 
structure of the carcinoma, the alveolar sarcoma of Bill- 
roth. 

Regarding, then, the sarcoma as a pure connective- 
tissue tumor always arising in this, it will be seen that 
it holds the same relation to this tissue that the carcino- 
ma holds to the epithelial tissue. Both are atypical tu- 
mors, the sarcoma showing this departure from the regu- 
lar type of connective tissue by the abundance of its 
cellular elements, and the carcinoma showing its depart- 
ure from the type of epithelial tissue by the number and 
arrangement of its cells. Hach may begin as a typical 
tumor. The sarcoma may first appear as a fibroma, and 
then, by an excessive development of cells, without any 
further development of formed tissue, become a sarcoma. 
The carcinoma may in like manner begin as an adenoma, 
and become atypical by the epithelial cells forming solid 
cylinders and growing into the connective tissue. There 
may be the mixed form of adeno-carcinoma, just as there 
may be the mixed form of fibro-sarcoma. The sarcoma 
bears the same relation to the fibroma that the carcinoma 
bears to the adenoma, but between the sarcoma and the 
carcinoma we have not only a morphological, but a histo- 
genetic, difference. 

No one sort of cell can be regarded as typical of the 
sarcoma. Almost every variety of cells may be met 
with, and even in the same tumor there may be found 
round cells similar to the granulation-tissue, spindle- 
shaped, and giant cells. The form of the cells, in great 
part, depends upon the physical conditions to which they 
are subjected in the tumor. When the intercellular sub- 
stance is relatively abundant, and fluid or semifluid, the 
cells are subjected to the same pressure in all directions, 
and they are then round. When the intercellular sub- 
stance exists in but small amount and is more or less solid, 
the cells are then pressed against one another, and they 
take various shapes. If the pressure is exerted laterally 
they become elongated and spindle-shaped. On such cells 
facets can often be seen, caused by the pressure of oppos- 
ing surfaces. The different characters of the cells may 
best be studied on small pieces of the tumor which have 
been macerated for along time in one-third water and 
two-thirds alcohol, as recommended by Ranvier, or in 
Miller’s fluid. The latter method gives in many cases 
excellent results. 

Spindle-cells are found more often than any other sort 
of cells in sarcomas. These are long cells terminating 
in long pointed extremities. In the middle the cell is 
swollen and contains a single nucleus, and rarely more 
than one. The nucleus is more refractive than the re- 
mainder of the cell, and often contains a bright nucleo- 
lus. In’some cases more than one process is given off 
from an extremity, giving the cell something of a stellate 
appearance. ‘These cells may vary a good deal in char- 
acter in the different tumors. In many cases cells are 
found which present a spindle appearance only when 
viewed in profile; on the side they appear as flattened 
epithelial scales. These cells are formed by pressure on 
the sides. Stellate cells are often found with long, 
branched processes, which may communicate with neigh- 
boring cells. The round cells vary much in size and 
general character ; some are found which are about the 
size of white blood-corpuscles, and contain a nucleus 


286 


which is very large in comparison with the cell. In 
other tumors large oval cells, closely resembling epithe- 
lial cells, are found, and between these two extremes 
there may be numerous other varieties. 

Whatever may be the character of the sarcoma-cells, 
they are always in the closest connection with the con- 
nective tissue. Even in those tumors which are richest 
in cells there is always a certain amount of intercellular 
substance between the cells, and there is not the same 
sharp contrast between the cells and the stroma which 
carries the blood-vessels, that exists in the epithelial tu- 
mors. In these the cells are arranged in groups like 
the glandular organs, with the stroma surrounding the 
groups of cells, but not entering into them. This isa 
diagnostic point of the greatest importance between the 
sarcoma and the carcinoma. Even in the case of the al- 
veolar sarcoma the separation of the cells into alveoli is 
only apparent, and on closer examination it will be 
found that small masses of connective tissue, and even 
blood-vessels, enter into the alveoli. 

Of late numerous growths, which were formerly con- 
sidered under the sarcomas, have been removed from the 
list of true tumors. This is the case with the pearly nod- 
ules which are found on the serous surfaces of cattle, 
and which Virchow placed among the sarcomas. They 
have been shown to be identical with tubercle-nodules, 
and to be due to the specific virus of tuberculosis. The 
same thing is true of actinomycosis. Before it was known 
that this disease was caused by a definite organism, the 
large tumor-like masses which it produces in the jaws of 
cattle were classed with the sarcomas, as a species of osteo- 
sarcoma, anditis probable that there may be other tumors, 
now classed with the sarcomas, which will be shown to 
be due to a specific virus. 

All sarcomas are very vascular, and, as a rule, only the 
larger vessels have any considerable amount of connec- 
tive tissue around them. The smaller vessels are in di- 
rect contact with the cells, they are more voluminous 
than vessels of a similar character in normal tissues, and 
their walls are composed of cells which in many cases 
are similar to those of the tumor. On section they ap- 
pear simply as spaces surrounded by the tumor-cells. 
They are similar to the vessels found in granulation-tis- 
sue. The close connection between the cells of the tumor 
and the blood-vessels is of great importance, and explains 
the course taken in the formation of metastases, 

In forming a classification of sarcomas, the only basis 
that we have is the character of the cells. As said be- 
fore, there may be different forms of cells in the same 
tumor, but one type will be found to be dominant. When 
divided into different species in this way, it will be found 
that, though there are a good many points of similarity 
in histological character, a study of the clinical features 
of each species will make these differences in structure 
still more evident. Some of the forms into which they 
may be divided will be found to be of much more clin- 
ical importance than others. The classification which 
we have adopted, one based principally on the character 
of the cells, is as follows: 

1. Round-cell sarcoma syn. ; granulation-sarcoma, sar- 
come encephaloide, lympho-sarcoma, embryo-plastic tu- 
mor. A tumor composed of a tissue similar to that of 
the upper layer of granulations. The cells are round, 
and there is a very small amount of intercellular sub- 
stance between them. 

2. Spindle-cell sarcoma; syn., sarcome fasciculé, fibro- 
plastic tumor, recurrent fibroid. A tumor composed of 
spindle-cells which are generally arranged in bundles. 
The intercellular substance is small in amount. 

3. Myeloid sarcoma. A tumor composed of cells simi- 
lar to those in the bone-marrow, and among these large 
multinuclear, protoplasmic masses known as giant-cells. 

4, Osteo-sarcoma. A tumor somewhat resembling the 
myeloid sarcoma, but in which there is a tendency for 
the embryonic tissue to organize and form more or ‘less 
complete bony masses. 

5. Melano-sarcoma. A tumor whose cells contain a 
dark-brown or black pigment, which differs from the pig- 
ment formed from blood-extravasations. j 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. SARCauS 


Sarcoma. 


6. Alveolar sarcoma. A tumor composed of cells often | cells are large and have more the appearance of epithe- 
resembling epithelium, and having, in the arrangement | lial cells, the malignant course is not so pronounced. 
of the cells into alveoli, some similarity to the carcino- | Most of the tumors known as encephaloid come under 
ma, but with the difference that the separation of the | the head of round-cell sarcomas. The term encephaloid 
tissue into cell-masses and connective tissue is not abso- | refers simply to the pulpy, brain-like character of the 


lute as in the carcinoma. tumor, due to the number of the cells and the softness of 
7. Angio-sarcoma. A tumor which combines an ex- | the material between them. 

tensive new formation of blood-vessels with an active The spindle-cell sarcoma is more frequently met with 

growth of the cells forming their walls. than any other form, and this tumor has been generally 


Some authors. have subdivided the sarcomas still fur- | regarded as the type of the sarcoma. The tissue of the 
ther, making twelve or more species. The division here | tumor is arranged in fasciculi, and this is so evident 
given will embrace most of the forms of sarcoma. The | that it has given rise to many of the names which the 
mixed forms, with other tumors, have already been | tumor bears. This arrangement into fasciculi can best 
treated of. See Fibroma, Myxoma, etc. Any classifica- | be studied by roughly tearing apart tumors which have 
tion that can be made, either from the histological or | been hardened in alcohol. The trabeculae are composed 
from the clinical features, is at best an artificial one, and | of spindle-cells and fibrils, all running in the same direc- 
cases are often found in which it is difficult to say to | tion. Often several of these fasciculi seem to arise from 
which one of the species mentioned it belongs. the same point, and take a more or less spiral course. 

Round-cell sarcoma. The cells of which this tumor | They run through the tumor in every direction, and are 
is composed may be very small, resembling those found | sharply separated from one another. Sections made 
in granulations, with a nucleus almost entirely filling the ' through the tumor cut them in every plane. When the 
body of the cell, or may be section cuts one of them at a 
larger, similar to some epithe- : pare right angle, it no longer ap- 
lial cells. They are round and pears aS a spindle, but as a 
surrounded by an inter-cellular round? "cell? aA 
substance which is very soft or blood-vessel gen- 
semi-fluid. On section of the erally traverses 
fresh tumor a small amount of the centre of one 
juice, more transparent than of these bands, 
that which comes from a carci- and in its walls 
noma, escapes; but after the every transition 
tumor has been kept for between the thin 
from twelve to twenty- wall of a capillary 
four hours, and the inter- and the thicker 
cellular substance has wall of an artery 
been softened by cada- or vein can be 
veric changes, this seen. The smaller 
juice is more abun- of them consist of 
dant. It is prob- é endothelial tubes, 
able that the inter- £ the cells compos- 
cellular substance 7 ing which can be 
is not naturally seen without treat- 
‘fluid, but of a ment with nitrate of 
jelly-like consis- silver. Besides these 
tency; or if fluid, it is held in the vessels passing through 
meshes of the tissue just as the fluid is the bundles, others will 
retained in dropsical tissues. When be found which surround 
the fresh fluid is examined large num- them like a long spiral. 
bers of cells will be found init. In Both the cells and the nuclei 
many cases the amount of fibrillar of the endothelium are much 
connective tissue is so small, that it larger than in normal vessels. 
is only by careful shaking and brush- Their nuclei, especially, are 
ing the section that it becomes visible. te eo pee apt PU le 
Some of this connective tissue is un- a eee above the level of the cells, anc 
doubtedly newly formed, but part is ot Silat eae igetensinin ach gore are seen in the lumen of the tube 
the old connective tissue of the place Fluid. x 300. as slight elevations, As a rule, 
of origin of the tumor, simply pushed : these blood-vessels are much wider 
apart by the rapidly-growing cells. Some spindle-shaped | than vessels ofa corresponding structure in normal tis- 
cells are always seen, either around the larger groups of sues. Either the entire vessel may be wider, or there may 
round cells or along bands of connective tissue. When | be dilatations at intervals, which may reach a considera- 
a thin section has been shaken for a long time in a test- | ble size. The spindle- or oat-shaped cells, of which the 
tube with water, most of the cells will be washed away, | tumor is principally composed, early attracted attention 
and if the section has been examined before this, one | when the histological structure of tumors began to be 
will be surprised at the amount of connective tissue | the subject of systematic study. For a long time they 
which is now visible. There may be an almost perfect | were considered as characteristic of the sarcomas and of 
reticulum, which can surround every cell in much the | the malignant tumors In general. These cells are not al- 
same way as in a lymphatic gland. The blood-vessels are | ways pure spindles in shape, but often show various tran- 
always very large and abundant. They seldom have nor- | sitions approaching the stellate form. They consist of an 
mal vascular walls, and on section appear as spaces be- elongated mass of protoplasm, which at each extremity 
tween the cells. Only the larger ones are surrounded by | runs out intoa long, thin process. Sometimes two or more 
any connective tissue. Along these vessels, and gener- | processes are given off from a single extremity, and these 
ally throughout the tumor, blood extravasations are com- | 1n turn may have lateral processes. The surface of the 
mon. The connection of the tumor with the surrounding | cell is rarely perfectly round and smooth, but is indented 
tissues is a very close one, and it is often difficult to say in various ways, and may be flattened into a ae 
just where the tumor ends. The most striking resem- | nous form. The protoplasm of the cellis finely granular, 
blance between this tumor and an inflammatory focus is | and more refractive than that of the white blood-cor- 
often seen. These round-cell sarcomas are very malig- | puscle. Occasionally one or more fat drops are outs i 
nant; they grow rapidly and diffusely, invading the sur- | a cell. The nuclei are ordinarily visible EA. the fhe 
rounding tissues, and produce metastases. When the | of acetic acid or any coloring agent. They lie in 


287 


f 


Sarcoma, 
Sarcoma. 


middle of the cells and occupy the entire body of the cell 
at this point. Rarely more than one nucleus is found in 
a single cell. The cells are not always of the same size, 
even in the same tumor. The smallest of them are about 
15 w long and 5. broad, while in other cases they are 
100 w long and 15 to 380 broad. This difference in the 
size of the cells has led to a division of the tumor into 
large and small spindle-cell forms. In general the cells 
are smaller in those tumors which have the most rapid 
growth, or in those parts of a tumor where the growth is 
most recent. The cells all lie in the same direction in 
the bundles, dovetailed into one another, with the largest 
part of one cell in contact with the smallest part of its 
neighbor. In a perfectly fresh tumor it is difficult to 
separate the cells from each other. A certain amount of 
fibrous tissue is always to be found in these tumors, and 
even in the bundles where the cells Jie thickest careful 
observation will show some fibrils between the cells. 
These fibrils often appear to be in direct continuity with 
the cells. The name fibro-plastic was given to this tumor 
on account of the supposed tendency of the spindle-cells 
to form fibres. Bands of connective tissue in which the 
cells are very numerous, are sometimes found between 
the larger cell-bundles. The slower the growth of the 
tumor, the more connective tissue is found in it. The 
spindle-cell sarcomas vary much in density, but are al- 
ways much firmer than the round-cell form. Some of 
them are fully as hard as a myoma, and on section re- 
semble this very much. The firmness of the tumor de- 
pends upon the amount and character of the intercellular 
substance. In the fresh state the cells are difficult to 
isolate, and on scraping the cut surface a clear, trans- 
parent fluid, containing but few cells or fragments of 
cells, will be obtained. 

The myeloid sarcomas are soft tumors whose tissue is 
similar to that of the embryonic bone marrow. The 
cells lie in close relation with each other, and the inter- 
cellular substance is small in amount and more or less 
fluid. Some of the cells are small and spherical, like 
those of embryonic bone marrow, and like the early em- 
bryonic cells in general. They have little protoplasm in 
comparison to the size of the nucleus, and are similar to 
those described in the encephaloid sarcoma. Sometimes 
numerous spindle-cells are found, but these have not the 
definite arrangement into bundles that is found in the 
spindle-cell sarcoma, and their processes are not so long. 
There are other cells, which though sometimes met with 
in other species of sarcoma, more properly belong here. 
These are large protoplasmic masses containing a great 
number of nuclei, frequently one hundred or more, and 
have received the name of giant cells. They are found 
in considerable numbers in embryonic bone marrow, but 
never reach the size that is met with in tumors. They 
may be round, or oblong, or irregular in shape, and pro- 
vided with numerous processes. The nuclei are some- 
times arranged at one or both ends of the cell, or may be 
packed closely together in the middle. They are rarely 
scattered evenly through the cell-substance. The typical 
arrangement of the nuclei along the periphery of the 
cell, with their long axes pointing to the centre, which 
is so often found in giant cells elsewhere, notably in tu- 
bercles, is seldom found here. These cells may fall from 
their places in sections, and the empty spaces which were 
occupied by them may give the tissue an alveolar appear- 
ance. It is not uncommon to find them in great num- 
bers in one part of the tumor, while other parts may not 
contain them at all, or only isolated examples scattered 
here and there in the tissue. The nuclei of these cells 
are large and refractive, and in most cases can be seen 
without the aid of any reagent. The cell-substance itself 
is composed of a thick, finely granular material, which 
frequently has a slight yellowish or greenish tinge; in 
these cases the cell may be so dense that the nuclei only 
appear when the protoplasm has been rendered more 
transparent by acid. ‘The size which these cells fre- 
quently attain fully justifies their name. They may 
reach a diameter of one-fifteenth to one-tenth of a milli- 
metre or more, and can be seen with the unaided eye. 
Although most frequently found in the myeloid sarcoma, 


288 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


they are often found in the other varieties also, especial- 
ly in the spindle-cell sarcoma. The myeloid sarcomas 
are almost always seated in a bone, and originate in the 
marrow. They gradually destroy the bone, but as the 
tumor grows a new capsule of bone is formed around it. 

Osteo-sarcoma. See Osteoma. 

Alveolar sarcoma. This name was first used by Bill- 
roth to designate certain sarcomas whose histological 
structure somewhat resembled the carcinomas, in that 
the cells were grouped together into alveoli. So striking 
is the similarity to carcinoma, that Billroth himself 
says that in many cases he is unable to make the dif- 
ferential diagnosis, It has been contended by many pa- 
thologists that the term was a misnomer, and that any 
tumor of such a structure must be a carcinoma. How. 
ever similar the structure of the two tumors may be, a 
careful investigation will always show points of differ- 
ence. In the strictest sense, no sarcoma has the alveolar 
structure of the carcinoma. Still, tumors which cer- 
tainly originate in the connective tissues, and which, 
from their general structure, must be regarded as con- 
nective-tissue tumors, are occasionally met with, which, 
on a superficial examination, appear to have an identi- 
cal structure with carcinoma. The cells are round or 
irregular in shape, are very similar to epithelial cells, 
and are arranged in groups which are surrounded by 
connective tissue. These groups of cells may be smaller 
or larger in the different tumors, and the connective tis- 
sue also varies in amount. In all cases the tissue around 
the groups of cells is richer in cells than ordinary con- 
nective tissue, and may be composed of spindle-cells. 
On closer examination it will be found that the connec- 
tion between these groups of cells and the tissue around 
them is much closer than is the case in carcinoma. 
When thin sections are made of carcinomas which have 
been hardened in alcohol, it will be found that in many 
cases the groups of cells have fallen out in the manipula- 
tion of the specimen, or have shrunken, leaving the con- 
nective tissue around them as a sharp, clear line. On 
shaking such sections in a test-tube with water, or care- 
fully brushing them, it is possible to remove all the 
groups of cells, leaving the connective-tissue framework 
intact. In specimens which have been injected, it is 
never possible to follow a blood-vessel into an alveolus. 
In the alveolar sarcoma the case is different. It is never 
possible to remove the cells as completely and easily as 
can be done in acarcinoma. After brushing the speci- 
men to remove as many of the cells as possible, it will 
be found that fine filaments of connective tissue enter 
into the apparent alveolus, and in some cases every cell 
is enclosed in a delicate meshwork. This is much bet- 
ter seen when the section is examined in water, as the 
fine fibrils are more refractive in this than in any other 
medium. The difference between the two tumors is also 
apparent from a careful macroscopic examination. On 
scraping or squeezing the cut surface of an alveolar sar- 
coma, a juice will be obtained which is never so abun- 
dant as that which comes from a carcinoma so treated, 
and on microscopic examination of this juice, numer- 
ous cells of various shapes and sizes will be found in it, 

The compact groups of cells so often found on exami- 
nation of the juice from a carcinoma, and which evi- 
dently represent the contents of an alveolus, will not be 
found. These tumors are very vascular, the connective 
tissue between the alveoli contains numerous large blood- 
vessels, and fine capillaries given off from these pene- 
trate the alveoli. ‘The tumor is frequently found in the 
testicle, and the soft and rapidly growing tumors of this 
organ generally belong to this variety. 

The most malignant of the sarcomas, and in many re- 
spects the most malignant tumor that is met with, is the 
pigmented sarcoma, the melano-sarcoma. This is char- 
acterized by the presence of a dark pigment, similar to 
that in the choroid of the eye, in the cells. The melan- 
otic sarcomas, as a rule, appear only in places where 
some pigment in the connective tissue is normally pres- 
ent, as in the choroid of the eye and in the skin ; they 
have also been seen in the lymphatic glands. Other sar- 
comas containing pigment may be mistaken for these 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sarcoma. 
Sarcoma. 


tumors. Heemorrhages are common in every variety of 
sarcoma, and the blood-pigment which results from this 
and is taken up by the cells may be mistaken for the es- 
sential melanotic pigment. In these cases, besides the 
pigment in the cells, some will be found free. This free 
pigment either results from the breaking down of cells 
which contained it, or it is formed by a metamorphosis of 
the blood-pigment which has taken place, not in the cells, 
but in the interstitial tissue. In both this accidental and 
the essential autochthonous pigmentation, the pigment- 
granules may be brown or dark-brown, and in some cases 
it is not easy to decide, except by a careful examination, 
what the nature of this pigment is. In the melanotic 
sarcoma in course of development, all of the cells are 
not impregnated with pigment, and in no case do all the 
cells of the tumor contain this pigment in equal amount. 
As arule, asection of such a tumor will show various 
zones of coloration, the color 
being deeper in those por- 
tions of the tumor which 
must be regarded as the old- 
est. The oldest portions are 
black, and the younger por- 
tions on the edge of the 
growth may be only brown- 


\ 


Y) >) * 
aah ; ) 
Pl/ ; 
is zs 
\ Dea 5 f 
w¥i -3,' 
SF eX 
AN eS // fy 
j ONO ig 
‘ 


PITS lire qT 


ish or 
not pig- 
mented at 
all. Although 
this partial pig-: 
mentation is the 
rule, some tumors 
are found which are 
black in their whole 
extent. The pigment- 
granules are most often 
disposed around the nucle- 
us, but they may fill up the 
entire cell. No pigment is ever 
found in the nucleus. The pig- 
ment which results from a meta- 
morphosis of blood coloring matter 
usually has a reddish tinge, which 
is absent in the true melanotic pigment. The cells of 
these tumors have no particular arrangement or form. 
The tumor may present the most typical appearance of a 
spindle-cell sarcoma, but as a rule they belong to other 


of the Testicle. 


forms, the arrangement of the cells into alveoli being | 


especially frequent. When such tumors are scraped a 
blackish, often inky, fluid is obtained, which contains 
many pigmented cells, but also free pigment-granules In 
great numbers. These free granules have an active 
molecular movement. The source of this pigment Isa 
subject which has for a long time occupied the attention 
of pathologists. In the consideration of this question, 
the fact that the tumor rarely originates in tissues except 
those in which pigment is normally present, is of the first 
importance. As we have said before, the favorite places 
of origin are the choroid of the eye and the skin. It 


_Vou. VI.—19 


Fig. 337%7.—Section of an Alveolar Sarcoma 


x 400. 


does not appear primarily in the other pigmented tissues 
of the body, as in the liver, the supra-renal capsules, and 
the seminal vesicles. The pigment is very similar to 
that found in the connective-tissue cells of the corium in 
the negro race. -Virchow believes that the pigment is 
formed in the cells themselves as the result of their own 
metabolism. This view is the one in favor of which 
most facts speak, and is the view most generally ac- 
cepted. Gussenbauer, on the other hand, believes that 
the pigment is formed directly from the blood-pigment, 
and calls attention to the frequency with which hemor- 
rhages are found in such tumors. Most strongly against 
this view speaks the fact that the secondary tumors ak 
ways show the same sort of pigmentation as do the pri- 
mary. Inno tumors are such minute metastases found 
as in these, some of the secondary growths being com- 
posed of but a few dozen cells, and being evidently of 
such a recent date that 

sufficient time would 

pelos not have been given 
Li LL for the formation 
: x of pigment from 
blood extravasa- 
tion, even were 
extravasation 
present.  Be- 
sides this, 
blood extra- 
vasations 
cannot be 
said to be 


more 
common 
in the mel- 
anotic sarco- 
ma than in any 
other. Akerman, 

in his interesting 
monograph on sarcoma, 
has called attention to the 
situation of the pigment in Ad- 
dison’s disease, and of the pigment 
which is often found in the skin of 
certain parts of the body of dark-skinned 
people. These pigment-cells lie in the 
neighborhood of the small vessels of the skin, are of long 
spindle shape, and contain a diffuse or granular brown 
coloring matter. He supposes that these pigment-cells 
are specific and have no connection with the ordinary 
cells of the connective tissue, and that the melanotic tu- 
mor may arise from a proliferation of these cells. In the 
skin the tumor most often originates from small, congen- 
ital, pigmented nevi. Many of these, which are to all 
purposes perfectly benign, show on section the most 
typical sarcomatous structure. In connection with these 
tumors, Virchow calls attention to the melano-sarcomas 
in horses. It is a well-known fact that white and gray 
horses are especially subject to these tumors, which ap- 
pear principally on the tail or around the anus. The tu- 
mors have not the malignant course that similar tumors 
have in man, and ordinarily do not reappear after com- 


289 


Sarcoma. 
Sarsaparilla. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


plete excision. A tendency to the development of these 
tumors is transmissible in high degree, especially by the 
stud; the offspring, both male and female, especially 
those of a whitish color, being liable to it. Virchow sees 
in the absence of color in such horses a weakness or lack 
of resistance in the skin. 

The angio-sarcoma is a tumor formed by an extensive 
development of blood-vessels and a sarcomatous growth 
of their walls. The tumor appears to be made up of long 
filaments, which are loosely attached to each other and 
may be isolated for considerable distances. ach fila- 
ment contains a blood-vessel in its centre, and around 
this an extensive formation of cells. There is no distinct 
wall to the vessel, save that formed by the tumor cells. 
The cells are distinctly epithelial in appearance, and are 
divided into groups by the formation of capillaries. This 
tumor may develop in any part of the body, grows rap- 
idly, reaches a large size, and is very malignant. The 
metastases which result from it have the same general 
structure as the primary tumor, but the arrangement of 
the blood-vessels with the cells surrounding them is not 
so well marked. 

After this description of the histological structure of 
the different forms of sarcoma, we will consider the tu- 
mor more as a whole, especially its macroscopic clarac- 
ters, most frequent seat, clinical course, etc. 

The growth and the general clinical characters of the 
sarcoma are so different in the several forms that we can 
find in this group of tumors representatives of completely 
benign as well as of the most malignant growths. Beyond 
doubt, in this regard, the separate varieties of the tumor 
have individual characteristics. The pigmented sarcomas 
may be regarded as the most malignant of tumors, not only 
on account of their local destructiveness, and rapid and un- 
limited growth, but also from their tendency to form me- 
tastases. The small-cell encephaloid varieties are but lit- 
tle behind these in malignity. The osteo-sarcomas come 
next, and the spindle-cell and myxo-sarcomas are in gen- 
eral only malignant locally. The spindle-cell sarcoma is 
the more malignant the smaller are its cells, and the 
more numerous they are in proportion to the amount of 
intercellular substance. Asa rule, it does not form me- 
tastases, but cases in which extensive secondary growths 
appear arenot uncommon. When the sarcomas are com- 
pared with the other tumors of the connective-tissue type, 
it is evident that they have a much greater malignity, and 
this is shown in all by their tendency to return after extir- 
pation. This tendency to local return, even in’ cases in 
which the entire tumor and much of the surrounding 
apparently healthy tissue have been removed, shows that 
the sarcoma is not a sharply circumscribed growth: The 
microscopic investigation of the periphery of sarcomatous 
tumors will often show that the tumor-cells have entered 
much more deeply into the surrounding tissue-spaces than 
is apparent on a mere macroscopic examination. The cells 
not only have an extreme degree of proliferative energy, 
but the tissue of the sarcoma, which is so much looser 
than that of any typical connective-tissue tumor, favors 
this outward growth of the cells. In addition to this 
direct outgrowth of the cells into the tissues, it is very 
probable that the cells of many sarcomas have the power 
of amceboid movements. This would explain the pres- 
ence of small foci separated by a greater or less interval 
from the parent tumor. Virchow advances the view that 
the sarcoma cells can excite the cells of the tissues with 
which they come in contact to a similar growth. This 
can take place both about the original tumor and in those 
places where the cells may be carried by the blood and 
lymph currents. Most of the recent authors do not ac- 
cept this view as to the mode of formation of secondary 
tumors, but believe that these result from a direct growth 
of the cells or collections of cells which have been carried 
from the tumor and deposited in distant organs. The 
power of the sarcomas to produce secondary metastatic 
nodules in the most different organs is not confined to 
any special species, though some show a much more de- 
cided tendency in this direction than others. In some 
cases the secondary nodules are of such small size, and 
appear in so many places in the body, that the condition 


290 


is known as sarcomatosis. These nodules, from their 
very small size, may be mistaken for miliary tubercles. 
The path of the metastases is almost always along the 
blood-vessels, the sarcoma in this again contrasting with 
the carcinoma, in which metastases follow the lymphatics. 
Although this mode of infection is most common in sar- 
coma, there are exceptions in which the lymph-glands are 
early infected. This is notably the case in sarcoma of 
the bones. The course that the metastasis usually takes 
is easily explained, when we consider how intimate the 
relation is between the cells of the tumor and the blood- 
vessels, the latter being in many cases without essential 
walls, and representing little more than channels be- 
tween the tumor-cells. It is by no means rare to finda 
sarcoma growing directly into a large vein, and it may 
extend in this for a considerable distance as a long, fleshy 
polypus, moving freely in the blood-stream, and appar- 
ently nourished by the surrounding blood.  Billroth 
mentions a case in which a sarcoma of the testicle grew 
into the spermatic veins, some of its cells being carried 
thence through the inferior cava into the heart, and pro- 
ducing numerous metastases inthe lungs. As we should 
suppose, metastases are most commonly found in the 
lungs, and next in the order of frequency come the 
spleen, the kidneys, and the liver. Infection of these 
organs is generally secondary to infection of the lungs. 
The metastases are often much larger than the primary 
tumor, and are the most frequent cause of death. 

The clinical importance of a sarcoma does not depend 
altogether upon the histological structure. The seat of the 
tumor is of great importance, for it is evident that, when 
seated in an organ whose functional activity is necessary 
for the life of the individual, the tumor may be very dan- 
gerous, even when it does not show any special tendency 
to the formation of metastases. The glio-sarcomas of the 
brain are malignant, though they are always confined to 
this organ. It is also well known that the mediastinal 
tumors are dangerous in consequence of the pressure on 
the great blood-vessels which they exert. This primary 
danger of the tumor in great part depends upon the ra- 
pidity of its growth. In general, it may be said that the 
growth is most rapid, and the tendency to metastases 
strongest, in those tumors in which the cells are smallest 
and most abundant. This growth may be restricted in 
various ways by the local relations of the tumor. The 
sarcomas of the bone grow slowly, and do not produce 
metastases as long as they are surrounded by the bone ; 
but when the surrounding osseous tissue is broken 
through, they show a very rapid growth and produce 
metastases. 

Although, from what has been said, it is seen that the’ 
sarcomas have a greater clinical malignity than the other 
tumors of the connective-tissue type, still, in comparison 
with the carcinomas, they may almost be considered be- 
nign. This is shown, apart from the lesser tendency of 
the sarcoma to metastases, in the influence which the two 
types of tumors respectively exert on the general consti- 
tution. A condition known as the cancerous cachexia is 
the ordinary result of a carcinoma, even when it is con- 
fined to a single organ, while an enormous sarcoma will 
not ordinarily produce such a condition. This difference 
is in great part due to the lesser tendency of a sarcoma to 


‘ulceration, and to the fact that the degree of pain expe- 


rienced from the sarcoma cannot compare with that pro- 
duced by the carcinoma. ‘This lesser tendency to ulcera- 
tion may be explained by the abundant vascularization 
of the sarcoma, and by the slight tendency of its cells to 
degeneration. In still another way is the minor malig- 
nity of the sarcoma, in comparison with the carcinoma, 
manifest. Even those sarcomas which are shown to be 
very malignant in their later course by a general exten- 
sion in the body, have a primary period when they may 
almost be regarded as benign. The carcinoma, on the 
other hand, from the moment it first appears and can be 
recognized as being such, is malignant, and shows this 
by the early infection. of those lymphatic glands which 
stand in relationship to it. The sarcoma in its beginning 
may be a perfectly circumscribed tumor, but the carci- 
noma never is. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sarcoma, 
Sarsaparilla. 


The benign period of the growth of a sarcoma is shown 
by its slow and circumscribed growth. In this early be- 
nign period the entire tumor is often enclosed by a con- 
nective-tissue capsule, and in those developing in bone 
this connective-tissue capsule may be substituted by an 
osseous capsule. The rapidity of the primary local 
growth varies in the different species of sarcoma. In 
many cases the growth is so rapid that we are reminded 
more of the extension of an inflammatory process than of 
the growth of atumor. The tumor itself, in these cases 
of primary rapid growth, is generally a round-cell, en- 
cephaloid sarcoma, and may be very similar, even in its 
histological structure, to an inflammatory focus. 

This primary benign period that a sarcoma passes 
through is of great clinical importance, and shows that 
the tumor should be removed as early as possible. In 
this removal care should be taken not only to remove 
all of the tumorthatisapparent, fA 
but a considerable amount of 
the surrounding tissue as well. 
Even when this appears to be f. 
unaffected, it may contain, at a f} *: 
comparatively early period in the }} 
history of the tumor, long pro- 
longations of tissue extending 
from the tumor. Any of this 
tissue left behind will serve as a 
point of departure for a return- 
ing growth. The known: ten- 
dency of the sarcoma to return, after appar- 
ently complete extirpation, is only to be 
explained by imperfection of its removal. 
When a sarcoma is seated in the marrow of 
bone, it is impossible to say how high up 
the marrow is affected, and in 
this case disarticulation ‘is 
a better operation than 
amputation. 

The seat of the sar- 
coma is most often 
found in the skin 
and subcutaneous 
tissue. In the in- 
termuscular and 
muscular connec- 
tive tissue, in the 
fascia, and _ espe- 
cially in the perios- 
teum, the spindle-cell sar- 
coma is a very common 
tumor. Other varieties of 
the sarcoma show an es- 
pecial predilection for cer- 
tain tissues, as the melano- 
sarcoma for the eye. The 
alveolar sarcoma is most 
often found in the testicle. 
Among the most interest- 
ing sarcomas, from a histo- 
logical point of view, are 
those which develop in 
glands. These almost al- 
-ways include some of the 
glandular elements, which 
undergo various changes of 
form. In general, glandu- 
lar structures show a comparative immunity from the 
development of sarcoma, though there are exceptions to 
this rule. The female breast is often attacked by sarco- 
ma, which forms here large, round, lobulated growths, 
often very elastic to the touch. The tumor grows slowly, 
causes little or no pain, and is separated from the remain- 
der of the gland. On section, small fissures are seen in 
the tumor, and often a mass of tumor-tissue will project 
like a polypus into one of these fissures, and be almost 
surrounded by it. On microscopic examination these fis- 
sures are found to be lined with epithelium, and are cer- 
tainly formed by the dilated and flattened glandular ducts. 
The entire tumor may be enclosed in one of these fissures. 


Fic. 8378.—Smilax Officinalis, H. B. K., the origin of Jamaica sarsaparilla; male in 
plant. 


Cysts formed both by degenerative processes in the tumor, 
and by an accumulation of secretion in gland-ducts, may 
be met with. The growth of these tumors is a very slow 
one, and is painless except when they attain a very large 
size. Many of them have the peculiarity of swelling up 
and becoming more painful during the menstrual period. 
Return after extirpation is not to be feared in young pa- 
tients, but it may occur in patients thirty or forty years 
of age or older. Sarcomas also appear in the salivary 
glands, especially in the parotid, and here they are accom- 
panied by a growth of the epithelium. The inner surface 
of the dura mater, and the substance of the brain or spi- 
nal cord, may be the seat of sarcoma. In the cord they 
may be multiple, one 
case having been seen 
oh by the writer in which 
four tumors, which 
varied in size from a 
small pea to a bean, were 
found at various places 
along the cord. The largest, 
which reached the size of a 
bean, was found in the cervi- 
cal swelling, completely en- 

closed by the cord. 
Concerning the etiology of sarco- 
ma, what little there is to be said will 
be found in the articleon Growths, It 
is an interesting fact that those tumors 
whose structure is most like 
very early embryonic tis- 
sue are most malignant. 

W. T. Councilman. 


vA SARSAPARILLA, U. 
SAMS. Ph. (Sarse Radia, 
le Br. Ph.; Radia Sarsa- 
Eger MINS VW pardiile, Ph. G.; Salse- 
ay" \< hf = pareiile, Codex Med.). 
The long, cylindrical 
roots of several Central 
and South American or 
Mexican species of Smi- 
lax; order, Liliaceae (tribe, 
Smilacee). The Smilax- 

es are perennials, with 
SY, woody, often very 
long and _= slender 
\ roots, and generally 
\ with tough, woody 
\j (rarely herbaceous), 
climbing or wander- 
\f ing stems. These 
| are generally green 
and smooth, or 
“Sq pubescent, round, 
‘ square, or several- 
angled, and armed 
with strong, flat- 
tened, recurved, 
sharp prickles. The 
leaves are alternate, 
generally two-rank- 
ed, petiolate, with, 
uae most species, 
bene a long, strong ten- 
dril, arising on each side of the petiole below the middle. 
Blade usually oval, ovate, or heart-shaped, from ¢hree- to 
five-nerved, reticulate between the principal nerves ; often 
coriaceous, and evergreen. Flowers small, greenish-white, 
in axillary umbels, dicecious or polygamous ; perianth 
three- to six-parted (or more). Stamens in the male 
flower usually six, attached to the bases of the sepals ; 
anthers introrse, apparently one-celled ; pistil rudimen- 
tary—in the female flower, pistil three-celled, with two 
(or one) ovules in each cell ; staminodes six, three, or 
variable. Fruit, a one- or two-seeded berry. _The genus 
contains toward two hundred species of tropical or tem- 
perate plants, some of which make the most impenetrable 


291 


Sarsaparilla. 
Sassafras. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


underbrush. Some are not spiny, a few are not climbers, 
and a smaller number have herbaceous, annual stems. 
The genus is well represented in the United States by 
toward a score of species, among which S. rotundifolia 
Linn., the common Greenbrier, and S. herbacea, the Car- 
rion Flower, with its horribly fetid odor when in bloom, 
are familiar examples. The former is a very good rep- 
resentative in appearance and habit of the medicinal Smi- 
laxes. Of these, it is surprising how little exact knowl- 
edge we have; specimens have been collected of most of 
them, but never in bloom, and the botanical details are 
therefore wanting, so that how much the different varie- 
ties of the drug owe to difference in species, and how 
much to difference in climate or cultivation, cannot in all 
cases be said. 

1. S. officinalis, a large, coarse, woody climber, with a 
short, thickened rhizome, whence are given off numer- 
ous long, cylindrical, horizontal roots, and several or 
many round, erect stems, soon becoming more or less 
angled, and branching into quadrangular, very long, 
flexuose, climbing branches, armed with stout, sharp 
prickles. Leaves very large, or smaller on the upper 
portions of the plant, round, heart-shaped, ovate, or 
broadly lanceolate ; in short, it is like a gigantic green- 
brier. It is a native of New Granada, and appears to be 
the plant introduced into the West Indies. It probably 
yields ‘‘ Jamaica Sarsaparilla.” Female flowers and fruit 
not seen. 

2. S. medica Cham and Schl., a large climber, with 
mostly unarmed angular branches, and frequently auri- 
culate or lobed leaves. It grows in Mexico, and supplies 
the Mexican variety. 

S. papyracea Poiret, with a many-angled stem ; flow- 
ers unknown ; of Guiana and Brazil ; may be the source 
of Para Sarsaparilla, etc. Of several other imperfectly 
known species there is a suspicion of probable connec- 
tion with the drug, but no certain knowledge. 

Sarsaparilla was first carried to Europe about 1536-45, 
and first or early employed as a cure for the same disease 
with which it has been since most generally associated, 
and for which another smilax, ‘‘ China,” had previously 
been used. The use in numerous other slow diseases, 
especially in eruptions and as a ‘‘ blood-purifier” in gen- 
eral, followed, and has continued extensive until the 
present time. Although now it has been nearly discarded 
as a serious medicine by physicians, it is still a much- 
prized popular remedy. 

CoLLECTION.—This has been observed several times, 
and consists in selecting clumps where numerous stems 
indicate plenty of roots, clearing away the dirt and other 
roots around them, and carefully digging up the long, 
whip-like sarsaparilla ; the crowns and remnants are then 
covered with dirt and leaves, and left to sprout again, or 
in some countries collected with the roots. The collected 
roots are simply dried and packed in more or less char- 
acteristic bundles. 

DESCRIPTION.—Sarsaparilla comes in long, simple, or 
sometimes forked, longitudinally wrinkled (when dry), 
flexible, slender, rope-like roots, in some varieties thicker 
in the middle than at either end, often one or two metres 
in length, and from two to five or more centimetres in 
diameter ; surface light or dark brown, with scattered 
fine roots, and sometimes short, velvety hairs. The rhi- 
zome—a dark, irregular, woody ‘‘chump”’”—is present 
in some varieties. ‘The roots vary considerably in their 
plumpness, owing to a very variable amount of starch in 
their tissues, which fact has given rise to their division 
into two general groups: a, Starchy, or mealy—Hon- 
duras, Guatemala, Brazilian, Para, etc.; 6, non-starchy— 
Jamaica, Mexican, Guayaquil, etc. There is no import- 
ant difference in their medicinal qualities, but the non- 
mealy varieties are darker and rather stronger-tasting. 
These varieties are more easily told sometimes by their 
mode of packing than by their individual appearance. 

Honduras Sarsapariiia is pretty plump and smooth, 
with more or less ‘‘ beard.” Near the middle the roots 
contain a thick zone of white, starch-laden tissue. They 
are packed in hanks seventy or eighty centimetres long, 
wound with a flexible root, and bound in bales with 


292 


hide. Guatemala Sarsapariila is yellowish, with a brittle 
bark. Brazilian comes in very large, long, closely 
wound bundles, cut smooth at either end. ‘‘ Jamaica 
Sarsaparilla” (the most esteemed in England, and from 
Central America, instead of Jamaica), isin short bundles, 
half a metre or so long, rather carelessly done up, wound 
like the others by a long, flexible root of the same ; it is 
a slender, deeply furrowed, dark root, brown within as 
well as without. Mezican is pale, not made into bundles, 
and often contains also the chumps and bases of stems. 
Guayaquil comes loose in large bales. It has a large, 
coarse-looking root, accompanied also by the rhizomes 
and some stem-bases.* 

The histology of Smilax roots has been studied with 
more care and detail than their unimportance deserves. 
(See Berg’s ‘‘Atlas zur Pharm. Waarenkunde.”) 

The (endogenous) woody portion is collected in a cen- 
tral core, and surrounded with a false bark of thin- 
walled, parenchymatous, starch-laden cells, of varying, 
often considerable, thickness. The woody column con- 


oo args eR 
Raneacean 


ECA TALES RLS ON 
epee HRA TE 


BN 
Hee 
Sra 


xX 
XS 


ee 


racer ®, iS soa 


RNS TE 


Fre. 3379.—Root of Smilax Officinalis, Enlarged Section. 


(Baillon. ) 


sists of a parenchymatous centre of thin-walled cells, sur- 
rounded by a progressively increasing number of scat- 
tered woody and vascular bundles, compacted into a hard, 
porous wood near the circumference of the column. 
ComposITion.—Most earnest attempts have been made 
to find a tangible and useful active principle in Sarsapa- 
rilla, with only partial success. Starch in most varieties 
is abundant, but unimportant. Hssential oil in minute 
quantity, a little resin, ‘‘ extractive,” etc., may have some 
value, but the most characteristic substance is parillin, 
of which about two per cent. may be obtained. It erys- 
tallizes in white scales or needles, permanent in the air, 
neutral, odorless, at first tasteless, but afterward bitter 
and acrid ; but little soluble in either cold water or alco- 
hol, freely so in hot. It is more soluble than in either 
alone in a mixture of alcohol and water. Parillin is a 
glucoside, yielding parigenin and sugar if treated by di- 
lute mineral acids (Fliickiger). Parillin is, as yet, of 
doubtful composition, but is nearly related to saponin. 
AcTION AND UsEe.—This paragraph will seem short 
compared with the preceding descriptions. Parillin, in 
doses of half a gram or so, produces nausea, vomiting, 
and retardation of the pulse; in larger doses, constriction 
in the throat, weakness, sweating. It has been tried to a 
slight extent in syphilis, without marked results (Huse- 
mann). Sarsaparilla itself, in large doses, only produces 


ee 


* Hanbury and Fluckiger. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sarsaparilla, 
Sassafras, 


gastric disturbance, so from the physiological action of 
this remedy little therapeutic value can be predicated, 
and it probably has not much. Yet, on the other hand, 
not only this, but other products of Smilax (China, East- 


cyrrhiza, 2; Mezereum, 1; water enough to make 100; 
strength 


because used as a vehicle. 


ale 


» 109 


and the Syrup, more used than the others, 
It is composed as follows: 


ern Sarsaparilla, etc.) are used the world over for syphi- nie Se AE cys re tates get ce sl Party 
litic and scrofulous diseases, in the United States perhaps Pak Seepage ONE a Raa ae ee . PP 
less seriously than elsewhere. It does seem possible GI ‘ shite Sih Be ONS Te a Daa tes a vote 
that Sarsaparilla in fair doses is beneficial in some cases g AAR eee A os er aaa “e 2 « 
of dyspepsia or mal-assimilation arising from winter diet Siege a OIE 2S any Go 
or improper food, and hence its popularity in ‘‘ Spring pee Hen ORG Race Coane itr 
medicines ;” but the bitters in general, and some laxatives Gaulth tps Tee Woe. te Py Sane Becca Sa 
(Gentian, Dandelion, Frangula, etc.), are equally or more g ree EGMONT RE 600 ¢ 
efficacious. Its use in ‘‘scrofula” is diminishing. In tions Bet Bop baee 


syphilis it is still a good deal prescribed, especially in 
England, India, etc. 

ADMINISTRATION, —Smilax is never given in substance, 
but the theoretical dose may be stated as from four to eight 
grams (3 j.-3ij.). The best preparations are the Fluid 


oe es 
(ie FSFE 


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(e= 
= a 
oo 5 
IVYoreaSe 


HAN 
ON reg 


PESSy fo (eH 
Sey, 


f 
oO 


Fie, 3380.—Magnified Section of One-half Diameter of Root of Smilax Officinalis. 


(Baillon. ) 


Extract (Hzxtractum Sarsaparille FPluidum, U. 8. Ph.), 
strength, +; the Compound Fluid Extract (Ha. Sarsa- 
partile Comp. Fluid., U. 8. Ph.): Sarsa., 75; Glycyr- 
rhiza, 12; Sassafras, 10; Mezereum, 3; Glycerin, 10; 
alcohol and water enough to make 100; strength, #; the 
Compound Decoction (Decoctum Sarsaparilla Comp., U. 
S. Ph.): Sarsa., 10; Sassafras, 2; Guaiacum, 2; Gly- 


Water and diluted alcohol enoug 
The Infusion and Fluid Extract are the best forms where 
full doses are to be given. 


to make 1,000 parts. 


ALLIED PLANTS.—The suborder Smilacew forms a rath- 
er distinct division of the great modern group collected 


under the name Liliacee ; it includes but little 
more than the great genus Smilax described 
above. China Root, from Smilax China Linn., 
in large, Jalap-like tubers, is used in the East 
for the same purposes as sarsaparilla. For the 
order, see SQUILL. 

ALLIED Drues.—In the treatment of syphilis 
and scrofula, and many of the conditions for 
which Sarsaparilla was once highly esteemed, 
Mercury, Iron, and Iodine have long since taken 
the principal place. There is, however, a long 
list of dubious remedies from the vegetable king- 
dom, which have a reputation, mostly local, as 
‘‘alteratives,” or anti-scrofulous and anti-syphi- 
litic substances; few of them are more than 
household drugs. China, just mentioned, He- 
midesinus or Indian Sarsaparilla, our False Sar- 
saparilla, are among them. Guaiacum, Mezere- 
um, etc., are more generally used ; Colchicum, 
Stillingia, Sanguinaria, Chelidonium, Dulcama- 
ra, and Arsenic also help to fill up this hetero- 
geneous collection. W. P. Bolles. 


SARSAPARILLA, FALSE, Arvalia nudicaulis 
Linn., order Araliacee. This little plant, gen- 
erally known among country-folks and herb- 
gatherers as ‘‘sarsaparilla,” has no botanical 
relation whatever to the preceding drug ; in taste 
and in the shape and size of the roots there is a 
little similarity. It consists of a long, slender, 
perennial root, about as large as a pipe-stem, 
and two or thred metres in length, with a light- 
brown surface and soft, flexible texture. It has 
a rather pleasant, aromatic odor, and an aro- 
matic, somewhat sharp taste. The stems, 
which arise at intervals of from twenty to fifty 
centimetres, are only one or two centimetres 
long, barely emerging from the ground, and 
give rise, each. to one twice ternately or qui- 
nately compound leaf, and one three-branched 
scape supporting three globular umbels of small 
greenish-white flowers. This Aralia is common 
in moist places over most of the United States, 
and is in some popular demand for the same 
complaints that sarsaparilla is reputed to bene- 
fit. Dose indefinite. Composition not known. 

ALLIED PLANTSs.—The genus contains thirty 
species, mostly Asiatic, of herbs, or rather 
shrubs, of mild, indefinite medical properties. 
A. racemosa Linn., American Spikenard, and 
A. quingvefolia D. & P., American Ginseng, 
are other native species employed in popular 
medicine. The Ivy (Hedera Helix) also belongs 
in the family. 


ALLIED DruGs.—See SARSAPARILLA. 


W. P. Bolles. 


SASSAFRAS, U.S. Ph. ; Codex Med. (Sassafras [a- 
dix, Br. Ph.; Lignum Sassafras, Ph. G.). 
officinale Nees, one of the very few plants of the Laurel 
family growing wild in this country, is a medium- or 


Sassafras 


293 


Sassafras, 
Scabies, 


good-sized tree, or, near the northern boundary, a shrub 
or small tree, with irregular, spreading, brittle branches, 
covered like the trunk with rough, furrowed bark, gray 
without, fawn-colored or pinkish when freshly cut, with- 
in, Wood light-colored, with darker heart. Twigs and 
smaller branches _ bright 
green, glossy; pith large, 
very mucilaginous. Leaves 
bright-green, smooth, oval, 
pointed at each end or blunt 
at the apex, entire, or else, 
especially those coming later 
in the sea- 
son, deeply 
three- lobed ; 
bet ween 
these shapes 
are various 
intermediate 
ones, lobed 
on one side, 
and not on the 
other, or merely 
auriculate on one 
or both sides. Both 
kinds of leaves are 
usually seen on the 
same tree. Flowers 
vernal, appearing with 
the leaves, in small ra- 
cemes; small, regular, 
dicecious, yellow. Perianth 
six-parted. Stamens nine; the 
three inner ones glandular at 
the base; anthers four-celled, 
each opening by means of a 
little valve. Pistil one, one- 
celled, with one pendant ovule. 
In the staminate flowers the 
.pistil is rudimentary ; in the pistillate ones there are six 
sterile stamens. Fruit a blue berry, on a reddish, cup- 
shaped receptacle. All parts of the tree are fragrant, es- 
pecially the bark of the root; the growing parts contain 
also considerable mucilage. 

Sassafras has a wide rangé over tlie United States, ex- 
tending slightly into parts of Canada, etc. In many re- 
gions it is very abundant, New Jersey, Pennsylvania, 
Maryland, and Virginia supplying large quantities both 
of the bark and oil. It has been valued since the settle- 
ment of the country, and is said to have been used by the 
aborigines even before. Although its reputation as a 
medicine is a thing of the past, as an agreeable flavor and 
cheap perfume it is in steady demand. There is very lit- 
tle call for the whole root in this country, excepting what 
is used on the spot in the manufacture of the oil; but 
considerable is exported to Great Britain and the Conti- 
nent, the Bark of the Root (technically called Sassafras, 
U.S. Ph.), being preferred. The officinal description is 
as follows: ‘‘In irregular fragments, deprived of the 
gray, corky layer; bright rust-brown, soft, fragile, with 
a short, corky fracture ; strongly fragrant, sweetish, aro- 
matic, and somewhat astringent.” Sassafras Pith (Sassa- 
Sras Medulla) is ‘‘in slender cylindrical pieces, often 
curved or coiled, light, spongy, white, inodorous, insipid. 
Macerated in water it forms a mucilaginous liquid, which 
is not precipitated on the addition of alcohol.” 

Composrrion.—Of the wood and bark : The most im- 
portant constituent here is the essential oil (Olewm Sassa- 
Fras, U.S. Ph.), of which the wood contains perhaps one 
per cent., the bark of the root from two to four per cent. 
It is a heavy (sp. gr. 1.087+-), white, or by age yellow, and 
then reddish-brown, very fragrant liquid, of an agreeable 
aromatic taste and a neutral reaction. Soluble freely in 
alcohol. By the action of cold, or upon standing, it can 
be separated into Safrol, or sassafras camphor, which 
comprises its principal portion, and safrene, a hydrocar- 
bon; both have the same odor. Both bark and wood 
contain also a little tannin, and the bark contains a red 
coloring matter, perhaps derived from the tannin. 


— 


Fie. 3381.—One of the Three- 
lobed Leaves of Sassafras. 
(Baillon.) 


294 


_ Krameria, etc. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sassafras Pith contains a peculiar non-adhesive muczi- 

age. ; 
Ratton AND Us8.—Sassafras, like Cinnamon, to which 
it is related, is an aromatic tonic and carminative, with 
little or no peculiarity of action to distinguish it from 
others of its class. It is said to be a stimulating diapho- 
retic, but probably is not more so than-most aromatics, or 
essential oils, when given in hot ‘‘ teas.” It is, however, 
of an agreeable flavor, and for this quality it is freely used 
as an adjuvant in medicine, and asa flavor for confec- 
tions, soaps, and other household luxuries. The mucil- 
age of the Pith (Mucilago Sussafras Medulle, U.S. Ph., 
+35) is used rarely as an eye-wash, or asa gargle or de- 
mulcent drink for pharyngitis. 

ADMINISTRATION.—Oil of Sassafras may be given in 
doses of from five to ten drops or more on sugar, or in 
emulsion with mucilage, or otherwise, for the same pur- 
poses as oil of Cinnamon or Checker-berry, or an infusion 
may be made of the bark. Sassafras Bark is an ingre- 
dient of the Compound Extract, the Compound Decoction, 
and the Compound Syrup of Sarsaparilla. 

ALLIED PLANTS, ETC.—See CINNAMON. 

W. P. Bolles, 


SASSY BARK, Mancona Bark. The bark of Erythroph- 
leum quinense Don.; order, Leguminose (Cesalpiniea), 
a good-sized, acacia-like tree, growing in tropical Africa, 
and employed by the tribes of the west side like Calabar 
Beans, as an ordeal. It was made known in Europe and 
America about forty years ago, and was revived as a 
medicine about ten years since. It is atponderous bark, 
heavier than water, of a dull red color, a fissured exter- 
nal surface, and a short fracture. Odor slight, taste as- 
tringent. The active principle of Sassy Bark is Hry- 
throphiwine, a crystalline alkaloid, first obtained by Gallois 
and Hardy. It is an active heart-poison of the digitalis 
kind, producing slowing of the pulse, increase of blood- 
pressure, and in experiments upon animals death, with 
the heart in systolic contraction: ‘The powdered drug is 
a powerful sternutatory. But little use has been found 
for this potent medicine. It is said to be employed at 
home in dysentery, etc., with benefit, as well as in inter- 
mittent and other fevers. In full doses it is nauseating 
and emetic, as well as somewhat narcotic. 

ALLIED PLANTS, ETC.—See SENNA. W. P. Bolles. 


SAUNDERS, RED (Santalum Rubrum, U.S. Ph.; Pter- 
ocarpt Lignum, Br. Ph. ; Santal Rouge, Codex Med.). 
The heart-wood of Pterocarpus sanialinus Linn., or- 
der Leguminose (Dalbergiew). A small tree with red 
wood, alternate trifoliate leaves, small yellow, papilli- 
onaceous flowers on axillary racemes, diadelphous 
stamens, and a flat, orbicular, wing-margined, one- or 
two-seeded, stalked, indehiscent fruit. It is a native of 
the Madras Presidency, but not common, and is now be- 
ing cultivated. 

Red Saunders is imported in billets three or four feet 
in length, and from two to eight or nine inches in di- 
ameter, the bark and sapwood being removed. It is of 
a bright blood-red color within, but darker upon the 
surface, becoming sometimes nearly black with age and 
exposure. For pharmaceutical use it is usually cut into 
chips or powder. There is a slight astringent taste, but 
little or no odor. Alcohol and ether extract its constitu- 
ents, but not so with water, which it scarcely colors. 
The important principle is Santalin, or Santalic acid, 
discovered by Pelletier. It crystallizes in minute red 
prisms, which are soluble as above, and in alkaline solu- 
tions and a few essential oils. Besides this, a number of 
less important or ill-defined substances are described. 

Saunders is essentially a dye-stuff. In medicine it 
has no employment, excepting as a harmless coloring 
agent. The Compound Tincture of Lavender contains 
eight parts in the thousand. 

ALLIED PLANTS.—KINO ; see also SENNA. | 

ALLIED Druas.—Saffron, Annato, Cochineal, etc.; 
also the red coloring matter of Kino, Red Cinchona, 
W. P. Bolles. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sassafras. 
Scabies, 


SAVINE (Sabina, U. 8. Ph.; Sabine Cacumina, Br. 
Ph.; Summitatis Sabine, Ph. G.; Sabine, Codex Med.). 
The leaves and young twigs of the European Juniperus 
Sabina Linn., order Conifere. This is acompact, horizon- 
tally spreading, evergreen shrub 
or small tree, resembling our 
common juniper on a small 
scale, and bearing similar 
berries. It is widely dis- 
tributed through the north 
temperate zone of the 
Old World, and is also 
met within the North- 
ern United States (in 
the Great Lake re- 
gion) and in Can- 
ada. The medical 
supply comes from 
Europe, in ‘short, 
thin, sub-quadran- 
gular branchlets, 
leaves in four rows, 
opposite, scale-like, 
ovate lanceolate, (edu 
more or less acute, Oe RS 
appressed ; imbri- 
cated,on the back 
with a shallow 
groove containing an 
oblong or roundish 
gland ; odor peculiar, 
terebinthinate; taste 
nauseous and bitter.” 

The odor and taste of 
Savine are mostly due to 
from one to two per cent. 
of essential otl (Oleuwm Sabi- 
ne, U.S. Ph.), a pale yellow, 
terebinthinous liquid, becom- 
ing thicker and darker by age, 
colorless if redistilled, of a spe- 
cific gravity of about 0.910. It 
has the odor of Savine, a sharp, bitter, camphoraceous 
taste, and is more rubefacient and irritating to the skin 
than others of its class. Tannin and resin are less im- 
portant constituents of Savine. 

AcTION AND Usr.—Savine and its oil are essentially 
like, but more intense than, oil of turpentine in physio- 
logical and therapeutical properties; irritating to the 
skin and mucous membranes, to the urinary apparatus by 
which they are eliminated, and to the uterus, which they 
may cause to abort. Besides these effects, convulsions and 
coma may follow. Vomiting, diarrhcea, gastro-intestinal 
inflammation, strangury, with or without convulsions or 
unconsciousness, these are the usual symptoms of Savine- 
poisoning ; abortion may or may not take place. This 
potent drug is not much employed. It has been given as 
an emmenagogue, also as a hemostatic, for leucorrhcea 
and other purposes mostly connected with the uterus. 
It is not infrequently used with criminal intent to pro- 
duce abortion, usually without success, unlessit nearly or 
quite kills the mother also; externally it is the basis of 
some moderately useful stimulating ointments, liniments, 
and ‘‘ hair-restorers.”’ 

In this country the Oil of Juniper, which is milder, is 
perhaps generally substituted for Oil of Savine. 

The dose of Savine (leaves) is about half a gram (0.5 
Gm. = gr. viij.); of the oil, from one to four or five drops. 
A Fluid Extract of the former (Hz. Sabine Fluidum, U. 
S. Ph.) is an eligible preparation and the basis of the 
Cerate (Ceratum Sabine, U.S. Ph., strength about 45 
Savine), 

ALLIED PLANTs.—See TURPENTINE ; also JUNIPER. 

ALLIED Druas.—Tansy, Ruz, TURPENTINE, CAM- 
PHOR, CAJEPUT, etc. W. P. Bolles. 


SAVORY, SUMMER (Sarriette, Codex Med.). The 
herb of Satureia hortensis Linn., order Labiate, a well- 
known European mint, now cultivated everywhere as a 


~~ 


Fig, 3882.— Savine, Fertile 
Branch. (Baillon.) 


flavoring herb for soups and sauces. It has no proper- 
ties not common to other mints and aromatics in gen- 
eral, and is only employed for its agreeable odor and 
taste. 

ALLIED PLANTS, ETC.—Hyssop, Thyme, Patchouly, 
Lavender, etc. See PEPPERMINT. W. P. Bolles. 


SCABIES (Latin, scabies, an itching eruption, from 
scabo, I scratch). Synonyms: The Itch; German, 
Krdtze ; French, Gale. Scabies is a contagious disease 
of the skin, wholly local in character, due to the pres- 
ence in, and upon, the skin of an animal parasite, the 
acarus or sarcoptes scabtet (see vol. i., p. 84). The erup- 
tion present may vary from the smallest amount imagin- 
able, a few papules, up to the most severe development 
of inflammatory lesions, even such as to render the pa- 
tient helpless; the subjective sensations may vary from 
a slight pruritus, which is described as not unpleasant 
when relieved by scratching, up to an itching which is 
almost unendurable, causing restless nights and distress- 
ing days. 

The most common sites for the lesions of scabies are 
the hands, especially about the wrists, in the soft skin 
between the fingers, and on the sides of the hands. But 
in many cases the eruption is entirely absent from this 
locality and is well marked elsewhere. In males the 
penis seldom escapes, and in females the region of the 
nipples is very apt to be affected; the anterior fold of 
the axilla is a very common seat of the lesions, and the 
elbows and extensor surface of the forearms are some- 
times most severely affected. In those who sit a great 
deal the buttocks often present an abundant eruption. 
In infants and children the softer parts of the feet and 
ankles generally exhibit lesions. It may be said that 
the head is never affected by scabies. 

The eruption of scabies exhibits the greatest variety of 
lesions, from the smallest papules and vesicles to large 
pustules, often ecthymatous in character, and in weakly 
children pustular bulle may form on the hands. The 
bulk of the lesions is papular, although small vesicles 
can generally be seen on tender portions of the skin dur- 
ing some period of the disease. Mingled with these pri- 
mary lesions there are generally found the results of 
scratching, abraded surfaces, and those covered with 
crusts. 

The only single pathognomonic sign of scabies is the 
cuniculus, furrow, or burrow (German, Milbengang ; 
French, Sillon), which is caused by the penetration of 
the female beneath the epidermal layer of the skin in the 
search of a place to lay her eggs; the male seldom, if 
ever, goes beneath the skin. This cuniculus consists of 
a minute dark-colored line, generally somewhat beaded 
in appearance and curved, appearing much as if a bit of 
dark sewing-silk had been run beneath the surface, rarely 
as long as a fourth of an inch, more often half that 
length ; this may generally be seen to terminate at one 
end in an inflamed papule or vesicle, or sometimes to 
run over a pustule. The female insect will be found at 
that end of the furrow, and the dark line is her track, 
which is found to be filled with eggs in various stages 
of development, and, among them, black particles of 
feces. If the skin is washed these dark lines, instead of 
being removed, become more apparent; but in recent 
vases, or in individuals who are very cleanly or have un- 
dergone treatment, it is often impossible to discover any 
of these cuniculi, although the disease may still exist, 
and, if left alone, will increase and may be communicated 
to others. 

Scabies is not a very frequent disease in this country, 
forming only about 1.5 per cent. of a large number of 
skin cases analyzed. In other countries it is more com- 
mon, and in Glasgow it formed twenty-five per cent. of 
ten thousand cases analyzed by McCall Anderson. 

DiaGnosis.—Considerable care is often required to 
diagnose a mild or unusual case of scabies, and cases 
sometimes go unrecognized for some time. The disease 
most commonly confounded with it is eczema, which 
may present almost identical appearances, except that 
there are no cuniculi; when these latter are positively 


295 


Scapula. 


senbion: REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


found the diagnosis is certain. The location and distri- | times an artificial: eruption is excited by the treatment, 
bution of the eruption, the history of contagion, and the | when soothing remedies are required. The clothing 
multiform character of the lesions are generally suffi- | should always be treated ; the underclothes should be 
cient to establish the diagnosis. Scabies may also be | boiled a long time and very thoroughly ironed ; the outer 
confounded with lichen, pityriasis, prurigo, pruritus, garments may be baked or very thoroughly ironed on 
and urticaria papulosa. the wrong side. Patients should be more or less iso- 
ErroLtocy.—There is but one cause of scabies, the lated, although when they are under treatment the 
presence of the parasite, acarus or sarcoptes scabiei (see chances of communicating the disease are very small, 
article Acari in vol. i. of this HANDBOOK), whose re- Proenosis.—The prognosis is, of course, favora- 
moval or destruction is followed by the cessation of ble ; there can never be the slightest harm in curing 
the disease. It often occurs, however, that the treat- even the most inveterate or severe cases of scabies. 
ment employed may occasion an amount of artificial In the hospitals abroad it is claimed that a cure is 
eruption or dermatitis which may mask the true \ effected in a few hours, but it is questionable if, in 
affection, and may even remain after the real cause \VE the large majority of cases, the relief is more than 
of the disease has been destroyed; this second Mi temporary, a portion only of the parasites being 
eruption may require a very different treatment, killed. Practically, cases require treatment for a 
of a soothing character. number of days, or even weeks, to make the cure 
PatnHo.tocy.—The only pathological lesions, certain ; when the skin is delicate the active 
aside from the presence of the cuniculus, which parasitic treatment may have to be inter- 
is a channel beneath the epidermis and just rupted, owing to the dermatitis excited, and 
above the papilla, filled with the female acarus, occasionally it will be found difficult to use 
its eggs, and feces, are those connected with remedies strong enough to effect a cure. 
inflammation of the skin (see article Derma- L. Duncan Bulkley. 


titis). The lesions are simply inflammatory 
masses of greater or less size, caused either SCABIOUS (Scadbieuse, Codex Med.); 
Morsus Diaboli, Succisa pratensis Monch, 


by the direct irritation of the burrowing in- 
sect, or by the scratching or other measures order, Dipsaceew (Scabiosa succisa Linn.), 
A European herb, whose roots, leaves, 


employed for the relief of the itching, or 
and heads were formerly in vogue as a 


both. When the local irritation is re- 
remedy for leucorrhea, diabetes, throat 


moved the eruption ceases; if the acari 
could all be removed mechanically, affections, and skin diseases. It is now 
obsolete. 


picked out, there would be no eruption. 
ALLIED PLANTS, ETC. — Dipsacus 


In patients who are paralyzed on one | 
Fullonum Uinn., in the same family, 


side, or who have been unable to . 
scratch, there is very little eruption on is the teazle used by woollen weavers. 
“Sweet Scabious” (Hrigeron) is an 


the portions of the skin which are out 
entirely different plant. W. P. B. 


of reach. 
TREATMENT. — The treatment of 
scabies is purely local, and consists SCAMMONY (Scammonium, U.S. 
in such measures as destroy the life Ph., Br. Ph. ; Seammonée ad’ Alep, 
of the parasitic insects and their Codex Med.; also Scammonie Ra- 
eggs. The patient first takes a diz, Br. Ph.). The impure resin 
warm bath, using plenty of strong obtained from the root of Convol- 
soap, rather alkaline in charac- vulus Scammonia, order Convolou- 
ter, such as the sapo viridis or lacee, This is a perennial with a 
the common laundry soap, rub- long, thick, cylindrical, several- 
bing the affected parts so as to headed, but otherwise usually 
break the furrows as much as simple, milky-juiced root, and 
numerous hollow, herbaceous, 
slender, smooth, twining stems, 


possible. After drying, the 

affected parts, or even much 
two or three metres long. The 
root, which is an article of 


of the body, should be well 

rubbed with an ointment of 
English trade, is up to a me- 
tre in length, and a decime- 


which sulphur is a chief in- 

gredient. The ordinary sul- 

phur ointment diluted once, tre in diameter at the crown, 

with the addition of a light brownish-yellow with- 

drachm of liquid storax out, white within, fleshy, and 
resinous. The leaves are in- 

frequent, alternate, 


to the ounce, answers as 
long-petioled, triangu- 


well as anything. After 
thorough friction with 


this for at least half an 
hour, the patient puts on 
underclothes, which are 
to remain on night and 
day until the end of 
treatment. The oint- 
ment should be freshly 
rubbed in twice daily 
for several days, and a 
bath is to be taken on 
the third day, the oint- 
ment being again rubbed 
in and afresh suit of un- 


lar, halberd- or arrow- 
shaped, pointed at the 
apex, with one or two 
obtuse dentations near 
the cordate base. Flow- 
ers five or six centime- 
tres across, pale yellow, 
solitary or in cymes of 
three, on long two- 
bracted peduncles. 
Calyx five-parted ; co- 
rolla conduplicate in 
the bud, broadly fun- 


Fia. 3383.—Scammony-plant in Blossom, (Baillon.) 


derclothes put on. After three days more of treatment 1 nel-shaped when open, with an indistinctly five-parted 
another bath may be taken, and it is then to be expected | border. . Stamens five, attached to the corolla tube, pis- 


that the cure is complete. 


But frequently some of the | til two-celled, four-seeded. 


cuniculi will be found to have escaped being broken, or This pretty plant is a native of the Levant—Greece, 
new infection may come from the clothing or elsewhere, | Asia Minor, Syria, etc. It is also cultivated in botanic 
and in such case the treatment must be repeated. Some- gardens. The resin is collected by cutting off the root 


296 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Scabies, 
Scapula,. 


at the crown, and either scraping off the exudation as it 
appears or putting a shell or some receptacle at the 
lower side to receive it as it runs down. It is then 
dried at once, constituting a very high grade of the drug, 
or more usually the separate collections are laid aside 
until enough is accumulated to make a ‘“‘ cake,” when it 
is all moistened and kneaded together. In this way the 
bubbles and sour odor are developed, and what is known 
as ‘‘ Virgin Scammony ” is produced. 

Scammony is in ‘“‘irregular, angular pieces, or circu- 
lar cakes, greenish-gray or blackish, internally porous, 
and of a resinous lustre, breaking with an angular fract- 
ure ; odor peculiar, somewhat cheese-like ; taste slightly 
acrid; powder gray or greenish-gray.” The porous, 
bubbly texture, and the sour, cheesy smell are results of 
fermentation during the process of drying. It is soluble 
to the extent of three-fourths in ether. The costliness 
and opaque color of Scammony render it especially lia- 
ble to adulteration. Lime, flour, ashes, gum, etc., are 
among the common admixtures. The proportion of 
resin is the best test of purity. This resin (Resina 
Scammonit, U. 8. Ph.) is obtained by digesting the drug 
with alcohol and evaporating the tincture so obtained, 
or by treating the root in the same way. It is a brown, 
translucent, brittle resin, with a sweet, fragrant odor if 
obtained from the root ; but, as usually seen, from crude 
Scammony, it is more greenish and dirty in color, and 
has the odor of Scammony itself. The action and value 
of the two products are about the same. 

CompositTion.—The peculiar resin of Scammony, un- 
fortunately called jalapin, first obtained in a state of 
purity by Johnston, in 1840, differs from the convoloulin 
of jalap by its solubility in ether. When purified it is 
a colorless, translucent, brittle, non-crystalline resin, 
tasteless and odorless, of nearly neutral reaction, and 
freely soluble in ether. It is a glucoside, and resolv- 
able into jalapinolic acid, a crystalline substance, and 
sugar. Good Scammony contains eighty or ninety per 
cent. of this resin. 

ACTION AND UsE.—Scammony and its resin are to be 
counted among the very active drastics, excelled only by 
croton-oil and elaterium. Their action is similar to that 
_of jalap, but considerably more intense. They are used 
as derivatives and hydragogue cathartics in cases of 
cardiac and renal .troubles associated with dropsy. 
Scammony resembles the action of jalap, but is more 
intense. Aromatics and carminatives are appropriate 
adjuvants. Dose, of good Scammony, half a gramme 
or so; of the Resin, three or four decigrammes. The 
compound Extract of Colocynth contains fourteen per 
cent. of Resin of Scammony. 

ALLIED PLANTS, ETC.—See JALAP. W. P. Bolles. 


SCAPULA: DISEASES AND INJURIES OF THE 
CORACOID PROCESS. The coracoid process (Syn.: 
Processus Cornicularis, Hawk-bill Process) is usually 
described as a short, thick, curved process of bone, 
rather more than one inch in length, which arises by a 
broad base, and projects beneath the outer end of the 
clavicle from the anterior part of the upper margin of 
the scapula. It is first directed upward and inward, 
then, becoming smaller, it changes its direction and 
passes forward and outward. The horizontal portion is 
irregular and flattened from above downward, the under 
surface is smooth, while the internal and external bor- 
ders are roughened for the attachment of ligaments and 
muscles. 

The ligaments are—the origins and insertions corre- 
sponding to the situations named—the coraco-clavicu- 
lar, coraco-acromial, and coraco-humeral. The muscu- 
lar attachments are the short head of the biceps, and 
the tendons of the coraco-brachialis and pectoralis mi- 
nor muscles. In position the coracoid process is almost 
unique, being uncommonly well protected by the cir- 
cumjacent bony and muscular structures. The clavicle 
is arched above, the head of the humerus protects it 
from external injuries, and the deltoid and pectoral mus- 
cles complete the defence with a buffer-like elasticity, 
shielding it from all assaults directed from either above 


or below. ‘The development of this process takes place 
from two centres of ossification, one in the body and the 
other near its base. It remains as an epiphysis until 
near the twenty-fifth year, a portion at birth being carti- 
laginous. Allen (‘‘ Human Anatomy,” sec. 11, p. 171), 
says: ‘‘ This process is homologous with the coracoid 
bone of batrachian reptiles and birds; as seen in these 
animals, the coracoid bone extends between the sternum 
and scapula very much after the manner of the clavicle 
in the human subject.”” In persons of moderate muscular 
and adipose development this process can be felt just be- 
neath the mesial portion of the outer third of the clavicle, 
a short distance to the inner aspect of the head of the hu- 
merus. The hand should grasp the shoulder, the fingers 
at the same time steadying and pushing the scapula for- 
ward against the back of the chest; it can then, ordinar- 
ily, be recognized, by the thumb being pressed in front, 
as a bulbous protuberance about the size of a large bean. 
The arm during the manipulations should be extended 
and rotated outward, which, by producing traction upon 
the accessory ligament, brings the process forward and 
facilitates its detection. There is one fact which de- 
serves to be specially mentioned because of its importance 
in regard to diagnosis. In the normal subject, where no 
disease nor injury is suspected, the coracoid will fre- 
quently be found intolerant of rude manipulation or 
pressure ; therefore, it should be impressed upon the ob- 
server, when making examinations in this region, that a 
precipitate diagnosis should not be made from the mere 
presence of pain uncorroborated by other morbid indica- 
tions. 

DisEASES.—The literature of this class of affections is 
very meagre. Nothing seems to have been recorded that 
would demand any special therapeutic measures, beyond 
what is usuall 
comprehended by 
ordinary estab- 
lished rules, and 
such as are appli- 
cable to bone dis- 
ease situated in 
analogous struct- 
ures elsewhere. 
It may be worthy 
of mention here— 
rather as a matter 
of curiosity—that 
the coracoid pro- 
cess is sometimes 


thought to become 

the seat of reflex 

neuralgic mani- 

f ions, du 

tee rs g My Fie,’ 8884.—Fracture of the Coracoid Process, 
Some inde ae € showing action of muscles in its displace- 
disturbances 1n_ ment. 

the abdominal vis- 

cera. Pain felt in the right process has been attributed 


to vague hepatic derangement, while that of the left 
side is supposed to be connected with morbid conditions 
operating in the spleen. How far these are to be cred- 
ited as demonstrations of disorder in these organs can- 
not at this time be determined; but it would be wise 
to regard these relations as extremely conjectural, and 
as such quite insufficient to warrant much serious con- 
sideration. 

Periosteitis, simple and tubercular osteitis, caries, and 
syphilitic necrosis have occasionally been observed in this 
process. It may be also said of these that the principles 
governing the management of such common forms of 
disease will be found the same here as elsewhere. It 
will, therefore, be amply sufficient for all purposes to 
limit our observations here to osteitis alone, this being in 
the common run of cases the form of disease most likely 
to be met with. 

‘“‘QOsteitis of this process occurs with greatest fre- 
quency in the period of adolescence, before the epiphyses 
have consolidated, and is liable to be confounded with 
scapulalgia, osteitis of the head of the humerus, or even 
cervical Pott’s disease. The diagnosis may be made by 


297 


Scapula. 
Scapula,. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the location of the pain on pressure, and by the presence 
of tumefaction, or of an abscess. The latter is found usu- 
ally in the subclavicular region rather than in the scapu- 
lo-humeral, or on the internal aspect of the arm, the pus 
following the sheath of the coraco-brachialis muscle, or 
the short head of the biceps. 

‘* Treatment.—This consists of resection of the process 
by means of a T-shaped incision. In case of tubercular 
osteitis union by first intention cannot be hoped for, and 
it will be necessary to provide for free drainage ” (Pon- 
cet, Lyons Bull. Gén. de Thérapeutique). 

Fracrures.—Injuries of this class involving the cora- 
coid process have always been considered as remarkably 
rare, the ordinary surgical authorities and text-books 
enumerating not above a dozen examples, which are 
generally accepted as constituting 
the entire list of authentic cases. 
These statistics are, however, mis- 
leading, and sufficient data are 
not wanting, as will be shown in 
the tables below, to prove that 
the lesion is much more common 
than is usually believed. Writers 
have seemed to be possessed with 
the idea that this process is so 
well protected that fracture is 
wellnigh impossible without the 
infliction at the same time of such 
an extensive injury to the surround- 
ing structures as to overshadow the 
coracoid trouble. This @ priort reason- 
ing has in time become dogmatic asser- 
tion. Experience, however, has shown 
that this process is not disproportionally ex- 
empt from simple fractures. The rarity of 
fracture of the cora- 
coid process has been 
greatly exaggerated 
in the past, and there 

can be no doubt that 
a careful investiga- 
tion, at any time dur- 
ing the past century, 
would have shown 
that very many ana- 
tomical collections 
contained specimens 
of this injury. The 
result of sucha study 
would have been to 
prevent the emphatic 
and misleading lan- 
guage of  Lizars, 
which is as follows: 

‘The coracoid is 
said to be broken off, 
but this I question 
very much; it must 
be along with the 
glenoid cavity, or 
there must be a fract- 
ure of the neck of 
the scapula.” No 
less pronounced are 
the remarks of the 
eminent Malgaigne. 
‘This fracture is ex- 
cessively rare, and 
does not occur except 
in company with 
other serious inju- 
ries.”” Holmes, Erich- 
sen, South, and Bry- 
ant bear similar testi- 
mony, regarding it either as highly improbable or ex- 
ceedingly rare, unless accompanied by marked complica- 
tions, rendering it a very serious accident. 

Varéeties.—There are three principal forms of this fract- 
ure that have been observed, ‘The first of these, which 


Fic. 3885.—Green-stick Fracture of Cora- 
coid Process, with Multiple Fracture of 
Scapula. 


298 


\ 

is the most frequent of any, may be defined to embrace 
all fractures limited to the process proper in which the 
line of fracture is simple and complete. ‘The second va- 
riety is denominated partial green-stick, or incomplete, 
fracture, an example 
of which is shown in 
Fig. 3385, taken from 
a case the dissection of 
which was reported by 
Bennett, of Dublin, to 
the Academy of Medi- 
cine of Ireland. This 
may be pronounced the 
most unique of speci- 
mens, and probably is 
the only case of the 
kind ever verified by. 
an autopsy. An ex- 
amination of the cora- 
coid shows two fract- 
ures, one at the apex and 
another at the base; the 
latter break runs from the 
junction of the process with 
the glenoid cavity, on 
through the entire concave 
surface which is related to 
-the subscapularis muscle. 
On looking at the supra- 
spinous fossa (Fig. 8885), 
there is no trace whatever 
of the fracture visible. The 
scapula came from a man 
who died a few hours after 
being crushed by a quantity 
of falling masonry. The 
third division of these in- 
juries is that known as the 
intra-articular or compli- 
cated. This is a fracture in 
which the break is not con- 
fined entirely to the process, 
but continues into, or runs 
through, the glenoid cavity 
or the subscapular fossa. 
(This is also seen in Fig. 
3385.) Those of the latter 
class belong more properly 
to the subject of fractures of 
the scapula, and the reader 
is referred to the article Fractures, in vol. iii. of. this 
HANbBOooK, for more thorough. information upon the 
subject. From the foregoing arrangement it will be seen 
that fractures of this process correspond to the ordinary 
types of a like injury occurring in the other bones of the 
body. 

History.—It will not be deemed necessary to sacrifice 


‘space to enter into a detailed history of this fracture. 


Du Verney, more than a century ago, called attention to 
its existence, and, only a few years later, among the first 
in this country to describe it was William Gibson, of 
Philadelphia. The latter recognized its importance in his 
‘Treatise on Surgery ” (vol. i., p. 258, 1885 edition), and 
mentioned two cases as having come under his own obser- 
vation, in which this was the diagnosis arrived at. He 
records the first of his cases as occurring in the person of 
the famous Charles Carroll, of Carrollton, who, while rid- 
ing in the carriage of the British Minister, Bagot, was 
upset, and by a violent fall upon the shoulder this pro- 
cess was broken off. Gibson remarks, ‘‘The subject 
being a remarkably thin one, I was able to distinctly feel 
and move the fragments one upon the other.” Of his 
second case he makes no further mention than to say it 
was in the person of a sailor. The following reports of 
cases, though not arranged to illustrate any particular 
feature of these injuries, will be found to describe this 
fracture when resulting principally from falls and vio- 
lence imparted to the humerus and the shoulder-joint as 
a Whole. As an apology for entering the reports of cases 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Scapula. 
Scapula, 


in a work like this, it can be said to best justify the 
general purpose of it, which is to present reliable infor- 
mation lucidly and briefly. 

Case I.—A milk-woman, aged thirty years, fell from 
a cart upon her right side into the street. The motions 
of the arm were not impaired, she could raise her hand 
to her head without any difficulty. The clavicle, hume- 
rus, and acromion were entire, there was neither deformity 
nor flattening ; but on attempting to grasp the coracoid 
process while the arm was freely moved up and down, a 
looseness and crepitus could be distinctly felt, and a 
grating was also perceptible in the axilla. The arm was 
secured to the side by means of a sling and bandage, and 
fomentations were applied. There was very little swell- 
ing, but the woman complained of pain which was in- 
creased by motion. (London Lancet, 1840-41.) 

Case II1.—Male, aged forty-five years, very thin and 
spare, fell down a steep flight of stairs feet foremost, 
striking heavily upon his left elbow, which was thrown 
backward in an effort to protect himself. Examination 
showed the arm shortened, elbow carried a little back- 
ward and slightly separated from the body ; motion, es- 
pecially forward, greatly restricted. To the inner side 
of the acromion was felt a prominence, which was the 
head of the humerus, dislocated but easily reducible. 
Crepitus was obtained by making traction upon the arm 
and carrying it outward and forward ; this crepitus was 
felt by the thumb when placed upon the coracoid pro- 
cess, and was plainly marked, though consisting of but 
a single click. Pain was localized at the point of crepi- 
tus. (Taken from Streeter’s case, Medical Record, 1887.) 

Case III.—Male, aged twenty-four years, fell down an 
open hatchway of a vessel, some twenty feet. The right 
hand at the time of the fall was in the pocket of his 
trousers. The injuries were fatal, and a dissection dis- 
closed a fracture of the coracoid process. The line of 
fracture ran obliquely from the inner and upper bor- 
der of the process, just beyond the attachment of the 
coraco-clavicular ligament, downward and outward to- 
ward the tip, and terminated on the external border, a 
fourth of an inch from its summit. There was no dis- 
placement of the fragment, the head of the humerus was 
dislocated forward, and at the moment of its passage 
from the glenoid cavity the upper portion had fractured 
the process by pushing against its under surface. (Ben- 
nett: Dublin Journal of Medical Science, 1878.) 

Case IV.—Male, aged seventy-six years, fell, striking 
his right shoulder against a projecting board. . . . 
The right arm was powerless, the shoulder somewhat 
swollen, and there was a contusion one and a half inch 
below the acromion, and slightly to the posterior side of 
the humerus. Movement was very painful, and occa- 
sional crepitus could be distinctly felt when the arm was 
rotated. The head of the humerus was thrown a little 
forward and inward, but readily answered to all move- 
ments imparted at the elbow. No pain or crepitus was 
found over the clavicle, the acromion was intact, and 
there was no break about the glenoid cavity. There was 
unmistakable bone crepitus, and pain was felt over the 
coracoid process. (Johnson: Medical News, 1885.) 

Case V.—Elderly woman, who slipped down in a 
narrow alleyway and struck her elbow, driving the head 
of the humerus forward. The symptoms were loss of 
function of the coraco-brachialis and pectoralis minor 
muscles, tenderness, and crepitus on pressure of the cor- 
acoid process. (Packard : Charleston Medical and Surgical 
Journal, 1859.) 

Case VI.—Male, aged thirty-three years, slender build, 
scanty adipose tissues, bony landmarks prominent. The 
patient had recently undergone an amputation of the 
forearm a few inches below the elbow, the stump re- 
maining unhealed and tender. He was found supporting 
his stump with the opposite right hand, nervous, pale, and 
evidently suffering intense pain. : The information was 
that, while endeavoring to avoid the wheels of a vehicle 
in the street, he had lost his footing and fallen backward 
into the gutter; in doing so he had, to use his own 
words, ‘‘ knocked his shoulder out of joint.” Further 
questioning as to the exact manner of the accident 


elicited the fact that, while falling, he had struggled to 
recover his lost equilibrium, and, as a consequence, 
landed heavily and awkwardly upon his left shoulder. 

The arm, it was ascertained, had been raised above the 
head and thrown outward, possibly instinctively as it 
were, to protect the sensitive stump, and in this position 
the bulk of the traumatism from the fall was sustained 
by that portion of the shoulder corresponding to the 
space between the deltoid insertion of the humerus and 
the dorsal aspect of the acromion. Upon exposing the 
limb for inspection it was found to hang lower than its 
opposite fellow, the elbow being held away from, and 
slightly to the front of, the body. The hand, in passing 
carefully along the clavicle, acromion, scapular spine, 
and head of the humerus, then into the axilla and the 
space corresponding to the coracoid process, detected no 
anomaly, excepting a slight subluxation forward of the 
head of the humerus. A little extension reduced this to 
position, and, the parts presenting their normal con- 
tour, the patient was assured that everything was in its 
place and nothing broken. Notwithstanding this assur- 
ance he continued, with considerable misgivings, to 
complain of severe pain. In order to convince him, the 
arm was immediately put through several brisk manipu- 
lations, as if nothing was the matter ; while carrying the 
limb outward and rotating, distinct crepitus was heard, 
which the patient was quick to notice, and remarked 
that he ‘‘felt it grate, and something must be broken.” 
A careful repetition of these movements, with the fingers 
pressed gently into the coracoid space, revealed the ir- 
regularity there. Any increased pressure from the fin- 
gers while the limb was moved, caused crepitus, and so 
augmented the pain that the patient energetically pro- 
tested against its being repeated, flinching each time 
the process was touched. He was then directed to shrug 
the shoulder, and was unable to do so. This peculiar 
movement of shrugging the shoulders (Hawsser les épaules) 
has not been before alluded to by writers when discuss- 
ing this injury; it is, however, of considerable value as 
an element in diagnosis. It will be recalled that the 
pectoralis minor muscle draws the scapula forward and 
downward, and at the same time causes it to execute a 
rotating motion, by virtue of which the inferior angle is 
carried backward and the anterior depressed ; if the arm 
be fixed the coraco-brachialis assists these movements, 
and in order to perform them it is necessary that the en- 
tire set of ligaments of this process should be in an in- 
tact condition. Ifafracture be present in which there 
is separation of the fragments, with an alteration in the 
position of the ligaments, these combined movements 
cannot take place. In this case the arm was elevated 
and abducted ; the force was severe, the whole weight 
of the body striking the curbing, and the head of the 
humerus, in partial dislocation, was directed against the 
process. There were localized pain and crepitus, with 
swelling and a suspension of the function of the muscles 
corresponding to the parts. (Byers: ‘‘Coracoid Fract- 
ures,” pamph., 1885.) 

There is little doubt, in this case, that when the head 
of the humerus was driven forward it pressed forcibly 
against the process, and caused rupture of the coraco- 
acromial ligament, the fracture being produced by one 
bone striking against the other. 

Allen says: ‘‘ The coracoid process acts as a check to 
this inward movement of the head of the humerus, and, 
unless it be broken off, subclavicular dislocation can 
scarcely occur.” Rotation of the head of the humerus 
outward, in a great many of the cases reported, produces 
crepitus, and appears at the same time to effect a reduc- 
tion of the piece broken off. The mechanism of this 
crepitus and restoration of the fragment has not been sat- 
isfactorily explained. The late Dr. Hamilton, upon one 
occasion, saw an instance in which the apex could be 
replaced, but how and upon what principle he confessed 
his inability to state, unless perhaps it was by drawing 
upon the muscle attached to the process. The most 
plausible explanation, however, would appear to reside 
in another and entirely different source, namely, trac- 
tion exerted by the accessory ligament. This arises from 


299 


scapula. 
Scapula. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the outer border of the coracoid and passes over across 
the capsular ligament—being partially blended with its 
fibres—and is inserted into the greater tuberosity of the 
humerus. It can now be seen that tension upon this lig- 
ament, caused by outward rotation, will produce results 
directly opposite to the ordinary action of the muscles 
mentioned. The action of the muscles is to displace 
downward, while traction exerted upon the accessory 
ligament lifts and carries the process outward. 

The foregoing cases are found to illustrate this fract- 
ure chiefly when it occurs as the result of violence im- 
parted to the humerus, this being by its displacement the 
principal factor in its production. Some cases will now 
be presented to show how it may be a consequence of 
violence applied to the process directly from the front. 
These two causes are found to be the most important ones 
in a large number of these accidents. The opinion has 
been entertained that force applied to any portion of the 
scapula, and especially from the front, would cause it to 
rebound upon its muscular supports, and that this would 
so mitigate the force as to render it virtually incapable of 
fracture. Agnew is of the opinion that the head of the 
humerus alone is capable of fracturing even the glenoid 
cavity when forcibly driven against it. That the hypoth- 
esis of its being protected by the muscles is not consist- 
ent with experience, will be seen from a study of the cases 
that follow : 

Case I.—Male, aged twenty-seven, fell in the dark, 
striking his shoulder against the edge of a door standing 
ajar. The pain was excessive, so much so as to render 
him unconscious for some little time. Upon a careful 
examination of the part no objective signs of the injury 
were at first evident. There was inability to place the 
hand upon the head, and also extreme tenderness on 
pressure, limited to a space just inside of the acromial 
end of the clavicle and just below it. No crepitus was 
at this time present, nor was there deformity. Next day 
there was tumescence, circumscribed to the injured spot, 
with impairment of the functions of the muscles attached 
to the process, and crepitus was now plainly perceptible 
over the seat of the injury. (Huse: Chicago Medical Hx- 
aminer, 1879.) 

Case II.—Male, aged sixty-six, while walking along 
the street was struck full on the right shoulder by a run- 
away horse, lifting him bodily off his feet and violently 
throwing him against an iron column, Upon making an 
examination, pain was found about the shoulder, very 
severe, the patient complaining that his arm was broken. 
But no false point of motion was found until the cora- 
coid process was reached. Manipulation here caused ex- 
quisite pain; some crepitation was made out, and there 
was a slight degree of displacement. (Borcheim, in At- 
lanta Medical Journal, 1886.) 

Case III.—Male, aged fifty-six, stout farmer, thrown 
down by a colt and kicked badly. Examination showed 
no displacement nor fracture, until by chance crepitus 
was noticed at a point in front of the right shoulder. 
The humerus was in place, and every motion of the arm 
could be made passively, the spine of the scapula and 
clavicle were entire, the crepitus being strictly localized 
to a point internal to the shoulder-joint and beneath the 
clavicle. (Higgins: Philadelphia Medical News, 1885.) 

Case IV.—Male, laborer, of intemperate habits, was 
struck by a plank falling from a great height, the point 
striking him full upon the tip of the shoulder. The arm 
hung helpless by the side of the body. The adjacent 
bones were all entire, crepitus was felt by manipulating 
the arm, and motion of a loose fragment could be de- 
tected on examination through the axilla; the line of 
fracture probably extended into the glenoid cavity. (S. 
W. Smith, N. Y., unpublished case.) 

Agnew and Hamilton have each observed cases in 
which violence, as a blow in front, was a cause. 

Diagnosis.—The detection of this injury may at times 
be a matter of difficulty, especially when the presence of 
other complications more important, such as swelling, 
dislocation, and other fractures, masks it. The history, 
with a knowledge of the kind and direction of the force, 
will frequently be of material service in its recognition. 


300 


Crepitus can usually be produced by outward rotation of 
the arm, and mobility of the fragment is occasionally 
seen and felt ; localized pain and tumefaction, with an 
inability to shrug the shoulder, and an absence of other 
injuries capable of producing analogous symptoms, are 
further aids to diagnosis. These will usually lead to a 
correct solution of the difficulty, should any be presented. 
Holden, in his valuable ‘‘ Landmarks,” says: ‘‘On the 
front surface of the clavicle, not far from the acromial 
end, there is, in many persons of mature age, a spine-like 
projection of bone. 
This is liable to be 
confounded with the 
coracoid, and it 
would be well to ex- 
amine the opposite 
side to see if there is a corre- 
sponding projection also, in 
order to clear up any possibil- 
ity of error from this source. 

Prognosis, — This will in 
most cases depend much upon 
complications, if there be 
such; if there be none, the 
final result as regards the use- 2 
fulness of the limb will be F16-3386.—Neill Specimen, show- 

ing Process Reunited by Two 
good, and assurances may be parallel Fibrous Bands. 
generally given to this effect. 

The exact seat of the fracture, as compared with its 
ligamentous arrangement, will be a matter to be deter- 
mined, if it is desired to obtain perfect union. If the 
fracture is in immediate proximity to the base, and if the 
acromial and clavicular ligaments are also ruptured, we 
certainly shall expect to find very marked displacement of 
the broken fragment. This will be evidenced by an un- 
usual degree of passive mobility, and by a more or less 
total suspension of the functions of the corresponding 
muscles. The union, as a consequence, will necessarily 
here be by an intervening fibrous band, since no sort of 
retentive apparatus is capable of acting as a perfect splint 
in these circumstances. Again, if the break be anterior or 
between the ligaments, and if their clavicular and acro- 
mial attachments escape rupture, the area of displacement 
will be materially abridged. If the process be broken in 
such a manner as to hinder or prevent its easy reposition 
and retention—as when the base is drawn down and tilted 
forward, or when there are spasms 
of the muscles—the union will be 
fibrous, and there will doubtless 
also be a permanently movable pro- 
cess. This con- 
dition is shown 
in Fig. 3386, and 
s the common 
sequence in a ma- 
jority of cases. 

Hamilton mentions sev- 
eral examples in which 
the process could be 
moved months after the 
accident. ‘These mova- 
ble processes will occur in all those 
cases where the bones have been 
widely separated, and where there 
has been a failure to retain the 
surfaces in proper apposition dur- 
ing the reparative effort. How- 
ever, this fibrous or ligamentous 
union does not mar the ultimate 
usefulness of the process, the 
Fig. 3387.—Specimen show- shoulder usually presenting noth- 

ing Partial Osseous De- ing yncommon excepting, at times, 

posit. (Warren Anatomi- 

cal Museum, Boston. ) an awkwardness observable solely 

by the patient. Many of the spe- 
cimens contained in museums show ligamentous union 
as a result, but very few manifest anything like an at- 
tempt at genuine osseous deposit, this being rare. Fig. 
3387 is taken from a photographic plate in the possession 
of Marcy, of Boston. The specimen is to be found in the 


pe: 


2 


44 


mee 2 ee) a ee a 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sex. 


Male, 


Male. 


Male. 


Male. 


Male. 


Male. 


Female. 


Male, 
Male. 


Male. 
Male. 
Male. 


Female, © 


Male. 


a aceoe 


eee nee 


Pee 


wees 


Male. 
Female. 
Male. 
Female. 


Male. 


Male. 


Male. 
Male. 


Age, 


45 years. 


66 years. 
33 years. 
56 years. 
Adult. 


Adult. 
Elderly. 


Adult. 
Adult. 


55 years, 
Adult. 
14 years. 
Adult. 


ereees 
er 
ec eee ee 
aeseee 


eee eee 


aeeeee 
eee eee 


eee eee 


Adult. 

16 years. 
35 years, 
Adult. 

32 years. 
27 years, 
15 years. 


76 years. 
Adult. 


38 years. 
Adult, 


Cause. 
Fall backward. 


Thrown bodily 
against an iron 
column. 

Fall backward. 


Kicked’ by a 
horse. 

Patient crushed 
by falling ma- 


sonry. 


a ee ary 


Fall upon elbow. 


Unknown. 

Gunshot. 

Fall upon shoul- 
der. 


Struck by aniron 
bar. 


se ae ee ere wees 


a ee 


Muscular action. 
Fall forward. 


ee ee ey 
ee ey 
ee 
ey 
er 
sere ccc e tts ose 
ee ee ee 


Pe ee ey 


Pe ce) 


ey 


ee 
ee | 


moka venniel @@).d) lene) o.6ne 


Fall. 

Plank falling up- 
on shoulder. 

Fall, 

Fall forward, 

Fall, 

Fall. 


Struck 
board. 


by a 


Struck by an iron 
rod. 
Fall forward. 


Evidence. 


Pain, crepitus, 
swelling, and mo- 
bility of process. 

Pain, crepitus, and 
mobility of pro- 
cess, 

Pain, crepitus, mo- 
bility, and loss of 
function. 

Crepitus, pain, and 


mobility of pro- 
cess. 
Post-mortem  dis- 
section. 
Post-mortem  dis- 


section, 
Pain, crepitus, and 
loss of function. 


Post-mortem. 


Post-mortem  dis- 
section. 


Pain, crepitus, and 
mobility. 

Pain, prominence 
of process. 


Post-mortem  dis- 
section, 
Mobility and crep- 
itus. 
Post-mortem  dis- 
section, 
Post-mortem  dis- 
section. 
Post-mortem  dis- 
section, 
Post-mortem  dis- 
section. 
Post-mortem  dis- 
section. 
Post-mortem dis- 
section, 
Post-mortem  dis- 
section. 
Post-mortem  dis- 
section. 
Post-mortem  dis- 
section. 
Post-mortem  dis- 
section. 
Post-mortem  dis- 
section. 
Crepitus, displace- 
ment, mobility 


of process. 


eee ree ne teen rose 


Post-mortem  dis- 
section. 

Post-mortem  dis- 
section. 

Crepitus, pain, and 
displacement. 

Post-mortem  dis- 
section, 

Pain, crepitus, loss 
of function. 

Pain, crepitus, and 
loss of function. 

Pain, crepitus, and 
loss of function, 

Mobility and crep- 
itus. 

Crepitus, pain, and 
impaired func- 
tion. 

Preternatural mo- 
bility 8 months 
after injury. 

Crepitus and dis- 
placement. 

Mobility and crep- 
itus. 


Scapula. 
Scapula,. 


Complication, 


Reference. 


There was some, but not 
stated. 


There was some, but not 
stated. 


Subluxation forward of | 


head of humerus, 


Not stated. 


See illustration of green- 
stick fracture, Fig. 
3385, 

Tip seen suspended by 
the clavicle ligament. 
Head of humerus dislo- 
cated forward and up- 

ward, 

Fragment hangs loose. 


Peewee rene rees see ersees 


Dislocation of head of 
humerus. 

Fracture of glenoid and 
base of acromion. 


eC a 


i a | 


ee ee re 


ee ee 


Not stated 

Dislocation of humerus, 
clavicle fractured. 

Dislocation of humerus, 


Fract. acromion and hu- 
merus. 

Broken twice and gle- 
noid involved. 

See Fig. 3387. 


Severe damage to the soft 
parts. 


Ce ee ee i Cs 


ee ee cs 


eee e reer ere sr sees - seers 


ee ee ee 


Horizontal fracture of 
scapula. 
Unreduced dislocation of 


humerus forward. 


er ee ee 


Dislocation of the head 
of the humerus, 

Supposed fract. of gle- 
noid cavity. 

Wounds of face. 


Loss of consciousness. 


Dislocation of the clav- 
icle. 

Humerus subluxated for- 
ward. 


Dislocation of the outer 
end of the clavicle. 


Paralysis of arms and 
hand. 


Pe ee 


Record, vol. i., 1887. 


| Dr. L. E. Borcheim, At- 
lanta, Ga., Med. and 
Surgical Journal, 1886, 

Dr. J. Wellington Byers, 
pamphlet, 1885. 


Dr. F. W. Higgins, Phila. 
Med. News, Dec., 1885. 


Bennett, Trans, Academy 
Med., Ireland, 1883. 


Wood’s Museum, 
Specimen 455, 
Dr. J. H. Packard, Charles- 
ton Med. Journal and Re- 
view, 1859. 

Wood’s Museum, N. Y., 
Specimen 475. 

Army Med. Museum, Wash- 
ington, D. C. 


aN, Vids 


Gibson’s Surgery, edit. 1836, 
vol. i., p. 258. 
Agnew’s Surgery, vol. i. 


Erichsen’s Surgery, vol. i. 
9 


Paule’s case, Bryant’s Sur- 
gery, 4th edit. 

Neill specimen, see Fig. 
3886; also Agnew’s Sur- 
gery, vol. i, p. 876. 

Gibson, Agnew’s Surgery, 
vol. i., p. 876. 

Lancet, London, 1873. 

Holmes’ Surgery, vol. i. 

London Med. and Surg. Re- 
view, 1840. 

Hamilton, Fractures, 
edit. 

Cooper, Fract. and Disloca- 
tion. 

Hamilton, Fract. and Dis- 
location, 7th edit. 

Marcey, Trans. Am. Med. 


7th 


Ass., 1885. 
Archives Générales de 
Méd., 1840. 
Malgaigne, Fract., Pack- 
ard’s Trans. 
Malgaigne, Fract., Pack- 


ard’s Trans. 

Army Med. Museum, Wash- 
ington, D. C. 

Gibson's Surg., vol. i., 1836. 

Bennett, Dub., case not pub- 
lished. 


Fergusson’s Surg., p. 231. 


Malgaigne, Fract. and Dis- 
location. 

Phila. Med. News, No. 671, 
Nov., 1885. 


Med. and Surg. Trans., vol. 
xli., p. 447. 

Dr. T. E. Little, Dub. Jour. 
Med. Sci., 1879. 

Notes by Dr. R.W. Smith, of 
Dub., case not published. 

Bryant’s Surg., third Am. 
edit., p. 829. 

Bennett, Dub. Jour. Med. 
Sci., 1873. 

Dr. S. W. Smith, of New 
York (Case IV., on p. 800). 

London Lancet, 1840-41. 


Huse, Chicago Med. Jour., 
August, 1879. 

Hamilton, Fract. and Dis- 
location, 7th edit. 

Dr. R. W. Johnson, Phila. 
Med, News, 1885. 


Hamilton, Fract. and Dis- 
location, 7th edit. 


Hamilton, loc. cit. 


Holmes, System Surg.,vol. i. 


Dr. F. B.. Streeter, Med. 


Results. 


Not stated. 


Not stated. 


Ligamentous un- 
ion. 


Union by liga- 
ments. 


i ee i er ey 


pair. 


es 


No attempt at re- 
pair. 

Osteitis, with 
spontaneous 
separation, 


ion. 


er ee sare eeeree 


Ligamentous un- 
ion. 


Union by liga- 
ment. 


Union 
ment. 


by liga- 


ey 


union. 


Ligamentous un- 
ion. 

Ligamentous un- 
ion. 

No effort at re- 
pair. 

Osseous union by 
unbroken peri- 
osteum., 


i ee ie a 


ee ee ay 


Bony union 
(doubtful). 


Ligamentous un- 
ion, 

Ligamentous un- 
ion. 


Ak ey Py Ce 


i ee ee oe 
tere sere seen ee 
Se ee 
ee 


eee e cee reecece 


ion, 


ee 


os fe oe 


eeeere 


se eeee 


eee eee 


sere ee 


ee eoee 


es 


Partially osseous 


e@oeoee 


eersae 


eecene 


cee see 


ere ee 


eeeese 


eee nee 


aeretee 


were oe 


serene 


a 


sooner 


Scapula. 
Scarlet Fever. 


Warren Museum of the same city, and is catalogued as 
No. 988, deposited by Warren, 1847. An examination of 
it shows that the edge of the fracture, which extends into 
the glenoid cavity, has undergone no effort at repair, yet, 
upon the superior border of the neck, there is an abun- 
dant formation of new bone, filling the suprascapular 
notch, and extending along a fissure running nearly the 
whole extent of the supraspinous fossa. Bennett men- 
tions a case in which the result was osseous union and 
unbroken periosteum, as was shown at the post-mortem 
examination. Two other cases, by Drs. Alan Smith and 
R. W. Johnson, of Baltimore, have been reported, but 
not confirmed, however, by autopsies. 

Treatment.—This can be set forth briefly and in a ver 
few sentences. The indications, in the light of what has 
been already stated, are plain. Usually we should en- 
deavor to restore the part broken off to as near its origi- 
nal position as is possible, and to retain it there by means 
of suitable apparatus. This can best be accomplished 
and the requisite indications fulfilled by first relaxing 
the muscles causing displacements. To effect this the 
forearm should be flexed, and rotated outward, bringing 
the fragment back to its normal position ; then the arm, 
still flexed, should be carried across the chest and se- 
cured there by means of a Fox apparatus, a Velpeau, or 
a four-tailed bandage. 

It is advisable to combat the inflammation that some- 
times follows in the loose cellular tissue by anodyne 
lotions. The effusions are abundant when they take 
place, frequently reaching to the elbow. . The appara- 
tus should be worn for six weeks, when osseous union 
may be expected. At first the muscles should be used 
carefully. 

ftemarks.—To summarize these reports of cases and 
the tables that are shown on preceding page, it will be 
seen that in all those which were not fatal there were 
associated with the fracture changes in the head of the 
humerus. Pain and crepitus are the most frequent 
symptoms met with. One-half of all the cases tabu- 
lated were verified by post-mortem dissections, these 
being principally reported by the older authorities ; 
whereas nearly all of the recent cases were diagnosed 
and clearly illustrated by the symptoms during the life 
of the subject. Of those not terminating fatally, seventy 
per cent. were the result of falls. No particular manner 
of falling seems essential for the production of this injury, 
since it is seen to occur while the arm is elevated, ab- 
ducted, thrown backward, or by the side, the body fall- 
ing either backward, forward, or sideways. Flower saw 
two cases in which the hands were stretched forward 
during the fall. Twenty-five per cent. of the cases oc- 
curred in adult males, five were women and young girls, 
the sex of the remainder being undetermined. The ages 
will be found to extend from fourteen to seventy-six 
years, a large per cent. certainly occurring after a con- 
solidation of the epiphyses ; the only cases showing any 
liability toward criticism from this source are those of 
Bryant, Paule, and one of Hamilton. The Neill speci- 
men has been objected to on account of this, but the 
scapula is large, well-developed, and doubtless came 
from an adult. As to this fracture being confounded 
with separation of the epiphyses, this term is only ap- 
plicable when the line of fracture is identical with the 
remaining interosseous cartilage, which during the years 
of adolescence merges into the bone of the scapula proper. 
Separations of this bone are only possible prior to the 
twenty-fifth year, unless, as a result of some malforma- 
tion or disease, the cartilaginous medium has persisted 
later in life. Therefore the attempt of some to pronounce 
all these injuries as merely separations of the epiphyses, 
rather than true fractures, is unwarrantable. As to direct 
violence being the principal cause of this injury, as is 
generally taught, an examination of fifty examples shows 
that this was the means in only six cases. Two cases are 
reported as the result of muscular action, but these, it is 
fair to assume, were associated with osteomalacia or 
other diseases. Gurlt’s ‘‘ Knockenbriicher” is said to 
contain a description of about twenty cases of coracoid 
fracture. 


302 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


BIBLIOGRAPHY. 


London Lancet: University Hospital Reports, 1840-41. 
Dublin Jour. Med. Sciences, 1878, vol. lvi., p. 345. 
Atlanta Med. Jour., May, 1586, Dr. L. E. Borcheim. 
Bul. Gén. de Thérapeutique, 1885, Poncet. 

Chicago Med. Jour., August, 1879, Dr. E. C. Huse. 
Coracoid Fract., Pamph., 1885, Dr. J. Wellington Byers. 
Dub. Med. Jour. Sci., 1879, Dr. E. H. Bennett. 

Gurlt’s Knockenbriicher, edit. 1862-64. 

London Lancet, 1878, vol. ii., Hulme. 

Med. News, Philadelphia, 1885, Dr. R. W. Johnson. 
Med. News, Philadelphia, 1885, Dr. F. W. Higgins. 
Med. Record, Dr. F. B. Streeter, vol. i., 1887. 

Trans. Am. Med. Ass., 1880, Dr. H. O. Marcey. 

Trans. Academy Med., Ireland, 1883, Dr. E. H. Bennett. 
Charleston Med. Jour., 1859, Dr. J. H. Packard. 


J. Wellington Byers. 


SCARBOROUGH, a city of about thirty-five thousand 
inhabitants, on the east coast of Yorkshire, is one of the 
best known and most popular of English watering-places. 
There are two mineral springs here, which are known as 
the North Well, or iron spring, and the South Well, or 
saline spring. The following are the analyses of these 
two springs, made by Phillips (Rotureau). In 1,000 
parts of water there are of 


North Well. South Well, 


Sodium chloridG yaw ses seeresce erotics. 2.016 3.140 
Petrous bicarbonate. - oe 44seee-se 0.210 0.192 
CalciumPbicarbonaleseseeee see eee 5.517 5.066 
Calcium sulphate....... RASA Saeed 11.877 11.713 
Magnesium sulphate................. 19,734 23.884 

Total. -.v5 oc Weak eee eee a oe 59.854 43.995 


The waters of Scarborough are used to some extent in 
therapeutics for the same purposes as are other saline and 
ferrnginous springs, being prescribed especially for those 
suffering from anemia who are also troubled with con- 
stipation, But the visitors are, as a rule, attracted more 
by the fine sea-bathing than they are by the spree 4 


SCARLET FEVER. Synonyms: Scarlatina (English 
and Italian); Scharlach (German) ; Scarlatine (French) ; 
Escarlatina (Spanish). 

DEFINITION.—Scarlet fever is an eruptive contagious 
fever. Its incubative period is brief, rarely less than 
twenty-four hours, usually lasting from four to six days, 
and not often exceeding this duration. This period is 
succeeded by a period of invasion which is ushered in 
by fever, usually of considerable intensity, and by sore 
throat. A scarlet eruption begins to appear before the end 
of the second day, and marks the end of the prodromal, 
and the beginning of the eruptive, period. The eruption 
rapidly becomes general, and the tongue becomes stripped 
of its coating and assumes a raspberry-red color. The 
eruption slowly fades after the first few days. The fever 
persists until the sixth, seventh, or eighth day, or longer. 
As the eruption fades, desquamation begins and con- 
tinues for from eight to fourteen days or more. It is 
peculiar in being lamellar, sometimes occurring in very 
large shreds and exfoliations. During the attack, and 
for weeks subsequently, there is an especial predisposi- 
tion to renal inflammation. Scarlet fever attacks chil- 
dren more especially. It usually affects an individual 
but once. 

Histrory.—Scarlet fever is probably a disease of very 
ancient origin, though until three centuries ago medical 
writers had not recognized it; indeed, definite knowl- 
edge of it as a specific, independent affection dates back 
hardly two hundred years, although as early as 1589 an 
epidemic, which we now presume to have been scarlet 


fever, was described as having occurred in Sicily in 


1543 (Paulus Restiva).’ It was not until 1676 that Syden- 
ham definitely separated this malady, as ‘‘ feb77s scarlatt- 
na,’ from measles, and gave it an established position. 
The observations of writers had already been leading 
them toward similar views, and within a few years scar- 
latina became recognized all over Europe. Although 
its place of origin can never be known, it is probably of 
European birth ; for it isa remarkable fact that scarlet 
fever has never succeeded in gaining a firm foothold in 
Asia or Africa. According to Hirsch, in whose most 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Scapula. 
Scarlet Fever. 


valuable work these facts have been recorded, the coast 
of Asia Minor is the only Asiatic district which is fre- 
quently visited with scarlatina in its severe forms. In 
nearly all other parts of Asia it occurs not at all, or only 
sporadically. Wernich, in 1871, declared the disease to 
be quite unknown there. In Africa, Hirsch states that 
it is only in Algiers and in the Azores that it is at all 
common. Following the carefully recorded data of 
Hirsch, scarlet fever appeared first in America, in New 
England, in 1785. It extended as far south as Philadel- 
phia in 1746, and penetrated to Ohio in 1791. Not un- 
til 1851 was it seen in California. In 1880 it began to be 
generally observed in South America. In the West In- 
dies it was first observed in 1802, in Martinique, asa mild 
epidemic. Greenland has heretofore escaped with but a 
solitary case. Australia and Polynesia appear to have 
escaped until 1848. In the Polynesian islands, except 
Tahiti, scarlatina has not been known. It is unques- 
tionable that scarlet fever has never occurred in some 
localities only because the inhabitants have not been ex- 
posed to its influence; but there can be no doubt that in 
other countries influences prevail that oppose the devel- 
opment of the disease. Whether these are climatic or 
racial, or due to other causes, is at present unknown. 
The American Indian is not exempt from its ravages, 
nor can any different degree of susceptibility be observed 
in the negro race in the United States. Frick,’ how- 
ever, noted a somewhat more pronounced tendency in 
the negro to scarlet fever. In the epidemic in Balti- 
more, between the years 1850 and 1854, of every ten 
thousand inhabitants 13.8 whites and 10.8 negroes died. 
This would indicate a relatively greater predisposition 
in the negro, as in the total population the whites were 
largely in the majority. Frick’s observations were too 
limited to secure an unhesitating acceptance of his con- 
clusions. It must be noted, however, that in this coun- 
try the negro is rarely of unmixed African descent. He 
may have inherited from white progenitors some of their 
-especial liabilities to disease. Drake and others have 
. Shown that scarlet fever prevails less in the Southern 
- than in the Northern States. It is also probably true 
that the disease is more frequent in cold than in hot 
countries. Yet it cannot be determined that the differ- 
ences depend upon temperature; Greenland has re- 
- mained without an epidemic, while Algiers has experi- 
enced them frequently. 

Scarlet.fever at once shows differences from small-pox 
and measles in not Sweeping over localities in great peri- 
odic waves. It may, it is true, sometimes invade very 
wide areas of territory with astonishing rapidity, but the 
intervals between epidemics are often very great. With- 
out obeying any well-defined periodic law, measles is 
often known to prevail with noticeable violence every 
third or fourth year, frequently disappearing completely 
in the interim: so, too, small-pox usually exhibits un- 
wonted activity at intervals of from five to ten years, or 
as soon as popular neglect of vaccination renders a large 
portion of a community susceptible to it. It is not thus 
with scarlatina. Hirsch has collected very valuable in- 
formation upon this point. At Miinster fifty years 
elapsed without the disease appearing. At Ulm there 
was only one small epidemic in seventeen years. At Tutt- 
lingen scarlet fever had not been seen for thirty-five 
years previous to the epidemic of 1862-63.. A number 
of writers, however, have observed an epidemic cycle in 
scarlet fever. Thus Fleischmann,’ at St. Joseph’s Hos- 
pital, in Vienna, observed one of four years. In Dres- 
den, according to Gerhart, there is an epidemic cycle of 
from four to five years ; in Munich, according to Ranke, 
of three years, On the other hand, scarlet fever often pre- 
vails sporadically for a long time in a locality, finally to dis- 
appear or to spread suddenly far and wide. Mayr‘ states 
that in Vienna the register shows that scarlatina has 
never absolutely died out in fifty years. Scarlet fever is 
remarkable in the varying intensity of cases occurring 
during a given epidemic, and in the differing severity of 
epidemics. At one time it was regarded as an insignifi- 
cant disorder, almost never proving perilous to life. 
Even now epidemics of an exceedingly mild type are fre- 


quent. Graves has told how, between 1800 and 1834 
whenever scarlet fever prevailed in Dublin, it was so 
uniformly mild that medical men attributed the bad re- 
sults of their predecessors to improper methods of treat- 
ment, and flattered themselves upon their superior skill, 
until a change in type brought their death-rate quite up 
to that of former times. 

ErroLtocy.—It is certain that scarlet fever has for its 
essence some active specific principle, which, conveyed 
by the atmosphere, or by fluids, or by mediate or imme- 
diate contact from one person to another, excites a pe- 
culiar morbid train of phenomena. Although, even re- 
cently, there have been those who maintain that it may 
be autochthonous, contemporary writers are unanimous 
in adopting the theory of a contagium vivum in its patho- 
genesis. The tendency of recent investigation has been 
to direct attention to certain low forms of vegetable 
life, belonging to the schizomycetes. or bacteria, as 
the probable cause of this elass of specific diseases. It 
is altogether probable that they maintain a similar rela- 
tionship to scarlet fever. As yet, however, they have not 
been identified with certainty. Carpenter, who claimed 
that the disease may arise de novo, asserted that it then 


‘results from germs of organic matter which have been 


given off from vertebrate blood in a particular state of 
decomposition, and that the decomposition of blood in 
slaughter-houses is a frequent source of scarlatina. This 
view has not been successfully maintained. Coze and 
Feltz® detected in scarlatinous blood diplococci (sphero- 
bacteria), and produced in rabbits by inoculation of this 
blood a fever-like disease. Riess* has had similar ex- 
perience. Recently Léoffler’ has described chain-shaped 
cocci in the membrane of scarlatinal diphtheria. He 
claims that if these be introduced into a joint, inflam- 
mation soon develops ; if simply beneath the skin, an in- 
flammation like erysipelas results. Hallier® found in the 
blood of three patients a greater mass of micrococci than 
he has ever seen in any other infectious disorder. They 
were more numerous than blood-corpuscles, swimming 
free in masses united by a gelatinous envelope, in or on 
the corpuscles. Exceptionally the white cells, which were 
unusually numerous, were pervaded with micrococci. 
Hallier made culture experiments, and concluded that 
the blood of scarlatina patients contains a micrococcus of 
unknown nature, and proposed for it the name Tvdletia 
scarlatinosa. Eklund ® recognizes as the cause of scarla- 
tina. a micrococeus which he calls plax scindens. He 
finds it in the urine of scarlatinous patients, and de: 
scribes it minutely. He has not found it in the urine 
of those who have not had scarlet fever, but has dis- 
covered it in the soil, on damp walls, on the margins of 
swamps, and in other places. Inoculations with plazx 
scindens have not been performed, and, indeed, we can 
only wonder that anyone could be convinced by such in- 
sufficient evidence. More recently, Mr. George F’. Cooke! 
has described a bacillus found in the nasal discharge and 
in the sero-purulent exudation from the inflamed lym- 
phatic tissue of the neck in cases of scarlet fever. It oc- 
curred in leptothrix-like filaments. Pohl-Pincus!! and 
Klamann ?? discovered micrococci in the scaling epider- 
mis after scarlatina. Klein, in investigating the very im- 
portant relations between scarlatina and a certain disorder 
in milch-cows, occurring at Hendon under the observa- 
tion of Mr. Power (vzde infra), discovered in the ulcers of 
the teats of affected cows a streptococcus which he was 
able to cultivate, and with it to successfully inoculate 
calves, producing a like affection. This streptococcus 
he also found in some condensed milk which was sus- 
pected to have caused an outbreak of scarlatina, He also 
succeeded in raising some colonies of the streptococcus 
in nutritive gelatine, etc., inoculated with human scarla- 
tina.'? Klein’s investigations were of a highly meritorious 
character, and seemed to lead to the identification of the 
true micro-organism of scarlatina, but doubts of their ac- 
curacy have recently been raised by the results obtained by 
Jamieson and Edington, in Edinburgh, whose conclusions 
by no means tally with those of Klein. These authors," 
after experiments and cultures performed under the 
strictest precautions and with the greatest care, describe 


303 


Searlet Fever. 
Scarlet Fever. 


. : | 
a number of organisms, of which diplococcus scarlatine | 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Fleischmann’s figures give 8 deaths of children under 


sanguinis and bacillus scarlatine deserve especial atten- | one year of age; 304 from one to four years of age; and 


tion. The former was found in forty-five per cent. of 
the cultures made from the desquamation, and in thirty per 
cent. of those made from scarlatinal blood. The specific 
cause of scarlet fever, however, is considered to be, by 
these writers, baczllus scarlatine. It was discovered ‘‘in 
every case but one of the tubes made from the desqua- 
mation, if taken after the termination of the third week, 
but never before this.” It also occurred in every tube 
made from scarlatinal blood, if taken before the third day 
of the fever. While these various observations are of the 
greatest interest, they are so little in accord that one can 
hardly admit as yet that the pathogenetic organism of 
scarlatina has been definitely determined. 

While we assume the exciting cause of the disease to 
be an, as yet, undetermined germ, in the presence of 
which alone scarlatina is possible, the question of the 
predisposing causes is a much wider one and demands 
careful consideration. 

There is a widespread impression that scarlet fever 
prevails more especially during the fall and winter 
months. There is, indeed, some difference in favor of 
these seasons, but by no means to the extent that is gen- 
erally supposed. Hirsch has tabulated the records of 
435 epidemics. These prevailed 178 times in the winter ; 
157 times in spring; 173 times in summer; and 213 
times inautumn. ‘The same relative prevalence is shown 
in his tables of deaths from scarlatina. Of more than 
fifty-five thousand deaths from scarlet fever in London, 
from 1888 to 1853, 32.1 per cent. occurred in autumn ; 
20.2 per cent. in summer; 24.6 per cent. in winter ; 
22.1 per cent in spring. These figures, however, cannot 
be accepted with perfect confidence, as they must have 
been influenced by the mildness or severity of the several 
epidemics. Hirsch’s data show also the season of preva- 
lence and the severity of type for two hundred and sixty- 
five epidemics. 


Of 77 winter epidemics ¢,..5. foe aeeene j pa A eA i 


severe, 
Of/b0 spring epidemicszy.2.. hanes e eee ee } - i * eee 
Of 66 summer epidemics’... ...2..6secse sees ie id ; ; ae ss 
Of %2 autumn’ epidemics’. 22)... 2 -sseee ee. { a : j - ue 


The maxima of malignancy fall in winter and summer ; 
but, as Hirsch remarks, the difference is unimportant. 
It may be concluded, however, that in the spring epi- 
demics are usually less frequent and milder. 

Scarlet fever attacks nearly all of those who are ex- 
posed to its influence for the first time. It is chiefly 
observed in young persons, because older people are gen- 
erally protected by a former attack. Nevertheless, adults 
who have never had scarlet fever are less liable to take it 
than children similarly circumstanced. This is not at- 
tributable to differences of age, but to feeble individual 
susceptibility, which probably held as well during the 
childhood of these persons. It is certain that a not very 
small percentage of persons successfully resist exposure 
to the scarlet-fever contagion throughout life. While, 
then, it is not difficult to understand why adults seldom 
take scarlet fever, it is more difficult to account for feeble 
predisposition observed during the early months of life. 
Infants less than a year old are rarely attacked, and often 
escape even when exposed directly and frequently. Ac- 
cording to J. Lewis Smith, infants less than four months 
of age almost possess immunity. Murchison tabulated the 
ages of 148,829 fatal cases of scarlatina occurring in Eng- 
land and Wales, as follows, viz.: 


Wesths unders vear ence, ass cote cictenecre s os 


‘* between 1 yearand 2 years...... ack 14.0 

SS a 2 Maes ee eae Ry ge ek RS 16, ce 
s 4 Stes des ae ake ete Aa: 15:15 sues 
oa uh 2 Oa APA Te era ty i ees ON 11.9 ve 
oe ss Bete ue U ee sen nee 25.9 Be 
Ss pear UAT ese AGE MY ges ie me 1 5.8 e 
a eel br 10 MG i taeeO: | Agcy etd eho be ede 2.6 ot 
ch SP OM ls Lele OO) Be ent ie oe are 0.8 we 
POMPE TOVOR, POD seitclic -etinie tte cates ale soon eae 0.8 4 


304 


206 from five to twelve years of age. J. Lewis Smith 
added 58 cases reported by Octerlony to 145 of his own, 
a total of 203 cases, from which he framed the subjoined 
table : 


1 year of age. 


25 + ty OELONIM ee eaheee ote ee lto 2 years of age. 
43 * v6 a REED A ey ee eee 2 ets AP ee ee 
‘ste ‘ad ay RAs he ers ately te ro 
53. OS ve LR ee ee ee 5 ** 10 ‘ Kr 
tsar a eebtp an th act abate ft By Ae I) Conta) 7 Ge i 
3 & ve (0G siete Rares 155720 ff. . 
qs es enh ey dey aoe fee 20 ** 30 a, ty Bebe 
Ot ee Sethe eee tes ae ae BO RE 40a eee 


Children less than one year of age, therefore, possess no 
absolute immunity ; indeed, scarlatina during foetal life 
has been reported. Leale observed such acase, as did also 
Tourtual. Thomas records several cases occurring in the 
practice of others. Veit noted scarlet fever in a child four- 
teen days of age. Numerous similar observations, more 
or less trustworthy, have been recorded. On the other 
hand, Murchison saw two new-born infants remain 
healthy while their mothers suffered from scarlet fever. 
New-born children are so subject to cutaneous and other 
disorders that may readily be mistaken for scarlatina, 
that we may well demand the most definite testimony. 
Scientific exactness should require that a new-born child 
must be proven either to have served as the medium of 
contagion for others, or to have developed characteristic 
symptoms in the midst of predisposing surroundings. 
The third year is the one during which the most cases 
are probably encountered. Nearly ninety per centwm of 
all cases of scarlet fever occur before the completion of 
the tenth year. Although the disease is rare in advanced 
life, it sometimes occurs. In Murchison’s tables there 
are recorded ten deaths of persons over eighty-five years 
of age. 

Barthez and Rilliet thought that boys were more often 
affected than girls. They were probably correct, though 
the difference is not great. Of 472 cases in St. Joseph’s 
Hospital, in Vienna, Fleischmann states that 263 were 
boys and 209 girls. Barthez and Rilliet observed that 
scarlet fever rarely attacks tuberculous children. (Gri- 
solle believed the same rule to prevail for the adult.) 

The predisposition to scarlet fever is much less uni- 
versal than that to measles and small-pox. While the 
two latter diseases will almost certainly attack all unpro- 
tected persons exposed to their contagion, scarlet fever 
often leaves unscathed persons who have been brought 
into the most intimate personal relations with it. It is 
consequently much easier to practise isolation with the 
hope of success. ~However, the immunity possessed by 
an individual, as shown by repeated exposures, may not 
prove perpetual, and well-marked, even fatal, scarlatina 
may follow a final exposure. A degree of immunity 
from scarlatina is sometimes exhibited in families, the 
members of which escape altogether, or have only light | 
attacks. Unfortunately, on the other hand, a decided 
family predisposition to the disease is occasionally en- 
countered, one member after another falling a victim to 
its virulence. 

Careful observation has failed to show that predispo- 
sition to scarlet fever is especially favored by the nature 
of the soil or the state of the weather; neither can it be 
proven that the type of the disease is especially influ- 
enced by any ordinary surroundings, further than that 
conditions of life prejudicial to the maintenance of good 
health diminish the powers of resistance to the onset of 
the disease. It is important to remember that in the ab- 
sence of the contagious principle no degree of filth, de- 
privation, dampness, bad ventilation or drainage, or ex- 
posure, no matter how injurious to general healthfulness, 
can serve as the starting-point for scarlet fever. Indeed, 
it is remarkable, considering the bad hygienic environ- 
ment of the poorer classes, that between them and the 
rich there should be so small a difference in the degree 
of predisposition to, and in the relative mortality from, 
scarlatina. | 

To develop scarlatina an individual must, of necessity, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Scarlet Fever. 
Scarlet Fever. 


receive into his body the materies morbi derived from 
one who has, or who has had, the disease. In all cases 
the contagion must be communicated by the air, or in 
solids or fluids received into the body. It is probable 
that physical contact occurs but rarely between infected 
and unprotected persons, and that when it does occur, 
the danger of infection is due rather to the increased 
liability of intercepting emanations from the body. 
Scarlet fever appears to be not contagious at the very 
beginning. In this respect it differs markedly from 
small-pox and measles. In the prodromal stage the 
contagion is probably not set free as readily as at a 
later period. Girard, however, has asserted that it is 
contagious only on the first day. This hardly needs a 
refutation. Longhurst !* also claims that it is most con- 
tagious during the pre-eruptive stage, and not at all 
during desquamation. These and similar opinions of 
individuals are negatived by the almost universal experi- 
ence of observers. Scarlet fever develops its highest 
properties of contagion during its period of eruption, 
and, still unlike measles, retains its contagiousness until 
desquamation is far advanced. Two children, at the 
Netherfields Institution at Liverpool, were believed to 
have been centres of contagion six and a half weeks after 
the beginning of their illness.'7 Cameron ?® reports a 
case in which, nearly nine weeks after the beginning of 
her own attack, a child communicated the disease to her 
sister by contact. It seems probable that the power of 
communicating scarlet fever is retained, gradually dimin- 
ishing in intensity, until the end of desquamation, which 
may not be completed for six, eight, even ten weeks. 
Thomas mentions cases where children, even after the 
completion of desquamation, while suffering from scarlati- 
nal dropsy, probably served as centres of contagion. The 
agency of the atmosphere as a contagion-bearer does not 
seem to extend beyond.a few yards. Thus, it often hap- 
pens that the disease does not spread beyond the sick- 
room, provided mediate contact can be avoided. Possi- 
bly the contagion is of too great gravity to be wafted 
for any distance. Yet it is certainly, under certain con- 
ditions, very tenacious of life, and may be conveyed long 
distances and preserve its properties for prolonged peri- 


ods. It has often been carried by a healthy person, who 


has been exposed to the malady, to persons at a distance. 
There are authentic accounts of physicians, nurses, at- 
tendants, and visitors serving thus to carry infection. 
Such unfortunate occurrences are not very common, and 
probably only happen when the carrier of contagion 
passes directly from the sick-bed to the unprotected 
person, without due regard to the proper disinfection 
of the person and clothing. A pernicious custom is the 
habit of putting on over-clothing and wraps over the 
dress in which the patient has been visited, without 
proper exposure to the free circulation of fresh air. The 
tenacity with which the contagion clings to inanimate 
substances is most remarkable. Articles of clothing, 


_ bed-linen, furniture, wall-paper, hangings, and the like, 


frequently serve to communicate the disease, and often 
after almost incredibly long intervals. Richardson gives 
an example of this. Four children lived with their 
parents in a thatched cottage. One child was taken with 
scarlet fever, and the others were sent away. After three 
weeks one of these was permitted to return. It took the 
disease on the first day and died. The walls of the cot- 
tage were now cleaned and whitewashed ; everything was 
thoroughly scrubbed, and all wearing apparel was washed 
or destroyed. After four months another child returned. 
The next day he was seized with the disease and died. 
Here the thatch was thought to have retained the conta- 
gion. The germs of the disease may be shut up in a let- 
ter and conveyed a long distance. Woollen clothing, put 
away and brought out after many months, pillows, cush- 
ions, toys, books, have all been known to preserve the 
contagion in full vigor. The dissemination of the virus 
in the atmosphere has been stated to be very limited, but 
the same cannot be said so confidently concerning the 
agency of fluids. The spread of scarlet fever has never 
been directly traced to the water-supply, but there is 
abundant reason to attribute its occasional extension to 


Vou. VI.—20 


the medium of milk. Thomas quotes two examples of 
this. -One, reported by Bell, leaves it an open question 
whether the milk, its receptacle, or the boy who carried 
it, was the medium. The other came under the observa- 
tion of Taylor, who noticed ‘‘ that one of the first severe 
cases which initiated an epidemic occurred in the house 
of a milkman whose wife milked the cows, the milk 
being supplied to about twelve families in the city. In 
six of these scarlatina occurred in rapid succession, at a 
time when the disease was not epidemic, and without 
any communication having taken place between those 
who were affected and the person who brought the milk. 
It is very probable that in this instance the milk was the 
carrier of the contagion, as, previous to its distribution, 
it had stood in a kitchen which had been used as a hos- 
pital for scarlatina patients.” More recently, Airy, in 
eighteen families, consisting of thirty-five persons, report- 
ed twenty-four of these sick with scarlatina within thirty- 
six hours. Every one of these patients received milk 
from the same source. Neighbors who had milk from 
other ‘sources were not attacked. It was found that a 
person who milked the cows lived with a child in full 
desquamation from scarlatina. Several observations of 
this kind make it hardly doubtful that milk may serve 
as the vehicle for the scarlatina virus, and that it, indeed, 
may be considered a favorable culture-fluid for it. But 
until recently it has not appeared that the virus-bearing 
milk received its contamination otherwise than through 
human sources. Later investigations seem to throw 
much light upon the possible origin of scarlatina in man, 
and upon one of the paths for its dissemination previously 
unrecognized. A recent outbreak of scarlatina among 
persons who received their milk-supply from a dairy in 
Hendon, in England, seemed to be traceable directly toa 
disease of the cow. The cows of this farm were affected 
with a peculiar affection, among the symptoms of which 
were a shedding of the hair and the formation of vesicles 
and ulcers upon the teats and udders. This is an inocu- 
lable disease among cows.* In this connection it is an 
important fact that inoculation of cows, especially when 
in milk, with the virus of scarlatina, results in the pro- 
duction of definite symptoms. The reports upon these 
observations by Mr. Power, Dr. Cameron, and Dr. Klein 
will go far toward establishing the prevalence of a scar- 
latina in cows, and its fruitfulness as a cause of the 
spread of scarlatina to mankind. Further information 
upon this most important subject will, doubtless, be soon 
forthcoming. 

The scarlatinal virus gains access to the blood through 
the respiratory tract, and is also conveyed in solid and 
liquid food to the stomach, whence it is absorbed. Though 
itis unlikely that absorption can occur through the sound 
skin, the disease is said to have been inoculated by arti- 
ficial deposition of contagion-bearing material upon the 
abraded cutis. Miguel d’Amobise claimed to have in- 
oculated children successfully with blood taken from 
scarlatinous patches. Stoel and Harwood have been re- 
ported as having conducted successful inoculations. On 
the other hand, Petit-Radel failed in his experiments. 
New observations upon this point are required. The 
contagion probably resides in the epidermis, and becomes 
diffused as this is exfoliated ; also in the buccal and fau- 
cial mucous membranes, and probably in the secretions, 
in the lymph, and in the blood. In the absence of reli- 
able inoculation experiments we have no fixed knowledge 
upon these points. Some writers deny that the exfoli- 
ated epidermis contains any virus whatever. 

CLINICAL History.—J/neubation.—Scarlet fever has a 
shorter and much less definite period of incubation than 
the other eruptive fevers. In determining the interval 
between infection and the outbreak of symptoms, it is 
much easier to reach correct conclusions when the fever 
has followed a single exposure than when the exposures 
have been repeated or prolonged. There is abundant evi- 
dence to show that the period of incubation may be less 
than twenty-four hours. On the other hand, it has been 


* The existence of scarlatina among animals has been ably upheld. 
Salmon’s and Peters’ papers upon equine scarlatina are very important. 


305 


Scarlet Fever. 
Scarlet Fever. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


claimed that four or five weeks may elapse before the dis- 
ease manifests itself. Most cases of scarlatina have an in- 
cubation period of from four to seven days. Even this 
wide limit, differing markedly from that of the other 
eruptive fevers, is subject to very many exceptions, and 
the literature teems. with examples of scarlet fever de- 
veloping a few hours after exposure, or only after many 
days, even weeks. Murchison believed the incubation 
period to be more often less than forty-eight hours in 
duration. The shortest authentic stage of incubation 
was in the case of Richardson, who after auscultating a 
scarlet-fever patient immediately became nauseated and 
chilly. He was conveyed home in the carriage of a 
friend, and dated an attack of scarlatina from that hour. 
Incubative periods of not more than twenty-four hours 
have been reported by many writers.!% In 20 cases 
Dukes found the duration to vary from one to nine 
days, in 10 cases it was less than five days. Murchison 
reported, in the ‘‘ Transactions of the Clinical Society,” *° 
the incubative periods of 75 cases, none of which ex- 
ceeded ten days. He considered a person safe from con- 
tagion who is not attacked within a week after exposure. 
Thomas?! thinks that from four to seven days is the most 
frequent interval ; Kaposi considers it to be about eight 
days; Gee thinks that seven days are rarely exceeded ; 
Lewis Smith, that it is ordinarily less than six days. 
Longer intervals, however, are not infrequently noted. 
In one case Hagenbach* determined it to be eleven 
days; in another, fourteen days. Intervals of twelve 
days or more have been recorded by Veit, Paasch, Bon- 
ing, Lewis Smith, and others. From the rather untrust- 
worthy results of inoculation, seven days would seem to 
have been the incubative period. Barthez and Rilliet, 
Gee, and others thought they had observed cases where 
the incubative period covered several weeks, and, indeed, 
in delicate children, especially those with rickets or other 
neuroses, it. may be much prolonged (Mayr). There is, 
however, a growing belief that the incubation of scarlet 
fever lasts less than six days, and, without attempting to 
be more accurate, we accept that as the common dura- 
tion. It is very often less than this, and but very seldom 
more. In this, as in most other features, scarlet fever 
shows great variability, and, if the term be allowable, a 
felyee ete contrasting strongly with the other specific 
evers. 

Period of Invasion.—For convenience of description it 
will be proper to describe scarlatina as following an or- 
dinary or mild, and a graver, course. The course is very 
often irregular, from the absence of characteristic symp- 
toms, or from the undue prominence of one or several 
of them, or from the presence of complications. In fact, 
scarlet fever may vary from an insignificant, even an un- 
appreciable, disturbance of health, to a malady pursuing 
its fatal course with lightning-like rapidity ; and although 
the type of the prevailing epidemic may be mild, severe, 
or malignant, individual cases can only in a measure 
conform to the standard, from which they will invariably 
differ to a greater or less extent. 

Milder Forms.—Ordinary Course.—Prodromal Period. 
At the end of incubation the active symptoms of scarlet 
fever usually develop suddenly ; rarely they appear more 
gradually. In most cases fever is the first symptom ob- 
served. In larger children and adults an initiatory chill is 
often noted. Convulsions may occur at the outset ; usu- 
ally, however, they usher in graver forms of the affection. 
The fever develops during the night, or during the day 
the child loses its playfulness and in a few hours is found 
to have a high temperature, in most cases not exceeding 
103° F. (39.5° C.), but occasionally reaching 104° to 105° 
F’, (40° to 40.8° C.). At the same time the pulse will be 
full and frequent, beating from 120 to 140 times in the 
minute very commonly. The rapidly rising temperature 
and great acceleration of pulse are characteristic, and 
under favoring conditions should excite suspicions of 
scarlatina. The face becomes flushed, the eyes bright 
and injected. There is much thirst, but almost complete 
anorexia. Nausea and vomiting are so frequent that 
J. Lewis Smith attaches some diagnostic importance to 
the symptom. Of 214 patients it was present in 162. 


306 


Jenner thought that severe vomiting is apt to precede 
severe throat symptoms. Diarrhoea sometimes occurs, 
especially in graver cases. The tongue may be only 
slightly coated ; frequently it is covered with a white, 
creamy fur, but remains red at the edges. Already the 
little patient complains of sore throat (indeed this may be 
the first symptom to attract attention), and upon inspec- 
tion the mucous membrane of the pharynx will be found 
to be swollen and dry, and of a bright or dusky-red hue, 
and often spotted with small areas of duskier redness. 
At this stage no curdy nor diphtheritic deposit will be 
observed. The nasal mucous membrane sometimes par- 
ticipates in the hyperemia, and a nasal catarrh is in- 
duced. There will now be difficulty in deglutition, and 
already there may be some enlargement of the submaxil- 
lary and cervical glands. There is often headache and also 
delirium, sometimes of an active kind. As the fever in- 
creases in severity the patient becomes dull, listless, and 
drowsy, and various symptoms of cerebral disorder are 
common in graver cases. In very many cases, however, 
all the symptoms will be mild. There may be little fe- 
ver, no noticeable disturbance of the various functions, 
not even sore throat. Beyond slight peevishness and ir- 
ritability the child may not seem to be unwell. In nota 
few cases there may be no prodromal period at all, the 
eruption first attracting notice. During the prodromal 
stage the urine is rather scanty, acid, and high-colored. 
According to Gee, the urine is diminished in quantity ; 
urea is not necessarily increased ; chloride of sodium is 
diminished, sometimes decidedly, the diminution gener- 
ally ceasing suddenly on the fourth, fifth, or sixth day ; 
phosphoric acid, at first normal, is notably diminished on 
the fourth or fifth day, remaining for four days from one- 
third to one-half the normal quantity, and then returning 
to the healthy standard ; uric acid is greatly diminished on 
the second and third days, becoming excessive on the fifth 
day, and then normal. Even at the earliest observation 
albuminuria may be observed. Boning, who denies a 
prodromal stage, and always encounters the eruption on 
the first day simultaneously with the chill, has found 
blood-corpuscles, renal epithelium, and albumen in the 
urine from the very start. The respiratory movements 
quicken in proportion to the rapidity of the pulse. 
Nearly all cases will begin to show the eruption within 
twenty-four hours, many within twelve hours, a few 
during the second day. When the eruption appears 
later, an abnormal or unusually severe form of the dis- 
ease often follows. 

Stage of Hruption.—The eruption first appears upon the 
sides of the face, upon the neck and submaxillary region, 
and on the front of the chest, in the clavicular region, as 
small, pale-red points, closely aggregated although at 
first discrete, and very slightly elevated. It rapidly ex- 
tends over the chest (where it becomes most intense), upper 
and lower extremities, and attains its full distribution by 
the end of the second day, acquiring a bright red or scar- 
let color. It occasionally happens that the eruption be- 
gins on other parts than those mentioned, or may never 
become general. Rarely it spreads more slowly, even 
fading in some localities before the lower extremities are 
invaded. It is especially apt to affect the flexures of the 
joints. In mild cases the spots remain discrete over most 
of the body, and may resemble a fine ‘‘ prickly heat,” 
densely arranged and of minute size. At times the erup- 
tion consists of dark-red points, surrounding hair-folli- 
cles, separated from each other by less intensely red areas 
(Henoch). In cases of greater intensity it is coalescent 
almost universally, and presents a continuous brilliant 
scarlet surface, like the shell of a boiled crab or lobster. 
The intensity of coloration varies somewhat, even in the 
same patient, depending much upon the degree of heat ; 
becoming paler when the surface is cooled, more scarlet 
when this is protected by heavy covering, etc. It is, 
however, not perfectly smooth, but shows the tiny pap- 
ules upon the reddened base, and communicates to the 
hand passed over it a sensation of roughness and of dry 
and pupgent heat. Upon the legs and arms the eruption 
very often becomes more scattered, assuming the form of 
separate tiny points ; rarely it is distributed over distinct 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Scarlet. Fever. 
Searlet Fever, 


areas of the trunk and extremities, with intervals of faintly 
erythematous redness (scarlatina variegata). This form, 
however, is apt to appear in severecomplicated cases. It 
must be remembered, however, that, unlike measles, scar- 
let fever affects the face less than other parts. Never 
very intensely developed over the forehead, temples, or 
chin, the eruption entirely spares an area around the 
mouth, including the upper and lower lips and some dis- 
tance beyond the angles of the mouth, and often extend- 
ing upward to include the nose. This area contrasts with 
the surrounding parts by its remarkable pallor. It has 
been asserted that the cheeks are also spared by the erup- 
tion. This is not true. The cheeks do not show the 
pointed redness of the early eruption elsewhere, but at 
once assume a scarlet or crimson redness that is deeper 
than the color induced by fever. The lips are often dry 
and cracked, and may bleed. The face becomes consid- 
erably swollen, especially in the loose tissue about the 
orbits. The ears are also swollen and of a bright red 
color. The eruption does not spare the scalp. Upon the 
backs of the hands and feet the eruption is discrete, and 
is arranged in groups the size of a lentil, while upon the 
palmar surfaces of the hands and fingers, and upon the 
soles of the feet, a bright, diffused redness, with swelling, 
is seen. At times the eruption will be partial, develop- 
ing upon the trunk alone, or on the extremities, or in 
isolated patches about the body. These cases may not 
be abnormal in other respects. The skin over the joints 
is especially prone to be affected. The lesions may be 
more or less disseminated spots, varying from the size 
of a pin-head to that of the finger-nail, or a half-dollar, 
or even larger. It has been asserted that the erup- 
tion constantly consists of a papulated rash upon a red- 
dened base, even when universally diffused. This is not 
invariably so, and one may encounter a smooth, uni- 
form redness inappreciable to the touch. Where the 
eruption is very intense, small hemorrhagic spots, or 
petechiz may appear. When thus occurring, their oc- 
casional presence is not of serious importance. In warm 
weather especially, and in children too warmly covered 
with bedclothes, the surface, particularly of the neck, 
chest, and belly, is sometimes plentifully sprinkled with 
-an eruption of sudamina. In some epidemics these are 
more often observed than in others. It is not impossible 
that the ‘‘ miliary fevers” that formerly occasionally pre- 
vailed in Europe, were, in reality, forms of scarlatina. 
Mayr has said that the eruption of scarlet fever often 
spares the skin of paralyzed limbs; but Kaposi asserts 
that it may be unusually intense upon these parts. In 
dark-skinned races the eruption undergoes some moditi- 
cations, which are greatest in those of full negro blood. 
In mulattoes and negroes it becomes often exceedingly 
-difficult to distinguish the eruption. Of course the scarlet 
color is absent, a tinge of red will often struggle through 
the darkly pigmented skin, especially of the cheeks and 
abdomen. The true character of the eruption may often 
be revealed by a finely papular condition, the tiny papules 
of the size of a pin-point being made apparent by their 
acuminated summits, which give, against the dark back- 
ground, a resemblance to a sprinkling of the surface with 
a fine dust. The hand passed over them can perceive the 
little asperities. These are closely aggregated. In many 
cases it is impossible to recognize the eruption, and the 
diagnosis must rest upon the concomitant symptoms, 
which will not be peculiarly modified. 

While the eruption—which attains its height by the end 
of forty-eight hours in mild cases, later in severe ones— 
is developing, the other symptoms become pronounced. 
The faucial mucous membrane is uniformly redder, or, 
occasionally, shows numerous red macules; the uvula, 
tonsils, and buccal mucous membrane are reddened and 
swollen, and pain in deglutition increases. As the erup- 
tion reaches its height, the tongue parts with its coating 
in patches, exposing areas of intense redness. By the 
third day it acquires a uniformly brilliant red color, with 
enlarged papillae scattered numerously over its general 
surface, and presents the characteristic ‘‘ strawberry ”” or 
‘raspberry ” appearance. Exceptionally, this exfoliation 
of the lingual epithelium does not occur, and the creamy 


deposit persists. In many mild cases there is slight nasal 
catarrh, with a thin discharge from the nostrils. A muco- 
purulent discharge from the nostrils is associated with 
the throat complications of the graver forms. 

During this period the fever continues to increase 
until the completion of the eruption, or the prodromal 
temperature remains unchanged. In the type of cases we 
are considering 105° F. (40.5° C.) is not often exceeded. 
Should the fever continue to increase after the third day, 
grave solicitude as to the result will be justifiable. The 
other symptoms continue with undiminished vigor—di- 
gestive disorder, nausea, vomiting, complete anorexia, 
rarely diarrhoea, persist. The skin burns or itches more 
or lessintensely. Nervous symptoms, restlessness, stupor, 
headache, delirium, usually diminish, but may continue 
unabated ; or active delirium may occur. Convulsions 
at this time are very ominous. The sore throat becomes 
distressing, and the cervical and submaxillary glands en- 
large and become painful.. Bronchial and pulmonary 
inflammation only occur as complications. After the 
fourth or fifth day nearly all of these symptoms cease to 
increase, and it becomes evident, ceterds paribus, that the 
course of the disease is to be favorable. The eruption, 
after persisting in full development for a day or two, be- 
comes duller and slowly fades, first in the parts earliest 
affected, latest from the back of the hands. The color, 
which at first completely faded, now leaves a yellowish 
stain when the finger compresses the skin. It is not, 
however, until after four, five, or six days, that the skin 
loses its scarlet color. This may last longer. Jenner *’ has 
known it to persist for from fourteen to sixteen days. The 
fever slowly declines, until it ceases about the sixth, sev- 
enth, or eighth day, or later, and not before the eruption 
has entirely disappeared. Sometimes, from unknown 
reasons, it persists for days after all local symptoms have 
ceased to be active. On the other hand, fever, in some 
very mild cases, will hardly be noticed, or will endure but 
a few hours. The throat manifestations, or the super- 
vention of complications, may protract the fever for many 
days. The sore throat, unlike the other symptoms, often 
fails to show signs of amelioration after the height of the 
eruption. The swelling and redness may increase, and 
white or yellowish curdy deposits form upon the tonsils 
and uvula, or the posterior wall of the pharynx may be 
bathed in a thick muco-purulent discharge from the pos- 
terior nares. True diphtheritic membrane is not apt to 
form in these cases, but the neighboring lymphatic glands 
may become highly inflamed and suppurate. It is prob- 
able that renal catarrh and nephritis occur more fre- 
quently during this period than is commonly supposed. 
Frerichs, Reinhardt, Eisenschitz, Boning, Begbie, New- 
bigging, Holder, and others, consider the renal symp- 
toms as essential in scarlatina. This is, however, not 
true. Thomas* practised microscopic examinations of 
the urine in twenty-five of eighty patients, and in twenty 
of these daily. In the prodromal and eruptive stages 
he found slight albuminuria only rarely and transitorily. 
Decided alterations in the renal tract were most uncom- 
mon. Mild catarrh was more often seen. Only the more 
severe forms he considered to depend upon a specific 
scarlatinal influence. Fleischmann,” in 472 cases of scar- 
latina, reported dropsy during the first week in 9 cases. 
Not enough, certainly, to bear out the sweeping asser- 
tions just quoted, but sufficient to direct attention con- 
stantly to the condition of the kidneys in scarlatina. 

Many cases of mild scarlatina fail to exhibit all the 
symptoms enumerated. The prodromal stage may be ab- 
sent, sore throat may be insignificant, or absent through- 
out. The tongue may never assume the ‘‘ strawberry ” 
appearance. The fever may be of feeble intensity. Fi- 
nally, the rash may be faint and not widely distributed. 
It may be limited to a few reddish or pinkish punctate 
spots upon the neck or chest ; or it may only affect the 
flanks or the flexures of the joints; or it may be so 
transitory as to escape observation or to be noted only 
during a few hours; or, finaliy, it may fail altogether to 
appear. On the other hand, sore throat may be the only 
active evidence of the disease. Cases that have been ex- 
posed to the contagion sometimes develop sore throat 


307 


Scarlet Fever. 
Scarlet Fever. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


only. These may subsequently become dropsical from 
nephritis, or they may desquamate more or less abun- 
dantly, or even communicate scarlet fever to others. An 
interesting feature is a tendency, often shown by those 
exposed to contagion, to suffer from_a mild attack of 
pharyngitis after every exposure. Many physicians, 
nurses, etc., experience this. Finally, the eruption may 
fail to appear, knowledge that scarlatina was present 
being acquired through the occurrence of desquamation 
or dropsy. Cases of this kind have been designated 
‘<scarlatina sine ecanthemate.” 'They are not so very rare, 
At other times the eruption is so indeterminate in ap- 
pearance that, in the absence of accompanying symp- 
toms, it is impossible to speak positively of its character. 

Stage of Desquamation.—After the fading of the erup- 
tion the patient passes into the stage of desquamation. 
This is an immediate result of the eruption. Desquama- 
tion begins usually upon the neck, and continues for from 
eight to fourteen days, but not infrequently for four, six, 
or even eight weeks or more. Usually not earlier than 
the sixth day of the disease it is noticed upon the neck 
and face, and quickly extends over the whole surface, and 
may even occur upon parts not visited by the eruption. 
Upon the face and neck the scales are mostly fine, but 
coarser than those following measles. From other parts 
the epidermis peels in great shreds. On the hands and 
feet the lamelle are always large, and sometimes from 
these members the cuticle is removed in masses resem- 
bling a glove or slipper. Desquamation endures longest 
where the epidermis is thickest, often for weeks; that 
newly formed exfoliating repeatedly. The hair and 
nails are sometimes shed after scarlet fever. Desquama- 
tion is at times observed in those who have had no erup- 
tion, or, at least, one of very circumscribed extent. With 
the completion of desquamation the disease may be said 
to have run its course. Great care, however, must be 
exercised for some weeks to protect the patient from 
the effects of complications and from the sequel to 
which the disease has made him liable. With the fad- 
ing of the eruption, the cessation of fever, and the be- 
ginning of desquamation, general improvement takes 
place. The tongue gradually resumes its normal ap- 
pearance, or for a time becomes again coated; the sore 
throat diminishes ; the various functions are properly per- 
formed; appetite and strength return. Desquamation 
may, however, be sometimes delayed. The local use of 
oils and ointments during the eruption tends to make the 
desquamation less free. The occurrence of dropsy some- 
times defers the beginning of desquamation, and this may 
not become abundant until after the dropsy has subsided. 
Contagion has spread from desquamation beginning in 
this manner, after isolation has been abandoned as no 
longer necessary. In rare cases desquamation can hard- 
ly be said to occur at all. Even in mild cases, in winter, 
the patient should not be permitted to leave his bed until 
the end of the third week, or to leave his chamber until 
the completion of desquamation. In midsummer it is 
usually not advisable to insist upon confinement to bed 
for so long a period. Cases which run the apparently 
mild course just described are by no means free from 
danger, as they are often accompanied or followed by 
local pathological processes which, while they may not 
be essential symptoms of scarlet fever, are especially 
prone to affect those suffering from it. Such lesions 
will be considered among the complications and sequels 
of scarlatina. 

Graver Forms.—Every case of scarlatina is dangerous. 
In those following the type just described the peril arises 
from processes that are not essential to the disease. Such 
forms pass, by insensible gradations, into those where life 
is imperilled by the greater or less intensity of character- 
istic phenomena. The graver forms of scarlatina may 
not differ in their initiatory symptoms from those already 
described. In most cases the severity of the disease is 
in great measure dependent upon lesions in the throat, 
while, as a rule, the eruption shows a more general dis- 
tribution and a more intense coloration. The prodromal 
symptoms do not differ in kind from those of milder 
types, but are more severe. Vomiting is more apt to oc- 


308 


cur, and nervous symptoms to become prominent. Head- 
ache, jactitation, and delirium become more marked, or 
the patient grows petulant, drowsy, and stupid. Con- 
vulsions also may occur. Fever attains great intensit 

at the very outset, reaching 40° to 42° C. (104° to 106° F.), 
the latter temperature always denoting extreme danger. 
There is already sore throat, with difficult deglutition 
and with swelling and deep redness of the faucial mucous 
membrane, which by the third day, in the less severe 
cases, shows curdy deposits scattered over the tonsils. 
These deposits do not involve the mucous membrane, 
and may generally be detached by a mop or a brush. 
They are quite like the exudation of ordinary catarrhal 
pharyngitis. After the third or fourth day, under con- 
ditions of constantly increasing fever and general dis- 
tress, in some cases, diphtheritic exudation begins to show 
itself over the tonsils and soft palate, and posterior wall 
of the pharynx. It is an interesting point of difference 
between primary and scarlatinal diphtheria that the lat- 
ter never begins to appear before the third or fourth day, 
after which date it is sufficiently common. Fleischmann 
reported diphtheria 168 times in 472 observations. The 
diphtheritic deposit is first developed on the lateral por- 
tion of the tonsils, except in those rapidly fatal cases 
where the whole pharynx seems to be simultaneously in- 
volved. The patches are of a whitish or grayish-white 
color, and involve the mucous membrane sometimes to 
a considerable depth and superficial extent. At times the 
diphtheritic membrane rapidly spreads in a continuous 
sheet over the fauces, extending forward into the buccal 
cavity and into the posterior nares. In the latter case, a 
fatal termination is almost inevitable. Heubner” asserts 
that those cases in which the entire mucous membrane, 
from the root of the tongue to the esophageal and tracheal 
orifices, iscovered with the membrane, die within twenty- 
four or forty-eight hours, without exception. Here the 
membrane is sharply margined against the dusky-red mu- 
cous membrane, and within a few hours the slough shows 
signs of separation and develops a gangrenous odor. In 
these cases the membrane hardly ever travels down into 
the trachea. Bretonneau has made a positive assertion 
that this does not occur. It does so occasionally, how- 
ever. Lewis Smith reports cases, with necroscopic ex- 
amination, where diphtheritic membranes extended along 
the trachea into the bronchial tubes. In the most severe 
cases, however, the deposit does invade the posterior 
nares, and the ordinary slight catarrhal discharge is sup- 
planted by an offensive sanio-serous or sanio-purulent 
discharge from the nostrils, which causes excoriation of 
the upper lip. At the same time the nares become ob- 
structed, and the little patient is driven to breathe almost 
entirely through the mouth. In many cases of extreme 
throat involvement the strength rapidly fails, pallor re- 
places the prematurely receding eruption, except at cer- 
tain spots where this may persist as circumscribed patches 
of dusky redness ; the temperature remains stationary or 
falls, the pulse becomes more and more feeble and rapid, 
and death ensues within a few hours, as if from blood- 
poisoning. Death either follows slow spread of gangrene 
to the soft palate and tongue behind the sinus pyriformis, 
and to the walls of the throat, or occurs through diphthe- 
ritic inflammation of the lymph-glands and connective 
tissue of the neck, or through oedema of the glottis. At 
other times the clinical appearances during the first week 
may not be alarming, danger becoming imminent about 
the beginning of the second week. The fever may remain 
elevated, the eruption brilliant and intense, until a short 
while before death. In the rapidly fatal cases the throat 
and neck may not appear very much swollen. At other 
times the neck and submaxillary region are greatly swol- 
len, principally from the inflammation of the glands and 
peri-glandular tissue. These parts become hard and 
brawny, and from the pressure upon the great veins ac- 
quire a livid appearance, which may also be communi- 
cated to the face and head. The tonsils and soft palate 
may be swollen until the throat will appear quite closed. 
The mucous membrane will be deeply congested, and 
covered here and there with diphtheritic exudation, and 
with ulcers caused by the separation of sloughs. The 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Scarlet Fever. 
Scarlet Fever, 


posterior wall of the pharynx may be bathed in muco- 
pus. Retro-pharyngeal abscess is sometimes formed, and 
may precede the fatal termination. Dyspnoea may result 
from swelling of the fauces caused by inflammatory exu- 
dation into the parts, from edema glottidis, or from exten- 
sion of diphtheria to the larynx and trachea, or it may bea 
result of the imperfect oxidation of the blood. The term 
‘‘ diphtheritic”” is here used in a clinical sense, to desig- 
nate a condition of coagulation-necrosis in the tissues in- 
volved, and has no reference to a pathogenetic relation- 
ship with true diphtheria. This necrosis occurs simply 
as aresult of the intensity of the accompanying inflam- 
matory changes. There is no evidence that true diph- 
theria may not co-exist with scarlatina, but that the 
commonly observed membranous pharyngitis of scarla- 
tina represents this combination is most improbable. J. 
Lewis Smith has seen four instances where the diphtheria 
became dissociated from the scarlatina, and attacked other 
persons as idiopathic diphtheria. Such observations are 
exceedingly uncommon. The scarlatinal diphtheritic 
membrane is, indeed, essentially identical with that of 
idiopathic diphtheria in structure. The differences are 
etiological. The diphtheritic poison and. the scarlatinal 
poison, differing in their specific natures, possess in com- 
mon the power to excite such violent inflammatory 
changes in the tissues that a coagulation-necrosis results. 
The diphtheritic membrane of scarlatina, then, is purely 
scarlatinal in its origin. This view has received solid 
endorsement. It has been adopted by Henoch. Heub- 
ner considers scarlatinal diphtheria to differ from pri- 
mary diphtheria both clinically and histologically. It 
begins with a simple catarrhal affection, and, following 
his observations, changes from catarrhal to diphtheritic 
inflammation on the fourth day. Koven also thinks that 
the throat affections of more severe grade are necrosis 
from direct intensity of the scarlatinal process, and not 
truly diphtheritic. He observes that while two acute 
diseases rarely co-exist, of 426 cases of scarlatina 125 
had necrosis faucium, although at the period of observa- 
tion there was not a single case of primary diphtheria 
in Christiania. He further declares that diphtheritic 
paralysis never occurs after scarlatina, and that while 
true diphtheria shows the membrane at once, the scarla- 
tinal slough usually appears after several days of increas- 
ing angina, and does not extend to the larynx.?’ Henoch 
has never seen a single case of accommodation paralysis 
of the eye or of the soft palate, nor of the neck, nor of the 
extremities, after scarlatinal diphtheria. The inflamma- 
tion may, often does, extend along the Eustachian tube 
to the middle ear, and excites changes that give scarlet 
fever one of its principal terrors, resulting often in more 
or less complete permanent deafness. These changes 
will be considered with the complications and sequel of 
scarlatina. In anumber of these cases cervical adenitis 
and periadenitis occur, and prolong the fever beyond the 
eruptive stage indefinitely, frequently resulting in sup- 
puration. Occasionally the pus burrows deeply among 
the tissues of the neck, and extensive gangrene may fol- 
low. Williams has reported a case of extensive slough- 
ing in the left anterior triangle of the neck, with exposure 
of vessels, followed by recovery. Other similar cases 
have been recorded. In most cases where death does not 
speedily occur after suppuration and evacuation of pus 
recovery will take place, but the patient may ultimately 
succumb under blood-poisoning and protracted fever. 
Occasionally, also, parenchymatous tonsillitis may cause 
rapid and enormous enlargement of the tonsil, with the 
formation of pus, a condition of extreme gravity, espe- 
cially if associated with retro-pharyngeal abscess and 
cedema of the glottis. In favorable cases the sloughs in 
the fauces will cease to extend, the edema and dusky 
redness will slowly subside, and the diphtheritic ulcers 
begin to granulate. i 

In many cases the faucial symptoms here described do 
not appear, only because life is early destroyed by the in- 
tensity of the action of the specific poison upon the blood 
and tissues. In such malignant cases the patients of- 
ten die with the rapidity of. those who succumb to nar- 
cotic poisoning; or a series of convulsions inaugurate 


the disease and terminate life within an hour or two. At 
other times brief initiatory symptoms have been followed 
by intense fever (106°-109° F.), with uncontrollable vom- 
iting, diarrhoea, delirium, rapidly deepening coma, and 
death, before the appearance of the eruption. Or, again, 
the disease may begin in the ordinary manner, not sugges- 
tive of a severe course, and alarming symptoms may not 
develop until after several days; or it may be intense 
from the beginning, with severe and repeated convul- 
sions, vomiting, profound nervous depression, and the ap- 
pearance of the eruption at the usual time, with steadily 
increasing gravity of all the symptoms, until, after a few 
days, death results from convulsions or coma. Finally, 
the malignant symptoms will appear suddenly in the 
midst of what has seemed a mild attack of scarlatina. 
An unusually protracted period of invasion is sometimes 
the forerunner of malignant scarlet fever, and should al- 
ways be regarded with apprehension. Cases may at times 
exhibit at the beginning alarming symptoms. <A decided 
apathy, in which no notice of what is passing is taken, 
with great apparent depression and even delirium, excites 
the apprehension of the attendants, yet the pulse and 
temperature will not show marked variation from the 
normal, After the second or third day such cases will 
very often pursue a mild course. A high temperature and 
very quick pulse may even be added to these symptoms 
and justly excite alarm, and yet the case may assume a 
favorable character after the development of the erup- 
tion. In such cases as these the probability of the issue 
in life or death seems to vary from hour to hour, All 
the symptoms show intensity. The fever, accompanied 
by more or less severe initiatory symptoms, rapidly in- 
creases, the eruption is copious and deeply colored, the 
pulse beats 130, 140, 160 times, or oftener to the minute, 
the respiration is proportionally accelerated, the throat 
duly shows more or less extensively the peculiar altera- 
tions. This course may be held throughout the first 
week, and even longer, without mitigation, the result re- 
maining doubtful all the while. 

In malignant scarlet fever the usual course is one of 
intensified general symptoms. Those of the invasion 
period are indicative of grave perturbation of the econ- 
omy. By the time the eruption appears it is already evi- 
dent that the patient is dangerously ill. He is apathetic, 
or perhaps extremely restless, remaining in one position 
not an instant. The skin is hot, dry, and pungent, the 
temperature very high, the features swollen, the conjunc- 
tive injected, the fauces reddened and dry, the thirst in- 
tense, but water and all ingesta are often vomited as soon 
as swallowed; the urine is scanty, or even suppressed, 
from acute renalinflammation. Diarrhoea may be present. 
The nervous phenomena become intensified. The erup- 
tion now appears, and may at first develop regularly, but 
after a while will become duskier and will not completely 
fade on pressure. The color tardily returns to the part 
whence it has been pressed. Coma or convulsions may 
now carry off the patient in full eruption. Often, how- 
ever, the eruption will recede from certain parts in whole 
or partially, or it may become paler universally ; or in 
place of the regular’ eruption hemorrhagic exudation 
will appear. Ecchymoses, from the size of a pin-head to 
that of the palm, or larger, will replace the usual eruption, 
which will in great measure disappear. Then livid spots, 
not fading on pressure, are found, generally upon the 
flanks and back, but may appear anywhere. Accord- 
ing to Mayr, the hemorrhagic eruption may appear over 
a large part of the surface in children, but in adults is 
mostly confined to the neck, upper part of the chest, the 
back, and about the joints of the upper and lower extrem- 
ities. This hemorrhagic variety is the most formidable 
form of scarlet fever, and is probably always fatal. Heem- 
orrhages from mucous surfaces are exceedingly uncom- 
mon.. Mayr has described a scarlatinal dissolution of the 
blood, in the gravest form of which death occurs in from 
twelve hours to five days. ‘‘ Extreme muscular depres- 
sion, with slight headache and a remarkably rapid pulse, 
are present from the very commencement. & ethe 
patient lies on his back with his eyes half open, but In an 
unconscious state. Quivering movements of the 


309 


Scarlet Fever. 
Scarlet Fever. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


muscles of the face and of the fingers are also commonly 
observed in these cases, and in children general convul- 
sions often occur. The pupils are moderately dilated ; 
the lips and tongue are dry, the latter being usually of a 
bright-red color. As the disease goes on, mucous rales 
are heard in the large bronchial tubes ; the abdomen be- 
comes distended, but there is seldom any enlargement of 
the spleen; the urine becomes scanty and of a dark-red 
color ; the pulse continually increases in frequency, reach- 
ing as many as 200 beats a minute; the features become 
shrunken and the extremities cold.” Death speedily fol- 
lows. This form resembles the so-called typhoid scarla- 
tina, in which drowsiness, stupor, delirium, and subsul- 
tus precede the fatal issue. The life-destroying symp- 
toms are often connected with impairment of the heart’s 
action, attributable to crippling of the vagus, when death 
occurs from heart-paralysis, without widespead molecu- 
lar disintegration. This failure is shown by increasing 
weakness, frequency and inequality of the pulse, with 
quickened and shallow breathing, and coldness of the 
hands and feet. Allbut has classified the modes of death 
in scarlet fever as follows: 1, Hyperpyrexia (this Jenner 
denies positively) ; 2, specific blood-poisoning ; 8, special 
malignity of the case; 4, asthenia. In the rather un- 
common event of recovery from any of the most severe 
forms of scarlet fever, the progress is slow, the essential 
symptoms, complications, and sequele proving all very 
obstinate. In those cases where extensive diphtheritic 
exudation precedes a rapidly fatal course, the eruption 
undergoes many modifications, the integument remain- 
ing pale except for some few splotches about the joints, 
at other times showing only a few dark-red patches irregu- 
larly distributed, and again entirely disappearing before 
death. At other times the eruption persists in full efflo- 
rescence. 

CoMPLICATIONS. — Nephritis. — Derangements of the 
kidneys are the most important complications of scarlet 
fever. Indeed, a number of recent writers assert that 
these organs are always affected in this disorder. Among 
these may be mentioned Frerichs, Reinhardt, Begbie, 
Newbigging, Holder, Boning, and Stevenson Thomp- 
son. Steiner states that evidences of kidney disorder 
are always present in those who die of scarlet fever. 
Thomas’ clinical observations do not bear out this state- 
ment, and Friedlinder, who examined the bodies of 
two hundred and twenty-nine persons dead of scarlatina, 
found kidney disorder in less than one-half. Though 
renal inflammation is not shown as yet to be a constant 
accompaniment of scarlet fever, it occurs much more 
often than is commonly supposed. Renal catarrh, which 
Hisenschitz declares to be as much a feature of scarlet 
fever as bronchial catarrh is of measles, is indeed an ex- 
tremely common complication. It usually escapes detec- 
tion from the general neglect to duly examine the urine. 
Thomas, in denying that this catarrh is at all constant, 
shows that it also occurs in measles, croupous pneu- 
monia, etc., and is often only an expression of the febrile 
condition. Yet the catarrh is relatively so common in 
scarlatina that he cannot avoid concluding that the spe- 
cific influence of the disease is often concerned in its pro- 
duction In many cases, from the very beginning, cylin- 
der-like masses of renal epithelium may be detected. In 
milder cases the urine will contain mucous casts with in- 
creased quantity of mucus, but no albumen. In more 
severe cases the urinary sediment will contain hyaline 
masses with epithelium and epithelial débrzs, and red and 
white blood-corpuscles. Slight albuminuria will also be 
present. This catarrh is usually insignificant, and but 
rarely serves as the starting-point for the graver and char- 
acteristic forms of nephritis scarlatinosa, though doubt- 
less many milder forms of nephritis and dropsy originate 
in it. Thomas concluded, however, that the cases of 
scarlatinal nephritis not developing from preceding ca- 
tarrh, but arising suddenly, usually end fatally. Scarla- 
tinal nephritis varies greatly in the relative frequency of 
its occurrence, involving from five to seventy per cent. of 
cases in different epidemics. In the Children’s Hospital, 
Hillier noted its occurrence in about half of the cases. 
Dickinson *§ considered this rather below than above the 


310 


average. Fleischmann” noted 95 cases of Bright’s disease 
in 472 observations. During 1861 every third child with 
scarlatina had dropsy, while in 1862 it affected only one 
casein ten. Thomas asserts that renal alterations develop 
in about one-half of all cases of scarlet fever. It has been 
shown that there are those who assert that the renal alter- 
ations are constant. On the other hand, Jaccoud * de- 
clares that for fifteen years he has never had a case of 
nephritis among his scarlet-fever patients, a result that 
he attributes to his treatment. Albuminuria may appear 
at any time during the attack of scarlatina, though its 
most common occurrence is during the second and third 
weeks. Dropsy should not be taken as marking the be- 
ginning of the nephritis, the signs of which may be pres- 
ent in the urine sometimes for days before this occurs. 
In Fleischmann’s cases dropsy occurred 9 times during 
the first week, 30 times during the second week, 23 times 
during the third week, 20 times during the fourth week, 
and 5 times after the fourth week. Of 60 cases at the 
Children’s Hospital, 42 began between the end of the 
first week and the end of the fourth week; 5 became 
dropsical during the first week. 

Nephritis during the first week of scarlatina often es- 
capes detection from the blending of its symptoms with 
those of the essential disease, and from the attendants’ 
neglect to examine the urine. Dropsy will, of course, 
attract attention, but this does not often occur so early, 
and may be confounded with the cedema from the exan- 
them. MRarely, the fatal issue of what was, apparently, 
malignant scarlet fever, may really have resulted from 
uremic poisoning due to a fulminating nephritis. The 
symptoms may be identical. Fever, vomiting, headache, 
delirium, amblyopia, coma, convulsions, may have been 
present. The convulsions are often very irregular. They 
may be general, partial, or unilateral, tonic or clonic. 
The patient may have them in rapid succession, or may 
pass into a status eptlepticus from which death alone 
will release him. The urine will be completely or par- 
tially suppressed. If secreted it will be of high specific 
gravity (1.020 to 1.040), dark and smoky in appearance, 
loaded with albumen, and forming an abundant sediment 
of hyaline, granular, epithelial, and blood tube-casts, with 
renal epithelium and white and red blood-corpuscles in 
greater or less quantity. If the kidneys become impli- 
cated toward the end of the first week, the symptoms 
may delay the course of what may otherwise appear to 
be an ordinary case of scarlet fever. Microscopical re- 
search will often betray the onset of the changes in ad- 
vance of chemical analysis ; casts of the renal tubules 
will be observed, with epithelial deposits and detritus, 
before albuminuria is established. This will shortly ap- 
pear, and in severe cases the nephritic symptoms will 
obscure those of the scarlatina. There will be no con- 
stant relation between the amount of albumen, the tube- 
casts, and the general detritus, one variety of sedimentary 
matter being at one time copious, at another scanty. At 
this time vomiting may appear with returning headache, 
the appetite will again fail, and pain in the loins may be- 
come annoying ; the patient may again become dejected 
and feeble, and his fever may cease to diminish—may even 
exceed its original intensity. At other times no appar- 
ent influence will be exerted upon the: scarlatina, which 
will follow its usually mild course until dropsy and al- 
buminuria reveal the state of the kidneys. When the 
renal disorder develops after defervescence, during the 
second, third, or fourth week, or later, the same series 
of symptoms may be observed, their severity being in di- 
rect ratio with the earliness of their occurrence. Cases 
developing after the fourth week may be expected to 
pursue a favorable course. Although it has been asserted 
that the renal disorder may arise several months after a 
scarlatinal attack, a patient will almost certainly escape 
it if he pass the sixth week in safety. The symptoms in 
cases arising during these weeks are not always gradually 
developed, and some of the most disastrous results of 
the disease may be encountered during the second, third, 
or fourth week, in children apparently convalescing from 
scarlatina, and often in full desquamation, who, after in- 
disposition for a few hours, with nausea, headache, con- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Scarlet Fever, 
Scarlet Fever, 


fusion of ideas or stupor, with return of fever, rapidly 
pass into coma or convulsions, ending after a short inter- 
val in death, before dropsy has developed, but after partial 
or complete suppression of urine. Scarlatinal nephritis 
has usually a mild and favorable course. Dropsy is usu- 
ally the first symptom observed, first appearing in the 
face and sometimes remaining confined to this locality ; 
at other times becoming general speedily, and giving an 
appearance of plumpness, but with a wax-like translu- 
cency of skin, The face, upper and lower extremities, 
body-wall, and prepuce, may thus become dropsical. The 
serous Cavities are also implicated, and more or less effu- 
sion into the pericardial, pleural, peritoneal, scrotal, and 
intracranial cavities occurs. Cidema of the lungs and 
of the glottis may imperil life. Desquamation is often 
completely arrested upon the supervention of dropsy. 
The temperature is more commonly but little above the 
normal (88.3° to 39° C. [101° to 103° F.]). The pulse, 
sometimes feeble and accelerated, will often become re- 
markably slow and intermittent, and so remain through- 
out the attack. The child will grow dulland listless, and 
extremely feeble. Pain in the belly and in the back may 
at times prove very distressing, or, again, it may be ab- 
sent. The tongue, having lost the strawberry aspect of the 
eruptive stage, will become pale, flabby, and coated. The 
appetite will fail, and the bowels become sluggish. The 
urine will rapidly diminish in quantity and may deposit 
urates abundantly, or may present a smoky and oily ap- 
pearance, due to the abundant presence of epithelial cells, 
white and red blood-corpuscles, and tube-casts. The 
total amount may now be reduced to a few ounces. The 
blood-corpuscles often form a thick red layer at the bot- 
tom of the test-tube. This free admixture of blood may 
amount to pronounced hematuria. Such hematuria is 
generally post-scarlatinal, and, according to Schiitz, oc- 
curs most frequently during the third or fourth week. 
Of itself it adds but little to the gravity of the case. 
The patient often feels fairly well, and may eat and sleep 
with comfort. While the pallor and cedema may be very 
decided, the temperature and pulse may vary but little 
from the normal, or may show the variations of ordinary 
nephritis. With the gradual improvement of the gen- 
eral symptoms the hematuria disappears. Heubner has 
reported a case of nephritis after scarlatina in which 
hemoglobinuria was present. The urine was brownish- 
black ; no blood-corpuscles were found. Death resulted 
-from asthenia on the fifth day after both albumen and 
hemoglobin had disappeared from the urine. 

The amount of albumen in the urine in scarlatinal 
nephritis is usually very great. The urinary sediment 
is abundant, and is largely composed of tube-casts, the 
hyaline character predominating; finely and coarsely 
granular, epithelial, and blood casts are, however, numer- 
ous. Later coarse fatty granules stud the casts plenti- 
fully. These casts are often almost diffluent, and differ 
strikingly from the firm and sharply outlined ones of 
more chronic nephritis. Crystalline deposits are scanty, 
and are mostly of uric acid and urates; on the other 
hand, the amorphous urates are often very abundant. 
The degree of albuminuria present is of less importance 
than the total quantity of urine secreted, rapid and pro- 
nounced diminution of this indicating the accumulation 
of nitrogenous waste in the blood, and consequently the 
danger of uremia. According to Glax, a lessening of 
the proportion of urine secreted to the fluid ingested 
(2: 8), not infrequently foreshadows the approach of 
uremic symptoms, even though the urine contain no al- 
bumen. Whether the temperature remain normal through- 
out the attack, or whether, after an initial chill, it be- 
come elevated, and all the symptoms of acute nephritis 
develop, complete recovery may reasonably be expected 
if the patient pass safely through the earlier phases of 
the disorder. But although nephritis may be mild, the 
dropsy lasting only a few days, and, perhaps, being limited 
to slight puffiness about the eyes, the disorder does not 
usually entirely subside in less than a month. It may 
endure as long as three, four, or even five months ; and 
there is good reason to believe that chronic nephritis in 
young people may, in rare instances, have had its begin- 


ning in antecedent scarlatinal inflammation of the kid- 
neys, Such a result is, however, exceedingly uncommon, 

The dropsy indicates the degree of renal derangement, 
except in the most acute cases, and sometimes attains 
enormous proportions. As the urine increases in quan- 
tity the albuminuria proportionately diminishes, and the 
dropsy disappears. The skin, which until now has been 
dry and inactive, becomes softer, more elastic, and re- 
sumes its proper functions. The appetite improves, the 
spirits, strength, and mental activity return, and good 
health becomes gradually restored. Just as the micro- 
scope reveals the earliest evidence of renal derangement, 
so does it continue to expose the results of pathological 
action after chemical tests fail to do so. Tube-casts con- 
tinue to appear in the urinary sediment, sometimes for 
weeks after the cessation of albuminuria, the blood-casts, 
epithelial, coarsely granular, and fatty casts gradually giy- 
ing place to finely granular, hyaline, and mucous ones, 
which, in turn, finally disappear. When the disorder 
terminates fatally, the symptoms will be those of acute 
nephritis ; suppression of urine may be followed by cere- 
bral disturbance, headache of violent character, during 
which blindness may occur, with or without dilatation of 
the pupil, vomiting, and convulsions, partial or general, 
coma, and sometimes paralysis ; or the fatal termination 
may be slowly reached through constantly increasing 
asthenia ; or, what is more frequent, complications may 
arise which cannot always be definitely ascribed to the 
nephritis or to the scarlatina itself. Such are inflamma- 
tions of the pleure, of the pericardium and endocardium, 
the peritoneum, the cerebral meninges, etc. Pneumonia, 
acute articular rheumatism, or enteritis, may also hasten 
the fatal issue. 

Cases are occasionally observed in which dropsy fol- 
lows scarlatina, but without albuminuria. Indeed, a 
tendency toward non-albuminuric dropsy after scarlatina 
has been associated with certain epidemics. Scarlatinal 
dropsy without albuminuria has been observed by Guer- 
saut, Rilliet and Barthez, Noirot, Bouchut, Loéschner, 
Duckworth, and others. Quincke#! tries to explain such 
cases of non-albuminuric dropsy as not depending upon 
nephritis, but as a consequence of the scarlatinal irrita- 
tion exerting some peculiar influence upon the connective 
tissue. Cases occur probably in the experience of most 
practitioners. One should be cautious, however, in de- 
ciding against a nephritic origin of these dropsies, except 
where they can be definitely attributed to anzemia and de- 
bility. Henoch* has asserted that nephritis may occur 
without albuminuria up to the time of death. He reports 
a case in which anasarca was present for three weeks 
after scarlatina, without tube-casts or albuminuria, until 
convulsions occurred, death resulting from cedema of 
the lungs. The necropsy revealed the presence of acute 
nephritis. He also reports the case of a child, dead on 
the thirteenth day, of malignant scarlet fever, in whom 
repeated tests during life had not shown albuminuria, and 
yet whose kidneys showed indubitable evidence of he- 
morrhagic nephritis. Steiner has seen nephritis without 
dropsy, but never dropsy without nephritis, after scarla- 
tina. It is altogether probable, however, that in many 
cases the dropsy following scarlatina without albumi- 
nuria is secondary to concomitant anemia, This is the 
view adopted by Henoch. Whatever be their expla- 
nation, such cases usually run no remarkable course. 
The general health is not much reduced. The urine is 
in normal amount, the various functions are fairly per- 
formed. With the disappearance of dropsy convalescence 
is established. 

Scarlatinal nephritis is not associated with any especial 
phase or type of scarlatina. It is as frequent after mild 
as after severe attacks ; indeed, it is possible that the care 
exercised over those who have grave attacks of the fever, 
in proper nursing and surroundings, may furnish a safe- 
guard against renal complications. At all events, there 
is a widespread belief that the milder cases are more apt 
to be followed by nephritis and dropsy. Violent ne- 
phritis may certainly follow a scarlatina so mild as to 
have escaped observation. Individual predisposition and 
epidemic type are probably the most important etiological 


dll 


Scarlet Fever. 
Scarlet Fever. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


factors, though at present enough is not known to jus- 
tify dogmatic statement. The nephritis and dropsy may 
occur without antecedent symptoms of scarlatina. In- 
stances of this are not uncommon. Several members of 
a family or of a school or asylum in which scarlatina has 
been known to prevail, may exhibit dropsy and albumi- 
nuria characteristic of scarlatina, without having mani- 
fested any other symptom of the disease. Such cases pur- 
sue an ordinary course generally, but at times develop a 
severity altogether unexpected. 

INFLAMMATION OF THE GLANDS AND CONNECTIVE T's- 
SUE OF THE NEcK.—Although Barthez and Rilliet, and 
others have observed cases of scarlatina in which there 
was no angina, in one form or another it is nearly always 
present. More or less hyperplasia of the neighboring 
lymphatic glands also constitutes part of the ordinary 
phenomena of scarlatina. It has already been shown 
that the inflammation sometimes leads to suppuration 
and even gangrene of the glandular and peri-glandular 
structures. This especially occurs in scrofulous and ra- 
chitic children, but is probably a result of septic absorp- 
tion. The active symptoms become prolonged beyond 
those of simple scarlatina into the second, third, or fourth 
week, and even later, and merit some especial notice. 
They may not develop until as late as the third or fourth 
week, thus constituting true sequele rather than compli- 
cations. Usually the fever continues after the subsidence 
of the eruption, the pain and stiffness of the neck increase, 
and deglutition continues painful and ‘difficult, or even 
almost impossible. The mouth may be held open and 
saliva constantly dribble from it. The neck becomes hard, 
brawny, and swollen ; the integument tense, smooth, and 
shining. The outline of the neck sometimes stands in line 
with that of the head and underjaw, and it becomes im- 
possible to distinguish the enlarged glands in the mass of 
inflammatory exudation. The patient is unable to find 
repose, or to swallow food or fluids, unless in small quan- 
tities and with great pain. Rest is broken and unre- 
freshing. Suppuration reveals itself by dark-red, livid 
spots which soon fluctuate ; or, it may be deep-seated and 
difficult to detect, or may point and discharge internally. 
The parotid gland and peri-glandular tissue often become 
involved. At times more or less widespread necrosis 
may lay bare important muscles, vessels, and nerves, and 
involve large areas of tissue. These diphtheritic and gan- 
grenous inflammations may give rise to phlebitis or ar- 
teritis with thrombosis, and embolism with metastatic in- 
flammation. Compression of the larynx, of the trachea, 
or of the jugular veins may also result. At times pus 
may burrow into the deeper cervical structures. Heemor- 
rhage may also occur from exposed vessels. Baader ** re- 
ported two cases of death from hemorrhage thus occur- 
ring. The extent of these phlegmonous inflammations of 
the neck varies greatly. In most cases, after the evacu- 
ation of pus, recovery follows, though slowly. In more 
severe cases death may result from exhaustion or from 
blood-poisoning. In healing, the scars may be insignifi- 
cant, or, where granulation involves a large surface and 
is protracted, the resulting cicatrix may occasion de- 
formity by its contraction. Retro-pharyngeal abscess, 
which has already been described, is not common. 
Schmitz, in the Child’s Hospital, in St. Petersburg, did 
not observe it once in 450 cases of scarlatina. Cases, 
however, have been reported. Bokai reported it as oc- 
curring 7 times in 664 cases. Of these two died. Le- 
wandowsky * reported two cases, both resulting in re- 
covery. 

DISORDERS OF THE AUDITORY APPARATUS. — These 
are very important complications of scarlatina. Prob- 
ably most cases of deafness acquired in early life are re- 
sults of scarlatina. Of 85 cases of affection of the middle 
ear following this disorder, 18 had lost the sense of hearing 
in one or both ears, and 3 were deaf-mutes.*° Milder de- 
grees of middle-ear inflammation arise by extension from 
the throat, and are simply catarrhal; but the severer 
forms are preceded by croupous-diphtheritic inflamma- 
tion of the fauces. The milder form of otitis media will 
cause the patient some earache, of which, if he is old 
enough, he will bitterly complain. Infants will indicate 


312 


their sufferings by cries, by raising their hands to the 
ears, by rolling the head toward the affected side. If the 
Eustachian canal remain pervious, all inflammatory exu- 
dation may escape, and no symptoms, other than those 
mentioned, and slight and transitory deafness, may occur. 
This latter symptom may result from the pressure of an 
enlarged parotid gland upon the external auditory canal. 
But in the severer forms the pain may be excruciating, 
deafness more or less complete, and fever high. The 
Eustachian canal becomes occluded from inflammatory 
swelling, and exudation accumulates in the cavity of the 
tympanum. Headache may be violent. The drum mem- 
brane will be bulged outward from internal pressure, and 
will be reddened and swollen. The pent-up fluid, unless 
released by puncture of the drum membrane, finds an 
exit for itself by perforation. Extreme pain is often pro- 
duced by pressure upon the tragus and over the mastoid 
process. Rarely, delirium may be followed by signs of 
meningitis from extension of the inflammation from the 
middle ear to the dura mater, along the course of the 
middle meningeal artery. In mild cases the inflamma- 
tion will subside, with or without perforation of the 
drum, and hearing may be perfectly restored. In severer 
cases, timely tapping of this membrane may yet preserve 
the sense of hearing, but, unfortunately, it but too often 
happens that the ossicles of the ear, and the tympanic 
membrane are destroyed ; the bony walls, even of the mid- 
dle ear, become carious, and irreparable damage is done. 
The severer inflammations involve a croupous diphthe- 
ritic process that often entails wholesale destruction. Ac- 
cording to Green, disease of the labyrinth, involving ab- 
solute deafness, may occur within a day or two. Insuch 
cases the watch held to the skull, the ear or between the 
teeth, may not be heard. Green *6 thinks that when loud 
‘‘clashing,” ‘‘ ringing of small bells,” or ‘‘ musical notes,” 
are heard during scarlet fever or cerebro-spinal menin- 
gitis, these are apt to be immediate premonitions of laby- 
rinthine disease ; whereas, the subjective sounds always 
accompanying acute purulent inflammation of the tym- 
panum are described as ‘‘hissing,” “singing,” ‘‘ buzz- 
ing,” or ‘“‘ throbbing.” He also suspects that the fluid 
secreted in immense quantity—a clear, limpid serum— 
differing from the wine-yellow serum of tympanic in- 
flammation, may be labyrinthine peri- and endo-lymph. 
Pus may form in the mastoid cells. These changes may 
occur either as complications or as sequele. Caries some- 
times appears quite early, and the chronic otorrhea thus 
set up may last for years, occasioning widespread disor- 
der of both soft parts and bone.*? Fatal hemorrhage 
from the ear may occur after scarlatina, from exposure 
of vessels from the diphtheritic processes. *® 

Chronic posterior nasal catarrh, and necrosis of the 
bones of the nasal cavity, constituting various degrees of 
ozena, sometimes follow the extension of the pharyngeal 
inflammation to the naso-pharynx. The eye may like- 
wise be implicated in scarlet fever. Conjunctivitis may 
develop as a complication, or diphtheritic inflammation 
may extend along the lachrymal canal and involve the 
conjunctive. It may produce keratomalachia, and even 
destruction of the eyeball. Retinitis after scarlatinal 
nephritis has been observed by Schréter. Its course is 
favorable. ‘Temporary blindness may be due to ureemia. 
Acute amaurosis after scarlatinal nephritis has been 
noted.** ‘Transitory blindness, lasting from twenty to 
sixty hours, has been observed by Ebert,*® Henoch,*! Tol- 
machew.*” In a case of Foérster’s it endured eighteen 
days. 

INFLAMMATION OF JOINTS.—Not very infrequently in- 
flammation of the synovial membrane of the joints appears 
as a complication or as a sequel of scarlet fever. The usual 
date of its occurrence is during the second week or later. 
It is often only indicated by pain without swelling, and © 
may be limited to a single joint. In other cases a num- 
ber of joints are involved, usually the ankles and wrists, 
knees and elbows. The hip-joints may be affected, and 
also the smaller joints of the extremities. The inflamma- 
tion may betray all the features of acute rheumatism—the 
fugitive character of the inflammation, the metastases, 
the sweating, the fever, even the tendency to implicate 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Scarlet Fever. 
Scarlet Fever. 


the other serous surfaces, the pleurz, the endo- and 
pericardium, and the meninges. Mahomed’s#* studies 
showed that, as the urine increases in quantity from the 


seventh to the fourteenth day, it loses its deposit of lith- | 


ates, and often its albumen (if this has been present). It 
is highly acid, and uric acid is abundantly thrown down 
by the nitric-acid floating test. It was at this period that 
he found the rheumatism most apt to occur. This rheu- 
matism seems identical with ordinary acute rheumatism, 
but follows a less protracted course. Cheadle ** quotes 
fifteen cases from West, in which endo- or pericarditis, 
or both, supervened upon scarlatina. These did not oc- 
cur during the acute stage, but during desquamation. 
He, however, considered them rather the result of uree- 
mia and nephritis than of rheumatism. Henoch* relates 
two cases in which acute arthritis appeared during the 
first week of scarlatina, followed by severe chorea and 
loud mitral murmur. As to the cardiac symptoms, 
Cheadle concludes that they occur in scarlatina as results 
both of scarlatina and of nephritis. He also thought 
that ‘‘scarlatina would appear to have a special influence 
in causing dilatation and hypertrophy without accom- 
panying valvular disease.”” Endocarditis, which rarely 
arises, may be very insidious, and may even pass unde- 
tected if not looked for. Probably not a few old valvu- 
lar affections have originated in attacks of scarlet fever. 
Acute pleuritis or pericarditis may accompany joint in- 
flammation, or may occur independently. In severe 
cases they may result in purulent exudation and ulti- 


mately terminate fatally. Sometimes the serous inflam-: 


mations are pyemic. Endocarditis ulcerosa may begin in 
this manner. Numerous writers have seen purulent ar- 
thritis as a sequel of scarlatina. It commonly occurs 
during the second or third week, and in most instances 
is mono-articular. Pyzmic arthritis usually results in 
suppuration, erosion, and destruction of the cartilage of 
the joint. According to Spender,* the wrist-joint is 
most often attacked, next in frequency the knee and hip. 
Recovery may take place, but usually death follows the 
discharge of pus and the formation of fistulous openings, 
from exhaustion, or from the further progress of the 
_pyzemia, The approach of these complications, which 
are fortunately rare, may be recognized through the ther- 
mometer. Peritonitis occurs most rarely, and is usually 
purulent. 

In the most severe and malignant cases of scarlatina 
the heart-muscle undergoes, first, cloudy swelling, and 
later, fatty degeneration, especially on the right side. This 
is the occasion of death from heart failure in many ma- 
lignant cases. Inflammation of the respiratory tract is 
decidedly uncommon in milder scarlatina Bronchial 
catarrh is apt to complicate serious cases. Pneumonia is 
seen sometimes as a secondary complication following 
nephritis, diphtheria, etc. Disorders of the intestines are 
also uncommon. Diarrhoea, when present, is usually 
associated with severer forms. Diphtheritic enteritis was 
the most frequent sequel in the cases observed by Fleisch- 
mann. Henoch has seen bed-sores complicate scarla- 
tina. 

SrQquEL&.—The affections that constitute true sequelee 
usually are disorders.that persist after scarlet fever has 
completed its course, having begun as complications. 
Thus are encountered chronic buccal, pharyngeal, nasal, 
and aural inflammations, nephritis (which, as a rule, ulti- 
mately entirely disappears), or inflammation of the vari- 
ous serous membranes. In some cases, marked by severe 
eclamptic seizures, there results contraction of different 
groups of muscles, giving rise to permanent deformity. 
Mania has been known to follow scarlatina.*’ Gangrene, 
apart from that resulting from diphtheria of the throat, is 
infrequent. Noma has been observed by a number of 
writers (Barthez and Rilliet, Heyfelder, Boning, and 
others), but it is notably less common than after measles. 
Necrosis of the nasal cartilage was observed by Henoch 
during convalescence. 

CoNCURRENCE WITH OTHER SPECIFIC AFFECTIONS.— 
Scarlet fever may be complicated by, or may complicate, 
other acute exanthemata, not to the extent, however, that 
many writers believe. Mayr and Hebra, indeed, taught that 


@ 


scarlatina never coexists with measles or small-pox. 
This question is involved in much obscurity. Scarlatina 
may be simulated by a variety of affections that may in 
fact co-exist with the exanthemata, by various erythem- 
atous eruptions, by the roseola that often precedes and ° 
accompanies the eruption of small-pox, by certain anom- 
alous forms of measles, and by various medicinal rashes 
—those caused by belladonna, copaiba, chloral, and es- 
pecially cinchona and its preparations. These considera- 
tions and faulty methods of observation and recording, 
lead to the rejection of much of the evidence adduced in 
favor of these coexistences. After all faulty observations 
are thrown out, however, there still remaizis strong proof 
that scarlet fever may coexist with other exanthems. 
It will be everywhere admitted that one exanthem may 
follow close upon the heel of another. Prior 4® noted a 
case in which scarlatina developed on November 18th, 
varicella on December 2d, and measles on December 13th. 
When the two exanthems develop simultaneously, there 
will often remain much doubt, in the absence of evidence 
of the double exposure of the unprotected individual and 
of his subsequent double protection. Where one pre- 
cedes the other by a few days, the difficulties are not 
so great. Scarlet fever has been observed as complicat- 
ing, or complicated by, other exanthemata by Steiner,” 
Monti,®°° Thomas,*! Fleischmann,” Fabore, Stillen, *4 
Zechmeister,©> Backer,** Dornig,®?7 Lewis Smith,®? Mur- 
chison,®®? and many others. The combinations and the 
order of occurrence have been noted as follows, viz.: 

Scarlatina and measles. 

Measles and scarlatina. 

Scarlatina and small-pox. 

Small-pox and scarlatina. 

Scarlatina and vaccinia. 

Scarlatina and varicella. 

Varicella and scarlatina. 

Scarlatina and typhoid fever. 

Concurrence of scarlatina and Rotheln has not been re- 
ported. A probable source of fallacy is the scarlatini- 
form rash that is often observed in small-pox, and oc- 
casionally in typhoid fever ; indeed, Simon asserts that 
Fleischmann has even made this very error. The possi- 
bility of these rashes should always be held in mind when 
questions of concurrence are under consideration. When 
scarlet fever develops after small-pox the eruption in- 
volves the parts of the skin left free by the lesions of 
small-pox, more especially about the chest and abdomen. 
When the two exanthems appear simultaneously, their 
course is shortened ; ‘‘the second mitigates the first and 
becomes shortened itself,” excepting, according to Fleisch- 
mann, when severe small-pox occurs in connection with 
scarlatina, when death usually results. The same author 
asserts that if scarlatina appear at the period of matura- 
tion of small-pox, the latter, in mild cases, is shortened 
and mitigated. When scarlatina complicates measles, 
the latter is shortened, but the scarlatina thus occurring 
may be mild or severe. Barthez and Rilliet noted that 
in scarlatina-measles, when the former malady predomi- 
nates, bronchitis is more marked; but when measles is 
most severe, faucial angina‘is worse. All of these state- 
ments lack such evidence as would entitle them to un- 
qualified acceptation. Very often neither disease is well 
developed, and the true condition may be very difficult 
of recognition. In America these concurrences are more 
uncommon than they seem to be abroad. 

Whooping-cough has been known to complicate scarla- 
tina, and a number of non-specific affections may occur 
simultaneously with it. These coincidences are purely 
accidental and present no peculiar interest. Biart ® has 
reported psoriasis as following scarlatina. Barthez and 
Rilliet assert that tuberculous children very rarely have 
scarlatina. Some chronic affections partially or entirely 
disappear during an attack of scarlatina. Among these 
may be especially mentioned certain cutaneous affections, 
eczema, psoriasis, etc., but they usually reappear upon 
the establishment of convalescence. 

SURGICAL SCARLATINA.—Sir James Paget, in 1864, and 
again in 1875, declared that patients who have under- 
gone surgical operations are peculiarly susceptible to the 


313 


Scarlet Fever. 
Scarlet Fever. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


action of the scarlet-fever poison. This question has at- 
tracted a great deal of attention. In France, Trelat was 
the first to accept this view, though scarlatinoid rashes 
had been observed by Civiale, Germain Sée, Tremblay, 
and others. Similar rashes were reported by Hutchin- 
son. Hilton, Bryant, Lee, Moore, Stirling, and others. 
They had generally been considered as of septicamic 
origin. In 1879 Paley and Goodhart ® and House*® re- 
ported observations of endemics of scarlatina in the Evel- 
ina Hospital for Sick Children and in Guy’s Hospital. 
The first-named authors based their report upon twenty- 
five cases of scarlatina occurring in surgical patients. 
Of these nineteen were known to have been exposed 
to scarlatina, and all the rest, save one, were known to 
have had possible sources of infection. House’s paper 
was based upon four cases of surgical scarlatina. The 
epidemic tendencies ceased upon the establishment of 
isolation, and one cannot doubt their scarlatinal origin. 
These writers were careful not to assert that add such red 
rashes should be attributed to scarlatina, or that there is 
not ‘‘ such a thing as a rose rash in a typical case of septi- 
cemia ;” but they believe that when occurring in groups 
they may nearly always rightly be attributed to scarla- 
tina. Riedinger and Howard Marsh also agreed that there 
exists in wounded persons a predisposition to scarlatina. 
While Holmes coincided with these views, he, however, 
declared that many cases of ‘‘ surgical scarlet fever” are 
really due to pyzemia and other causes. Most recent 
writers incline to the opinion that these eruptions are 
due to true scarlatina. When any epidemic tendency is 
shown, everyone will agree with such conclusions. This 
cannot be granted of rashes occurring in isolated cases. 
Of 25 cases reported in Paley and Goodhart’s paper, scar- 
let fever attacked 17 after operations ; 7 were without any 
wound whatever, and 1 had only an old sinus. In many 
of the cases reported by other writers there was no open 
wound. These reporters, unfortunately, most rarely note 
whether their patients had ever previously had scarlatina. 
Most children, when first exposed to the contagion of this 
disease, become infected. Is it remarkable that they are 
unable to withstand it when it attacks them, weakened by 
injury or surgical operation ? Apart from epidemic in- 
fluences, it is probable that scarlatiniform eruptions in the 
wounded may justly, ina large proportion of cases, oc- 
cur quite independently of scarlatina. Rashes of septi- 
czmic origin are well known to occur. Various fugitive 
eruptions often result from emotional and nervous irri- 
tations, or from the ingestion of certain articles of food 
or medicines. It must be admitted that scarlatiniform 
septicemic rashes are uncommon. But there is excel- 
lent evidence that they occur. Attempts have been 
made to establish a differential diagnosis for the surgical 
scarlatiniform rash. Cheadle,® for example, claimed that 
it has specific characters in not often being universal, and 
in being confined to the body and parts covered by the 
clothing ; that it rarely lasts twenty-four hours, and that 
it never desquamates. He also asserted that there is no 
tonsillar swelling, nor glandular enlargement, nor the 
peculiar ‘‘ strawberry tongue.” Such points of differen- 
tiation do not appear to be well founded. Scarlatiniform 
eruptions also occasionally follow the ingestion of certain 
drugs. They may be evoked by belladonna, copaiba, 
opium, chloral, mercury, and other drugs, but, above all, 
by cinchona bark and its derivatives. These eruptions 
are much more common than is generally supposed. The 
quinine eruptions are only beginning to receive due at- 
tention. The drug is frequently given to those who 
have been injured or submitted to surgical operations, 
and beyond question eruptions evoked by it are often at- 
tributed to other causes. A number of eruptive forms 
are observed, but the one of especial moment is the 
scarlatiniform rash. At the onset it often cannot be dis- 
‘tinguished from scarlatina. Beginning with high fever, 
and often with sore throat, the eruption appears upon 
the face, chest, and neck, and within twenty-four hours 
the entire surface may present a bright scarlet aspect. 
At the end of this period the resemblance may be made 
perfect by the ‘‘ strawberry tongue.” Up to this point 
the diagnosis may be impossible. Rarely it remains so 


314 


throughout the attack, especially when the ingestion of 
the cinchona preparation is continued. Usually, how- 
ever, after thirty-six or forty-eight hours the type of nor- 
mal scarlatina is departed from. The fever rapidly de- 
creases, the angina disappears, and the rash either fades or 
acquires features unlike those of true scarlatina. It be- 
comes duller, more papular, and often tends to form 
miliary vesicles. Eventually it may resemble ordinary 
‘‘ prickly heat.” Sometimes, however, the scarlatinal 
features are preserved throughout. In either case a co- 
pious desquamation is sure to follow. This is usually 
lamellar. Even albuminuria has been known to add to 
the embarrassment of the diagnostician. These medicinal 
and septiczemic rashes occur in isolated instances, and 
may at times baffle the keenest diagnostic powers. We 
may conclude that unprotected persons who have suf- 
fered injury, or who have undergone surgical operations, 
are rather more liable to scarlatina than the unprotected 
healthy. Scarlet fever is more apt than the other ex- 
anthemata to attack such persons, because its symptoms 
vary within such wide limits that it often escapes the at- 
tention of those who readily detect other infectious dis- 
orders and provide against them. When an epidemic 
tendency of the symptoms we have been considering is 
shown to prevail, it may be confidently concluded that 
true scarlatina is present. Septiceemia is occasionally 
accompanied by a scarlatiniform rash which does not 
depend upon the scarlatinal poison. These rashes are 
often attributed to scarlatina, 

ScCARLATINA PUERPERALIS.—While pregnant women 
seem to enjoy a remarkable immunity from the specific 
eruptive fevers, it is well known that during the puerpe- 
rium they are especially subject to them after exposure, 
and that the disease is then apt to pursue a grave and 
often fatal course. Not only scarlatina, but measles and 
small-pox may affect the lying-in woman with such ma- 
lignity that the symptoms may not acquire the features 
of the maladies to which they belong, but become indis- 
tinguishable from those of malignant septicemia. Scar- 
latina is especially liable to attack the lying-in woman. 
It may assume the virulence referred to, or it may pursue 
a course in which it is difficult to determine whether its 
symptoms are septic or really scarlatinal, or, finally, it 
may appear with typical and unmistakable features, 
Not a few writers have thought that the scarlatinal virus 
may produce in the puerperal woman septicemia, pure 
and simple. This view is maintained by Playfair, Brax- 
ton Hicks, Leishman, and others. They assert that in 
these women, after exposure to the specific contagium, 
symptoms of acute blood-poisoning may be developed, 
and not those of scarlatina. On the other hand, just as 
in septic conditions, independent of puerperal causes, an 
erythematous rash and other scarlatinal symptoms may be 
observed in which true scarlatina has no part, so must one 
guard against assigning to scarlatina every scarlatiniform 
rash occurring in obstetrical cases. It may be septic in 
origin, or it may be a medicinal eruption. When a septic, 
or medicinal, or other form of erythema can be excluded, 
and when exposure to scarlatinal influence is followed by 
any degree of the symptoms we are considering, are we 
in atypical cases to look upon the results of the infection 
as distinctly scarlatinal ? More recent writers regard the 
scarlatinal nature of the disorder as preserved, and as 
capable of further dissemination. It has not been deter- 
mined to what extent women who have already had scar- 
latina preserve an immunity from further attacks during 
their lying-in period. It would appear that the intensi- 
fied predisposition of the childbed carries with it an in- 
creased liability to second or third attacks. Busey °° has 
related a case in which the patient had already had scarlet 
fever. Other such cases are upon record.* 

In all probability the scarlet-fever contagium evokes 
scarlet fever, and not septic disorder, in the puerperal 
woman, whose systemic condition affords peculiar sus- 
ceptibility to its influence, and predisposes her to a viru- 
lence of its activity that often leads to disastrous results. 
The less remote the date of delivery, the graver the course 
of the malady is apt to be. If the symptoms do not ap- 
pear before the seventh day, their development is no 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Scarlet Fever. 
Scarlet Fever. 


longer to be feared. Olshausen ® collected from the lit- 
erature 141 cases, of which the scarlatina attacked, during 
pregnancy, 7; in 8 it immediately followed delivery ; in 
62 it occurred on the first and second days ; in 27 on the 
third day ; in 22 after the third day. After the fifth day 
none was attacked. While the puerperal woman shows 
intense susceptibility to scarlatina, the pregnant woman 
enjoys a marked immunity from it. Olshausen thinks, 
however, that the period of incubation may last for 
months during pregnancy, but only a few days during 
childbed. ‘This opinion he rests upon no solid basis. 
Primipare are more often attacked than multiparee. The 
mortality in puerperal scarlatina is high. In the series 
just alluded to it was forty-eight per cent. (3 cases during 
pregnancy and 64 in childbed). 

In the recorded cases studied by McClintock ® the 
mortality was over sixty-six per cent. In 34 cases at 
the Lying-in Hospital the death-rate was thirty per 
cent. Of 10 deaths at this hospital, 8 occurred when 
scarlatina had developed within thirty-six hours after 
delivery. Of 18 patients attacked on the first or second 
day, 8died. Of those attacked on or after the third day 
(16 in number), all but 2 recovered. McClintock also 
quotes Dr. Halahan’s cases, as follows, viz.: 3 patients, 
ill of scarlatina at the moment of delivery, died ; of 5 
attacked during the first twenty-four hours, but 1 re- 
covered; of 10 attacked during the second day, but 1 
recovered ; of 4 attacked during the third day, but 1 re- 
covered. The remaining 3, attacked on or after the fifth 
day, recovered. Braxton Hicks’” contributions to this 
subject have been most important. He believed that in 
one-half of the cases the usual symptoms of scarlatina are 
manifested, and that the disease almost always com- 
mences after the third day after delivery. The death- 
rate will be greater, the earlier after labor the symp- 
toms develop. Though lying-in women are peculiarly 
liable to scarlatina, they are frequently exposed to its 
influence without detriment. Women have not seldom 
been confined in the room, even in the bed, occupied at 
the same time by scarlet-fever patients, without experi- 
encing the slightest interruption of their normal con- 
valescence ; a result that is not astonishing in protected 
persons if the scarlatinal virus only transmits scarlatina, 
but which would not be expected were the virus equally 
competent to communicate septicemia in these cases. 
While a large proportion of cases pursue a grave and 
anomalous course, there are many others in which a per- 
fectly typical scarlatina is observed, without seriously 
endangering life. Secondary inflammations are not un- 
known. Metritis, cellulitis, peritonitis, or pyamia may 
be developed, but whether these are direct results of 
scarlatina or of the puerperal condition is undetermined. 

RELAPSES AND RECURRENCES. —There are recorded nu- 
merous instances of relapse, of scarlet fever within a short 
period after the original attack, and second or even third 
attacks after a more or less prolonged interval are well 
known to occur. By a relapse is meant a second attack 
of scarlatina that is evidently due to the persistent activ- 
ity of the influences that excited the first attack. Within 
a short period (three days after deflorescence in a case of 
Woldberg’s”) after the original attack all the symptoms 
are repeated ; the initial disturbances, the fever, the erup- 
tion, the angina, and other phenomena, with ensuing des- 
quamation, are developed. It is held that the second 
attack is but the completion of the first, that it occurs 
after an incomplete primary attack, and that it tends to 
be severe in proportion to the mildness of the first, and 
often to affect in eruption only those parts which were 
originally spared,” imparting thus to the second eruption 
the appearance of scarlatina variegata. The relapse may 
be accompanied by complications of throat, kidney, and 
other disorders, that were not present in the earlier dis- 
order, and vice versa. These relapses are usually very 
rare, but seem to be more frequent in certain epidemics. 

Thomas applies the. term pseudo-relapse, or reve7'svo 
eruptionis, to those cases in which the exanthem returns be- 
fore the disorder has entirely completed its course. ‘Tru- 
jawsky found the interval between the two attacks to be 
from seven to ten days, with an average of eight and five- 


eighths days. The intermissions are completely afebrile. 
These relapses have been explained by, (1) a recrudescence 
of the original contagion, and (2) the action of a newly 
acquired contagion from a source different from the orig- 
inal one. The prognosis is often graver than in the pri- 
mary attacks. Recurrences or attacks of scarlet fever 
occurring after a more or less protracted interval, are 
more common, and are due to fresh infection. They may 
occur at almost any period. Trujawsky ™ noted, in 300 
cases of scarlatina, 18 patients who had had a former at- 
tack. Of these 4 were under ten years of age ; 10 were 
over ten years, and 3 were adults. The interval between 
the attacks varied from one and a half to seven years. 
Thomas had personal knowledge of a case in which a 
second attack occurred. Willan never saw one. Many 
years may elapse between the two attacks, as when a 
mother who had the disease during childhood again de- 
velops it by contagion from her child. Heyfelder him- 
self had a second attack twenty-seven years after the 
first one. Trujawsky thought that immunity is greater 
against contagion originating at the home or in the 
neighborhood of the patient than when it is brought from 
a distance. A third attack in the same individual may be 
observed (as in Richardson’s case), and there are reports 
of repeated attacks of scarlet fever. Bernouilli,”* for ex- 
ample, mentions the case of a woman, fifty years of age, 
who experienced in rapid succession six attacks of an ex- 
anthem indistinguishable from scarlatina. Other similar 
cases are on record, but their consideration suggests that 
they may rather have been forms of medicinal eruption. 
Acute exfoliative dermatitis may also be mistaken for 
scarlet fever, and may attack repeatedly the same per- 
son. Rashes resembling scarlatina may occur in va- 
rious other affections, such as typhoid fever, small- 
pox, ete. © Hallopeau and Tuffier” saw a scarlatiniform 
eruption in acute rheumatism, in which there were two 
relapses with intense erythema, followed by copious des- 
quamation. The possibility of all such cases being mis- 
taken for scarlatina should be remembered. It is a 
rather singular fact that many persons suffer from an- 
gina whenever they are brought into close personal rela- 
tionship with those who have scarlet fever. This is com- 
monly mild, but may occasion serious discomfort. Those 
who suffer thus from exposure to the scarlatinal influ- 
ence do not communicate scarlatina to unprotected per- 
sons. Mild desquamation is said to have been noted in 
some such cases. This, however, would indicate a true 
scarlatinal infection. 

PATHOLOGICAL ANATOMY.—In most fatal cases every 
trace of eruption disappears after death. After a very in- 
tense exanthem, more or less redness may remain. After 
malignant cases blood extravasations may present the only 
post-mortem discoloration. Remy and Neumann” 
have lately investigated the histology of the skin in scar- 
latina. Remy found the capillaries of the papillary layer 
dilated and hyperemic, and filled with leucocytes which 
were enlarged and of different sizes, but not so large as 
in leukemia. The vascular wall was not altered. The 
epidermis was thickened by increase of its cylinder-cell 
layer. The horny layer, sebaceous glands, and_ hairs 
were unchanged. The sweat-glands were empty and 
shrunken. Neumann found the cells of the rete swollen. 
In many specimens the prickle-cells were elongated, and 
here and there formed interspaces in which exudation- 
cells were imbedded, and into which small blood extrav- 
asations often occurred. Exudation-cells extended abun- 
dantly as far as the horny layer, and at the orifices of the 
follicles they were very numerous. The corium was 
swollen, the fibres thickened, partly separated by prolif- 
eration, partly by enormously dilated vessels that were 
at times bulbous. It is this exudation into the epidermal 
layers that causes the loosening of the horny layer from 
its bed, and the characteristic desquamation. Léschner 
and Fenwick have also noted this infiltration of the rete. 
The latter writer found the basement membrane of the 
sweat-glands also thickened, and the lining membrane 
gone in places, but in other places it was increased so as 
to occlude the sweat-glands. The deeper layers were 
normal throughout. The scarlet-fever exanthem, then, 


315 


Scarlet Fever. 
Scarlet Fever. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


consists of hyperemia with exudation. Remy found 
the changes he describes, regularly and uniformly dis- 
tributed. 

The throat symptoms, as constant as are those of the 
skin, are due to lesions that are always recognizable after 
death. The milder alterations offer nothing character- 
istic ; they are identical with those of pharyngeal ca- 
tarrhal inflammation. In more intense degree follicular 
inflammation, with suppuration and ulceration, is super- 
added, and cedema becomes more prominent. The in- 
flammatory changes extend beyond the pharynx into the 
buccal and nasal cavities, while parenchymatous tonsil- 
litis and inflammation of the cellular tissues of the throat 
and neck develop, with, sometimes, extensive gangrene. 

According to Harlin (Thomas), scarlatinous angina is 
specific, and is marked by ‘‘a deep, bluish-red injection 
of the mucous membrane of the tonsils and neighbor- 
hood, of the uvula, of the posterior portion of the tongue 
in the neighborhood of the highly swollen papille, of the 
posterior portion of the region of the cricoid cartilage, 
and of that portion of the pharynx which includes these 
different parts, and measures about two inches in breadth.” 
This coloring is said to be sharply outlined in the direc- 
tion of its transverse diameter. A point of the highest 
importance is the nature of the diphtheritic membrane so 
often formed in scarlatinous angina. By most writers it 
is assumed to be pathogenetically identical with primary 
diphtheria. Now, while there can be no doubt that pri- 
mary diphtheria may and does complicate scarlatina, it 
is almost equally certain that in many cases the mem- 
brane is simply a result of the intensity of the inflamma- 
tion evoked by the action of the scarlatinous virus. In 
the one case the scarlatinal, in the other a true diphthe- 
ritic, poison acting upon the vascular tissues of the throat, 
causes a coagulation-necrosis that results in the produc- 
tion of the membrane. The lesions of the two processes 
are identical. They only differ etiologically and in their 
results. The membrane sometimes extends to the nasal 
cavity, the larynx, and the trachea. Lewis Smith has 
seen, in four cases, the diphtheria become dissociated from 
scarlet fever, and attack other members of a family as 
idiopathic diphtheria. On the other hand, there is very 
satisfactory reason to believe that the diphtheritic mem- 
brane is most often without the specific nature of primary 
idiopathic diphtheria. Heubner concludes that scarla- 
tinal diphtheria differs from primary diphtheria clini- 
cally and histologically. It begins with a simple catarrhal 
affection ; the change from catarrhal to diphtheritic com- 
monly occurs on the fourth day. Henoch likewise de- 
nies that the affection is primary diphtheria. Koven™ 
gives some remarkable figures that go to prove the non- 
identity of the two affections. His report includes 426 
cases. He shows that while it is most uncommon for 
two infectious diseases to coexist, of 426 cases 125 had 
necrosis faucium, while at the very time there was not a 
single case of idiopathic diphtheria in Christiania. More- 
over, diphtheritic paralysis was not once observed. Scar- 
latinal diphtheria, also, much more rarely than primary 
diphtheria, extends to the larynx and trachea. 

Kipnrys.—Friedlander ™’ describes three forms of renal 
inflammation with scarlatina. These are: 1, Initial ca- 
tarrhal nephritis, the early form; 2, the big, flabby hem- 
orrhagic kidney, interstitial septic nephritis; 3, glomerulo- 
nephritis, nephritis post-scarlatinosa. The first, he asserts, 
appears at the beginning of the exanthem, or a few days 
later, and disappears in a few days or weeks. It rarely 
excites oedema, and hardly ever kills. It is analogous to 
the alterations productive of the febrile albuminuria of 
many infectious diseases. Cloudy swelling and _ prolif- 
eration of the tubular epithelium, and, later fatty degen- 
eration, are shown. Within the tubular lumen are hya- 
line and granular cylinders, round cells, and desquamated 
epithelium. In the interstitial tissue are scattered round 
cells. _Bowman’s capsule is thickened, and there may be 
a small quantity of albuminous fluid between the capsule 
and the glomerule. Micrococci are sometimes found in 
the capillaries and tubules. The large, flabby hamor- 
rhagic kidney was found in 12 of the 229 scarlatinal ne- 
cropsies made by Friedlander. It was found especially 


316 


where the scarlatina had been complicated with diph- 
theria, abscess, etc. It is not characteristic of scarlatina, 
but is also seen in primary idiopathic diphtheria. The 
kidneys are enlarged and soft, and show pronounced cor- 
tical changes. The cortex is invaded by small extravasa- 
tions and larger blood infiltrations. The epithelium is 
only slightly altered, but the interstitial tissue is thick- 
ened and abundantly infiltrated with round cells. Em- 
boli of micrococci are commonly present. It develops 
between the first and fourth weeks, and proves fatal so 
rapidly that cedema does not develop. It is an especially 
severe form of septic nephritis. Glomerulo-nephritis, 
Friedlander holds to be the only characteristic scarlatinal 
nephritis. Here the kidneys are firm, often hyperemic, 
and resemble the cyanotic kidney, except that the glom- 
eruli do not appear red upon section, but gray and anzem- 
ic, ‘They are enlarged and prominent. Alterations are 
almost limited to them. Their nuclei are enlarged, their 
coils empty of blood, their walls thickened, their lu- 
mina contracted or obliterated. Bowman’s capsule is 
not much thickened. There are also slight interstitial 
cell infiltration, fatty degeneration of epithelial cells, and 
hyaline formation in the arteries. The alterations in the 
glomeruli account for the anuria and uremia, as well as 
the rapid hypertrophy of the left ventricle by the ob- 
struction of the renal arteries, as nearly all of the renal 
arterial blood has first to pass through the glomeruli. 
Klein,® who has given the subject especial attention, in a 
series of 23 necropsies did not observe the identical glom- 
erulo-nephritis as described by Klebs.*' Klein’s cases 
had died at various periods between the second and forty- 
fourth day. Their ages were between two and thirty- 
six years, the largest number being under twelve years 
of age. Changes resembling the glomerulo-nephritis of 
Klebs were observed, but they’ were only characteris- 
tic of the early stages of scarlet fever. A sharp defini- 
tion betweén the early and late changes is not practicable. 
The first set of changes are chiefly limited to the cortex. 
They are: 1. Increase of nuclei (probably epithelial) cov- 
ering the glomeruli. 2. Hyaline degeneration of the elas- 
tic intima of minute arteries, especially of the afferent 
arterioles of the Malpighian tufts. The intima of these 
vessels is swoilen here and there into spindle-shaped 
hyaline masses, causing narrowness of the lumen. There 
is similar hyaline degeneration of the capillaries of the 
glomeruli, rendering them often impermeable. These de- 
generated parts become fibrous in appearance, and Bow- 
man’s capsule becomes thickened. 3. A third change is 
multiplication of the nuclei of the muscularis of the mi- 
nute arteries, with increased thickness of their walls. This 
is greatest at the point of entrance into the glomeruli, but 
is also distinct in other arteries of the cortex and in the 
base of the pyramids. There are also swelling of the epi- 
thelia of the convoluted tubules and proliferation of their 
nuclei, especially of the tubules close to the afferent arte- 
rioles of the glomeruli. . In some cases the epithelium of 
the large tubules of the pyramids is detached. Klein’s 
observations, 1, that the hyaline changes readily affect 
the arteries near their point of branching, and, 2, that the 
hyaline substance is of the nature of elastic tissue, agree 
with the conclusions of Neilson concerning the arteries in 
various cerebral disorders and in many infectious diseases. 
He does not think that the anuria and uremic poisoning 
in scarlatina, when the kidney does not show conspicuous 
change, are due to compression of the vessels of the glom- 
erulus by the nuclear germination, as claimed by Klebs, 
but rather to the changed state of the arterioles, and 
suggests that the increased formation of arterial mus- 
cular fibres, under the stimulus supplied by the disease, 
may cause a contractility that obliterates the calibre of 
the arterioles and shuts out the glomerulus from the cir- 
culation, and thus, so far as it operates, suppresses the 
secretion of urine. The parenchymatous changes found 
in the early stages are slight and difficult to detect, the 
cloudy swelling and granular degeneration being limited 
to small portions of convoluted tubules. The second or- 
der of changes begins about the ninth or tenth day. They 
are interstitial as well as parenchymatous. Round cells 
are found around the larger vascular trunks, spreading 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Scarlet Fever, 
‘Scarlet Fever. 


into the bases of the pyramids and into the cortex. This 
process begins about the end of the first week, and gradu- 
ally increases until portions of the cortex, rarely portions 
of the bases of the pyramids, are converted into pale, firm, 
round-cell tissue, in which the tubules become compressed 
and obliterated. The parenchymatous element of the ne- 
phritis consists in crowding of urinary tubules with lym- 
phoid cells and various kinds of tube-casts, and fatty de- 
generation of the epithelium of the tubules. This grows 
more marked with the advance of interstitial changes. 
The round-cell infiltration of the cortex begins at the 
roots of the interlobular vessels, spreading rapidly toward 
the capsule of the kidney, and laterally among the con- 
voluted tubes around the glomeruli, att first’ between 
the medullary rays, later it encroaches upon them. Por- 
tions of the cortex may be converted into firm, pale, 
bloodless cellular masses in which Malpighian tufts and 
urinary tubules become more or less destroyed. In one 
case renal embolism was encountered ; both interstitial 
and parenchymatous inflammation was very intense. The 
kidney was markedly enlarged. Klein also noted deposi- 
tion of lime in the epithelium and lumina of the tubules, 
first of the cortex and then of the pyramids, at an early 
stage of scarlatina, when only slight changes are other- 
wise shown. Heconcludes that cases of scarlatina which 
die after the ninth or tenth day usually show more or 
less well-marked interstitial nephritis. 

LYMPHATIC GLANDs.— Peculiar changes have been 
noted in the lymphatic glands by Klein. In addition to 
the ordinary inflammatory infiltrations which he describes 
as occurring in the lymphatic follicles connected with the 
organs of the throat and in the glands of the neck, the 
ordinary uninuclear lymph-cells are greatly diminished 
in number, and are replaced by large granular cells con- 
taining numbers of germinating nuclei. 

Liver.—This viscus becomes slightly enlarged from 
cloudy swelling. In one case Klein noticed, after two 
days’ illness, acute interstitial hepatitis. The middle and 
internal coats of some arteries show the same alterations 
as in the kidneys. Wagner observed lymphoid new for- 
mations and numerous collections of cells and nuclei, 
_ especially in the interacinous connective tissue. 
SPLEEN.—In the spleen the changes are uniform and 


constant. They are: 1. Enlargement of the Malpighian 
corpuscles. 2. Hyaline degeneration of the intima of the 
arteries. 3. Proliferation of the nuclei of the muscular 


coat of the ultimate arterioles, with increased thickness 
of their walls. 4. Hyaline swelling and degeneration of 
the adenoid tissue around the degenerated arteries. 5. 
In the central parts of the Malpighian corpuscles the or- 
dinary nuclei of the lymph-cells disappear, and in their 
stead are found large hydropic cells containing pigment 
(Klein). Other writers assert that there is no uniform- 
ity in the splenic changes, beyond a slight enlargement. 
Biermer has observed enormous enlargement of the Mal- 
pighian bodies. 

Disorders of the alimentary canal are not frequent in 
scarlatina, and when they occur it is usually in grave 
cases. They then not infrequently constitute the prin- 
cipal complicating lesion. In the cases of Fleischmann, 
diphtheritic enteritis was the most common sequel, The 
peculiar ‘‘shaved-beard appearance” of Peyer’s patches 
has been at times observed, and at times these patches 
and the solitary glands are prominent, reddened, and in- 
flamed, with associated tumefaction of the mesenteric 
glands (Harley). Barthez and Rilliet show, however, 
that in cases where the typhoid-like lesions have been 
discovered, the symptoms shown during life did not re- 
semble those of typhoid fever ; and conversely, cases of 
typhoid scarlatina cannot be expected to reveal these le- 
sions after death. Enteritis is more often catarrhal in 
nature. It has been asserted that in scarlatina the exan- 
them invades the mucous membrane to the same degree 
as the skin. Post-mortem evidence of this, however, is 
by no means constant. The glands throughout the ali- 
mentary tract are sometimes swollen, and sometimes form 
small ulcers and extravasations. 

Meningitis is rarely the cause of even the most intense 
cerebral symptoms. Hypereemia of the brain and me- 


ninges, with great venous engorgement, is often seen, but 
signs of pronounced change are extremely uncommon. 

_ Periosteitis and osteitis occur in connection with affec- 
tions of the joints, of the nose, of the pharyngeal and 
aural cavities, and of other parts, but afford nothing 
characteristic. Neither do the general serous surfaces 
show peculiar lesions. The condition of the blood and 
blood-vessels after certain rapidly fatal cases is important. 
Sometimes the blood is very fluid and black. At other 
times clots are abundant and firm ; again, it may have 
become diffused throughout the tissues. Remy has seen 
all the vessels of the papillary layer of the skin filled 
with coagulated blood. Thrombosis of the sinuses has 
been noted after scarlatinal diphtheria (Thomas). Fatty 
degeneration of the heart following cloudy swelling, with 
dilatation, occurring particularly in the walls of the right 
ventricle, is a frequent result of scarlatina, as it is of 
other infectious disorders. 

Draenosis.—Scarlet fever must be distinguished from 
measles, rubella (Rotheln), roseola variolosa, scarlatini- 
form rashes of septic or medicinal origin, certain idio- 
pathic erythemata, and diphtheria. From measles it dif- 
fers in its shorter incubative stage, and in the characters 
of its prodromes. In the former affection there are 
symptoms of coryza and bronchitis, with photophobia, 
sneezing, and coughing, while in scarlatina the prodromal 
symptoms especially involve the throat. In scarlatina 
the eruption begins to appear during the first or sec- 
cond day; in measles during the third or fourth day. 
During the course of scarlatina there is an absence of 
catarrhal symptoms for the most part. There are the 
characteristic sore throat, the peculiar ‘‘ strawberry 
tongue” (after the first two or three days), the well-de- 
fined eruption, the more protracted fever, the pronounced 
desquamation, and the tendency toward renal complica- 
tions. The eruptions differ both in their development 
and distribution in the two affections. In scarlatina the 
face is characteristically invaded by the eruption, which 
entirely spares the area about the mouth, and is no- 
where copiously developed in this region; while in 
measles the eruption is, probably, most intense upon the 
face. The macules in measles are large, irregular, and 
mostly papular. In scarlatina the eruption is punctate 
and more regularly distributed, not elevated ; it is scar- 
let in color, and generally coalescent, while in measles 
it is more discrete, elevated, arranged very extensively 
in forms of crescents and segments of circles, with 
greater or smaller areas of healthy skin between the le- 
sions, and is of a darker raspberry color. In measles the 
stage of eruption lasts from three to four days, and begins 
to decline as soon as the eruption upon the lower extrem- 
ities becomes complete. It occupies about thirty-six 
hours in attaining its acme. In scarlatina this stage 
lasts from two to six daysormore. It attains its acme in 
about eighteen hours. In measles there is a rapid return 
to a normal temperature in uncomplicated cases, while in 
scarlatina both eruption and fever decline more slowly. 
The conjunctival, nasal, and bronchial catarrh of measles 
is absent in scarlatina. In measles the tongue remains 
coated throughout. Sore throat is constant in scarlatina, 
quite uncommon in measles, and when present is almost 
invariably only catarrhal. The fever in scarlatina is at 
once more intense and more protracted. The desquama- 
tion of scarlatina is pronounced and lamellar; that of 
measles insignificant and branny. Scarlatina is frequent- 
ly complicated by diphtheritic pharyngitis and renal in- 
flammation, measles by inflammations of the respiratory 
apparatus. ; 

The eruption of rubella (Rétheln) more closely resem- 
bles that of scarlatina. It is paler, more discrete, and 
its lesions are larger and more distinctly papular. It is 
more transitory, and fades almost without desquama- 
tion, which, when present, is branny. Rotheln, more- 
over, has a longer incubation, almost no prodromal stage, 
sometimes marked catarrh, and but slight elevation of 
temperature. It is feebly contagious, of much shorter 
duration, and is hardly ever followed by nephritis and 
dropsy. The diagnosis is difficult only when the erup- 
tion of rubella becomes confluent. Here, however, the 


317 


Scarlet Fever. 
Scarlet Fever. 


confluence involves certain areas. It is sharply circum- 
scribed by normal integument, and shows in contrast the 
outlying characteristic lesions. It is of a pale rose-red, 
and not of a scarlet color, and is accompanied by the pe- 
culiar symptoms of rubella, and rarely lasts more than 
thirty-six hours. Both measles and rubella may at times 
closely resemble the milder forms of scarlatina, and from 
the eruption alone the diagnosis may be difficult; but a 
consideration of all the symptoms will usually lead to 
correct conclusions. Roseola variolosa should only ex- 
cite embarrassment when it occurs before the peculiar 
eruption of small-pox has appeared. It is less general, 
is more like a simple diffuse erythema than is scarlatina, 
and is so speedily followed by the characteristic vesicular 
eruption that doubt will soon be dissipated. Its coexist- 
ence with the essential eruption may excite suspicions of 
a concurrence of scarlatina and small-pox. Such an 
error may readily occur. Obstetrical and surgical scar- 
latina have already received attention. When erythema 
begins near a wound and becomes scarlatiniform in 
spreading, a septic origin must usually be allowed, 
though instances of scarlatina thus beginning have been 
reported ; otherwise, septic erythema is more circum- 
scribed and irregular. Scarlatina in the wounded and in_ 
lying-in women may be perfectly typical. Medicinal 
eruptions have unquestionably been at the bottom of 
many errors of diagnosis. It has been shown that many 
drugs may excite eruptions and general symptoms very 
like those of scarlatina; but for the most part they are 
simple active hyperemias, such as are produced by the 
action of belladonna upon the cutaneous arterioles. Such 
eruptions differ from that of scarlatina in the absence of 
prodromes, and, usually, of fever. They are also mostly 
partial and without the history, course, or results of scar- 
latina ; but at times, and especially when they follow the 
ingestion of preparations of cinchona, the whole complex 
of scarlatinal symptoms may be accurately simulated. 
The conditions for diagnosis have already been pointed 
out. In second or repeated attacks of so-called scarla- 
tina, due consideration of the possible influence of drugs 
as an etiological factor will, doubtless, convert some very 
puzzling cases into very simple ones. Acute exfoliative 
dermatitis and desquamative scarlatiniform erythema ® 
may well be mistaken for scarlatina upon their first ap- 
pearance. Therash is more protracted than in the essen- 
tial fever, and is less abrupt in its onset. The local 
symptoms are very marked, while the constitutional phe- 
nomena are usually insignificant. The desquamation 
may begin while the eruption is in full florescence. These 
affections are not contagious and have no specific se- 
quele. An erysipelatous eruption may be like that of 
scarlatina. It, however, differs markedly in its distri- 
bution, its evolution, and course, being never universal, 
always progressive, and of indefinite duration. The sub- 
jective symptoms are quite different in the two affec- 
tions ; the erysipelatous eruption is painful both spon- 
taneously and on pressure. Much cedema accompanies 
the latter eruption. Diphtheria may complicate scarla- 
tina, and the intensity of the local inflammation may in- 
duce a coagulation-necrosis exactly corresponding to 
the membranous formations.of diphtheria. Idiopathic 
diphtheria may especially resemble scarlet fever when it 
is accompanied by the erythematous exanthem that is 
sometimes developed, either early in the disorder, or 
later, in cases of blood-poisoning. At first it may not 
be possible to arrive at a correct diagnosis. According 
to Robinson,* in the early diphtheritic erythema there is 
no marked elevation of temperature. The rash may be- 
gin in any region, and rarely extends to the whole sur- 


face. The tongue is not affected, and there may be no 
special general disturbance. Desquamation does not oc- 
cur. The late diphtheritic erythema is septic. When 


the eruption of scarlatina is imperfectly developed, or 
when it does not appear at all, and when sore throat and 
fever are the only symptoms to attract attention, the 
diagnosis must rest upon the history of the patient and 
his surroundings, and upon the course of his illness. In 
not a few cases a retrospective diagnosis of scarlatina 
must be made, after the occurrence of desquamation or 


318 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the supervention of nephritis and dropsy under condi- 
tions that indicate their scarlatinal origin. 
Proenosis.—The mortality from scarlet fever varies 
widely in different epidemics. From the affection that 
in Sydenham’s time ‘‘ hardly deserved the name of dis- 
ease,” to a pestilence of intense malignity, all degrees of 
fatality have been, and continue to be, observed. Epi- 
demics have been recorded in which no deaths have oc- 
curred, Recently Whitla*+ has recorded but a single 
death in 133 cases of scarlatina treated in hospital. Such 
results are, unhappily, exceptional. The mortality has 
been known to reach thirty and forty per cent. An ex- 
cessively high rate of mortality is, in great part, attrib- 
utable to epidemic tendencies toward grave complications, 
diphtheria, nephritis, etc. In private practice the death- 
rate will not often exceed ten per cent. In hospitals the 
percentage of deaths is usually much higher, the result 
being due to the fact that milder cases are kept at home 
for the most part, and not to differences in social condi- 
tion, except in so far as neglect and exposure previous to 
admission may have aggravated an attack or have excited 
a complication. The death-rate will be high or low in 
accordance with the type of the prevailing epidemic, and 
the average mortality of the disease should always be 
considered with reference to this. Neither season nor at- 
mospheric condition appears to exert any influence upon 
the epidemic type. Likewise, telluric conditions do not 
modify it. Benign and malignant epidemics follow each 
other without evident cause. The mortality at the begin- 
ning and during the height of an epidemic is greater than 
during its decline. Barring the effects of extreme pov- 
erty and exposure, scarlet fever affects the rich and poor 
impartially. The sexes are almost equally attacked, but 
age exerts a striking influence upon the result. Children 
under one year of age, though less apt to be attacked, are 
especially liable to fatal forms of the disease. According 
to Fleischmann, the mortality at St. Joseph’s Hospital 
was: Under one year of age, seventy-five per cent. (8 
cases, 6 deaths); from one to four years of age, forty- 
three per cent. ; from five to twelve years of age, 19.6 
per cent. ; the total mortality being ten per cent. The 
majority of deaths occur under the sixth year of age; 
with increasing years the prognosis becomes more favor- 
able. Fleischmann’s records show a higher mortality than 
those of some other writers. For example, Kraus gives 4 
deaths in 13 cases less than one year of age ; 29 deaths in 
118 cases from the close of the first to the close of the fifth 
year of life ; 10 deaths in 106 cases from the end of the 
fifth to the close of the twelfth year of age; and 2 deaths 
in 40 cases from the twelfth to the twentieth year of age. 
Voit reported 1 death in 5 cases less than one year of age ; 
24 deaths in 166 cases from the first to the close of the 
sixth year of age ; 10 deaths in 109 cases from the sixth 
to the twelfth year of age. Roset reported 16 deaths in 
43 cases less than one year of age; 31 deaths in 156 cases 
from the first to the close of the fifth year of age; and 
3 deaths in 88 cases over five years of age. An ex- 
ception must be noted to the favorableness of the prog- 
nosis in persons of maturer years, in the case of puer- 
peral women, in whom scarlatina has already been shown 
to be especially malignant. No case can appear to be so 
mild as to justify a prognosis unqualifiedly favorable. 
From the beginning until the termination in recovery 
there is no period when a sudden change may not place 
the life of the patient in jeopardy, whether by an aggra- 
vation of the essential symptoms of the disease, or by the 
supervention of complications. The prognosis, however, 
is generally favorable if the disease pursue a regular 
course ; if the eruption follows a brief prodromal stage, 
and is regularly developed ; if the fever, more or less in- 
tense from the first, does not exceed at the height of the 
eruption 40° C. (104° F.), and, steadily falling, reaches 
the normal on the sixth, seventh, or eighth day; if the 
angina do not assume a diphtheritic character, and is 
not complicated by parenchymatous tonsillitis, retro- 
pharyngeal abscess, or cellulitis of the throat or neck ; if 
the kidneys remain unaffected or show only slight evi- 
dences of disorder. On the other hand, the prognosis is 
more grave when the eruption appears after a prolonged 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Scarlet Fever, 
Searlet Kever,. 


prodromal stage, or when the attack is ushered in by con- 
vulsions or other profound nervous disturbance ; or when 
the temperature reaches a high degree, 40.6° to 41° C. 
(105° to 106° F.), at once ; or when intractable vomiting 
is present ; or when diarrhcea is a prominent feature ; or 
when the pulse beats more than one hundred and twenty 
times to the minute, and is feeble, unequal, and irregu- 
lar ; or when the throat is ulcerated and develops diph- 
theritic inflammation ; or when suppurative, parenchy- 
matous, or gangrenous inflammation of the tonsils, or 
retro-pharyngeal abscess supervene ; or when the neck 
becomes swollen, brawny, and livid from glandular, 
peri-glandular, and diffuse cellular inflammation. Ap- 
prehension should always be excited if the eruption come 
out imperfectly or irregularly while the fever is intense ; 
or if, once fully developed, it suddenly fade; or if the 
eruption assume a livid color ora distinctly hemorrhagic 
character. A coppery hue of the eruption is unfavor- 
able, as is also a livid coloration of parts not invaded b 
the eruption. Small, scattered petechize in the midst of 
an otherwise normal eruption are unimportant. Miliary 
vesicles, developing in the ordinary course of the fever 
are insignificant ; occurring later, during an attack of un- 
usual severity, they are often the forerunners of death. 
Convulsions first occurring after the height of the fever, 
are more ominous than if occurring earlier. Should the 
eruption, and especially the fever, continue unabated 
after the usual period, dangerous complications are to 
be apprehended. Coma is of grave augury, as indicat- 
ing uremia, cdema of the brain, or even meningitis. 
Nephritis is more serious the earlier it is developed. It 
occasionally happens that scarlet fever at first shows the 
symptoms of a mild attack, but before the completion of 
the eruption assumes a malignant character. If symp- 
toms of malignancy occur after the completion of the 
eruption, they are usually attributable to complications. 
On the other hand, all the signs of malignant scarlatina 
may be present at the outset. High fever, rapid pulse, 
convulsions or coma, protracted vomiting, intense erup- 
tion, may all yield after the second or third day, the 
disease thenceforward pursuing a mild course; again, 
symptoms of malignancy may disappear upon the super- 
vention of a delayed eruption. Mayer *® observed a tem- 
perature of 48° C. (109.4° F.) on the evening of the second 
day. The temperature subsequently varied slightly until 
the fourth day, when, upon the appearance of the erup- 
tion, it subsided. The occurrence of scarlatinal diph- 
‘theria always increases the danger of death. Heubner 
regards its sudden extension to the soft palate and to the 
portals of the cesophagus and trachea as certainly to be 
followed by death within from twenty-four to forty-eight 
hours, the fatal issue occurring either through gradual 
progress of gangrene, by inflammation of the lymphatic 
glands and connective tissue of the throat and neck, or 
by edema glottidis. When circumscribed spots are in- 
vaded and the lateral portion of one tonsil shows the first 
patch, from which the membrane gradually spreads, re- 
covery may occur. Diarrhoea persisting during the at- 
tack greatly increases the danger. Nephritis is always 
a serious complication, though terminating favorably in 
most cases. The danger is usually proportionate to the 
earliness of its occurrence. Death may occur as in or- 
dinary nephritic inflammation. Scarlatinal nephritis 
most rarely becomes chronic. Inflammation of the or- 
gans of hearing, while rarely imperilling life, often re- 
sults in partial or complete deafness. This, according to 
Burkhardt-Merian,*" depends upon croupous-diphtheritic 
inflammation primary in the throat. The prognosis is 
more unfavorable if the process be allowed to go un- 
treated. Rheumatic and rheumatoid inflammations are 
not commonly dangerous complications. Endo- and 
peri-carditis, pleurisy, peritonitis, meningitis, pneumonia, 
dysentery, parenchymatous degeneration of the heart, 
etc., are all complications of extreme danger. Purulent 
inflammations of pyemic origin usually constitute se- 
quelee of scarlatina, and are of the gravest Importance. 
TREATMENT.—Mild cases of scarlatina require little 
more than good nursing. As soon as the nature of the 
disease has been recognized, the patient should be re- 


moved toa clean, well-ventilated room, supplied with only 
such furniture as is indispensable. Only the attendants 
of the patient should be admitted to the sick-room. All 
superfluous articles of clothing should be discarded. As 
far as practicable, woollen outer garments should not be 
worn. In summer the windows should be kept open 
sufficiently to secure free movement of air and agreeable 
temperature ; in winter an open wood or coal fire should, 
if possible, be kept constantly burning. The tempera- 
ture of the room should not exceed 21° C. (70° F.), nor 
fall below 18° C. (65° F.). The patient, unless an infant, 
should be kept in bed even during the mildest attack. 
The bed-covering should be sufficient to secure comfort, 
nothing more. The diet should consist in easily assimi- 
lable food ; the nearer this approaches a pure milk diet 
the better. Cold drinks may be allowed ; cold water, 
lemonade, raspberry vinegar properly diluted, soda-wa- 
ter agreeably flavored, are grateful to the patient and 
preferable to warm and mucilaginous drinks. Though 
milk should form the principal article of food, light 
broths and soups, beef-tea, chicken-jelly, and, especially 
during convalescence, the various appetizing and whole- 
some preparations of food now so abundantly supplied, 
may be given. Clothing and bed-clothing may be fre- 
quently changed under precautions providing for appro- 
priate disinfection. In such cases internal medication 
may be held in reserve, a careful observation of all symp- 
toms being meanwhile maintained ; the condition of the 
kidneys being systematically ascertained by daily obser- 
vation. For the angina, if this does not exceed a simple 
hyperemia, soothing gargles of flaxseed, sage, or chamo- 
mile tea, or of decoction of quince-seed, will prove effi- 
cacious. Should the throat develop the whitish curdy 
deposits of follicular inflammation and the erosions that 
so often accompany acute catarrhal pharyngitis, a mildly 
antiseptic gargle will act beneficially and will correct 
fetor of breath, and, to some extent, disinfect the secre- 
tions and exhalations. For this purpose one of the sub- 
joined gargles may be employed : 


Foe CIC, CATDOUCHCEV Sb... ara chs maces 2 88, 
CEIVCODENG co Neale werd ec sle uate nines rac 
DCCL SUL sila. 6 okt man a euetsie ats Q. $aa0 fay 

M. Sig.—Gargle. 

Or, 

Bae linctsfertl colorids s...arteete marae seb 
Potases chloraty . 0s tec seieas acta eens 3 Ss. 
GUY Cerin Woitds ott centers hae eee os {3 j. 
A ee CLESU Lie. cts gletetetara: celts q. s. ad f % viij. 


M. Sig.—Gargle. 


External applications to the throat are often useful. 
A favorite domestic remedy is a strip of bacon-rind ap- 
plied to the skin of the throat. It produces a slight ve- 
sicular eczema, and is probably of some advantage as a 
counter-irritant. Obviously, such applications are inad- 
missible when diphtheritic inflammation is present. 
Mildly stimulating liniments are more handy and ele- 
gant, and quite as efficacious. The itching and burning 
of the eruption will be greatly alleviated by inunctions 
with camphorated oil, cold cream, vaseline, or lard. 
This practice is especially commended as restricting the 
spread of contagious particles. Tepid bathing or spong- 
ing under the bed-covering is refreshing to the skin and 
nervous system, contributes greatly to bodily comfort, 
and may be practised several times daily. Although 
every case demands constant watchfulness, when the 
temperature does not exceed 39° C. (102.5° F.) medica- 
tion beyond that mentioned will not be called for, un- 
less complications develop. When the degree indicated 
is exceeded, marked benefit will be derived from anti- 
pyretic remedies. These may be administered inter- 
nally or externally. Of internal antipyretic remedies, 
until recently, the most popular was quinine. The sul- 
phate may be prescribed in capsules, in doses of from 
three to five grains to a child five years of age, at intervals 
of two hours, for two or three doses. It must be con- 
fessed, however, that in scarlatinal hyperpyrexia quinine 
is at best an uncertain and feeble remedy. In severe 
cases there is often intractable vomiting, and quinine 1s 


319 


Scarlet Fever. 
Searlet Fever. 


especially apt to be rejected almost as soon as swallowed. 
It is better, therefore, to give it in solution by the rec- 
tum or hypodermically. By the latter method a solution 
containing four grains of the hydrobromate of quinine 
in twenty minims of water, or of the muriate of quinine 
with urea,* may be injected once or twice daily. Other 
agents occasionally used for the reduction of fever are 
aconite and veratrum viride. In mild cases, however, 
they are unnecessary, and in severe ones they are both 
unsatisfactory and unsafe. Salicylate of sodium pos- 
sesses positive antipyretic properties, and may be used 
in scarlatina with frequent benefit. The synthetically 
prepared alkaloids of the aromatic series of carbon com- 
pounds, of which thallin, antipyrin, and antifebrin may 
be considered the most reliable and safest for the reduc- 
tion of temperature, are probably the most valuable rem- 
edies by the internal administration of which exalted 
temperature may be reduced. These drugs, which prom- 
ise to hold a firm position in therapeutics, will most prob- 
ably serve a very useful purpose in the treatment of scar- 
latinal hyperpyrexia. At present, however, observation 
has not been sufficiently extended to justify definite con- 
clusions. Antipyrin acts well with children, and seldom 
produces objectionable diaphoresis or eruptions. Argu- 
tinsky recommends the following minimal doses of this 
agent : For children under one year of age, three grains 
thrice daily, at intervals of three hours ; for those of from 
one to three years, five grains; for children between this 
age and five years, from five to six grains three times 
daily, at intervals of two hours; for children of from six to 
eight years, from eight to ten grains daily, at intervals of 
two hours; and for children of ten or twelve years, from 
ten to twelve grains thrice daily; at intervals of one hour. 
Thallin may also be used to effect the same purpose. 
The dose of thallin is about one-fourth of that of antipy- 
rin. There is a somewhat greater tendency to collapse 
after thallin than after antipyrin, and, therefore, the ear- 
lier doses should be given very cautiously. Antifebrin 
affords advantages over either of these agents. Vomiting 
ost rarely occurs after its use. The dose is one-half of 
that of antipyrin, though its full action is produced more 
slowly. Neither is sweating quite so constantly pro- 
duced, though a pronounced cyanosis of the cheeks and 
mucous membrane and of the extremities is often ob- 
served. These agents are also active when administered 
by enema. 

During the administration of these drugs the ther- 
mometer should be constantly employed, care being taken 
to avoid collapse. After afew hours the influence of the 
dose fails and recourse must be had to them repeatedly. 
By far the safest and surest agent for reducing tempera- 
ture in scarlatina is cold water. This may be applied in 
various ways. The simplest method is by frequent 
spongings with cold or tepid water under cover of the 
bedclothes. At the same time cold wet-cloths may be 
applied to the head, and the patient may be permitted to 
suck small pieces of ice. In most cases it is better that 
the water be warm. The spongings may be repeated 
frequently during the day and night. In cases where, 
with an elevated temperature, the eruption develops in- 
completely, or is much delayed in appearance, the body 
may be immersed in water somewhat cooler than its nor- 
mal temperature. A cool bath (27° C.= 80° F.) has been 
extolled as of singular virtue in such cases, and at times 
it is of the highest value. The tepid, even the warm 
bath, is probably of equal benefit in most cases. Recent 
writers have denied that efforts to ‘‘ bring out” an im- 
perfect or delayed scarlatinal eruption are of any avail. 
Therescan be no doubt, however, that treatment with 


* This salt, which is also called “ quinia bimuriatica carbamidata,” is 
prepared by Andrews & Thompson, of Baltimore, as follows: Muriate of 
quinine, 793 grains; muriatic acid (specific gravity 1.070), 500 grains; 
pure urea, 120 grains. Mix the muriate of quinine in the Hcl in a por- 
celain capsule, and when it is dissolved add the urea and heat carefully 
over a water-bath until sufficiently concentrated to form crystals (evapo- 
ration to dryness under a low temperature may be practised). ‘T'o pre- 
pare the solution for hypodermic use, take of muriate of quinine and 
urea, 3ij.; of distilled water, f3j. Dissolve and filter. Twenty minims 
of this solution contain five grains of muriate of quinine. I'or hypoder- 
mic use this solution leaves nothing to be desired, 


320 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


this object in view is often successful. The hot bath, 
even with the addition of mustard, by exciting cutaneous 
hyperemia, will often relieve the congestion of internal 
parts. Warm and hot drinks made from various vege- 
table substances were formerly much employed to “ bring 
out” the eruption. They were given copiously, and of- 
ten in combination with such diaphoretics as spiritus 
mindereri, spirits of nitrous ether, etc. This plan of 
treatment is not much practised to-day. The cold bath, 
which should be of a temperature not lower than from 
24° to 27° C. (75° to 80° F.), should be reserved for cases 
whose temperature exceeds 40° C, (104° F.). The body 
should be immersed but for an instant, the benefit of the 
plunge consisting largely in the dilatation of the vessels 
of the skin through reaction. The cold pack is also of 
value in these cases. When the temperature steadily 
rises to an alarming degree, or when hyperpyrexia is de- 
veloped almost at the outset; when, with or without 
well-developed exanthem, stupor or coma, or other grave 
nervous disorder, arises, and when the pulse becomes 
very rapid, feeble, and irregular, the maintenance of life 
depends upon the reduction of temperature. Here it is 
impossible to give hard and fast rules for conduct. 
Water below the normal temperature of the body still 
remains our most efficient means of reducing the exces- 
sive heat. The lower the temperature of the bath, the 
more rapidly is this result attained, but the shock of the 
sudden contact with the cold water may exert a depress- 
ing effect that may not speedily pass off. The body 
cannot remain in very cold water longer than a minute 
or so without exciting chattering of the teeth, lividity 
about the mouth, and a pinched appearance of the feat-. 
ures and of the surface. Cold affusions may often be 
most profitably employed. They were strongly com- 
mended by Currie. The affusion may be practised by 
pouring from a pitcher, from a moderate height, cold 
water upon the head of the patient, until the necessary 
fall of the temperature has been achieved. The warm 
bath (82° to 35° C.= 90° to 95° F.) has been highly ex- 
tolled as favorably influencing the course of scarlet 
fever when used at the very beginning. Thompson em- 
ployed it thus constantly, and never lost a case treated 
in this manner. In a bath of from 27° to 30° C. (80° to 
85° F.) the patient may remain for five or ten minutes. 
These baths should be repeated as often as the tempera- 
ture of the body becomes as high as 39.5° to 40° C. (103° 
to 104° F.). To avoid alarming the little patient, the 
bath-tub may be covered with a sheet or blanket. Plac- 
ing him upon this, he may slowly be lowered into the 
water. Upon removal from the bath the patient should 
be wrapped in a dry blanket. As the body soon dries 
under the protection afforded, rubbing with towels may 
be avoided. The skin should now be anointed with oil 
or other agreeable fatty substance. Refreshing quiet 
and sleep often follow this bath. In using the wet pack, 
a blanket may be spread upon a hard couch or bed cov- 
ered with oil-cloth ; upon this a sheet wrung out in cold 
water is laid. The naked patient is stretched upon this 
sheet, which along with the blanket is wrapped about 
him snugly. The brief sensation of chilliness is soon 
replaced by one of warmth, and after a few moments 
the body breaks out into copious perspiration. This 
may be encouraged by hot drinks, and hot bottles to the 
surface. The patient should not remain too long in the 
pack, otherwise hyperpyrexia may rather be increased 
than diminished. In the intervals of the baths, in ex- 
treme cases, an ice-cap may be worn, and cloths wrung 
out in iced water may be applied to the epigastrium. , 
Nothing can exceed the efficacy of the above-described 
method of treating scarlet fever with high temperature ; 
but to secure its full influence, it must be pursued sys- 
tematically and intelligently. The thermometer must 
constantly direct the actions of the physician. The 
prejudices of friends and attendants against the immer- 
sion of the fevered body in ice-cold water will not ex- 
tend to the use of tepid and cool baths, from which, in- 
deed, equally good results may be obtained. The baths 
may have to be repeated at intervals of two or three 
hours for days before the fever begins to yield; or they 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Searlet Fever. 
Scarlet Fever. 


may unhappily altogether fail to control the irresistible 
intensity of the disease. On the other hand, they fre- 
quently exert a most gratifying influence upon the 
course of the malady, the temperature becoming per- 
manently reduced, the pulse quieter, fuller, and regular ; 
jactitation, delirium, and coma being replaced by com- 
posure, consciousness, or natural sleep. Often an at- 
tack that appeared about to pursue a malignant course, 
under the influence of the bath becomes benign and ter- 
minates favorably. While exalted temperature that 
threatens to destroy life can, in the manner indicated, 
often be reduced, the course of the disease itself cannot 
be aborted. No remedy is known that can be said to 
exert a specific influence over it. Vaunted specifics 
have not withstood the test of experience. Bennett 
claimed to have never lost a case of malignant scarlet 
fever, a result that he attributed to the administration of 
fresh yeast,in one or two tablespoonful doses, several 
times daily. One no longer hears of Schneemann’s plan 
of rubbing the surface with bacon, and of Deline’s oil 
inunctions as curative, though the value of such adju- 
vant treatment is universally recognized. Recently Hay- 
ward ®* reported several cases of malignant scarlatina 
successfully treated with crotalus. The agent was ap- 
plied to the denuded surface of the throat, and was also 
given internally. The mineral acids, though highly ex- 
tolled by authors, do not confer any signal advantage in 
the ‘treatment of scarlatina. Acetic acid has been sup- 
posed to exert a favorable influence over the disease, and 
is a favorite remedy. Probably the most popular routine 
treatment of ordinary scarlet fever is that of carbonate 
of ammonia. By many it is considered to have a speci- 
fic influence. When in cases of very elevated tempera- 
ture the heart-action flags, the pulse becoming rapid, 
feeble, and unequal, when delirium or stupor appears, the 
preparations of ammonia are demanded. The carbonate, 
in doses of one to three grains to a child five years of age, 
may be given every third hour in aqueous solution with 
milk, which in a great measure destroys the pungent, 
disagreeable taste ; or it may be given in solution of the 
acetate of ammonia, a most commendable combination. 
The aromatic spirits of ammonia may be employed for 
the same purpose. Hoffman’s anodyne, whiskey, or 
brandy is especially indicated when the nervous system 
shows alarming signs of perturbation, delirium, jacti- 
tation, stupor, etc. Purgation, which should usually be 
avoided, may at times become necessary. Small doses 
of calomel (one-sixth to one-fourth grain) repeated every 
hour, until the bowels are moved, generally act well. 


Castor-oil is a harmless and safe, but nauseous, agent. . 


Rhubarb and scammony are also efficient cathartics. 
Either may be given in doses of five grains to a child 
six years of age. The taste of scammony resin is not 
unpleasant, but its difficult miscibility with water is an 
objection to its use. Ringer recommends as a purgative 
for children a few drops of a solution of one grain of 
podophyllin in a fluid drachm of alcohol given in syrup. 
When depression is profound, reliance should be placed 
on enemata in preference to active cathartics. During 
the progress of the disease the expectant plan of treat- 
ment is most to be recommended. The daily bath or 
sponging should be continued. It is probable that renal 
complications are thus frequently avoided. As the fever 
and eruption decline, a more liberal, but always easily 
assimilable, diet should be allowed. The patient should 
be jealously guarded from draughts and dampness, and 
even the mildest cases should be kept in bed for at least 
ten days after the cessation of fever ; nor should the pa- 
tient be allowed to leave his room before the expiration 
of the third week. Out-of-door exercise cannot be re- 
sumed in disregard of season, or of barometric and ther- 
mometric variations. In midsummer, when windows and 
doors must remain open, the question of out-of-door ex- 
ercise is rather one of danger to others than of personal 
risk ; while in spring, autumn, and winter the risks of 
exposure are especially great. During these seasons the 
patient should not venture into the open air before the 
sixth or seventh week of perfectly normal scarlatina. 
During convalescence the daily baths should be contin- 


Vou. VI.—21 


ued until desquamation is completed, and daily inunc- 
tions with oil both expedite this process and minimize 
the dangers of contagion. No further medication, or at 
most a ferruginous tonic, will be required. 

Unfortunately, during the course of scarlatina there 
constantly arise complications frequently demanding 
more energetic treatment than the original malady. Of 
these the most common (indeed, in its milder degrees it is 
essential) is pharyngeal inflammation. The milder grades 
of this will require no more active treatment than that 
already described. Where the inflammation is more se- 
vere, and accompanied by more or less superficial ulcer- 
ation, applications should be made with a probang or 
camel’s-hair pencil, or by means of the spray. When 
the surface is foul and covered with offensive exudation, 
an excellent application is the following, first recom- 
mended by J. Lewis Smith : 


By eAcid,, carbolic.. 1.22 BRACE Bis 4 oe eae gr. iij.-vj. 
Liquor ferri subsulphat............ £5 1 
Glycerin prt. tj dks bi. ahd £3 vj. 


S.—Apply with a brush three or four times daily. 


Or the following : 


dp LINCUMLOCIDIT ae toy ve tet saia: eer Lae f 
CVcerl niet eee oe ne tah wees ie Ly age 

Or, 

HAA CIGs boraciews SiMe Pe ee Pee. 3.88.-3 ij 

CLE CCRCLL ST Gere et ee ae ee feive 


M. 8.—Apply with a brush, 
with the atomizer. 


This may also be used 


Most therapeutic agents may be profitably given through 
the hand-atomizers in the case of children intelligent 
enough to assist by inhalation. Subjoined are suitable 


formule : 

Hoa Linct, fetmrirCnlovigd.. <4. os. us cate tee wieGe 
Olas. CULOL ALG ima as seere ae meee ce ca 
NCICB LULOS cr access Ser doe ae Lai f: 
Dpiserviti amaliice te ery kee wea te £2): 
GLY Cert te attr cedtite Sean ohio ae f Z ss. 
ENC ACBS ELL Ses a itn cna eben Ce iG tiene: 

M. 

FEMA Qh LOK Tarp rne thie Sa SU) oe eg Oe f 2 ss; 
Aquidestik. Dest CR au.We ies sete ees f% vss 

M. 


The various carbolized sprays are most extensively em- 
ployed. Diphtheritic inflammation calls for the same 
treatment as idiopathic inflammation.* Cauterization 
with silver nitrate, acid nitrate of mercury, chromic acid, 
or other agent, should not be practised. Asa gargle in 
diphtheritis faucium permanganate of potash is valuable. 


R. Potass. permanganat..... greene aL ae 1 ee 
Any destil. sa. ng en Gn wakes ne 12 1yi. 
M. 


Tracheotomy should never be performed. A case of 
scarlatinal diphtheria which presents the symptoms that 
demand this operation, in the idiopathic disorder, is be- 
yond the resources of surgical art. Inflammation of the 
lymphatic glands of the neck and of the adjacent connec- 
tive tissue may be treated first by inunction of oil or cerate. 
In severer forms, cold wet applications, and where sup- 
puration threatens, flaxseed, or cornmeal, or hop poul- 
tices should be applied. Suppurating points should be 
incised early and freely to prevent burrowing. Gangren- 
ous inflammation may sometimes be arrested by strong 
caustics. Iron, quinine, stimulants, and nourishing and 
supporting food should be administered in these condi- 
tions with a free hand. Nasal catarrh will not usually 
require treatment. When diphtheria extends to the nasal 
passages, similar applications to those made in throat 


* Dusting powders of subnitrate of bismuth and salicylic acid, and, 
under proper precautions, of iodoform, is often most useful. 


321 


Searlet Fever. 
Scarlet Fever. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


diphtheria should be made through a nasal syringe. 
Scarlatinal aural inflammation calls for more special treat- 
ment; the nasal douche should be used and _ the diphthe- 
ritic pharyngeal and nasal cavities should be repeatedly 
syringed with antiseptic solutions, for it is by the exten- 
sion of the inflammation along the Eustachian tube, that 
the severer forms originate. When the aural inflamma- 
tion is established, inunctions of mercurial ointment, or of 
the oleate of mercury, or of iodoform ointment, should be 
made about the ear several times daily. When the tym- 
panic membrane becomes strongly injected and bulges 
outward, paracentesis for the release of the pent-up exu- 
dation should be performed. Timely tapping of this 
membrane will often preserve the imperilled sense of hear- 
ing. This operation is especially commended by Buck 
and Olshausen. It is simple and very easily performed. 
The sensitiveness of the membrane may be obtunded by 
the instillation of a four per cent. solution of muriate of 
cocaine. Pomeroy’s directions for performing the opera- 
tion are as follows: ‘‘ A good-sized speculum is intro- 
duced into the meatus. Then an ordinary broad needle, 
about one line in diameter, with a shank of about two 
inches, such as oculists use for puncturing the cornea, 
should be held between the thumb and fingers, lightly 
pressed so as not to dull delicate tactile sensibility. The 
part being well under light, the most bulging portion of 
the membrane should be lightly and quickly punctured 
with a very slight amount of force. The posterior and 
superior portion of the membrane is most likely to bulge. 
The chorda tympani nerve usually lies too high up to be 
wounded. The ossicles are avoided by selecting a pos- 
terior portion of the membrane. After puncture the ear 
should be inflated by an ear-bag whose nozzle is inserted 
into a nostril, both nostrils being closed, so as to force the 
fluid from the tympanum. The puncture may need to 
be repeated at intervals of a day or two, provided that 
the pain and bulging return.”*? When pain and tender- 
ness only are present, hot fomentations to the external 
ear, and to the parotid and mastoid regions, are very 
soothing. Laudanum and sweet oil, or a two to four 
per cent. solution of sulphate of atropia instilled warm 
into the external meatus, often give relief. Frequently 
renewed solutions of cocaine are very efficacious. Bags 
of hot table salt, or of heated flowers of hops, are well- 
known domestic remedies. When perforation occurs 
spontaneously the hearing may be preserved, but partial 
deafness is often permanently established, and sometimes 
the sense of hearing is totally abolished. In such cases 
the ear should be frequently syringed with warm water, 
or warm solutions of boracic acid. Jodoform, however, 
is by far the most effective application in chronic aural 
inflammation with perforation, with or without necrosis 
of the bones of the aural cavity. Its disagreeable odor 
may be masked by adding to the phial a drop or two 
of some essential oil (cloves, citronella, cinnamon, etc.). 
Granulations and polypi developing in the course of 
chronic otitis may be benefited and even cured by as- 
tringent powders and washes. Surgical interference 
will at times be necessary. 

When nephritis arises in the course of scarlet fever, or 
as a sequel, prompt measures for its relief must be 
adopted. Where it forms a feature of rapidly fatal ma- 
lignant scarlatina, it may have no time to develop symp- 
toms, or these may escape detection, or the virulence of 
the disease may throw the renal disorder into the back- 
ground, or render attempts to treat it futile. In milder 
cases, and later, during the latter part of the first or dur- 
ing the second or third week, especial attention may be 
devoted to the treatment of nephritis. Slight albuminuria 
will occur, according to Mahomed, during convalescence, 
associated with constipation and a hard pulse, indicative 
of high arterial tension, without subjective symptoms, 
and remediable by a brisk purge. This author also as- 
serts that a slight chilling of the surface is sufficient to 
cause transitory albuminuria. The patient should there- 
fore be carefully protected, in the manner already indi- 
cated. Dietary management will go far toward prevent- 
ing renal complications. <A rigid milk diet, in all cases 
of scarlatina, is regarded -by Jaccoud as absolutely pre- 


322 


ventive of nephritis. Though this may be an extravagant 
statement, it is certain that in scarlatina there is no better 
diet than one of milk. Should nephritis arise, it is the 
more important that the milk diet should be continued. 
From two to three or four pints may be given during the 
twenty-four hours, in small quantities, at brief intervals, 
the latter amount being sufficient for an adult without 
other food. If there are reasons why milk cannot be taken, 
light broths and soups and chicken jelly may be substi- 
tuted, together with light farinaceous food. Buttermilk 
may, at times, be preferred, and bonny-clabber and slip or 
junket (milk sweetened and flavored and coagulated with 
liquid rennet) are often relished, and are excellent articles 
of food. Proper regard having been paid to the hygienic 
surroundings and nutrition of the patient, a brisk hydra- 
gogue cathartic should be administered, unless diarrhoea 
be already present. For this purpose there is nothing 
better than the compound jalap powder. For a child, 
from five to twenty grains of this should be ordered 
every night, as required, the object being to secure sev- 
eral watery actions of the bowels every twenty-four hours. 
The proper dose for an adult isone drachm. The de- 
sired watery stools may also be readily secured by the 
saline cathartics if given in concentrated watery solution, 
as has been shown by the researches of Dr. Matthew 
Hay. The more drastic purgatives will rarely be re- 
quired, except in uremic intoxication and in extreme 
dropsy, when podophyllin, croton-oil, elaterin, etc., 
may occasionally be employed with benefit. When 
dropsy is but slightly pronounced, purgation may not be 
required. 

The action of the skin should next demand attention. 
Frequently during the day the body may be wrapped in 
flannels, wet or dry, as hot as can be borne; or the wet 
pack may be applied. When available, the steam bath 
or hot-air bath is to be strongly recommended. The hot- 
plunge bath may also be employed most advantageously. 
Pilz has especially lauded this treatment. It should be 
used after the method of Liebermeister, by gradually in- 
creasing the temperature of the bath from 36° C. to 40° 
C, (96° to 104° F.), in a half-hour. Under its daily use 
dropsy speedily disappears. Diseases of the heart and 
lungs, while not positively contraindicating this plan of 
treatment, necessitate great caution in its application. 
Sudden chilling of the surface after the bath should be 
avoided. The imminence of the danger is usually pro- 
portionate to the degree of impairment of the function of 
the kidneys. In giving remedies to modify their action, 
none calculated to increase their hypersemia should be 
employed. Exception can hardly be made in favor of 
juniper, which enjoys with some writers considerable 
reputation in scarlatinal nephritis ; but digitalis, the phar- 
macological position of which is not as yet definitely de- 
termined, has received very general approval as a most 
useful diuretic in acute nephritis. From one fluidrachm 
to a half fluidounce of the infusion (which is much the 
best preparation for the production of diuresis) may be 
given three or four times daily, the dose varying with 
the age of the patient. Its effects, however, are hardly 
as happy as when dropsy is associated with, or dependent 
upon, cardiac weakness. Diuretics that act specifically 
upon the secreting cells of the urinary tubules, the seda- 
tive or refrigerating diuretics, are to be preferred, as a 
rule, in the treatment of scarlatinal nephritis, and will 
often achieve most astonishing results. Of these the salts 
of potash are most efficacious—the citrate, the acetate, the 
bitartrate, and the bicarbonate. For slight nephritis and 
anasarca a lemonade made with bitartrate of potash will 
be taken with avidity, and will often almost magically 
increase the quantity of urine, reduce the dropsy, rapidly 
diminish the albuminuria, and cause a radical change for 
the better. This lemonade may be made by adding one 
drachm of cream of tartar to a pint of boiling water, into 
which a sliced lemon has been dropped. This quantity, 
properly sweetened, may be drunk during the day by a 
child five years of age. Water may be allowed freely, 
or any of the mild domestic infusions may be substituted 
for it, their virtue residing principally in the amount of 
fluid. Dickinson especially recommends the free use of 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


water as unirritating, and tending to wash out of the tu- 
bules the exudate choking up their lumina. In more se 
vere cases, where life is threatened through one or an- 
other form of uremia, very energetic treatment will be 
required. Jaborandi may now prove useful. J. Lewis 
Smith, Hirschfeld, and others have commended its action 
highly. For a child two years of age, one-twentieth of a 
grain of pilocarpin may be given by the mouth every 
fourth or sixth hour, or the same amount may be injected 
hypodermically. Both diuresis and diaphoresis will be 
promptly increased, and in favorable cases the uremic 
symptoms will disappear. Uremic coma and convul- 
sions, developing suddenly or after progressive renal em- 
barrassment, should be treated without reference to the 
scarlatina and upon general principles. A remedy of 
most undoubted value, at least for the control of convul- 
sions, is chloral, which, if the patient be unable to swal- 
low, may be injected in full doses under the skin or into 
the rectum. After the more acute nephritis has sub- 
sided and convalescence promises to become established, 
iron becomes one of our main reliances, in virtue of its 
combined heematic and diuretic properties. The mistura 
ferri et ammoniez acetatis will generally be found to be 
the best preparation. Quinine is also a remedy of great 
value in the treatment of convalescence from scarlatinal 
nephritis. During the height of the inflammation, local 
treatment is often of great importance. If fever is in- 
tense, the pulse full and strong, and if pain and tender- 
ness in the back are pronounced, the abstraction of blood, 
by leeches or cups, from the loins will often prove bene- 
ficial. Large sinapisms and poultices may be applied 
over the kidneys. Besides assuaging the irritation they 
tend to promote diuresis and diaphoresis. For obvious 
reasons, turpentine should not be employed as a counter- 
irritant in these cases. Ascites may occasionally be so 
excessive that the pressure exerted upon the kidneys in- 
terferes with the action of therapeutic agents, and im- 
pedes the functional activity of these organs. Paracen- 
tesis abdominis, by relieving this compression, will often 
be followed by copious diuresis and the rapid disappear- 
ance of general anasarca. Cases of scarlatinal nephritis 
which pass into chronic Bright’s disease, as rarely hap- 
pens, will require the treatment appropriate for this con- 
dition. During convalescence the usual precautions will 
be necessary. The treatment of other complications and 
sequel of scarlet fever is not peculiar, and will require 
no special notice here. 

_ Prophylactic Treatment.—When scarlet fever attacks 
one member of a household, intelligent prophylaxis can 
be more successfully practised than is the case with the 
other specific fevers. All unprotected persons should be 
rigidly excluded from the part of the house in which the 
patient is confined. Those entering the sick-room should 
have no communication with the healthy. Soiled cloth- 
ing, utensils, excreta should be removed, under cover, 
by passages and stairways that are not used. by others. 
Soiled linen should not be washed with articles belong- 
ing to the unprotected. It should be boiled in separate 
vessels. As the contagion is especially prone to cling to 
woollen fabrics, the garments of the attendants should 
not be of this material. During the fever, daily inunc- 
tions will greatly restrict the dissemination of the con- 
tagium particles. The patient should not put on his 
regular apparel until the end of the third week. Daily 
warm baths should, after this, be practised until the sixth 
week and the completion of desquamation. This usually 
marks the limit of contagiousness. A number of in- 
stances are on record, however, where the disease seemed 
to spread from cases of scarlatinal nephritis, but it should 
be remembered that in such cases desquamation is occa- 
sionally suspended. Very wide differences of opinion 
still prevail upon this point. Thompson, who enforces 
warm bathing, has never known the disease to spread 
from his patients. Not afew writers consider that pro- 
tracted isolation of the patient is unnecessary, and _ that 
the completion of desquamation need not be waited for, 
if proper disinfectant inunction and systematic warm 
bathing be practised. Contagion, however, sometimes 
occurs after very prolonged intervals, and generally it is 


Searlet Fever. 
Scarlet Fever. 


better to observe the rule that isolation should be prac: 
tised until the completion of desquamation. Ashby” 
noted the spread of scarlatina in a ward where an oper- 
ation had been performed for the removal of pus from 
the chest of a patient on the forty-ninth day from the 
beginning of his scarlatina. He concludes: 1. If des- 
quamation is complete, scarlet-fever patients may be dis- 
charged at the end of the sixth week, though, in order 
to secure absolute immunity, it is wiser to delay until the 
end of the eighth. 2. Cases complicated with nephritis, 
empyema, otitis, or glandular abscess, should be detained 
until the cure is complete. 3. While it is important that 
desquamation should be as complete as possible, the de- 
tention of patients beyond the eighth week, in order that 
the epidermis should be removed from the soles of the 
feet, etc., is unnecessary. When the patient is prepared 
to leave the sick-room, he should be bathed and should 
put on no article of clothing that has in any manner been 
exposed to the contagion. - The sick-room should be dis- 
mantled ; carpets and hangings should be removed after 
thorough fumigation of the apartment has been prac- 
tised ; the bedding should be destroyed or steamed ; paint 
and furniture should be washed ; the wall-paper should 
be removed or the walls whitewashed. All articles of - 
wearing apparel or of furniture that cannot be washed 
should be submitted to the steaming process now. availa- 
ble in most large cities, and which is thoroughly effec- 
tive. Some persons fail to become infected, though un- 
questionably exposed to the contagion. 

Several drugs have been supposed to possess the prop- 
erty, when rightly administered, of protecting from 
scarlatinal infection those who have been exposed to its 
influence. Hahnemann attributed such influence to bel- 
ladonna. The supposed action of this drug was based 
upon an untenable hypothesis, but remarkable results 
have been reported as following its administration 
(Schulte, Massius, Hufeland e¢ al.). As, however, scar- 
latina often fails to spread even when a number of per- 
sons have been exposed, the disease exerting its contagi-- 
ous properties most capriciously, the dangers of drawing 
incorrect conclusions are very great. The most careful 
observers have about reached the conclusion that bella- 
donna is absolutely without prophylactic value in scar- 
latina. Nevertheless, there are those who have faith in 
its efficacy and who always have recourse to it. If it is 
concluded to try the merits of this drug, the sulphate 
of atropia may be given in doses of z}> to 74a Of a grain 
daily ; or the tincture of belladonna (which is usually 
employed) may be given. The dose of the tincture should 
be one drop for each year of the child, administered 
once or twice daily. It has been claimed that to obtain 
the desired protection the characteristic effects of bella- 
donna should be produced in the throat and upon the 
skin. J. Lewis Smith. believes that boracic acid, regu- 
larly administered, exerts a favorable influence over the 
course of the disease, and in great measure confers im- 
munity upon those who take it for purposes of prophy- 
laxis. Fordyce Barker®! claims that salicylic acid pos- 
sesses prophylactic properties. A few drops of a weak 
solution in alcohol and warm glycerin should be given 
once or twice daily. 

At one time it was hoped that inoculation with scarla- 
tinous virus might afford a protection from scarlatina 
similar to that derived from small-pox by inoculation, 
In the few rather questionable cases in which this has 
been attempted, the resultant scarlatina appeared to be 
unmodified. The asserted prevalence of scarlet fever 
among dogs and cats,® and in horses * (Peters), has 
recently again stimulated the hope that protection to the 
human family may be obtained by a process similar to 
vaccination. Strickler“! made a very interesting set of 
observations, which, however, have not as yet received 
confirmation. He inoculated rabbits with the nasal se- 
cretions of a horse supposed to be suffering from scar- 
latina. Symptoms of what Strickler considered to be 
modified scarlatina followed. Later these animals were 
inoculated with scarlatinal human blood without notice- 
able result. Again, he inoculated twelve children with 
matter from ‘‘scarlatinous” horses. This was followed 


323 


Scarlet Fever. 
Schizomycetes. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


by light eruption, etc. Subsequently these children 
were inoculated with human scarlatinous blood without 
effect. Strickler concluded : 1. The subcutaneous injec- 
tion of scarlatinous virus from horses is without danger. 
2. After its injection under the human skin a circum- 
scribed eruption like mild scarlatina appears. 3. After 
horse-virus inoculation the organism remains resistant 
to inoculation with scarlatinous virus. It is to be hoped 
that further investigation will confirm these observations. 
I, EH. Atkinson. 


1 Historisch-Geograph. Pathol., vol. i. New Sydenham Soc. Trans- 
lation, p. 172. 2 Amer. Journal of the Medical Sciences, October, 1855. 
3 Jahrbuch f. Kinderheilk., 1870. 

4 Hebra: Diseases of the Skin. 
p. 218. 5 Maladies Infect. 

6 Reichert’s Archiv, 1872. 

7 Berliner klin. Wochenschr., November 3, 1884. 

8 Archiv f. Kinderheilk., 1869, 2. 

® Annales de Dermatol. et de Syph., 1882, p. 405. 

10 Lancet, 1888, i., p. 557. 

11 Gentralbl. f. d. Med. Wissensch., 1883, 36. 

12 Allgem, Med. Zeitschr., lii., 1349. Berlin, 1883. 

13 Righteenth Annual Report of the Local Government Board, 1885- 
86; Proceedings Royal Society, vol. xlii., 1887. 

14 British Medical Journal, 1887, i., 1262. 

15 Pepper's System of Medicine, vol. i., p. 509. 

16 Tancet, 1883, i., 194. ‘17 Thid., 1885, i., 854. 

18 Tbid., 1883, i., 685. 19 Rehm: Jahrb. f, Kinderheilk., 1869, 4. 

20 Vol. xi., 1878. 21 Ziemssen’s Cyclop., vol. ii., p. 169. 

22 Jahrbuch fur Kinderheilk.. 1875, viii. 23 Lancet, 1870. 

24 Jahrb. f. Kinderheilk., i., 1870. 25 Loc. cit. 

26 Jahrbuch. f. Kinderheilk., 1879, xiv., 1. 

27 Vierteljahr, f. Dermatol. u. Syph., viii., 522. 

28 Albuminuria, p. 820. 29 Jahrbuch f. Kinderheilk, 1870, 411. 

30 Gazette des H4pitaux, 1885, lviii., 418. 

31 Berlin. klin. Wochenschr., 27, 1882. 32 Tbid., 50, 1873. 

33 Correspondenzbl. f. Schweizer Aerzte, No. 8, 1876. 

34 Berlin. klin. Wochenschr., 8, 1882. 

35 Burkhardt-Merian: Volkmann’s klin. Vortrige, 128, 1884. 

36 Boston Med. and Surg. Journal, cx., 228, 

37 Gundrun: Med. News, 1882, xli., p. 231. 

38 Baader: Loc. cit. Hynes: Lancet, ii., 1870. 

39 Deutsche Med. Woch., x., 37-40. 

40 Berlin. klin. Wochenschr., 1868, No. 2. 

42 Jahrbuch. f. Kinderheilk., 1872, v., 324. 

43 The Practitioner, 1875, xvi., p. 21. 

45 Charité Annalen, 1876, iii., p. 538. 

46 British Medical Journal, No. 498, 1870. 

47 Robuske: Deutsche Med. Woch., October 8, 1881. Mitchell : Edin- 
burgh Med. Journ., February, 1882. 

48 Deutsche Med.-Wochenschr., 31, 1883. 

49 Jahrbuch f. Kinderheilk., N. F. 1., p. 434. 

50 Tbid., viii., H. 2, p. 15. 51 Tbid., N. F., 4, 1870. 

52 Thid., iv., 166. 53 T’Union Médicale, April 80, 1882. 

54 Wiener Med. Wochenschr., 39, 1877. 55 [bid., 43, 1877. 

55 Deutsch. Med. Wochenschr., 31, 1883. 

57 Berlin. klin. Wochenschr., 43, 1883. 

58 A Treatise on the Diseases of Infancy and Childbirth. Philadel- 
phia, H. C. Lea. 59 Med. Record, ii., 1859. 

69 Journal of Cutan, and Venereal+* Diseases, vol. i., 1883. 

61 Clinical Lectures and Essays. 

62 Guy’s Hospital Reports, 1879. 63 Tbid. 

64 Konetschke: Wien. Med. Presse, 1882, xxiii., 1483; Ffolliott: Brit. 
Med. Journal, i., 1879. 65 British Med. Journal, 1879, ii., p. ‘75. 

66 Amer. Journal of the Med. Sci., ixxxvii., 1884. 

67 Page: Lancet, 1885, i., 887. 

‘68 Archiv f. Gynakologie, ix., B. 2, 1876. 

6) Dublin Journal Med. Sciences, February, 1866. 

79 Obstetrical Transactions, 1871, vol. xii., p. 58. 

71 Berlin. Klin. Wochenschr., 47, 1872. See also Smith: Med. Times and 
Gaz., 1870, ii, 10538. Schwarz: Wien. Med. Wochenschr., 42, 1871. 
Broadbent: Brit. M. J., April 1, 1876. Barrs: Lancet, 1883, ii., p. 102. 
Farrar: Lancet, 1875, i., p. 109. 

72 Trojanowsky: Dorpat. Med. Zeitschr., i., 1871, 

73 Dorpat Med. Zeitschr., iii., 1873. 

74 Correspondenzbl. f. Schweiz. Aerzte, No. 5.1876. 

75 T/Union Médicale, &, 1883. 76 Progrés Médical, 1880, 47. 

77 Wiener Med. Jahrb,, 2 H., 1882. 

78 Norsk Magazin for Ligervidenskaben, 1880; Viertelj. f. Dermatol. 
u. Syph., viii., 522. 79 Fortschritte d. Med., Nc. 3, 1888, p. 81. 

80 Transact. Patholog. Spc., London, 1877, xxviii., p. 435. 

81 Handbuch der Path. Anat. 

82 Broeq: Journ. Cutan. and Venereal Dis., August. 1885. 

83 Journal Cutan. and Venereal Diseases, April, 1883, 

84 Dublin Jour. Med. Sci., March, 1885. 

85 J., Lewis Smith: Pepper’s System, vol. i., p. 534. 

86 Ann. de Médecine @’Anvers. London Med. Rec.. 1882, 52. 

87 Volkmann’s Sammlung klin. Vortriige, No. 128, 1880. 

88 Lancet, 1883, ii., 54. 

8° J. Lewis Smith: Pepper’s System of Medicine, vol. i., p. 548. 

80 British Med. Journal, 1886, ii., p. 813. 

#1 New York Med. Journal, No. 2, 1879. ENING: x e.0-48.4y [ifoh 

93 Journ. Compar. Med. and Surg., New York, v., 134. 

94 New York Med. Record, March 24, 1883. 


New Syden. Soc. Translation, vol. i., 
1872. 


41 Ibid., 1868, No. 9. 


44 Lancct, 1885, ii., p. 795. 


SCHINZNACH is a Swiss spa, in Canton Aargau, or 
Argovie, lying at an elevation of 1,150 feet above the 
level of the sea. It is protected against the cold winds, 


324 


yet the climate is somewhat changeable ; the average 
temperature of the summer months is 62.6° F. An anal- 
ysis of the spring here situated, made by Bolley and 
Schweizer, gives the following results (Rotureau). A 
litre of water contains : 


Grammes 

Sodium ‘sulphate <ocs mow dcto oe cates Ukitake ee 1.2863 
Calcium sulphate dtr tcccnceace se cricecctin nes tree 0.1571 
Potassium: stlphatel... con ea see eee Aeon eee 0.0805 
Calcium chloride ..... LAE th ere aoe, Ween Cane. opie 0.7144 
Magnesium chloride ...... yr en ee 8 ee ae | 0.0836 
Calciini ¢arbonate ss. 1 ane ceaion ote ate ee oe 0.1426 
Mapnesinumicarhonater. ses. fee. serie aoe eee 0.0042 
Ferrous: OXIGE:, Wee acts Soe eae ORE eee eee 0.0011 
SUL CO roe ett hosts es etek eters ake She Cera cents aero 0.0128 
PW Gebcovhsyh eh ic kate that. Bete, Meh nos pie ae eae ok se a a oe 0.0103 

Totals Ye spat ete ara Se ele SOE oe ore Tea ace eee 2.4929 


The temperature of the water is 86° F. The gases are 
carbonic acid and sulphuretted hydrogen. 

The waters are employed for both drinking and bath- 
ing purposes. They are prescribed in the treatment of 
osteitis and periosteitis, chronic rheumatism, scrofulous 
affections of the glands, skin, and joints, mercurial and 
lead poisoning, and various forms of moist and scaly 
skin eruptions. The season extends from the middle of 
June to the middle of October. A course of treatment 
lasts about one month. Dies Bie ee 


SCHIZOMYCETES AND OTHER VEGETABLE MI- 
CRO-PARASITES. Micro-organisms have been found to 
bear a most important relation to hygiene and to pathol- 
ogy, and the class of organisms most concerned are the 
schizomycetes or bacteria. But the mould fungi, the yeast 
fungi, and the protozoa are also concerned, and have, there- 
fore, been given a place in the following description. 

Micro-organisms are present everywhere, in our food 
and water, in the air, and in the upper layers of the 
ground. Some of them are of great value, causing pu- 
trefaction of dead animals and plants ; others cause vari- 
ous fermentations, such as the alcoholic, the acetic acid, 
etc. ; still others cause infectious diseases of animals and 
plants. 

HistToricau.*—Although the connection between bac- 
teria on the one hand, and disease, fermentation, and 
putrefaction on the other hand, has been established only 
in comparatively recent years, the germ theory had its ad- 
vocates more than two centuries and a quarter ago. The 
idea prevalent at that time was that diseases are caused 
by the putrefaction of humors in the secret recesses of 
the body. A learned ecclesiastic of the ‘‘ Society of 
Jesus,” named Athanasius Kircher, found living organ- 
isms, invisible to the naked eye, in all sorts of foul mat- 
ter, in blood, air, water, etc., so that he concluded that 
if putrefaction is caused by microscopic organisms outside 
of the body, and if these organisms are found in the 
blood, etc., they must necessarily. cause putrefaction 
there also. Of course, Kircher was unable to see bacteria 
with the microscopes in use in his day.{ And it matters 
not what he did see, his observations seemed to substan- 
tiate the view that infectious diseases are caused by sub- 
stances which, introduced into the body, give rise at first 
to no symptoms, but increase till they bring about dis- 
ease. ‘The only substances capable of so increasing at 
the expense of the tissues are living beings, ¢.e., plants or 
animals. 

The first observer who really saw micro-organisms was 
Anthony van Leeuwenhoek, a private citizen of Delft, in 

Let Sg Holland. He spent the latter part of his life 
tual obser. 10 grinding and polishing lenses, and examin- 
vation of ing surrounding objects of all sorts. LLeeuwen- 
micro-or- hoek (1675) described minute round bodies, 
ganisins. rods, threads, and spirals, and spoke of their 
motion. He examined various sorts of water, the intes- 
tines of flies, frogs, doves, chickens, etc., and his own 
diarrhoeal feeces, and found numbers of animalcula, as 
he called them, varying in form and size and in the char- 
acter of their motion. In 1683 he observed several dif- 
ferent kinds, but one kind was especially abundant in 


* Authorities: Lifer, Fliigge, and others (see Bibliography at end of 
article), t 1657 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the scrapings from between his teeth, notwithstanding 
previous cleansing, and he made drawings of them. 
These observations were communicated to the Royal 
Society of England in a number of letters. Leeuwen- 
hoek made no attempt to assign any importance to these 
organisms as to any role they might play in the economy 
of nature. He considered it impossible for them to be 
taken up in the blood, because he imagined that the ab- 
sorbent vessels were too narrow to allow of the entrance 
of any such particles, even if they were a thousand times 
smaller than they really are, and he considered them a 

Revival thousand times smaller than a grain of sand. 
of the vital- But Leeuwenhoek’s contemporaries, and those 
istic theory. who immediately followed, seized upon the idea 
of these little worms causing a great number of diseases ; 
even in cases where they were not found they reasoned 
from analogy that they must be present. Then followed 
a reaction, and the idea was ridiculed out of existence 
(1726). 

A few men of science, however, still retained the idea 
of acontagium vivum. Linné held to the idea, as did 
Plenciz, and the latter deduced logically the connection 
between Leeuwenhoek’s discoveries and contagious dis- 
eases, as well as putrefaction. Still all of this was a 
matter of speculation, and not proven by direct experi- 
ment, so that the theory won very few disciples, and was 
regarded as a vagary till well into the present century. 

Thus the réle that micro-organisms play was often as- 
serted and as often denied ; but as matters of curiosity, 

First et. their forms were studied with the microscope 
forts at a With great interest and zeal. The twenty-one 
classifica- different forms that Baron von Gleichen-Russ- 
pion. worm observed and pictured in 1778, and the 
contributions of the many observers from the year 1734 
for the next half century, bear evidence of the lively 
interest, but they led to no important results and may be 
passed over without further mention. F. O. Miller 
made an exhaustive study of the various forms of micro- 
organisms in 1786, and pictured many of those known to 
us at the present day. The question, however, as to the 
origin of these micro-organisms seems to have been of 
greater interest in those days than the question as to what 
function, if any, they performed. The earlier observers 
satisfied themselves with studying their morphology 
and attempting to classify the micro-organisms, but their 
biology was merely a matter of surmise, which has had 
to suffer many alterations in the light of the experiments 
of recent years, Another question, too, which attracted 
the liveliest interest was as to the source of 
these minute beings, and the theory of spon- 
taneous generation, which had been overthrown 
for insects, again occupied the most serious attention of 
the scientific world. It would be aside from the purpose 
of this article to eyter into a detailed account of the dis- 
cussion of generatio aequivoca, but the following experi- 
ments, which overthrew it, shed a flood of light upon a 
number of important points. 

_ Charles Bonnet attacked the idea of spontaneous gen- 
eration, upon theoretical grounds, in 1762, and Lazarus 
ah Spallanzani showed the correctness of Bonnet’s 
egin- —;3 ; : A 
ning of Views by experiments in 1769. Spallanzani 
‘scientific Convinced himself that in infusions exposed 
experi-to the air there was always a development 
mens: of animalcula, as they were then supposed 
to be. He then heated his vessels, and poured boiled 
infusions into them, and sealed them ; but in spite 
of that some of the infusions became foul. He rea- 
soned correctly from this, that the air contained in the 
vessels must contain the organisms of putrefaction. So 
in his following experiments he sealed the vessels con- 
taining the infusions and kept them an hour in boiling 
water, and all of the infusions remained sterile. Franz 
Schulze showed, in 1836, that the air could have access 
to sterilized infusions without causing putrefaction, if it 
were sterilized, 7.e., passed through sulphuric acid ; and 
Schwann effected the same thing, in 1837, by passing the 
air first through molten metal, or by heating it with a 
spirit-lamp. Schroeder and von Dusch then showed, 
in 1854, that if the air was filtered through cotton wool, 


Generatio 
aequivoca, 


Scarlet Fever, 
Schizomycetes. 


it was incapable of producing putrefaction. H. Hoff- 
mann showed, in 1860, that it was not even necessary to 
pass the air through cotton, but that, if the neck of the 
flask were drawn out and bent over, there was no putre- 
faction in the previously boiled contents. Chevreul 
and Pasteur made the same observation in 1861, inde- 
pendently of Hoffmann. Van der Broek had shown, in 
1857, that if grape-juice, blood, or urine were caught in 
sterilized vessels, with proper precautions against con- 
tamination from the air, they could be preserved indefin- 
itely, and this was substantiated by a number of observers, 
beginning with Pasteur, in 1863. But a certain percent- 
age of the experiments with infusions which had been 
boiled and protected from subsequent contamination 
failed, and a series of experiments of Bastian, in 1873, in 
which he took an infusion of turnips and added bits of 
cheese, seemed to indicate that there must be spontaneous 
generation, for after boiling his mixture ten minutes there 
was still a growth of organisms after three days’ time. 
But Ferdinand Cohn showed, in 1875, that in infusions 
of hay, in cheese, and in all fluids which showed a growth 
of organisms after having been subjected to the boiling 
temperature and protected from subsequent contamina- 
tion, there were micro-organisms which possessed the 
power of assuming a more resistant form. Bonnet had 
already, in 1762, suggested the possibility of there being 
organisms capable of such resistance, and Pasteur found 
he could only sterilize milk at a temperature of 110° C. 
(230° F.). Schroeder had met with the same difficulty. 
I shall reserve the discussion of this very important prop- 
erty of micro-organisms, viz., the formation of spores, 
till later on. The question of spontaneous generation 
was thus finally settled in the negative. 

But, in the meantime, the study of the morphology 
of micro-organisms was pursued with great energy. 

Further Christian Gottfried Ehrenberg published a sys- 
efforts at tematic account of bacteria in 1838. His ob- 
classifica- servations were made with the improved mi- 
ORs croscope of that time, and constitute a new era 
in the study. Ehrenberg, however, erroneously assigned 
them a place in the animal kingdom on account of their 
undoubted independent motion, and also on account of 
the flagella which he saw on many forms ; and finally, 
he thought he saw eggs and granules, and the process of 
self-division. Ehrenberg made experiments in feeding 
bacteria with carmine, and as he found the particles 
taken up and lodged in various parts of the organisms, 
he classified them under the polygastrica. Even those 
organisms which did not take up the carmine granules 
he regarded as belonging to this group. He called the 
genus ‘‘ The Animalcula of Infusion.” Ehrenberg was 
fully aware that his classification was imperfect, and 
Dujardin’s attempted improvement was also equally un- 
reliable. These were, however, steps in the right direc- 
tion, for, with the exception of Miiller’s classification, 
which was made with a microscope greatly inferior to 
that of Ehrenberg, there was no previous classification. 
The observations during the next few years of the strong 
analogy between the algee and bacteria, led many ob- 
servers to doubt whether Ehrenberg’s idea that the lat- 
ter belonged to the animal kingdom was correct, and 
Perty expressed the opinion, in 1852, that a part of them 
belonged to the animal, and a part to the vegetable, king- 
dom. The final blow to Ehrenberg’s classification was 

Cohn’s given, in 1854, by Ferdinand Cohn, in his work 
classifica- On the life-history of the microscopic alge and 
tion. fungi. Cohn established the fact that a hope- 
less confusion existed as to all the forms which had 
been observed ; that the observers had worked with dif- 
ferent powers of the microscope, or made their obser- 
vations loosely ; and, finally, had mixed up the young 
with the matured cells, so that there was the greatest 
complication. He, therefore, selected the bacterium 
termo of Dujardin, or the vibrio lineola of Ehrenberg, 
which is found in all sorts of infusions undergoing pu- 
trefaction, and made a thorough, systematic study of this 
class of organisms. He made a special family out of it, 
which he called zooglea, and established a very close 
relationship to the family oscdllaria, a distinctly vege- 


325 


Schizomycetes. 
Schizomycetes. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


table class belonging to the alge. The question was 
thus settled for the vibrio lineola, but Cohn reserved his 
decision in regard to the other vibrios. Other authors 
also inclined to the opinion that all these lower forms 
belonged to the vegetable kingdom. Naegelihad already, 

Naegeli's in 1849, emphasized the resemblance between 
classifica- the algee with colorand the colorless alge, and 
tion. finally made a separate class of the latter, be- 
cause he observed that they were unable to derive their 
nourishment from inorganic materials. ‘The former class, 
algz with color, are able to subsist upon simple COs, 
NHs, and H:O, with certain dissolved salts, just as are 
the higher plants; the colorless alge, however, require 
elaborated pabulum, as is the case with animals, and 
are not able to liberate oxygen. He consequently con- 
sidered all the forms which had no chlorophyll as be- 
longing to the fungi, and used the name schizomycetes 
for the whole group of bacteria, vibrios, spirilla, sar- 
cine, mother of vinegar, and a specific organism which 
Cornalia had discovered as causing a disease in silk- 
worms, called nosema bombycis. But Naegeli left it an 
open question whether they belonged to the vegetable 
or to the animal kingdom. Nevertheless, he showed 
that they all had certain very distinctive qualities in 
common, and, as already stated, he and Cohn empha- 
sized the near resemblance through the alge to the vege- 
table kingdom. 

As far, however, as the establishment of specific groups 
of schizomycetes was concerned, there was nothing more 
determined up to this tine (1857) than had been already 
done by Miller in 1786. 

As already stated, the physiological properties of the 
schizomycetes were also studied in the meantime, with as 

Stnay of Much success, if not more, than the morphology 

‘ y 0 : ; saa : f 
physiologi - and classification. Omitting observations which 
cal proper- tended more to arouse interest than to advance 
eras, our knowledge in regard to the role played by 
micro-organisms in various chemical processes and dis- 
eases, the first scientific proof that organisms do play 
such a réle was made by Cagniard Latour and Schwann, 
independently, in 1837. These authors observed the 
growth and reproduction of the organism which had 
been seen by Leeuwenhoek, and which Turpin had called 
torula cerevisie, in the fermentation of beer and wine, 
and showed that its growth and reproduction caused the 
fermentation. Although the belief in the causal connec- 
tion between organism and disease was strengthened, it 
was not proved by these experiments. But it was not 
long before the necessary proof was given, at least for 
one disease, for in the same year Bassi discovered that a 
disease of silkworms was due to a fungus, the spores of 
which covered the bodies of the worms in the form of a 
white powder, and a trace of this powder produced the 
disease upon healthy worms. 

Jacob Henle was convinced of the connection between 
micro-organisms and disease by a careful consideration 
of the above facts. The plausibility, theoreti- 
cally, of a belief in a contagium vivum in infec- 
tious diseases also forced him to this conviction, 
and the weight of the opinion of this great authority con- 
tributed much to arouse interest in this line of investiga- 
tion. Henle was not led to change his opinion by not find- 
ing organisms in the tissues in various contagious diseases, 
for he contended rightly that at that time (1840) there 
were no means known by which it was possible to dis- 
tinguish. between various cells, or cell-nuclei, or nucleoli, 
and micro-organisms. Nor did he consider the presence 
of organisms alone sufficient proof of their causal rela- 
tion, but postulated conditions which we shall presently 
see have been fulfilled to the letter. The conditions 
were constant presence, isolation, and proof of the con- 
tagiousness of the isolated organisms (by inoculation). 
When these conditions are fulfilled there can surely be 
no room for doubt. Similar conclusions were reached 
by deductive reasoning by J. K. Mitchell, independently, 
at about the same period. 

The next several years were spent in ceaseless activity, 
by a host of workers, in seeking organisms in various 
diseases. Bassi’s discovery and Henle’s deductions in- 


Henle’s 
deductions. 


326 


spired the liveliest interest in this line of research ; but 
as the methods at that time employed were very crude as 
compared with the methods of the present day, much of 
the work has since been shown to be of little or no worth. 
The discovery of the sarcina ventriculi by the Goodsir 
Brothers belongs to this era, and attracted the widest 
attention. 

The epidemic of cholera, which appeared for the sec- 
ond time in 1849-50, in Europe, also awakened great 

Cholera activity in the search for organisms, for it was 
in 1849 and considered very likely that this disease is caused 
1850. by a living contagium. The observations on 
cholera at that time have, however, been found to be erro- 
neous, for the same micro-organisms which were then 
observed in the excretions of cholera patients were after- 
ward found in a variety of other diseases, and even in 
feces from healthy individuals. Bits of food in the 
cholera stools were also mistaken for micro-organisms. 
But aside from these results, which were either erroneous 
or not sufficiently convincing, a great number of diseases 
of insects, and of the cereals and potatoes, were proven 
to depend upon micro-parasites, and the same was also 
shown for favus and several other diseases of the skin. 
Pollender, too, about this time (1849), observed the an- 
thrax bacilli in blood, and he was followed by Davaine 
the next year. But there was more zeal than judgment 
displayed by many workers at this time, and progress 
was retarded, especially by the writings of Hallier, who 
thought he had discovered the specific organism for a 
great many diseases. 

The next important epoch was ushered in by Pasteur’s 
discovery of the réle played by micro-organisms in various 
sorts of fermentation, in 1857. Cagniard Latour 
and Schwann, it will be remembered, had al- . 
ready established the relation between organ- 
isms and the alcoholic fermentation, but Pasteur deserves 
the credit of finally establishing that lactic-acid fermenta- 
tion, butyric-acid fermentation, acetic-acid fermentation, 
etc., are all caused by micro-organisms, which not only 
differ in their physiological workings, but are well 
characterized by morphological and biological peculiari- 
ties. In this connection Pasteur also made the discovery 
of.micro-organisms not capable of growth in free oxygen, 
and assigned to them the names anaérobic micro-organ- 
isms, to distinguish them from the aérobic, or those re- 
quiring the presence of free oxygen. Pasteur, more- 
over, discovered that certain organisms were capable of 
growing either with or without free oxygen, and these 
he called facultative anaérobic organisms. He considered 
all the micro-organisms of putrefaction as anaérobic, but 
offered proof only in a few cases. Pasteur next studied, 
more exactly than had as yet been done, the products ob- 
tained by vinous and acetic-acid fermentation. After 
having established the important réle played by micro- 
organisms in so many processes in the economy of nat- 
ure, Pasteur rightly concluded that they are necessary 
for the life of plants and animals, for without their 
agency the higher plants, incapable of feeding upon the 
complex molecules of dead animals and plants, would 
die if dead bodies did not undergo a putrefactive disin- 
tegration through the instrumentality of micro-organ- 
isms. Thus the germ theory was established; and al- 
though there have been, and still are, points about which 
all authorities do not agree, no one at the present day 
can have a reasonable doubt of the existence of micro- 
organisms, nor that they are an important element in 
nature. 

CLASSIFICATION.*—The mycetes, or fungi, embrace all 
the vegetable micro-organisms which are known to cause 
disease, fermentation, and putrefaction. They are cryp- 
togamic plants, @.e., they have no blossoms, but many of 
them reproduce by means of spores, small, highly re- 
fractive, oval or spherical cells, which are not as readily 
killed as the vegetative cells. The phanerogamic plants, 
on the other hand, embrace all the ordinary flowering 
plants and reproduce by means of seed. The cryptogame 


Pasteur’s 
work. 


* Leunis: Synopsis der Pflanzenkunde, 8. Abth. Kryptogamen, bearb. 
von Frank —— and Fliigge, as above. ‘ 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Schizomycetes. 
Schizomycetes. 


are divided into C. vasculares, or those with leaves and 
stems, e.g., ferns, etc.; and @. cellulares, those without 
leavesand stems. C. cellulares are divided into the mosses, 
alge, lichens, and fungi. The alge, lichens, and fungi 
constitute the thallophyta, or plants forming a thallus, to 
be described further on. 

The mycetes, or fungi, are divided into seven orders— 
ascomycetes, basidiomycetes, zygomycetes, phycomycetes, blas- 
tomycetes, schizomycetes, and myxomycetes. The first four 
orders have many points in common, and may be con- 
veniently described under the collective name mould 
fungi, as they cause the moulding of bread, cheese, etc. 
The dlastomycetes contain no pathogenic micro-organisms, 
but the family saccharomycetes, belonging to this order, 
causes alcoholic fermentation. The schizomycetes, or bac- 
teria, are of more interest than all the others. 

Beside the botanical classification it becomes necessary 
to divide micro-organisms into parasites, or those capable 
of growing upon living plants and animals, and sapro- 
phytes, or those growing upon dead plant or animal mat- 
ter. Pathogenic micro-organisms must, of course, be 
parasites, but many of them grow as saprophytes also, 
and these are called facultative parasites. Therefore, all 
the pathogenic micro-organisms which are grown in cul- 
tures are facultative parasites. 

A. The mould fungt consist of microscopic cells with 
membrane and cell-contents ; the former consisting of a 
substance resembling cellulose, but differing 
from it in not giving the violet iodine reaction. 
The cell-contents consist of protoplasm possess- 
ing no demonstrable nucleus, no starch granules, and no 
chlorophyll, but often having vacuoles, oil-drops, various 
coloring matters, and, occasionally, crystals of oxalate of 
calcium. These crystals are very often found upon the 
outer surface of the cell-membrane. The cells are in the 
Shape of threads called hyphe. The hyphe generally 
have transverse cell-walls, and are nearly always branch- 
ing, the branches growing out from the side of the cell, 
or each cell sending out two prolongations in the process 
of growth. The hyphe are either fruit-bearers or myce- 
lia, and whether consisting of one thread or more, or 
whether they are all mycelia or all fruit-bearers, bear the 
collective name thalius. The mycelia form the vegeta- 
tive part, the fruit-bearers form the reproductive part of 
the thallus. The thallus is usually composed of a tangled 
mass of hyphe, but occasionally a mycelium assumes, 
secondarily, a thick fleshy form, the so-called sclerotéwm. 
The sclerotium has a cortical and a medullary portion, 
and is only capable of sending out fruit-bearers when ex- 
posed for a long time to favorable conditions of tempera- 
ture and moisture. 

The mycelia are capable of penetrating into the cells 
as well as into the intercellular tissue of dead plant and 
animal matter. But some of them are not restricted to 
dead animal and vegetable matter. The mycelia of the 
latter fungi either penetrate directly the cell-walls of liv- 
ing cells, or they send out short suckers, haustoria, which 
press their way through the cell-membrane. Even bones 
and teeth are sometimes destroyed by fungi, and their 
tissues are then found to be crowded with masses of 
mycelia. 

Reproduction takes place, as already stated, by means 
of spores, which afterward germinate, sending out one 

Fructig. OF More hyphe. Spores are formed in several 
cation in Ways: 
the mould (a) Intercalary Spore-formation. Some of 
=uBel the cells of the hyphe in the process of growth 
change directly into spores or into mother-cells. 

(b) Acrogenic Spore-formation. The ends of the fruit- 
bearing hyphee are divided off by a transverse mem- 
brane, and perform the function of spores. The thin 
stems of the fruit-bearers are called das¢dia, and in some 
cases fine branches connect the spores to the end of 
a basidium. The fine branches are called sterigmata. 

Libera- [here may be one or more spores given off 
tion of froma basidium. In the latter case the spores 
spores. form one after another in a row, or in several 
parallel rows. The spores themselves are usually called 
conidia. They are also known as basédiospores or acro- 


Mould 
fungi. 


spores. The separation of the conidia from the basidium 
takes place in one of three ways: 

First, the fruit-bearer simply falls to pieces and liber- 
ates them ; second, the part of the basidium or sterigma 
immediately behind the spore dies and allows them to 
fall off ; third, the spores may be ejaculated from the end 
of a tubular basidium as follows: The mem- 
brane of the basidium is very elastic, and as the 
spore approaches maturity this membrane be- 
comes stretched by the absorption of water into the cell 
to such an extent that it bursts at the weakest spot, which 
is the zone just where the spore joins the basidium. As 
soon as the rupture takes place, the elastic cell-membrane 
contracts and squirts out the contents of the cell. The 
basidia may grow out from the inner wall of a hollow 
organ of fructification ; in this case they cover the entire 
inner surface of the capsule, and give off numberless 
spores. 

(c) Endogenic Spore-formation. This takes place in 
the interior of mother-cells, or sporangia. The spores 
are liberated from the sporangia by the bursting of the 
latter, or by its membrane becoming dissolved in water, 
or by ejaculation. The spores have no distinct mem- 
brane. Tubular or club-shaped sporangia are called ascé, 
and the spores are called ascospores ; these are generally 
eight in number to each ascus. The asci are often en- 
closed in spherical or flask-shaped organs, called per?- 
thecta. Some of the endogenic spores are liberated under 
water and have cilia, and are endowed with motion. 
These are called wandering spores. They finally come 
to rest and gradually form a cell-membrane, and may 
then germinate as other spores. 

(d) Formation of Zygospores and of Oéspores. Fun- 
gus spores often result from copulation. The copulation 
may be asexual, in which case two mycelia of apparently 
the same sort send out club-shaped processes which 
unite. The resulting spores are then called zygospores. 
But in some cases there is a male and a female organ. 
One mycelium sends out a long, tubular, or club-shaped 
made organ, called an antheridium, to unite with a spher- 
ical female organ, or odgonium, of a different mycelium. 
These are called odéspores. They are spherical and pro- 
vided with a membrane of cellulose. 

Odspores and zygospores are generally perennial, re- 
quiring a period of rest before they can germinate. They 
are usually simple, but may be compounded of a number 
of cells of various shapes. They are either spherical, 
oval, or occasionally rod-shaped. The cell-membrane is 
composed of a colored episporium and a delicate, color- 
less endosporium, which encloses the protoplasm and 
often contains oil-drops. The spores may develop into 
sporangia, or they may send out mycelia. 

All these methods of forming spores may take place 
coincidently or alternately on the same plant. Further- 

Pleomor. More, the same fungus may require entirely 
phism in different nutrition in successive generations. 
the mould It may act as a parasite to a certain higher or- 
one ganism in one generation, but require an en- 
tirely different host in the next. Thus there is quite a 
wide range of pleomorphism in the broad sense in these 
fungi. 

The ascomycetes are the only order that forms asci, and 
they only do so at the summit of their development. 
Some of them are parasites, but do not form asci till 
after the invaded plant or animal is dead. The asci are 
formed directly on the mycelium only in the lower mem- 
bers of this order. A very large number of fungi belong 
to this order, but only three of them concern us at pres- 
ent—Aspergilius, Penicillium, and Oidiwm. 

The true Aspergilli usually form conidia. The fruit- 
bearers are long and swollen at the ends into spherical 
or club-shaped vesicles. The spores are at- 
tached to the vesicles by means of a mass of 
radiating sterigmata (Fig. 3388), which are 1n 
some cases branched and in others unbranched. The 
spores vary from 1 / to 6 uw in diameter. ‘ 

Occasionally there is a formation of asci inside of 
small spherical perithecia, which are about one milli- 
metre in diameter, and have -each a separate membrane ; 


327 


Asper- 
gilli. 


Schizomycetes. 
Schizomycetes, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the latter is usually colored and has hair-like projections 
on the surface. This membrane bursts at maturity. In 
the eurotium-aspergillus the peritheci- 
um is preceded by what is possibly a 
process of sexual copulation, as fol- 
lows: Several fine branches are first 
given off from a mycelium; these 
branches then twist together, forming 
a sort of corkscrew ; this is the so- 
called ascogontwm, which represents 
the female organ. After the formation 
Fie. 3388.*—Fruit- of the ascogonium several branches 

bearer of a ‘True As” grow out from the base, and finally 

Pei olen Hay blend together to form the membrane 

with Numbers of Of the perithecium. These secondary 

Spore-bearing Ster- branches which form the perithecium 

feat a are called pollinodia, and one of them, 
while they are still separate, lays itself upon the last turn 
of the screw-like ascogonium and an intermixture of con- 
tents takes place (see Fig. 3889). The 
pollinodia are looked upon as the male 
organ. 

The formation of delicate perithecia 
is met with in the so-called eurotium- 
aspergillus, as already stated, and this 
distinguishes the latter from the true 
aspergilli, which form sclerotia. The 
thick sclerotium of the true aspergillus 
remains inert as long as itis dry, but in 
the presence of moisture it sends out 
threads which afterward form asci. 
For the formation of perithecia the 
very best nutrition is required. 

THE PATHOGENIC MouLp Funet.— 
The lesions produced by the pathogen- py¢. 3389,—Formation 
ic mould fungi differ from those pro- of a Perithecium by 
duced by the pathogenic bacteria, Copulation. The 
The tendency of the latter is to cause Seen eT the 
a general infection of all the organs  Pollinodia. > 250. 
and tissues of the body. Even where ° 
the lesion is at first local, the organisms usually get into 
the blood and are conveyed to all parts of the body. 
The mould fungi, on the other hand, become lodged in 
the internal organs, especially in the kidneys, and the 
mycelia grow out and form distinct foci. 

The Pathogenic Aspergilli.—Three species of aspergillé 
have pathogenic properties when injected into the veins 
of various animals. Inhalations of the spores produce 
mycosis in the lungs of birds. Animals have been found 
suffering from an infection without intentional inocula- 
tion. The aspergilli are widely distributed, and are found 
upon mouldy bread, etc. . 

Aspergillus fumigatus.— Greenish. Conidia- bearers 
short and swollen into hemispheres, 8-12 » in diameter, 
very thickly set with awl-shaped sterigmata. Conidia 
round, smooth, show no membrane, and are generally 
colorless, 2.5-3 « in diameter. Sclerotia are unknown. 
Grows best at 87°-40° C. Possesses more powerful 
pathogenic properties than the other two. 

Aspergillus niger.—Brownish-black. Fruit-bearers are 
exactly globular. Sterigmata, 20-100 uw long and branch- 
ing. Conidia round and brownish-black at maturity, and 
3.5-5 « in diameter. Sclerotia size of rape-seed, and 
brownish-red. Optimum temperature about 85° C. Does 
not seem to have any very great malignant power. 

Aspergillus flavus or flavescens.— Green or greenish- 
brown. ' Conidia yellow or brown, with a finely nodular 
surface, 5-7 wu in diameter. Sclerotia very small and 
black. Grows best at about 28° C. Stands next to A. 
Sumigatus in pathogenic power. 

The most common of all fungi is the Penicillium glau- 
cum. In the family to which this belongs, penicillium, 
the conidian fructification is alone met with, 
except under very extraordinary conditions of 
nutrition. In the latter case the penicillium 
occasionally produces a small protuberance, about the 


Penicil- 
lium. 


* The accompanying figures were not drawn from actual observation 
with the microscope, except Figs. 3895 and 3396 (p. 383). Some of them 
are modified copies from Fliigge’s Die Micro-organismen (see p. 348). 


328 


size of a grain of sand, upon a mycelium, and this protu- 
berance behaves like a thick-walled sclerotium. Still, 
as a rule, the fruit-hyphe ‘are 
branched, and have a cluster of 
conidia upon the end of each 
branch. As is shown in the ac- 
companying cut (Fig. 3390), the 
conidia are formed in rows upon 
the finger-like terminal branches 
of the hyphe. 

Penicillium has no interest aside 
from its frequent occurrence. 

The O¢dia form sum- 


mer and winter spores. Witt ee ge 


ee The former are es 
Patna sas 2007: Ti a Rade wee Mane 
Mildew, Simple conidia 


separated in a Fie. 8390.—Two Fruit-bearing Hyphe 


row from the ends of the of a Penicillium. > 170. 

long, straight mycelia. The winter spores are formed 
in perithecia, which develop secondarily upon the same 
mycelia from which the summer spores were given off. 
The winter spores require a state of rest, 7.e., through 
the winter, before they germinate. 
The oidia cause the so-called ‘‘ mil- 
dew.” A scurf of the comb and 
gills of poultry, and favus of mice, 
and perhaps favus and herpes ton- 
surans in the human being, are 
caused by the growth of oidia. 

Some of the members of the 
Basidiomycetes and Phycomycetes 

ing Four Sporangia. gre parasites of plants, but as none 

eee of them have been found to cause 
disease in animals they may be omitted without descrip- 
tion. 

The Zygomycetes order has among its families the Mu- 
corinee, to which the mucors belong. In the Mucorinez 
the organs of copulation blend to form a zygo- 
spore. Spores are also formed without copu- 
lation in the interior of sporangia (Fig, 3391), by the di- 
vision of the protoplasm into small unicellular spores 
(Fig. 3392), which are liberated by 
the dissolution of the membrane of 
the sporangium in water. This mem- 
brane is at first: colorless, but after- 
ward becomes black. The fruit-bear- 
ing hyphe grow up perpendicularly. 

Pathogenic Mucors.—Two mucors 
have pathogenic properties when in- 
jected into the blood. Rabbits die in 
forty-eight to seventy-two hours after 
injections of the spores of M. rhizo- 
podiformis and of M. corymbifer. 
The mycelia are found upon post- 
mortem examination chiefly in the 
kidneys, but also in the mesenteric 
glands and Peyer’s patches. 

B. The Saccharomycetes, belonging 
to the order Blastomycetes, grow by 

budding. The parent cell 

Yeast becomes enlarged at some Fic. 3392.—A Sporangi- 


Fie. 3891.—Mucor, show- 


Mucors. 


ede point into a protuberance joy eee ea 
which grows larger, and either sepa- with Spores. < 1240. 
rates or remains attached, and be- 

comes in turn a mother-cell (see Fig. 3393, 6). The for- 


mation of ascospores hag also been observed. 

No pathogenic saccharomycetes have as yet been dis- 
covered, but they are of great interest because many of 
them cause the alcoholic fermentation of sugar. _ This 
function, however, is not peculiar to the saccharomycetes, 
for mucor racemosus also causes the same fermentation. 
It is even probable that all the saccharomycetes are 
merely a form of mould fungus, since this same mucor 
racemosus assumes the budding growth if it is immersed 
in a solution of sugar. The CO, which is liberated in 
the fermentation buoys the mucor, which has for the time 
become a budding fungus, up to the surface, where it 
again sends out hyphe. 

C. The Schizomycetes, or Bacteria, are very minute uni- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Schizomycetes, 
Schizomycetes. 


cellular organisms, They play an exceedingly important 
role in pathology and hygiene. Some members of this 
group cause many of the most terrible maladies 
of animals and plants, they constitute the con- 
tagium vivum of many infectious diseases ; others are of 
the greatest use in preparing dead vegetable and animal 
matter for assimilation 

by the higher plants; 


Bacteria. 


: 3 dp 
others, again, are con- _* se Aye 
cerned in fermenta- % vias 
tion. 4 
A bacterium con- . 
sists of protoplasm “.°"" Se ® chr 1G: 
* ese rif Bo# cq 
enveloped in a cell- a, 3 aro 
membrane. The cell 2 Bi wy 
is generally colorless ; +43 
in some rare species % 7 6 
it contains chlorophyll 
or other coloring mat- Fie. 3893.—1, Staphylococci. 2, Strepto- 


cocci, showing in two places larger forms, 
to signify arthrospores. 3, Micrococci 
tetrageni. 4, Sarcine. 5, Diplococci. 
The four diplococci to the right, colored 
black throughout, are called biscuit- 
shaped (see Chicken Cholera and Gonor- 
rhoea, below), and are also regarded by 
many as bacilli. 6, Saccharomycetes. 


ter. The protoplasm 
may also contain mi- 
nute granules of sul- 
phur, and sometimes 
refractive oily parti- 
cles. It is sometimes 
granular. Some bac- 
teria give the blue iodine reaction, which is especially 
marked just before the formation of spores. Under un- 
favorable conditions of growth the protoplasm becomes 
cloudy and breaks up into granules. The cells have no nu- 
clei. The cell-membrane is sometimes colored, and some- 
times is surrounded by a gelatinous envelope or capsule, 
which can be occasionally brought out by staining. 
It is sufficient for our purpose to divide bacteria into 
micrococc?, bacilit, and spirilla. Micrococci are spherical 
Classifica. OF Slightly oval, and bacilli are rod-shaped. It 
tion of bac- is evident that the individual bacteria may lie 
teria. separated from one another after cell division, 
or they. may hang together and form chains, threads, 
irregular clumps, ete. Now, an organism which grows 
so as to form chains always retains this tendency ; it 
does not form chains in one generation and clumps in 
another. This property of organisms has been used as 
an important means of diagnosis, especially of the cocci. 
Micrococci which always tend to form chains are called 
streptococct ; those forming irregular clumps staphylococct. 
Micrococci which grow so as to form tetrads are called 
tetragont. If they hang together in all three dimensions 
of space, they resemble packets bound tightly around 
with two cords at right angles, and are called sarcine. 
Although bacilli also form chains and clumps, no such 
distinction is made as in the micrococci, except that 
bacilli in chains are some- 
ieee times called  leptothrix. 
7 Very short bacilli were for- 
(i) we es merly called bacteria, but 


red — c> the latter name has 

y come to be univer- 

LY RP 0 pies sally adopted for the 
QA ee eo schizomycetes in 
© crs ue) general, Some 
—sFe~ a es) of the distinc- 
“a C=) tions of the 

ae varieties of bac- 

PEE 2 teria are very 

fo slight, and are only apparent 

Gis to the practised eye. Thus, 


clostridia (Fig. 3394, 1) are 
bacilli of a spindle shape, 
and bacilli with a constric- 
tion in the middle are called 
dumb- bell or figure -of-8 
Shaped (Fig. 3394, 3), and 
rods with parallel sides may 
have rounded, square, or even concave, ends. Bacilli that 
are curved on the long axis are called commas, or comma- 
bacilli (Fig. 3394, 4), anda chain of them constitutes a 
spirobactertum or spirillwm. But there are also spirilla, 
or long spiral threads, which show no division into 


Fig. 8394.—1, Bacilli of various 
shapes. 2, Bacilli in the process 
of forming spores. 3, Bacilli en- 
closed in capsules and figure-of- 
8 bacilli. 4, Comma bacilli and 
spirilla, 5, Forms of involution, 
< 70. ; 


commas (Fig. 3394, 4). The bacteria never branch as do 
the mycelia of the mould fungi. 

The schizomycetes multiply by fission, the cells simply 
grow larger and divide, and afterward separate or hang 
together as already explained. Micrococci show no 
variation, they simply form micrococci from one genera- 
tion to the next, but the other members of this order are 
subject to quite decided changes of form, owing to vari- 
ous conditions. 

Under favorable conditions bacteria continue to repro- 
duce vegetative cells indefinitely, and under unfavorable 
conditions they either form spores or undergo 
a retrograde metamorphosis-—ti-the latter case 
they degenerate into what is known a$\fotmsyef-involu- 
tion (Fig. 3394, 5). The cellsyjbecome swolleniand have 
irregular protuberances on them, and are often so dis= 
torted as to bear no resemblaiice to the wormal*ells. 


Involution. 


even requiring an abundant supply of nutrition, etc., for 
their production. Indeed, the life-history of the fungi is 
incomplete without the formation of spores. But it is 
comparatively rare in the bacteria, and all the conditions 
which tend to bring it about are not yet known. It is 
not the result of copulation. 

Bacteria are said to form two kinds of spores, endo- 
genie spores and arthrospores. Both kinds survive the 
action of agents which would kill vegetative cells, but 
endogenic spores are more resistant than arthrospores. 
The latter have been but little studied. They possibly 
are present in all sorts of bacteria, and are generally not 
distinguishable in appearance from the other cells, though 
sometimes they are larger and have a higher refractive 
index, etc. (see Fig. 3393, 2). The term, therefore, merely 
means that certain individual bacteria have a higher re- 
sisting power than the ordinary vegetative cells, but are 
not as resistant as endogenic spores, and may or may not be 
distinguishable under the microscope. But the endogenic 

Charac- Spores have very marked characteristics. They 
teristics of are very highly refractive, and appear as round 
pperee: or oval bodies lying in and among the vegeta- 
tive cells (see Fig. 3394, 2). Their resisting power is very 
great ; the endogenic spores of some bacteria survive 
even the temperature of boiling water several minutes 
(see p. 825). As we shall see presently, the vegetative 
cells are readily stained with aniline dyes, but the endo- 
genic spores are not stained under ordinary circum- 
stances. ‘They are only found in bacilli, and possibly in 
spiro-bacteria. Micrococci are restricted to the forma- 
tion of arthrospores. In the following the word spore is 
meant to refer to endogenic spores. 

Spores represent a state of suspended activity, and 
they may remain inactive for months and years, till they 

Germina- 2re removed from the medium in which they 
tion of the have been formed and are placed under proper 
spores of conditions for germination. Under suitable 
bacilli. conditions of temperature, moisture, etc., the 
clear globular mass in which each spore is embedded 
becomes ovoid and gradually elongates into a rod, the 
spore in the meantime becoming less and less refractive, 
and finally disappearing (Koch). Or, the spore swells 
and loses its refractive power, its dark contour, and its 
transparent capsule. Germination then takes place, either 
in the direction of the long axis of the spore or at right 
angles to it. In the latter case there appears a dark cres- 
centic shadow at each pole of the spore, and a papilla 
grows out from one side and increases in length till it 
becomes a rod. In the other case, the cell-membrane of 
the spore becomes uniformly thickened, and the bacillus 
is liberated by growing out and breaking through at one 
of the poles (Prazmowski and Brefeld). The membrane 


329 


Schizomycetes. 
Schizomycetes. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


of the spore which has been thus abandoned by the ba- 
cillus remains for some time lying near the latter. 

Many of the bacilli and spiro-bacteria are endowed 
with the power of independent motion ; the micrococci 

reepen have no motion of their own. If bacteria are 
dent motion examined in water, there is always more or less 
of bacilli agitation, due to unintentional movement of 
aan toeia, the microscope, and currents caused by evap- 
andthefor. Oration, etc., but this is the so-called Bruno- 
mation of nian molecular motion, and has nothing to do 
zovglea. with the independent motion of some bacteria. 
Bacilli thus endowed dart about in all directions, with a 
wriggling motion, always end foremost, never sideways. 
The spirilla have also a twisting motion. The motion in 
some cases is due to the vibration of a flagellum or fine 
thread at the ends of the rods. When bacteria accumu- 


late into masses they cease to move, and the masses are 
called zodglea. 

Although the individual bacteria are so minute, their 
multiplication is so rapid that, starting from an invisible 
number, they may form macroscopic masses in 
one or two days in solid media. ‘These masses, 
whether they are macroscopic or microscopic, 
are called colonies, and we shall see farther on that they 
are characterized in each species by color, contour, etc. 

CONDITIONS OF THE GROWTH OF ORGANISMS.—Some 
of the conditions of growth have been already mentioned, 
but in order to understand the laws of nutrition more 
clearly, the following chemical analysis is not without 
value. The analyses of the mould fungi and saccharo- 
mycetes have been reserved for this place, in order to 
compare them with that of the schizomycetes. 


Colonies 
of bacteria. 


UNDRIED. WATER DRIVEN OFF. 
Water. Albumen. Cellulose. Fat. Ash. 
Per cent, Per cent. Per cent. 
Mould Hume tss.\isercet corte o oie cieteteie o alate hie sie eae ee cre titotelc aataiee eee ate eee 88 29 50 Appreciable. | Appreciable. 
Saccharomycetes............ Ce ee Clee diclnars oreo ae ye Soe 40-80 4Q 37 Appreciable. | Appreciable. 
Schizomycetes Jos.00 acts ce oie een eee aie eid ns ck mrpeie taba cee eet cir 88-85 84-87 None. Appreciable. | Appreciable. 
The composition of the ash is as follows : 
z : : Oxide of Phosphoric ae ty Hydrochloric Sulphuric 
Potash. Soda. Lime. | Magnesia, iron anid Silicic acid. acid: doid. 
Per cent. | Per cent. | Per cent. | Per cent. Per cent. Per cent. 
Mould Funpis..-e 50 1.5 af 2 1 30 Small amount. Small amount. | Variable. 
Saccharomycetes.... 28-39 eS 3 1-4 GB FA Fete 53-59 _ Sometimes a trace? i Gaeta oe eee 
Schizomycetes.* 


* Probably the same as for the Saccharomycetes. 


The above analysis of the ash of the mould fungi is 
really the mean of a number of analyses of the ash of the 
higher fungi, but is probably approximately correct for 
the lower fungi. 

From the foregoing it will be seen that water en- 
ters largely into the composition of all three classes. 
The schizomycetes contain the largest amount of albu- 
men, and the mould fungi the least. The mould fungi 
have the largest amount of cellulose, and the schizomy- 
cetes none at all. Potassium and phosphoric acid are 
the principal ingredients of the ash of all three. 

It is evident that these organisms require carbon, ni- 
trogen, oxygen, and hydrogen in some form. 

As bacteria are, with very rare exceptions, devoid of 
chlorophyll, they cannot utilize the carbon in the CO, of 
the air, and are therefore compelled to have 
more elaborate molecules, such as are supplied 
by plants and animals. Double molecules of car- 
bon, or C in combination with N or O, are unsuited, but 
C in combination with H (CH; and CH.) are readily as- 
similated. Thus the sugars constitute a very good source 
of carbon, whereas cyanogen cannot be used. 

Nitrogen is, preferably, derived from albuminous mat- 
ter and peptone, but NH, and NH compounds 
may also serve as a source. Nitrates are also 
available, but cyanogen is not. 

The hydrogen and oxygen are supplied by the nitro- 

Sources gen and carbon compounds, and also by water. 
of hydrogen The above is true for the mould fungi, and 
and oxygen. saccharomycetes as well, except that the latter 
are not capable of assimilating the ammonium salts or the 
nitrates. Furthermore, the mould fungi require free 
oxygen for their normal growth. The saccharomycetes 
are capable of growing without it, they are facultative 
anaérobic organisms. The schizomycetes, as we have 
seen, vary in their behavior toward oxygen; some of 
them are aérobic, some anaérobic, some both. The 
mould fungi grow best in slightly acid media, whereas 
the other two classes prefer neutral or slightly alkaline 
substances ; some of the latter refuse to grow in the pres- 
ence of even a trace of free acid. 

The water organisms seem to defy all the laws of 
nutrition above laid down. Other bacteria require at 


330 


Sources 
of carbon. 


Sources 
of nitrogen. 


least an appreciable amount of nitrogen and carbon com- 

ver y pounds and salts, whereas the aquatic cocci 
ppleaig ee and bacilli find nutrition enough for active 
bacteria de. growth in freshly distilled water. Distilled 
rived from Water has been used, in fact, to cultivate them 
water. through many successive generations. 

Of physical conditions temperature plays the most im- 
portant part. Roughly speaking, temperatures of 30° to 

Influence 80. C. (86° to 95° F.) are most favorable to active 
of tempera- cell multiplication, and also for the formation 
ture, etc. of spores. Below 18° C. (64.4° F.) growth is re- 
tarded. Some organisms refuse to grow at the lower tem- 
peratures, and others refuse to grow at the higher ; others, 
again, vegetate very well at temperatures below 18° C. 
(64.4° F.), so that a general statement is hardly permissible. 
The vegetative cells are killed in a few minutes by temper- 
atures above 60° C. (140° F.) (Sternberg et al.). The pres- 
ence or absence of light seems to make no difference, ex- 
cept that direct sunlight killsthe spores of anthrax in a few 
hours (Arloing). Pressure of 600 atmospheres continued 
for twenty-four hours had no effect upon anthrax bacilli, 
and yeast stood a pressure of 3800 to 400 atmospheres ; 
putrefaction did not cease under a pressure of 350 to 
500 atmospheres (Certes). Electricity has no effect ex- 
cept very powerful constant currents, which check the 
growth of organisms (Cohn and Mendelssohn). Mechani- 
cal agitation has been repeatedly tried, but the results of 
the experiments do not agree. It would seem, however, 
that rest is conducive to growth, for the peculiar class 
of aquatic bacteria multiply with enormous rapidity in 
stagnant water (Cramer), but whether this is due to stag- 
nation alone or to other causes is not known. 

A great many chemical substances have been found 
to kill micro-organisms, but the most valuable one for 
disinfecting purposes is corrosive sublimate (Koch), 
when it can be applied. In the laboratory a 0.1 per 
cent. solution is employed to disinfect cultures when 
they are to be destroyed, and for similar purposes ; but 
a very much more dilute solution is sufficient, if allowed 
to act for an hour or so. Aqueous solutions of chlorine, 
bromine, iodine, carbolic acid, osmic acid, permangan- 
ate of potash, and bleaching powder, all act as disin- 
fectants, but the solutions have to be much more con- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Schizomycetes, . 
Schizomycetes, 


centrated than solutions of corrosive sublimate. Fora 
complete discussion of disinfectants and germicides see 
under the headings Disinfectants and Germicides. 

Media Hmployed for Bacterial Cultures.—From the 
above consideration of the conditions of growth, it be- 
comes apparent that suitable media must contain soluble 
albumen and certain salts, and, moreover, abundance of 
water. Three substances have come into universal ac- 
ceptance as fulfilling all these conditions : Infusions of 
flesh, boiled potatoes, and blood-serum. 
most generally used, and is prepared as follows : 

A half of a kilogramme of lean beef is freed of all 
tendons, etc., and chopped up fine in a sausage-mill or 

ee otherwise. It is then put into a litre of pure 
tion of nu- Water and allowed to stand in the cold eigh- 
trient gela- teen to twenty-four hours. The'water, which 
tine and has by this time dissolved out most of the solu- 
fe ble albumen, salts, etc., from the meat, is now 
filtered through a cloth. One per cent. (ten grammes) of 
peptone and a haif per cent. (five grammes) of common 
salt are then added. Gelatine in the proportion of five to 
ten per cent., or even more, or agar in the proportion of 
0.5 to one per cent., are also added for reasons which will 
become apparent presently. But this mixture is acid, 
so for the cultivation of bacteria and yeast fungi it is 
necessary to neutralize with carbonate of soda. Gelatine 
itself has an acid reaction, so the neutralization must 
take place after its addition and solution by heat; but 
agar is neutral, so that where it is used it is immaterial 
at what point the soda solution is added. In both cases 
the mixture is now boiled until all the coagulable albu- 
men is precipitated, and poured at once upon a hot paper- 
filter which has been just before washed with boiling 
water. If the filtrate is not absolutely clear, a small 
amount of egg-albumen is added, and it is again boiled 
and filtered. While it is still hot 5-10 c.c. of the filtrate 
are poured into test-tubes stopped with cotton wool. 
Now, it is evident that the cotton will prevent the subse- 
quent entrance of organisms from the air, but the cotton 
wool itself and the test-tubes all have organisms clinging 
to them, so that before the nutrient gelatine or agar is 
poured in they must be sterilized, ¢.e., freed from adherent 
germs. This sterilization is effected by plugging the tubes 
pretty tightly with cotton and heating them up in an air 
bath to 140°-150° C. (284° to 302° F.) for about an hour. 
But in the process of filtering and in filling the tubes 
organisms are likely to find their way in, so that after 
the tubes have been filled they must be again sterilized. 

Koch’s Lhis is accomplished by subjecting them to a 
steam ster- temperature of 100° C. ina Koch’s steam ster- 
ilizer. ilizer. The sterilizer is simply a metallic 
cylinder set upright upon a boiler, so that all the steam 
which escapes from the boiler: streams through the cyl- 
inder. It has been found that all objects placed in the 
cylinder are brought up to 100° C. (212° F.) ina few min- 
utes after the steam begins to be given off. The steril- 
ization in the steam apparatus has to be repeated upon 
three successive days for the following reason: ‘The first 
sterilization kills all the vegetative cells, but we have 
seen that spores resist the boiling temperature for sev- 
eral minutes. The spores which were not killed in the 
first sterilization will have germinated by the second or 
third. It would simplify the process to steam the tubes 
for a half or three-quarters of an hour at once, for this 
would kill vegetative cells and spores as well, and agar 
may be treated in this way. But if gelatine is boiled 
too long at a time it turns to paragelatine, so that the 
sterilization has to be effected as above described. 

The method of preparing potatoes is very simple. 
Pieces of potatoes, with the skin removed, are put into 

Potatoes Some convenient vessel and steamed in the 
for bacteri- sterilizer for an hour or more. For reasons 
alcultures. readily understood, the vessels containing the 
bits of potatoes must have an arrangement for excluding 
the micro-organisms of the air. Small glass dishes with 
perpendicular sides, and tops to fit over them, are useful 
for this purpose (Esmarch). The dishes should be of 
such a size that a thick round slice of potato will about 
fill one of them, and the flange of the top should come 


Beef-broth is — 


well down around the sides of the dish. Wide test-tubes 
plugged with cotton serve also equally as well. In this 
case the potatoes are cut in the shape of cylinders and 
fitted nicely into the tubes. The cylinders should have 
one side cut away obliquely, so as to afford a greater sur- 
face. Of course, the dishes and test-tubes may be first 
sterilized in the hot-air bath, but it is hardly necessary. 

Blood-serum is prepared by allowing a quantity of 
blood to stand until the serum separates from the clot. 
It is then drawn off with a pipette and dis- 
tributed into sterilized test-tubes as for agar 
and gelatine. It is desirable to catch the blood, 
in the first place, with all possible aseptic precautions, in 
a sterilized vessel. The carotid artery of a dog or other 
animal affords a convenient source. The instruments 
used in opening the artery, and the cannula which is in- 
serted, should be first heated, z.e., sterilized, in the Bunsen 
flame and then allowed to cool. The blood is allowed to 
flow into a wide-mouthed vessel, which has been sterilized 
by heat and has a cotton stopper; after the serum sepa- 
rates it is drawn off as already indicated. If the process 
has been successfully accomplished it is unnecessary to 
sterilize the serum. It can be at once coagulated by 
placing the test-tubes containing it in a slanting position 
in a special apparatus, and subjecting them to a tempera- 
ture of not above 70° C. (158° F.) for three hours. If 
desired, the serum may be first sterilized by Tyndall’s 
method, which consists in keeping the tubes at a tem- 
perature of 60° to 65° C. (140° to 149° F.) an hour or more 
at a time, for five or six successive days. The principle 
of this is readily understood from what has gone before. 

Other media, such as chicken-broth, veal-broth, and so 
forth, have been employed, but the three media above 
described are more employed than any other. 
They are sometimes varied, for special purposes, 
by the addition of sugar, glycerine, etc. 

The most useful of them all is nutrient gelatine, but its 
use is limited to comparatively low temperatures, for it 

Applica- becomes liquid at about 22° or 23° C. (71.6° to 
bility of the _73.4° F.). The other media may be used at all 
various me- temperatures. Gelatine is liquefied by many 
Bee organisms, and Sternberg has shown that this 
liquefaction is not necessarily dependent upon the growth 
of organisms, for cultures of liquefying organisms, in 
which the latter had all been killed by heat, were capable 
of liquefying a second tube of solid gelatine, even when 
introduced in small amounts. Only one or two organ- 
ismsas yet known liquefy agar. Where it is not specially 
mentioned in the following, it is understood that it is not 
liquefied. Most organisms have a very characteristic 
growth upon gelatine and potatoes ; their growth is less 
characteristic upon agar. 

The French school use bouillon without the addition 
of gelatine or agar, but the growth of organisms is not as 
characteristic in liquid media; and for purposes of isolat- 
ing various species of organisms, and for the study of pure 
cultures, the solid media possess very great advantages. 

METHODS OF OBTAINING PURE CULTURES.—Various 
methods of obtaining pure cultures have been suggested, 
and more or less successfully employed. Lister suggested 
a method which is essentially the same as that employed 
by Miquel and the French school generally. It consists 
in diluting a suspension of the micro-organisms to be 
isolated with sterilized water or other liquid, so that in a 
certain volume, é.g., one drop, it is estimated that only 
one organism is present. Several flasks of bouillon are 
inoculated with one drop each of the diluted suspension, 
so that only one organism is thus introduced and grows 
out to form a pure culture. But this and the other 
methods now employed by some of the French school 
are so far inferior to those which we owe to Robert 
Koch, that I shall restrict myself to a description of the 
latter. 

Solid media had been already employed by Klebs and 
others, but Koch’s adaptation was so original that it may 

__ almost be said that he was the first to use them. 

Solid och’s methods are very readily understood, 

media. ' °p 
and their advantages are manifest. 
It is plain that a number of different species may grow 


331 


Blood-se- 
rum. 


Other 
media. 


. Schizomycetes. 
Schizomycetes. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


for a longer or shorter time, side by side, on the surface 
of a potato or upon a layer of gelatine, without coming 

Aavanta- in contact, at least until the colonies grow so 
ges of the large that they touch; or, in the case of nutri- 
Paine. ent gelatine, until the latter becomes liquefied. 
If, on the other hand, liquid media are used, all the spe- 
cies which happen to be present are mixed together by 
the currents in the liquid, by their power of independent 
motion, etc. If, now, a trace of any of the isolated colo- 
nies on the potato or gelatine be inoculated into any 
proper medium, and the culture thus made protected 
from subsequent contamination, it is evident that it will 
be a pure culture. It is also equally evident that a pure 
culture cannot be obtained by inoculating directly from 
any liquid containing more than one species, for every 
trace of the liquid will almost certainly contain repre- 
sentatives of each of the species present. 

To illustrate the actual process, suppose it is desired to 
separate the various organisms in any substance which 

Process Contains them. A tube of nutrient gelatine, as 
for isolat- above described, is liquefied at a temperature 
ing  bac- not exceeding 40° C. (104° F.), and a small quan- 
tgs tity of the substance under examination is intro- 
duced and thoroughly disseminated through the gelatine. 
The contents of the tube are then poured out upon a cold 
glass plate which has been previously sterilized in the 
hot-air bath. The plate is allowed to stand under a cover 
till the gelatine is solidified, and it is then transferred to 
a glass dish with a cover, and placed at a temperature of 
18° to 22° C. (64.4 to 71.6° F.). In a few days there will 
bea number of dots apparent in and upon the gelatine, and 
a microscopic examination shows that these dots are lit- 
tle masses of micro-organisms. Each one of these masses, 
or colonies, is composed of micro-organisms of the same 
sort ; for while the gelatine was fluid the various organ- 
isms were distributed through it, and when the gelatine 
became solid each separate organism, or zodgloea, was fixed 
in the place where it happened to be, and had to remain 
there and grow without interfering with any neighboring 
organisms. If a trace of one of these colonies is intro- 
duced into a tube of solid gelatine, it grows and consti- 
tutes a pure culture. 

If agar is used the process is essentially the same. Agar 
does not become liquid at any temperature below the 
boiling-point of water, and becomes solid again at 40° C. 
(104° F.). So it becomes necessary to liquefy it and allow 
it to cool down nearly to the solidifying-point before in- 
troducing the substance under examination. In practice 
there are always a number of dilutions made from this 
first or ‘‘ original tube,” by inoculating a second from it, 
and a third from the second, and so on. The reason for 
this is, that usually there are so many organisms in the 
first tube that when they grow out they may come in 
contact with each other, and thus one colony may con- 
taminate another. But if several diluted plates are made, 
one or more of them will have the colonies well isolated, 
and they may be studied and used for inoculations. 

When the plates are examined there is always danger 
of contamination from the air, or contact with the fin- 
gers, etc., so that Esmarch’s modification of the Koch- 
plate method has great advantages. According to Es- 
march’s method, the original tube and dilutions are made 
just as in the other, but instead of pouring the gelatine 
or agar upon sterilized plates, a rubber cap is fitted over 
the tubes and they are held horizontally and twirled in 
ice-water till there is a film of the nutrient medium coy- 
ering the inside of the tube. Dr. Booker, in the Johns 
Hopkins Pathological Laboratory, instead of using ice- 
water, rolls the tubes ina groove melted ina block of 
ice. This avoids the use of rubber caps, which some- 
times permit the ice-water to run into the tubes. After 
the colonies have grown out, they may be examined, 
under the lower powers of the microscope, through the 
walls of the tube. They are thus not exposed, for the 
cotton remains in; but even when it is removed for pur- 
poses of transplanting, etc., the danger of contamination 
is reduced toaminimum. The Esmarch tube is, there- 
fore, a most valuable contribution to our technique. 


The inoculation of the gelatine and the transplanting - 


332 


from colonies are effected by means of a platinum wire 
melted into the end of along glass rod. Hach time be- 
fore it is used the wire is glowed in the Bunsen 
flame, and the glass handle is also passed a few 
times through the flame. Cultures may be made 
either with a straight platinum wire, by taking a trace of 
a colony, or culture, upon the end of it and simply thrust- 
ing it into a tube of gelatine or agar; or the surface of 
any of the media may be inoculated by means of a plati- 
num loop. The latter cultures might be called smear- 
cultures, and the former stick- or stab-cultures. Agar 
and gelatine for smear-cultures are allowed to solidify 
with the tubes in an oblique position, so as to afford a 
greater surface. 

Several methods have been recommended for the culti- 
vation of anaérobic organisms. Theair may be excluded 
from the colonies upon plates by covering the 
tion of an- gelatine or agar with a thin sheet of isin- 
aérobic mi- glass, applied directly to the surface. Another 
cro-organ- method is to place the plates under a bell-glass 
ce and displace the air with hydrogen or CO.. 
Test-tubes of peculiar construction have also been used.! 
These test-tubes have a narrow glass tube opening in the 
side, about 5 ctm. from the bottom, just above the gela- 
tine or agar. The tubing projects for about 3 ctm. at 
right angles to the test-tube, and it then bends downward 
and is plugged with cotton. The air in the test-tube is 
displaced by connecting the narrow tubing with a COs, 
or, preferably, with a H generator, and allowing the gas 
to stream through. As soon as the air has been displaced 
the upper end of the test-tube and the narrow tubing are 
melted off. A modification of these tubes consists in 
having the narrow tubing to project down into the bot- 
tom of the test-tube, so that the gas bubbles through 
the gelatine, or agar, which in both cases is kept liquid 
till after the gas has been allowed to stream through. 
Still another way is to make Esmarch tubes and fill 
them afterward with gelatine or agar, as the case may be. 
Flasks with narrow necks and a tube projecting from the 
side have also been used as follows (Hifner, Rosenbach) : 
The agar is boiled in one of these flasks till all the air is 
replaced by the gases from it, and the narrow neck and 
projecting tube are sealed. This. projecting tube has had 
some of the material containing the anaérobic organism 
previously introduced, and after the agar has cooled 
down to 40° C. this material, which must be fluid, is driv- 
en into the flask by gently heating the end of the tube. 
Anaérobic organisms only grow at the bottom of the tube 
in a stab-culture, but if the air is excluded by a layer of 
oil they grow nearer the upper part. They grow at the 
bottom of the vessel in liquid media. 

The methods are all simple and readily understood, but 
require great care in manipulation. 

Merrnops oF Examination.—The difficulty of dis- 
tinguishing between bacteria and cell-nuclei, and so forth, 
which Henle met with, was overcome in the most satis- 
factory way by Weigert’s brilliant discovery of the tenac- 
ity with which bacteria retain watery solutions of the | 
aniline dyes. Nearly all parts of a tissue are readily de- 
colorized, after staining with various aniline colors, by 
treatment with acids, etc. ; but to effect a decolorization 
of the bacteria, the decolorizing agent has to be allowed 
to act for a much longer time. This is a perfectly deci- 
sive, sharp reaction, and renders the detection of bacteria 
in most cases very simple. 

The limits of the present paper will not allow a full ac- 

Methods count of the various methods of staining, and I 
of staining can merely give a few general principles and one 
bacteria. or two special applications. 

Ehrlich distinguishes two classes of aniline dyes, acid 
and basic. The acid dyes need not necessarily have an 
acid reaction, but they include all the dyes which form 
salts with the bases, and whose coloring property is con- 
sequently due to an acid radical. The basic colors are 
generally not found as free bases in the market, but are 
sold as salts ; thus fuchsine is a chloride or acetate of ros- 
aniline. The basic dyes are almost exclusively used as 
stains for the bacteria. The cell-nuclei also show an affin- 
ity for this class of dyes, and in order to get rid of the 


Pure cult- 
ures. 


Cultiva- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Schizomycetes, 
Schizomycetes, 


diffuse stain in other parts of the tissues the latter are 
decolorized in very dilute acetic acid or in alcohol. This 
treatment leaves the bacteria and nuclei stained, and the 
rest of the tissues unstained. If sections treated in this 
way are afterward slightly stained with some contrasting 
color, the bacteria and nuclei often show to better advan- 
tage. The most usual 
colors are methylene 
blue, gentian violet, 
fuchsine, and methyl 
violet, all in watery so- 
lutions. These solu- 
tions are conveniently 
prepared by having sat- 
urated alcoholic solu- 
tions and adding a few 
drops to water as re- 
quired. Saturated alco- 
holic solutions may be 
kept indefinitely. 

Bacteria in sections of 
tissues are stained by 
oe ee Section of the Kidney allowing the latter to re- 

Sete ee erate Ny main from twenty min- 

utes to several hours in 
a watery solution of any of the above dyes. They are 
then put for a very few seconds into very dilute acetic 
acid, about 1 drop acid to 20 c.c. water, and are after- 
ward thoroughly washed in water, dehydrated in alcohol, 
cleared up, preferably, in origanum oil, and mounted in 
balsam dissolved in xylol. 

Most bacteria stain very well in this way, but tubercle 
bacilli require special staining as follows: 11c.c. of a sat- 

Staining Urated alcoholic solution of fuchsine or gentian 
of tubercle violet, 100 c.c. of a saturated aqueous solution 
bacilli. of aniline oil, and 10 c.c. of alcohol, are mixed. 
The aqueous solution of aniline oil is prepared by thor- 
oughly shaking 6 or 7 c.c. of the oil in 100 c.c. of water, 
and after fifteen minutes filtering, Sections must be left 
in the staining fluid twenty-four to forty-eight hours, and 
are then decolorized in twenty to thirty per cent. nitric 
acid, or, better, in dilute hydrochloric acid and alcohol 
mixed as follows: 100 c.c. of alcohol, 20c¢.c. water, and 
1 c.c. concentrated hydrochloric acid. 

Tissues are embedded and cut in the usual way. Cel- 
loidine and paraffine are used for embedding. A mixture 
of glycerine and gelatine, in such proportions as 
to be of a firm consistence at ordinary tempera- 
tures, is a convenient embedding medium for 
bacteriological purposes. <A piece of tissue to be embed- 
ded in this way, after it is thoroughly hardened in alco- 
hol, is placed on a bit of cork and the gelatine-glycerine is 
heated till it melts, and is then poured over it. As soon 
as the gelatine-glycerine becomes hard, which takes place 
in a few minutes, the cork, with the tissue thus attached, 
should remain about a 
day in alcohol, when the 
tissue will be ready for 
cutting. The sections 
must be cut as thin as pos- 
sible, and can be stained 
as above described. 

The so-called cover- 
glass preparation (Fig. 

Cover- 0396) is of es- 
glass prep- pecial value in 
arations. the examina- 
tion of bacteria. They 
are prepared by spread- 
ing a very small quantity 
of the material to be ex- Fic. 3396.—Cover-glass Preparation 
amined on a thin cover- from the Blood of a Mouse, showing 
glass. If the material is Anthrax Bacilli. x 400. 
too dry it is well to have a very small drop of sterilized 
water or salt solution on the cover-glass. After the cover- 
glass is thoroughly air-dried, it is passed once or twice 
rapidly through the Bunsen flame and then colored in the 
same way that sections are. They need not be treated 
afterward with alcohol and oil, but can be mounted in 


Embeda- 
ding. 


balsam as soon as they are dry. Tubercle cover-glass 
preparations are stained in the way already described for 
the tissues. Tuberculous sputum and preparations from 
cultures may be rapidly stained by heating the ccloring 
fluid till it gives off visible vapor. There are, besides 
these, many methods for staining tubercle bacilli, but I 
must refer the reader to some one of the special works 
on the staining methods for a description of them.? 

Many bacteria are very beautifully stained in tissues 
and on the cover-glass by Gram’s method, which consists 
in staining with the gentian violet solution, 
which has already been described, for tubercle 
bacilli, and decolorizing in dilute Lugol’s solu- 
tion and absolute alcohol. The dilute Lugol’s solution 
consists of 2 grammes of iodide of potassium, 300 c.c. 
water, and 1 gramme of iodine. 

It is often desirable to examine micro-organisms while 
they are alive to determine whether they have indepen- 
dent motion, their method of forming spores, 
etc., and this is done in so-called drop-cultures, 
A very small drop of beef-broth, prepared as 
above, without the addition of gelatine or agar, is put on 
a very thin cover-glass and inoculated with a trace of a 
pure culture of the micro-organism to be examined. 
The slides used for this purpose have an excavation in 
the middle so constructed that a cover-glass will fit over 
it and-close it. The cover-glass with the inoculated drop 
of sterilized beef-broth is put on one of these slides, so 
that the drop hangs down into the excavation. <A small 
amount of vaseline is smeared around the edges of the 
excavation in the slide, so that when the cover-glass is 
put on it adheres all around and prevents the broth from 
evaporating. The cover-glass and slide are first sterilized 
by passing them several times through the flame. After 
the drop-culture is prepared it is put at a temperature of 
35° to 87° C. (95° to 98.6° F.), and examined with the oil 
immersion-lens from time to time. It is always well to 
prepare a number of drop-cultures at a time, for it often 
happens that they become contaminated in their prepara- 
tion. Such cultures may be afterward allowed to dry, 
and stained and mounted for preservation. 

INOCULATION OF ANIMALS, AND DESCRIPTION OF THE 
PATHOGENIC PROPERTIES OF ORGANISMS.—Guinea-pigs, 
rabbits, and mice afford the best material for testing 
the pathogenic properties of micro-organisms. ‘They are 
more susceptible to infectious diseases, as a rule, than 
other animals, and are easier to handle. But dogs, cats, 
sheep, etc., are sometimes used. In some cases even 
human beings have been used. 

The material for inoculation is either simply inserted 
under the skin, or suspended in sterilized water, three- 
fourths per cent. salt solution, bouillon, or other conven- 
ient liquid, and injected into a vein. The outer vein of 
the ear of a rabbit is generally selected for this purpose, 
and the injection is made with a previously sterilized 
Pravaz’ or Koch’s hypodermic syringe. In subcutane- 
ous inoculations a pouch is made under the skin with a 
sterilized instrument and the material introduced, or a 
suspension is injected with a hypodermic syringe. The 
root of the tail is generally selected in inoculating mice, 
and the abdomen of other animals. These points are 
merely selected for convenience, the object being to in- 
troduce the organisms so that they may be taken up by 
the circulation. 

If animals are so inoculated with a substance contain- 
ing organisms of a disease to which they are susceptible, 
they sooner or later show all the symptoms peculiar to 
the disease. Cover-glass preparations from the blood, 
spleen, liver, etc., show the characteristic organisms in 
greater or less abundance, and the organisms can be cul- 
tivated in most cases. Pure cultures can generally be 
made, with proper precautions, directly from the blood, 
etc., but it is preferable to make plates or Esmarch tubes 
first. 

If an organism is cultivated through a number of gen- 
erations outside of the living body, and is always followed 
by typical symptoms when inoculated in minute quantl- 
ties, the evidence of its pathogenic power is complete. If 
itis not cultivated through several generations before it 


399 


Gram’s 
method. 


Drop-cult- 
ures, 


Schizomycetes. 
Schizomycetes, 


is inoculated, the objection can be raised that some poi- 
sonous substance from the original material may have 

Under been transferred ; but, of course, this objection 
what cir- falls to the ground if the culture which has 
cumstances heen used is the last of a long series of trans- 
inn seit to Plantations, for traces of the original material 
be patho- could not possibly be transferred so often. 
genic? Such a culture represents simply the organisms 
which have descended from the original culture. In this 
case the proof is perfectly conclusive ; but suppose the 
organism is only pathogenic for man? In this case a 
most important point in the proof fails, and before bac- 
teriology was as firmly established as it now is, it seemed 
that it was a necessary point in the proof. But authori- 
ties are now agreed that, although the actual production 
of the disease in the lower animals may be wanting, 
still, in such cases, bacteria have been shown, beyond 
reasonable doubt, to be the cause of the disease. Before 
our methods of diagnosing bacteria were as perfect as 
they are now, we were unable to say positively that a 
certain bacterium was found in every case of a given 
disease ; we could only say that morphologically similar 
bacteria were constantly present. At present, however, 
it is only necessary to find an organism constantly present, 
with characteristics sufficiently marked to recognize it in 
all cases. It must be absent in all other diseases and in 
healthy individuals. Among other examples, Bumm’s 
failure to produce gonorrhcea in the lower animals with 
his cultures was no proof that the organism was not the 
cause of the disease in man, because the lower animals 
have an immunity from gonorrhea. Bumm found his or- 
ganism in all cases, and it was so well marked that it 
could be readily recognized. It was absent in all other 
cases, and the production of typical gonorrhea in man 
(see below) was hardly necessary, though, of course, it 
strengthened the proof. 

GROUNDS FOR ACCEPTING SPECIFIC DIFFERENCES IN 
BacTEeRIA.—In the foregoing discussion I have assumed 
that there are distinct species, reserving this hotly con- 
tested point for special consideration. Hallier has been 
already quoted incidentally as having claimed that all in- 
fectious diseases are caused by an organism which he 
had discovered. His idea was that all organisms of 
disease are simply various forms which a certain fungus 
assumed under various circumstances. He thought that 
he had in his coccus found the cause of the infectious 
diseases, and that this coccus was derived from a mould 
fungus. It is easy to understand how Hallier was led 
into his error, for, as everyone acquainted with the sub- 
ject knows, micrococci can be found in all sorts of 
diseases, and if the cocci are not cultivated with great 
precaution mould fungi invariably take possession of the 
culture. His theory was very plausible, and it fitted in 
exactly, even in the minutest details, with all the ob- 
served facts ; but it disregarded all of Henle’s postulates, 
and was consequently wanting in proof. Cocci were con- 
stantly found by Hallier ; this would satisfy Henle’s first 
demand if the cocci found at one time were of the same 
species as those found at another in the same disease ; 
but supposing they were the same, they would have to 
be isolated, and with the methods known in Hallier’s 
day this was impossible. Even starting from a pure cult- 
ure, there was no guarantee that it remained pure; on 
the contrary, there was almost an absolute certainty that 
it would become contaminated, and that the contamina- 
tions would finally crowd out the original species, ¢.e., 
that mould fungi would at length occupy the field, for 
these fungi are specially apt to contaminate our cultures. 
It is by no means so easy to reconcile many recent obser- 
vations with the classification of organisms into distinct 
species. Pasteur has observed that certain micro-organ- 
isms lose their pathogenic properties under special con- 
ditions. Thus chicken cholera, rabies, etc., lose their 
virulence when inoculated into certain animals, and this 
loss of virulence is transmitted. Anthrax virus loses its 
power also under certain circumstances. Thus Pasteur 
was able to get cultures of anthrax and other organisms 
of various strengths, one strength capable of killing mice, 
but not fatal to larger animals, a still weaker sort incapable 


304 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


of killing even mice. Butif the virus which is capable of 
killing mice, and is incapable of killing larger animals, be 
once passed through a mouse it resumes its virulence for 
larger animals. This is mentioned to show that organisms 
are subject to most important changes of properties, and 
under the head of morphology we have seen that they 
may suffer quite marked changes of form, so that every 
characteristic seems more or less variable, at least in a 
number of cases. In spite of all this, however, the 
weight of evidence is in favor of a classification into dis- 
tinct species, for the changes just spoken of are brought 
about by definite, controllable causes, and had best be 
regarded as mere expressions, in each case, of wide but 
nevertheless limited power of variation. We may trans- 
plant various cultures with absolute certainty that we 
shall obtain similar cultures, generation after generation, 
if we use the proper precautions as to the avoidance of 
contamination. The transplanted cultures will have the 
same characteristics as the cultures from which they are 
transplanted. The modification of the physiological 
function already alluded to is more decided than that 
observed in the higher plants. The latter are subject to 
decided modifications of form and function under vary- 
ing conditions of nutrition, etc., but such modifications 
are not subject to inheritance, except when they are pur- 
posely cultivated through many generations, or result 
from the law of natural selection ; and even then there 
appears a tendency on the part of the plant or animal to 
return to the normal type. The micro-organisms, on 
the other hand, as we have seen, may be stamped in one 
culture representing many generations, it is true, with a 
modification from the normal which they retain tena- 
ciously, and such modified cultures can be cultivated 
under circumstances which we would suppose to be 
favorable to a return to the normal type, and still remain 
modified, generation after generation. This is a pecu- 
liarity which shows that analogical reasoning from the 
higher plants is misleading, and that the utmost care 
should be used in the observation of each experiment. 
Especially in the study of bacteria is the greatest possible 
objectivity of prime importance ; every preconceived 
idea isa hindrance, and only results which have been 
obtained repeatedly under every variation of circumstances 
can be of any value. For this reason all observations 
which have as yet been made in favor of pleomorphism 
of bacteria are not convincing. Until it is proven by 
actual observation of experiments, in which every source 
of error is excluded, that there is a metamorphosis of 
species, we are forced to accept specific differences. 
Direct argument for the existence of species may be de- 
duced from what has gone before. 

Some of the forms known to us at the present day have 
existed for a very long time, for some of them have 
been detected in fossils. The tartar from the teeth of 
Egyptian mummies has been found to contain forms 
identical with those found as constant inhabitants of the 
mouth at the present day (Zopf and Miller). 

THE PaTHoGENIc Bacrrerta.— Although there are 
many saprophytic bacteria which are of great scientific 
interest, the limits of this article will not permit a de- 
scription of individual species of saprophytes. It is, there- 
fore, thought best to restrict the description of species to 
the pathogenic bacteria, in view of their immediate bear- 
ing upon medicine. 

THE ParHocEenrc Coccr.—Cocet of Pus.—All ordinary 
suppuration, as met with in every-day practice, is caused 
by micrococci. It is true that certain chemical agents 
cause it also, but such cases are rare, and when they oc- 
cur micrococci are usually secondarily involved. 

Staphylococcus pyogenes aureus (Ogston, Rosenbach, 
Krause, and Passet), 8. p. albus (Rosenbach, Passet), and 
S. p. citreus (Passet), are the most common pus-produc- 
ers. One or more of them are found in acute abscesses, 
in empyema, and in ordinary boils. They are often pres- 
ent in pyeemia, ulcerative endocarditis, and osteomyelitis. 
They therefore cause many diseases which differ clinically. 
S. p. aureus is perhaps the most common, and albus next. 

These organisms are round, and about 0.87 « in diam- 
eter. They usually form into clumps, but isolated cocci 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Schizomycetes. 
Schizomycetes. 


and short chains are also met with. They are readily 
stained with the ordinary watery solutions of the aniline 
dyes. 

‘They grow upon all the different media at low and 
high temperatures. Colonies in gelatine are visible in a 
few days in the form of little white dots sunken down 
into the substance of the gelatine, owing to a little zone 
of liquefaction around each colony. These little funnel- 
shaped depressions are very apparent when the plate is 
seen at avery acute angle. The liquefaction gradually 
spreads, and the colonies at the bottom of the liquefied 
zones become orange-colored if the organism is the au- 
reus, lemon-yellow if it is citreus, and remain white if it 
is albus. They show a similar difference of color when 
cultivated upon the other media. Their growth coagu- 
lates milk in from one to eight days, with the production 
of lactic (and other ?) acids. 

Under the lower powers of the microscope the colonies 
are light brown, with a dark centre. They are perfectly 
circular, and have a sharp, smooth edge. Subcutaneous 
inoculations of traces of the cultures have no effect upon 
mice, guinea-pigs, or rabbits. Inoculation upon the cor- 
nea of the last-named animal causes an inflammation and 
a grayish-white infiltration which passes away in a few 
days. Larger amounts rubbed up in bouillon, etc., and 
injected subcutaneously, cause local abscesses, which 
either remain local and heal, or lead to general infection 
and pyemia. Injections into the peritoneum or into a 
vein generally prove fatal in from two to ninedays. The 
most characteristic lesions are found in the kidneys, 
which are filled with yellowish-white foci varying from 
microscopic points to the size of a pea. The foci occa- 
sionally form wedge-shaped. masses. 

Staphylococcus pyogenes salivartus was obtained from 
saliva by Biondi, in Koch’s laboratory. It differs from 
the albus and aureus in cultures by liquefying gelatine 
much more slowly and having a whitish color, which 
afterward turns gold-yellow. It often forms a skin over 
the surface of liquefied gelatine.* 

Staphylococcus of the Clou de Biskra. The Clou de Bis- 
kra is an endemic disease of Aleppo, Bagdad, Biskra, and 
Tunis. It is characterized by nodules which appear upon 
the face and extremities, and which break after a year or 
more. The cocci have been found in the blood of indi- 
viduals affected with the disease, and have been cultivated 
in calf-broth. They lose their pathogenic properties after 
they are cultivated for a time. 

Streptococct of Suppuration. —There are also strepto- 
cocci which produce suppuration. They all resemble 
each other under the microscope and in culture, and dif- 
fer essentially only in virulence. They are round and 
somewhat larger than the staphylococci. Some of the 
individuals are larger than others, and some of these are 
probably arthrospores. Colonies on gelatine are sharply 
marked and raised slightly above the surrounding sur- 
face, without spreading over it. They always remain 
small, and do not cause liquefaction. Under the micro- 
scope they are circular, seldom oval, of a yellow color 
with a granulated surface. Older colonies are almost 
brown and the edges are irregular. On agar they are of 
a flat conical shape, sloping off all around in steps from 
the centre to the periphery. Stick-cultures in gelatine 
show a number of isolated points of growth upon a part 
or all of the line of puncture. Growth upon potatoes is 
not visible to the naked eye for a long time. They grow 
slowly upon all media, but more rapidly at 35°to 37° C. 
(95° to 98.6° F.). The varieties are: 

Streptococcus pyogenes. This organism is found in a 
great many cases of suppuration, but does not seem to act 
as energetically as the staphylococci. It causes chiefly 
inflammations which follow the lymphatic vessels. It 
permeates the tissues, but seems to require some little 
time to cause the death of the latter. It has also been 
found in progressive gangrene and pyzmia. It is prob- 
ably identical with Fehleisen’s streptococcus of erysipe- 
las. It. hangs together in chains of four to ten or more 
individuals. 

Subcutaneous inoculations of small quantities either 
have no effect upon mice, or produce local abscesses 


which occasionally lead to death. It produces a tran- 
sient swelling and reddening of the ear in rabbits. But 
with this exception, subcutaneous inoculations, and even 
intravenous injections, are usually without effect unless 
the animals have been first poisoned, or there is a lesion 
of the aortic valve. In the latter case there follows an 
extensive endocarditis in from two to five days. 

Streptococcus septo-pyemicus is probably identical with 
S. pyogenes. It was obtained by Biondi from two cases 
of primary erysipelas of the larynx, and once in angina 
phlegmonosa (loc, cit.). 

Coceus salivarius septicus was also found by Biondi in 
the saliva of a patient suffering from puerperal septice- 
mia. It was also fully described in the above article, to- 
gether with the bacillus salivarius septicus, which is 
probably identical with the M. Pasteuri (see below). 

Streptococcus pyogenes malignus (Fligge). This coccus 
was obtained, in the Gottingen Hygienic Laboratory, from 
a spleen in a case of leuceemia. As the name implies, it 
is very virulent. It kills mice and rabbits almost always 
when inoculated in small quantities under the skin. It 
produces a somewhat extensive local abscess at the point 
of inoculation, and diseased foci, filled with the strepto- 
cocci, are found in the spleen and other organs, as well 
as in the blood. The animals often have one or more 
joints filled with the streptococci. 

Streptococcus articulorum (Loffler) has been found in a 
large number of cases of diphtheria, but probably has no 
causal connection with that disease. It forms very long 
chains of one hundred or more links. The colonies differ 
somewhat from the above description in that they are 
grayish under the microscope and have a wavy margin. 
Intravenous injections produce marked suppurative 
changes in the joints asa primary effect, and the animals 
gradually die. The joint affections with the other strep- 
tococci are secondary. Rabbits inoculated under the 
skin of the ear are affected just as with S. pyogenes. 

Streptococcus septicus (Nicolaier, Guarneri) does not 
form chains under all circumstances, and grows more 
slowly than the other streptococci. Traces of a culture 
suffice to kill mice and rabbits with absolute certainty 
in two or three days. The cocci are found in all the or- 
gans and tissues in great abundance. 

Micrococcus pyogenes tenuis (Rosenbach) was found in 
a few cases of closed abscesses. It does not tend to form 
into masses or chains. It often shows an unstained cen- 
tral portion and deeply stained poles. It forms almost 
transparent masses upon agar, afterward becoming more 
opaque. Experiments upon animals have not yet been 
made. 

Micrococcus gonorrhaw, gonococcus (Neisser, Bumm). 
This organism causes gonorrheal inflammation of the 
urethra, bladder, ureters, pelvis of the kidney, cervix 
uteri, and conjunctiva. It has also been found in gon- 
orrheeal inflammation of the knee-joint. Its growth is 
restricted to these localities, as far as observation goes. 

It is a diplococcus rarely undivided, and is sometimes 
seen in groups of four. The apposing surfaces are either 
straight or slightly concave, so that the intervening 
space between the two halves of the diplococcus is double 
convex. The space is usually unstained. The long di- 
ameter of the diplococcus is about 1.25 wu, the transverse 
diameter about 0.6 “. Watery solutions of methylene 
blue stain the cocci readily. They do not stain by 
Gram’s method. It only grows upon blood-serum, and 
poorly at best. It requires a temperature of 82° C. 
(89.6° F.), and the cultures often die without any ap- 
parent cause. Inoculations upon various animals have 
been followed by negative results, but inoculations upon 
man have been successful. Its pathogenic power is in 
inverse proportion to the age of the disease. Secretions 
from old chronic cases have often to be examined repeat- 
edly before finding the organisms, but cover-glass prep- 
arations from fresh cases always show them. It is the 
only cause of gonorrhcea, and is, therefore, of great diag- 
nostic value. Errors have been made in mistaking the 
following for it : ; 

Micrococcus subflavus (Bumm) has been found in catar- 
rhal affections of the bladder, in pemphigus neonatorum, 


335 


Schizomycetes. 
Schizomycetes,. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


in a mammary abscess, and in colpitis. It resembles 
the gonococcus in cover-glass preparations, but is readily 
distinguishable by the fact that it grows readily upon 
gelatine and serum at ordinary temperatures, and liquefies 
them both. Colonies are at first white, but afterward 
run together and form a yellowish mass, which finally 
becomes of an ochre color... It is not pathogenic for ani- 
mals, but produces abscesses in human beings. 

Micrococcus found in erysipeloid inflammation (Rosen- 
bach) of the hands and fingers of tanners, butchers, and 
others who handle animals. It grows upon gelatine and 
agar, making extremely small colonies. 

Micrococcus tetragenus (Gaffky) is found in tubercu- 
lous and other sputum, and upon the walls of tuberculous 
cavities of the lungs. It is 1 ~ or more in diameter, and 
there are generally four together, but in many of them 
the tetrads are not distinctly marked. Each tetrad is sur- 
rounded by a gelatinous envelope in preparations from 
sputum and lungs. Gelatine colonies are white, the su- 
perticial ones projecting above the surface. Under the 
microscope they are yellow, and either round or lemon- 
shaped, with a nodulated surface like a mulberry ; the 
circumference is consequently regularly scalloped. 

Micrococcus Pasteuri (Sternberg) is frequently found in 
the saliva of healthy persons. It was first observed by 
Sternberg, who found that it produced septiczemia in rab- 
bits, and could be cultivated at higher temperatures ; it 
very rapidly lost its virulence in cultures. A. Fraenkel 
regards this organism as the cause of croupous pneumonia. 

Micrococci have, furthermore, been found in variola, 
vaccine - matter, scarlatina, diphtheria, cerebro- spinal 
meningitis, influenza, ozena, hemophilia neonatorum, 
acute yellow atrophy of the liver, yellow fever, trachoma, 
porrigo decalvans, and granuloma of the skin. But none 
of them have been, as yet, sufficiently studied to estab- 
lish their relation to the processes in which they are 
found. The same, probably, holds true of the micrococci 
found in Rinderpest in Russia and pleuro-pneumonia of 
cattle. 

The following micrococci have also been partially 
studied : 

Streptococcus perniciosus psittacorum (Eberth, Wolff) 
was found in nodules of the lungs, spleen, blood, etc., 
of parrots which had died of a peculiar disease. 

A streptococcus was found by Charrin in the blood 
and internal organs of rabbits which had died of anthrax. 
It was called the micro-organism of septicaemia conse- 
quent upon anthrax. It produced septicaemia when in- 
oculated, and is, probably, identical with Koch’s coccus 
of septiczemia (see below). 

Streptococcus bombycis (Béchamp) produces coma in 
silkworms. <A different disease is caused by nosema 
bombycis (Cornalia, Lebert, Neegeli, Pasteur). 

Micrococcus of progressive necrosis of the tissues in mice, 
destroys all sorts of tissue, even tendons. Animals inoc- 
ulated with it die in about three days. The blood and 
internal organs remain free. Koch obtained the organ- 
ism by inoculations of foul substances upon the ear of 
mice, but only got it pure by using field mice. 

Koch, furthermore, obtained micrococci in cases of 
progressive abscess caused by injecting putrid blood ; 
also a micrococcus in pyemia in rabbits, and another in 
septicemia of rabbits. 

ParHoGentc Bacriui.—Bacillus anthracis* attacks 
whole herds of cattle and sheep, sometimes producing 
local boils, but generally it kills by producing septiceemia. 
Most animals and human beings are usually killed when 
they become inoculated with the minutest trace of a ma- 
terial containing the bacillus anthracis. Algerian sheep, 
white rats, adult dogs, and frogs are almost insuscepti- 
ble. Natural infection takes place by the introduction 
of the spores into the alimentary canal along with the 
food, and the disease consequently begins in the intes- 
tines. Cattle and sheep are especially sensitive to this 
mode of infection. The bacilli are formed in every or- 


* Observed first by Rayer in 1850, and in 1855 by Pollender, indepen- 
dently of Rayer; Davaine, in 1863, claimed that the bacillus caused the 
disease, and this was established by Koch in 1876, 


306 


gan and tissue of the body in the diseased animals (Figs. 
3395 and 3396). Inoculations of very small quantities 
always kill mice in about twenty hours, and guinea-pigs 
and rabbits in twice that length of time. . 

The rods vary in length from 5 to 20 u, and in breadth : 
from 1 to.1.25 u. They often hang together in long 
threads. The ends are slightly thickened and very 
sharply cut across, or even somewhat concave. They 
have no flagella and no independent motion. The forms 
of involution are often met with, especially in old cult- 
ures. Spores are formed in the long threads; they are 
oval, and each one is embedded in a round. gelatinous 
capsule. The latter becomes oval, andis broken through 
when the spore germinates. They are very resistant, and 
are not killed by boiling in water one or two minutes. 
Direct sunlight kills them in a few hours (see p. 3380). 
Anthrax spores are never found in the blood or other 
organs. 

The bacillus anthracis grows very readily in alkaline 
urine, alkaline vegetable infusions, and the customary 
nutrient media at low and high temperatures, in the latter 
case usually forming spores in a few days. It thrives 
best in free oxygen. ; 

Gelatine colonies under the microscope are greenish- 
black, and the surface is marked with parallel, zigzag, 
or shaggy lines ; this is most noticeable around the edges. 
There are often long threads, twisted like a rope, running 
off from the colony. It gradually liquefies the gelatine, 
which becomes syrupy. 

Bacillus edematis malignt (Koch). Before the days of 
antiseptic surgery this organism often caused progressive 
gangrenous cedema and emphysema. It is usually pres- 
ent in decaying matter, in dust from dwellings, old rags, 
hay, etc., and in earth which has been fertilized with 
foul feecal matter; in the latter it is often associated with 
the bacillus of tetanus. It probably plays an important 
part in putrefaction. It can be obtained by inoculating 
various animals subcutaneously with rich garden earth, 
and may then be inoculated from one animal to another. 
Such inoculations of garden earth sometimes produce 
tetanus. Malignant cedema is characterized by extensive 
infiltration around the point of inoculation of an abun- 
dant, clear, reddish fluid containing the bacilli in great 
abundance. There are also gas-bubbles here and there 
in the fluid. The internal organs are not much altered, 
but the serous surfaces contain numbers of bacilli. The 
bacilli are not present in the heart’s blood before and im- 
mediately after death, but appear very soon post mor- 
tem. Mice are an exception to this rule, and as the 
bacilli are found in their blood, ete., in great abundance 
just after death, malignant cedema has often been mis- 
taken for anthrax in these animals. Mice die in sixteen 
to twenty hours after inoculation. 

The inoculation requires to be made with larger quan- 
tities than is the case with anthrax. 

The bacilli of malignant cedema resemble anthrax ba- 
cilli. Individual bacilli measure from 3 to 3.5 « by 1 to 
1.1 », and have a tendency to form long chains of ten 
or more. These chains are generally bent and twisted. 
They often have a granular appearance in stained prep- 
arations, and the ends are more or less rounded. They 
form long threads in the blood, etc., in.contrast with the 
anthrax bacilli. Independent motion is sometimes, but 
by no means constantly, observed. Spores are found in 
the isolated bacilli, but not in the long threads. It is an 
exquisite anaérobic organism. It liquefies gelatine, agar, 
and blood-serum, with the production of gas-bubbles ; 
the gas has a faint, stale odor. é 

Bacillus of sympathetic anthrax, black-leg, Rauschbrand, 
etc. (Arloing, Cornevin, and Thomas), causes an endemic 
disease of cattle. Animals affected with the disease have 
hard, tense nodules under the skin and in the muscles, 
especially in the fleshy portions of the body, such as the 
rump, breast, etc. They may also have; secondarily, all 
the symptoms of an acute infectious disease, such as loss 
of appetite, disinclination to move about, etc.; or the con- 
stitutional symptoms may be primary and may be followed 
by the local. The nodules are at first very painful on 
pressure, but gradually they become insensitive. The 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Schizomycetes, 
Schizomycetes. 


swollen parts present upon pressure an emphysematous 
crackling ; hence the German name Rauschbrand. The 
nodules are rarely found in the deep muscles. The fever 
reaches about 48° C. (109.4° F.), but before death the tem- 
perature sinks to subnormal. Animals die in thirty-six 
to forty hours after the fever begins. The stage of incu- 
bation is from fourteen to twenty hours. Animals often 
recover when there are no local symptoms, and are 
then protected from subsequent infection ; but they al- 
most always die if the nodules make their appearance. 
The sound .given out on pressure of the nodules is due 
to an accumulation of a gas in the cellular tissue; the 
gas is composed of 13.15 per cent. CO, 76.51 per cent. 
H, and 10.34 per cent. N. The internal organs are 
covered with a dirty-red fluid, as if red wine had been 
poured over them. 
fected muscle, or with the gall, are successful with vari- 
ous animals if used in considerable quantities—two or 
three drops. Guinea-pigs are more susceptible and die 
from inoculations of much smaller quantities. The or- 
ganism presents also* very remarkable peculiarities. 
Calves up to five months old show no symptoms when 
inoculated with as much as six drops. They die from 
inoculations of larger quantities, and are not protected 
by inoculations of smaller amounts. Cattle reared ina 
black-leg district are rarely affected after they are two 
years old ; they have all probably suffered from the dis- 
ease in a mild form and are consequently protected. Im- 
ported cattle are susceptible at all ages over five months. 
Inoculations with blood of diseased animals are generally 
not successful till just before or after the death of the 
latter ; the blood contains very few bacilli up to that 
time. Inoculations with portions of a foetus, or with the 
amniotic fluid of a pregnant animal suffering from the 
disease, have been successful. Bacilli have been found 
once in the urine. Natural infection rarely takes place 
from the intestines. Very superficial inoculations, and 
inoculations far removed from the fleshy portions of the 
body, are usually followed by insignificant symptoms, 
but animals so inoculated are thereby rendered insuscep- 
tible to subsequent infection. If cattle are inoculated at 
the extreme end of the tail, they recover, as already said ; 
but if they have a wound in any muscular part, the ba- 
cilli lodge there and finally cause death. It is also re- 
markable that even intravenous and intratracheal injec- 
tions cause only slight local trouble, unless the tissues 
are much wounded in injecting, or unless there is a lesion 
at some other point. All of these methods have been 
successfully employed-for preventive inoculations, but, 
as will be readily understood, they are attended with 
risk. The methods for preventive inoculation will be 
discussed in another place. 

Frogs inoculated with sympathetic anthrax bacilli or 
spores, and kept in water at 22° C. (71.6° F.), suffer ap- 
parently no inconvenience ; they crepitate in fifteen to 
twenty hours, just as warm-blooded animals do, and 
their tissues are equally virulent. 

The bacilli are 3 to 5 long and 0.5 to 0.6 wu thick, 
usually with a knob on one end which makes the indi- 
vidual bacillus resemble the tongue of a bell. The spores 
form in the knob-like enlargement, one to each bacillus. 
The bacilli are endowed with independent motion. They 
grow in blood-serum, gelatine, agar, etc., but have prob- 
ably never been obtained in pure cultures. If a portion 
of diseased muscle of an animal, which has died of 
Rauschbrand, be introduced deep down into a tube of 
blood-serum or gelatine, it. liquefies the media and pro- 
duces gas. This organism is anaérobic. 

Bacillus typhi abdominalis, typhoid-fever bacillus 
. (Eberth, Klebs, Koch), is readily obtained in pure cult- 
ures from diseased portions of the intestines, the mesen- 
teric glands, and the spleen, often also from the liver and 
kidneys. They occur in separate clumps in these or- 
gans, and are not distributed throughout them. The 
constant presence of this organism in typhoid fever, and 
its absence in all other conditions, makes its etiological 
significance almost certain. Injected in large quantities 
into the veins of various animals, and under the skin of 
mice, it causes death with somewhat characteristic symp- 


VoL. VI.—22 


Inoculations of the juice of an af-. 


toms, such as swelling of the Peyer’s patches. But the 
death of the animals is probably due to intoxication, and 
not to a multiplication of the bacilli. 

The bacilli are about .2 or 3 long, and 0.6 to 1 “in 
thickness. The ends are distinctly rounded. The ba- 
cilli in cultures resemble those found in the diseased tis- 
sues, etc., but the former tend to hang together in long 
threads. The aniline dyes stain the bacilli rather slowly, 
but very satisfactorily, if allowed to act long enough. 
They do not stain by Gram’s method, 7.e., they are com- 
pletely decolorized by Lugol’s solution and alcohol. The 
bacilli often remain unstained at various points, and this 
gives them the appearance of being notched and of hav- 
ing holes in them. 

They grow readily, at high and low temperatures, upon 
all the various media—potatoes, agar, gelatine, milk, ete. 
Colonies on gelatine plates appear as small white dots in 
thirty-six hours, at a temperature of 18° to 20° C. (64.4° 
to 68° F.). Under lower powers of the microscope they 
appear light lemon-yellow, are either circular or lemon- 
shaped, with a sharp contour and indistinctly granular 
surface. The colonies which lie upon the surface of the 
gelatine, or which have broken through in the process of 
growth, are spread out flat, they never project apprecia- 
bly above the surface of the gelatine. Under the micro- 
scope they have an irregular contour, often fissured at 
various places, and their surface is marked with zigzag 
parallel lines. To the naked eye they have a very deli- 
cate bluish tint. Although the growth is vigorous in all 
cases, it does not produce such thick masses, either in 
colonies or in cultures, as do many other organisms. 

It grows luxuriantly upon potatoes, but the growth is 
invisible to the naked eye; this characteristic is not ab- 
solutely constant. On touching the surface of a potato- 
culture with a platinum needle, it seems to be covered 
with a slightly elastic skin. 

At a temperature of 35° C. (95° F.), the typhoid bacil- 
lus forms oval refractive bodies much resembling spores, 
but they do not seem to be very resistant to agents which 
do not usually affect spores. ; 

Bacillus pneumonie, pneumococcus (Friedlander), is 
found in the alveolar exudate, and in the exudate from 
the pleura and pericardium in cases of croupous pneu- 
monia. It has been seen in the rusty sputum, and once 
in the blood. Its value in diagnosis is limited by the 
fact that there are quite a number of bacilli which re- 
semble it, that it is not constantly present, and that pneu- 
monia is caused by other organisms. 

Mice are killed by injections into the thoracic cavity, 
and by inhalations. Post-mortem pneumonia is some- 
times found which is not generally of the typical lobar 
variety, and the organisms are readily obtained from the 
diseased lungs and the blood. Rabbits are unaffected. 
Of 11 guinea-pigs, 6 died after inoculation, and there 
died one dog out of 5 inoculated. 

The bacilli are short and thick, some of them look like 
cocci. The ends are rounded. In preparations from 
animal tissues the bacilli are each surrounded with a 
gelatinous capsule, or it may be that a single capsule en- 
velops two or more bacilli. The bacilli have no inde- 
pendent motion. 

They grow very readily upon various media. Gela- 
tine colonies twenty-four hours old are white, and after- 
ward project like little knobs above the surface. Under 
the microscope they have a dark granulated centre, and 
a narrow olive-green peripheral zone. In stab-cultures 
a knob forms on the upper surface of the medium, and 
the line of inoculation tapers as a whitish line from this 
knob downward, so as to make the so-called nail-growth. 
In old cultures the gelatine and agar become dark red- 
dish-brown around the line of inoculation. Gas-bubbles 
are formed in potato-cultures. 

The following five organisms bear resemblance to the . 
bacillus pneumonie : 

Bacillus of rhinoscleroma* causes a hardening and 
thickening, or it may be a diffuse cellular infiltration, of 
the mucous and submucous tissues of the nose resem- 
bling a lymphomatous growth. The disease may spread 
to neighboring parts. It is comparatively rare and has 


337 


Schizomycetes. 
Schizomycetes, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


been observed chiefly in Southern and Southeastern Eu- 
rope and in Central America. 

The bacilli are indistinguishable in cultures and under 
the microscope from the pneumonia bacilli, and inocula- 
tions upon animals are followed by the same results with 
both kinds of bacilli. 

Bacilius crassus sputigenus (Kreibohm) is indistinguish- 
able from bacillus pneumoniz in cultures and under the 
microscope. It was obtained twice from sputum, and 
once from the coating of the tongue. Mice die of septi- 
cxemia when inoculated with traces of a culture. Rab- 
bits react only when large amounts are injected into a 
vein, and the same is true for dogs. 

Bacillus pseudo-pneumonicus (Passet) is even more in- 
clined to occur in an isodiametric form than is the bacillus 
pheumoniz, and Passet called it a micrococcus ; but, ac- 
cording to Fliigge, it is a bacillus. It was derived from 
the pus of two abscesses. It is in many respects similar 
to bacillus pneumoniz, but in stab-cultures it only 
forms the head of the ‘‘nail,” and does not grow along 
the line of inoculation. Colonies are, moreover, grayish- 
white. 

Bacillus pneumonicus agilis (Schou) was obtained from 
pneumonia of rabbits in which the vagus nerve had been 
severed. The bacilli resembie bacillus pneumonie, but 
they liquefy gelatine and blood-serum, and cultures on 
potatoes are reddish-yellow and spread out. Injections 
into the trachea and inhalations produce severe pneu- 
monia in rabbits. 

Bacillus septicus sputigenus. See Micrococcus Pasteuri. 

Bacillus tuberculosis (Koch) is the cause of tubercu- 
losis, including lupus and scrofula. No animals seem 
to have an absolute immunity from the disease, al- 
though they present marked differences in susceptibility. 
The disease is never brought about in any other way 
than through infection with the tubercle bacilli or their 
spores. Infection takes place by inhalation, by swallow- 
ing the virus, and by inoculation. The bacilli are most 
certain to be found at the place where the disease is just 
beginning to attack a new place, ¢.e., the early stages of 
the disease, or the parts just commencing to be affected. 
At first the separate bacilli are isolated, and are found in 
the cells close to the nuclei; where the process is older 
the bacilli occur in thick clumps. In old cheesy masses, 
unless exposed to the air, the bacilli are not so readily 
eee The bacilli are almost always found in the giant 
cells, 

The tubercle bacillus can be cultivated upon blood- 
serum at 85° C. to 87° C., and is said to grow best when 
glycerine is added. It is best obtained for cultures by 
inoculating a guinea-pig in the belly with sputum from 
a phthisical patient. After the animal dies or is killed 
(in from four to six weeks), a tuberculous nodule is cut 
out with the greatest possible aseptic precaution and 
rubbed up in a sterilized glass dish, and introduced into 
tubes of blood-serum. There is no apparent growth for 
fourteen days or more, it then becomes especially appar- 
ent around any little bits of tissue that have been intro- 
duced, in the form of little grayish masses which after- 
ward turn to dry crusts. The tube should be prevented 
from drying out by warming the mouth of the tube and 
wrapping the cotton plug with thin rubber sheeting, 
which adheres nicely. This or some other method to 
prevent evaporation must be resorted to. 

The bacilli are 1.5 » to 3.5 «long and about 0.2 w in 
thickness. They are generally curved or bent at an 
angle; they often have from two to six spores, which 
have a larger diameter than the thickness of the bacilli. 
Bes: ee for staining has already been given on 
p. : 

Bacillus lepre (Armauer Hansen, Neisser) is found 
exclusively and in great numbers in all organs and tis- 
sues affected with leprosy. The bacilli are congregated 
into characteristic clumps, and the clumps are probably 
cells filled with bacilli. Some of them are similar to the 
giant cells containing tubercle bacilli, and are called 
leprosy cells. These bacilli are also met with lying free 
in the lymph-spaces. Bordoni-Uffreduzzi® claims to 
have cultivated the bacilli in blood-serum to which 


338 


glycerine had been added. He obtained his cultures 
from the marrow of a leprous bone. After cultivation 
on glycerine blood-serum, he contends that the bacilli 
will grow upon our ordinary media (except potatoes and 
bouillon) at 22° C. to 25° C. The bacilli direct from the 
tissues are more readily stained than tubercle bacilli, 
but from Bordoni-Uffreduzzi’s cultures less readily. 
To distinguish them from tubercle bacilli in cover-glass 
preparations, Baumgarten leaves them six to seven min- 
utes in an alcoholic solution of fuchsine ; decolorizes fif- 
teen seconds in acidulated alcohol, washes in water, and 
colors afterward with methylene blue. Leprosy bacilli 
are colored red in this way, but tubercle bacilli are not. 
Animal experiments have not been very successful. The 
bacilli resemble tubercle bacilli very closely, and they 
also have the appearance of containing spores, but Bor- 
doni-Uffreduzzi contends that these are not spores, but 
that the bacilli form arthrospores. 

Bacillus mallet, B. of glanders (L6ffler, Schiitz), is the 
cause of the disease from which it derives its name. It 
attacks human beings, horses, asses, young dogs, guinea- 
pigs, and field mice. House mice are not affected, rab- 
bits sometimes, and in one case a sheep was success- 
fully inoculated. After inoculation the wound ulcerates, 
and the neighboring lymphatic glands enlarge. If the 
amount inoculated is small, the animal may live several 
weeks, and one or more joints of the feet may ulcerate. 
There is also swelling of the testes or of the ovaries 
and vulva, and ulceration of the nasal cavities. 

This organism grows readily upon various media, pref- 
erably at temperatures above 25° C., producing a reddish- 
brown, slimy coating upon potatoes. The bacilli are not 
unlike tubercle bacilli, but are more uniform in length 
and thicker. In stained preparations they often look like 
chains of cocci. They are not easily stained in sections. 

Bacillus of Rothlauf, microbe du rouget du pore, ete. 
(Thuillier, Pasteur, Loffler). Hogs affected with Roth- 
lauf become sick quite suddenly. The temperature rises 
to 48° C, (109.4°F.), and they have bloody mucous pas- 
sages. Sooner or later the skin of the abdomen, neck, etc., 
becomes red, and finally reddish-brown. ‘They die on 
about the fourth day with paralysis or cramps. Chiefly 
young hogs from three months to three years are subject 
to it. The disease is believed by some to start in the in- 
testines from the hogs eating mice or other animals, and 
feces containing the micro-organism. On post-mortem 
examination the mucous membrane of the small intes- 
tine is found to be red and swollen, the Peyer’s patches 
and solitary follicles are prominent, and are here and 
there ulcerated, especially in the neighborhood of the 
ileo-ceecal valve. The liver and spleen are somewhat 
enlarged. The lymph-glands, especially of the mesen- 
tery, are enlarged and dark red with punctiform ecchy- 
moses ; these are also found upon the epicardium of the 
auricles. The lungs are also filled with blood. The 
muscles are soft, and of a dirty reddish color. The kid- 
neys are the seat of a hemorrhagic parenchymatous ne- 
phritis. 

House mice and pigeons die of septicseemia in forty to 
sixty hours after inoculations of traces of diseased tissues 
or cultures. The bacilli are found in all the organs and 
tissues lying in and among the white blood-corpuscles; the 
latter are sometimes filled with the bacilli. Guinea-pigs, 
field mice, and, to a certain extent, rabbits, are not sus- 
ceptible, but the latter sometimes have a local inflamma- 
tion at the point of inoculation, and are then thoroughly 
protected. 

The bacilli are 0.2 w thick and 0.6 to 1.8 u long, and 
probably form spores. They are readily cultivated at 
various temperatures and upon different media. They 
stain readily in the ordinary way, and also by Gram’s 
method. 

The colonies in gelatine are characterized by a delicate 
bluish-gray cloud which surrounds the thicker central 
portion. This cloudy zone is seen under the microscope 
to consist of a very fine network of delicate threads. 
Colonies never lie on the surface of the gelatine, but are 
always found to be in the substance. In stab-cultures 
the cloud appears all around the line of inoculation ; 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Schizomycetes, 
Schizomycetes. 


the most vigorous growth is in the lower parts of the 
tube. 

Bacillus murisepticus was obtained by Koch from mice 
which had died after inoculations of fluids just begin- 
ning to putrefy. It behaves in cultures and inocula- 
tions upon animals precisely like the Rothlauf bacillus. 
It is said to be shorter than the latter. 

Bacillus diphtheria. Loffler, who discovered this or- 
ganism, was at first cautious in assigning to it its full 
importance, because it could not be detected in some typi- 
cal cases of diphtheria, and because it was always nec- 
essary to produce some lesion of the mucous membrane 
in inoculations upon animals. It is possible, however, 
that in those cases where it was not found it might have 
been present in the form of spores or retrograde forms ; 
and as to the latter objection, it may be that in the hu- 
man being also minute lesions are necessary. Ldoffler 
ulso found the bacilli once in a number of examinations 
of persons not affected with diphtheria. Still, it is very 
probable that this organism causes at least one group of 
diphtheritic diseases. 

ats and mice show no reaction after inoculation. 
Guinea-pigs and small birds die after subcutaneous in- 
oculation with extensive cedema in the subcutaneous con- 
nective tissue around the wound. A very characteristic 
pseudo-membrane was formed in the trachea of rabbits, 
chickens, and pigeons, where cultures were applied to 
the wounded mucous membrane; beside the pseudo- 
membrane there were also bloody cedema and hemor- 
rhage in the tissues of the lymphatic glands, and effusion 
in the pleural cavity. Similar symptoms have been also 
noticed after inoculations upon the conjunctiva of rab- 
bits, and the vulva of guinea-pigs. Young animals 
seem to be more readily affected than older ones. 

The rods are of very different lengths, and about as 
thick as tubercle bacilli. They are often curved, with 
one or both ends enlarged ; in the latter case they are 
dumb-bell shaped ; they have no independent motion. 
In uncolored preparations the poles, and occasionally 
other parts of the bacilli, are refractive, and these por- 
tions are more intensely colored in stained preparations, 
so that many of the bacilli seem to be composed of a 
chain of irregularly shaped pieces. Forms of involution 
are often met with. 

Young colonies under the surface are round or oval ; 
under the microscope they are dark-brown, coarsely gran- 
ular, and their contour is not sharply marked. Super- 
ficial colonies are grayish-yellow, with a rough granular 
surface, and a fine undulating margin. The bacillus 
grows slowly upon gelatine at 22° C, (71.6° F.). The best 
nutrient medium for it is a mixture of three parts calf’s 
or sheep’s blood-serum, with one part of neutralized 
veal bouillon containing one per cent. peptone, one per 
cent. grape-sugar, and 0.5 per cent. common salt. 

Bacillus of Syphilis. Lustgarten discovered bacilli re- 
sembling tubercle bacilli in sections from syphilitic tis- 
sues, by using the following method of staining : Sections 
remain from twelve to twenty-four hours in the gentian 
violet stain for tubercle, and are then dipped several times 
alternately in a 7.5 per cent. watery solution of perman- 
ganate of potassium and in dilute sulphuric acid. A ba- 
cillus found in smegma preputialis and labialis may be 
stained in the same way, so that there is as yet no re- 
‘ liable method of applying bacteriology in the diagnosis 
of syphilis. It does not grow upon any of our media, 
and is not very abundant in the tissues. The. bacilli re- 
semble tubercle bacilli. They are usually embedded in 
peculiar cells which are large, and either oval or polyg- 
onal. It is often necessary to make a number of sec- 
tions before finding them. 

Bacillus cholere gallinarum, microbe du choléra des 
poules, chicken cholera ; B. cuniculicida, rabbit septicemia. 
I describe rabbit septicemia and chicken cholera to- 
gether, because they are probably identical. Several au- 
thorities have observed the disease in epidemics and in 
isolated cases, where the animals had taken the disease 
through accident. Koch obtained the organism from 
dirty water, and from a piece of foul salt-meat. The 
smallest trace suffices to kill rabbits, house mice, click- 


ens, pigeons, sparrows, and pheasants. . Field mice and 
guinea-pigs are not susceptible. Animals that have died 
of it have the bacilli in all the tissues, etc., but not always 
in abundance. Animals have also been infected by feed- 
ing them with cultures. 

The bacilli grow readily upon various media. Gela- 
tine colonies, under the microscope, are finely granular, 
and have a light-yellow centre surrounded by a brown 
ring and a light peripheral zone. 

The bacilli are short and stain at the poles, so that they 
resemble diplococci. They are about 1.4” long and 
0.7 wbroad. They sometimes hang together and form 
short chains, and are often surrounded by:a capsule. 
They stain readily in the aqueous solutions of various 
aniline dyes, but are not colored by Gram’s method. 

Bacillus septicus agrigenus was obtained from manured 
earth by Nicolaier, in Fliigge’s laboratory. It is like the 
foregoing, except that it kills field mice. 

Bacillus diphtheria columbarum was obtained by Lof- 
fler from epidemics of diphtheria in pigeons. The dis- 
ease attacks, preferably, young birds and fancy breeds. 
The bacilli resemble those of chicken cholera, but are 
a little longer. This organism grows upon various me- 
dia. The surface of the potato where it is grown as- 
sumes a grayish color, but is otherwise unchanged. -The 
most characteristic feature is that it produces a very pe- 
culiar marbled appearance in the liver of mice which 
have been inoculated with it. In the centre of the white 
spaces thus marked off in the liver are found intravas- 
cular masses of bacteria. The animals die in about five 
days after subcutaneous inoculations. According to 
Loffler, the diphtheria of chickens is not caused by the 
above bacillus, for they are not susceptible to inocula- 
tion. Guinea-pigs, rats, and dogs are also unsusceptible. 

Bacillus diphtheria vitulorum was found by Lofiler in 
diphtheria of calves. Cultures were not successful, but 
inoculations from animal to animal were. The bacilli 
are about 0.5 « broad and about five or six times as long. 

Bacillus aivet was discovered by Watson Cheyne and 
Chesire in the so-called ‘‘foul brood” of bees. It is 
readily cultivated upon various media. The bacilli vary 
from 2.54 pw to 5.08 w in length, and are 0.85 pw thick. 
Some of them have a sluggish motion. They bulge out 
to a spindle shape and form spores in the enlarged part. 

Bacilli are found in infusions of jequérity and in in- 
flammations caused by it, but they are probably not the 
active principle of the drug. 

Bacillus tetantd was cultivated from garden earth by 
Nicolaier, in Fliigge’s laboratory. It is an exquisite 
anaérobic organism, and cultures inoculated into various 
animals produce tetanus ; but pure cultures have probably 
never been obtained. The bacilli constantly present are 
narrow and bristle-like, with a knob at one end. They 
have no independent motion, are thicker, and about two 
or three times as long as tubercle bacilli, and are readily 
stained with fuchsine (Hochsinger).® But these bacilli are 
always accompanied by others, so that it is possible that 
the tetanus bacillus will grow only in combination with 
one or more kinds of bacteria ; in other words, it may be 
an example of symbiosis (Fligge). Inoculations of gar- 
den earth are sometimes followed by tetanus and some- 
times by malignant cedema (see above). Even white rats 
are subject to infection from inoculations of earth. In- 
oculations from the diseased tissues of patients dead of 
tetanus have also been successful. The bacilli are found 
in the tissue dividing the healthy from the diseased por- 
tions, and in the pus. They are rare or lacking in the 
blood, in the cerebro-spinal fluid, in the substance of the 
nerve-centres, in liquid squeezed from nerves, and in the 
internal organs ; but subcutaneous inoculations with parts 
of the tissues surrounding the wounds, and with the 
purulent secretions rubbed up in water, have been found 
to produce tetanus (A. Bonome’). Inoculations with 
blood are occasionally successful (Fligge, Hochsinger). 

Brieger® has isolated a specific ptomaine (tetanine), 
along with other toxines, from impure cultures of tetanus 
bacilli. j 

Bacillus parvus ovatus, Bacillus of swine plague (L6f- 
fler, Schiitz, Salmon), was found in a hog that had died 


339 


Schizomycetes, 
Schizomycetes. 


of a disease similar to rouget du pore. It was pres- 
ent in the cedematous skin, in the liver, etc. Mice, rab- 
bits, and guinea-pigs all died after subcutaneous inocula- 
tions with bloody cdema of the subcutaneous connective 
tissue and red patches in the lungs, etc. A hog was 
successfully inoculated. Rats were not affected. 

The bacilli are readily cultivated upon gelatine, etc. 
They are found in enormous quantities in the tissues, and 
are about half as large as rabbit septicemia bacilli, but 
resemble the latter sometimes. They are ovoid in shape. 

Loffler® found that the principal lesions were situated 
in the intestine and skin. Schitz?° found in his cases that 
the respiratory organs were mainly affected, and succeed- 
ed in producing the disease by inhalations of cultures. 
Salmon !! has described two diseases: One, in which the 
intestines are principally involved, he calls hog cholera; 
the other, in which the lungs are affected with multiple 
pneumonia, he calls swine plague, in the latter disease 
the intestines are sometimes unaffected. 

Smith has found that cultures from the spleens of hogs 
which had died of swine plague in Nebraska, differed 
from those from other sources by forming a skin on the 
surface of liquid media, by forming a denser mass at the 
bottom of the test-tube, by not growing in neutral gelatine, 
and by not being pathogenic for guinea-pigs. 

Bacillus necrophorus was obtained by L6ffler from in- 
oculations of bits of condylomata into the anterior cham- 
ber of rabbits’ eyes. The animals died in about eight 
days with caseous necrosis around the wound, isolated 
pneumonic foci with hemorrhage, or necrosis of large 
portions of the lungs, and foci in the heart. Rabbits in- 
oculated on the ear are similarly affected. Mice are also 
susceptible to the disease when inoculated. 

The bacilli refuse to grow upon ordinary gelatine, etc., 
and are best cultivated in neutralized rabbit bouillon, 
though they grow in chicken bouillon and upon blood- 
serum from the horse. They make a downy, fluffy mass 
around any bits of tissue which have been introduced 
into the liquid media above referred to. They are quite 
narrow and vary in length, but are usually long and 
wavy. In cultures they often have swollen and refrac- 
tive spots when examined on a cover-glass unstained, but 
the latter are probably not spores. 

Bacillus cavicida, Brieger’s bacillus, was obtained from 
human feces. It kills guinea-pigs, when inoculated 
in traces under the skin, inside of seventy-two hours with- 
out exception. Rabbits and mice are for the most part 
insusceptible. It produces violent inflammation of the 
small intestine. The individual bacilli are very small ; 
they grow upon gelatine, etc. The surfaces of colonies 
on gelatine are divided up by fissures running irregularly 
in all directions, so that they resemble the back of a 
terrapin. 

The four following bacilli, like some of the preceding, 
produce extensive disturbances of the alimentary tract 
when injected into the veins of animals. But those which 
have been already treated of are more or less active in 
minute quantities. The following group can hardly lay 
claim to pathogenic power in the sense of multiplying in 
the body, causing necrosis of tissue, stopping up the cap- 
illaries, etc.; they act by intoxication. They possibly 
multiply in the body if they are introduced in such large 
quantities that the organs can no longer resist, but the 
death of the animal is clearly due to poison, either intro- 
duced in inoculation or subsequently produced. Injec- 
tions of smaller quantities produce the same symptoms 
in a modified form. Furthermore, the same effects are 
produced by injections of sterilized cultures, ¢.c., where 
the bacteria have been killed but the products of growth 
are not destroyed. ‘This production of intestinal disturb- 
ance, vomiting, dysentery, etc., also follows injections 
of large quantities of various organisms, even of some of 
those which have come to be regarded as distinctly patho- 
genic; but some of the pathogenic organisms show no 
such action, and even in large quantities produce no ef- 
fect except the characteristic symptoms of the peculiar 
disease. 

Bacillus oxytoxicus perniciosus was obtained from milk 
by Wyssokowitsch, in Fligge’s laboratory. It is a short, 


’ 


340 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


thick bacillus, and produces the gastro-enteric disturb- 
ances above described. It grows upon various media. 

Bacillus Neapolitanus was obtained by Emmerich from 
the feces and organs of cholera patients. Emmerich 
claims that it is the cause of Asiatic cholera, but his 
proofs are not conclusive, and he has found but few 
followers. It very much resembles the typhoid-fever 
bacillus in cultures and under the microscope, except that 
on potatoes it has a brownish-yellow, oily, slimy growth. 
The symptoms following inoculations are as above. As 
Weisser has found ‘‘that in human feces, normal as well 
as abnormal, in the air, in putrefied fluids, bacteria are 
present which are identical with the so-called Neapolitan 
cholera bacteria in their morphological character, biologi- 
cal function, and pathogenic action,” !* there is every 
reason to believe that Emmerich was mistaken in claim- 
ing that his bacterium is the cause of Asiatic cholera. 

Bacterium colt commune and Bacterium lactis aéro- 
genes'® were found constantly in the feces of milk-fed 
infants, and these bacteria were found alone as long as the 
infants were healthy. They constitute, therefore, a most 
important diagnostic sign. In proportion to the extent 
and severity of gastro-enteric disturbance the two organ- 
isms become more and more displaced by other bacteria. 
It is advisable to isolate the two bacteria from the feces 
of a healthy breast-fed infant a few hours after birth, and 
use the cultures for comparison in other cases. The 
feeces should be obtained by introducing a sterilized glass 
tube into the rectum, and inserting a second smaller tube 
or a platinum loop inside of the first. Bacterium lactis 
aérogenes is found in large numbers in the upper part of 
the intestines, but in the lower part it becomes rare or 
even absent, and its place is occupied by the colon bac- 
terium. Plates from the feces seem at first glance to 
contain colonies of the colon bacterium alone, but there 
are always some colonies of the other. 

Bacterium lactis aérogenes is 0.5 to 1.0 « in thickness 
and about twice that in length. Its growth on all the 
media resembles that of Friedlander’s pneumococcus (B. 
Pneumoniz), except that in stab-cultures the growth 
along the line of puncture is more vigorous in the deeper 
parts, and often consists of a line of large, isolated, round 
masses. It also forms gas-bubbles on potatoes. 

The bacterium coli commune is about 0.4 to 0.6 u thick, 
and varies in length up to 3 “and more. It has indepen- 
dent motion and is not colored by Gram’s method. The 
deeper colonies in gelatine are yellow and granulated, the 
superficial colonies are spread out and are regularly gran- 
ulated or folded into radiating lines. 

Both coagulate milk, but the B. lactis aérogenes seems 
to have more energetic power; it produces coagulation 
and the formation of lactic acid in about twenty-four to 
forty-eight hours, whereas the colon bacillus requires a 
longer time. They both cause a fermentation in solu- 
tions of grape-sugar ; the bacterium lactis aérogenes also 
causes fermentation in milk-sugar. Experiments upon 
animals are essentially as above. 

THE SPIRO-BACTERIA.— Comma bacillus, sptrillum chol- 
ere asiatice, was discovered by Koch, in 1883. It is 
always found in Asiatic cholera and never in any other 
disease, nor in healthy persons. The bacilli are some- 
times met with almost unmixed with other bacteria in the 
intestines, especially in the lower part of the small intes- 
tine, where the cholera lesions are greatest. They are ~ 
found, furthermore, occasionally in the gall-bladder and 
vomit. They are not present in the tissues, except in the 
intestinal wall. 

A. process similar to cholera asiatica has been pro- 
duced by injecting a few drops of a bouillon culture of 
the comma bacilli into the duodenum of guinea-pigs. 
Under ordinary conditions the organisms cannot pass 
through the stomach, because they are destroyed by the 
gastric juice ; but if the stomach of a guinea-pig is made 
alkaline with about 5 c.c. of a five per cent. solution of 
soda, it remains so for several hours, and the organisms 
are not destroyed. It therefore becomes necessary, in 
order to infect guinea-pigs per os, to make the stomach 
alkaline, but it is also requisite to administer opium in 
some form so as to check intestinal peristalsis. Guinea- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


pigs treated either by injections into the duodenum, or 


by the introduction of cultures into the stomach, pre- 
pared as above, generally die with symptoms very much 
resembling cholera in man. But simple injections into 
the duodenum are not sufficient, for unless the intestine 
is somewhat roughly handled it does not react ; it seems 
necessary that there should be more or less bruising of 
the tissues. 

The bacilli are generally curved in the direction of the 
long axis, sometimes hanging together, forming a long 
or short spiral thread. The separate ‘‘commas” vary in 
length from 0.8 » to 2», and are about one-sixth to one- 
third as thick. Many of them are straight, especially in 
stained preparations. They possess independent motion. 
They may be colored with various dyes, but are not col- 
ored by Gram’s method. 

Colonies on gelatine at 22° C. (71.6° F.) in twenty-four 
hours are little white points; at this stage they appear 
under the microscope round, light-yellow, with an un- 
even, wavy outline and surface. They soon assume a 
glistening appearance, so that plate-cultures appear as if 
sprinkled with pulverized glass. The gelatine around each 
colony is liquefied to a slight extent. The liquefaction 
is not very rapid. In stab-cultures it liquefies all along 
the line of inoculation in two days, forming a funnel-like 
depression in the upper part of the gelatine. In this 
funnel-like depression there is generally the appearance 
as if an air-bubble were shut off in its upper part. The 
liquefaction finally extends till all the gelatine is lique- 
fied. It only grows at 30° to 35° C. (86° to 95° F.) on 
potatoes, forming a light-brown, slimy coating, which 
afterward changes to a grayish-brown. 

Spirillum of Finkler and Prior, and spirillum tyrogenum 
(Deneke). ‘These two organisms are of interest merely 
because of their resemblance to the cholera organism. 
Finkler and Prior’s organism was first found in the de- 
jecta which had been kept for some time from cases of 
cholera morbus. Deneke’s organism was found in old 
cheese. ‘The bacilli of the former are longer and thicker 
than the cholera bacilli, and are somewhat pointed at 
the ends. Deneke’s organism is a trifle smaller than the 
cholera organism, and the curve is sharper. The spiral 
threads of cholera are shorter than those of Deneke’s or- 
ganism, and longer than those found in Finkler-Prior’s 
organism. The colonies in gelatine of Finkler and 
Prior’s spirillum, and of Deneke’s also, have a sharp, 
smooth edge, and are dark colored. Finkler and Prior’s 
organism liquefies very rapidly, and Deneke’s occupies 
the middle place in this respect ; it liquefies much more 
rapidly than cholera, but less so than Finkler and Prior’s. 
Finkler and Prior’s organism grows readily at low and 
high temperatures on potatoes, and Deneke’s refuses to 
grow upon potatoes at any temperature. Neither of them 
seems to have as marked pathogenic properties as the 
cholera organism. Cholera bacilli are killed by drying, 
they require some moisture ; whereas Finkler and Prior’s 
bacilli may be thoroughly dried and retain their vitality 
for months. The addition of hydrochloric or sulphuric 
acid to a pure culture of the cholera spirillum produces 
a bright-red color (Bujwid). 

Spirillum Obermetert. Long spiral threads, 16 to 40 
in length. They are readily stained. Only found in the 
blood during the fever in cases of remittent fever. They 
have never beencultivated. Apes and human beings have 
been successfully inoculated subcutaneously with a small 
quantity of fresh blood from a patient suffering from an 
attack of the fever. It is only during the fever, when the 
spirilli are present, that the inoculations are successful. 

UNCLASSIFIED MICRO-PARASITES.—Actinomyces, or ray 
parasite, causes the disease from which it derives its 
name. Itis found in diseased foci in the tongue, jaw, 
lungs, etc., of cattle, producing in these animals the dis- 
ease known as ‘‘ swelled head.” The parasite is also ca- 
pable of infecting human beings. Under the microscope 
the parasite is seen to consist of a mass of club-shaped 
branches, more or less radiating from a central point. 
Bostrém claims to have succeeded in making cultivations 
by taking a portion of tissue containing the organism, 
and allowing it to remain a few days in nutrient gela- 


Schizomycetes. 
Schizomycetes. 


tine. He then took it out, and pressed it between two 
glass plates, so as to break it up, and inoculated it upon 
agar and blood-serum. He found that the ciub-shaped 
extremities of the branches were not capable of growth, 
and regards them as forms of involution. The central 
mass, composed of branching threads, grew well upon 
gelatine, etc., in the form of reddish-yellow knobs, with 
finely feathered margins and feathery projections. Old 
colonies are feathery all over. Cultures were said to be 
successfully inoculated upon animals. 

It is not decided whether this organism belongs to any 
of the classes described, but it is considered by Bostrém 
to belong to the higher form of bacteria. 

The protozoa are attracting ever-increasing interest 
from the fact of their occurrence in certain diseases. 
Since the investigations of Laveran, who first observed 
the malarial parasite, Marchiafava and Celli, Councilman 
and Osler, have all been able to find protozoic organisms 
constantly present in the blood from malarial patients. 
Dr. Councilman’s investigations are still in 
progress, but he has already established the 
following important facts: He divides the 
forms in which the organism occurs into two classes, 
the intracorpuscular forms and the free forms. The 
former are always found where the symptoms are of an 
intermittent type. They vary in size and appearance. 
The smallest of them are simply small hyaline proto- 
plasmic masses in active amceboid motion, contained in 
the red blood-corpuscles. They are not easy to see, be- 
cause they differ so slightly from the surrounding proto- 
plasm. They increase in size till they finally fill the 
blood-corpuscles in which they lie. They also become 
pigmented at the expense of the hemoglobin of the lat- 
ter ; the red corpuscles becoming paler as the pigmenta- 
tion of the organisms increases. Just before, or during, 
a chill the latter lose their hyaline appearance, and be- 
come coarsely granular; and the pigment, which up to 
this time is arranged in fine rod-like masses, becomes 
collected in the interior of the body. The protoplasm 
finally breaks up into the small round bodies mentioned at 
first. Theseare liberated along with the pigment. The 
latter is soon taken up by the white blood-corpuscles. 
This segmentation is so characteristic that a chill may 
be diagnosed with certainty two or three hours in ad- 
vance. 

The free forms, on the other hand, are met with in ma- 
larial cachexia. They vary in shape. Most of them are 
crescentic, but round and oval forms are also met with. 
These have highly refractive edges and a mass of pigment 
in the middle. The crescents are about once and a half 
as long, and one-third as broad,-as the diameter of a 
blood-corpuscle. 

But besides these forms is another, to which Council- 
man attaches most importance. This is a body about the 
size of a blood-corpuscle, and containing pigment gran- 
ules in active motion. Attached to the body are one or 
more narrow filaments three to six times as long as the di- 
ameter of a blood-corpuscle. These filaments are in ac- 
tive motion, and have little nodular swellings at various 
points; they also occur detached from the bodies above 
described. These filamented bodies are not often seen, but 
may be found in any of the forms of malarial infection. 

The blood drawn from the spleen always contains a 
greater number of organisms, especially the flagellated 
forms, than the blood drawn from the finger. And it is 
a very interesting fact that the intracorpuscular forms 
disappeared from the blood when forty-five grains of 
quinine were given for two successive days; whereas the 
other forms were only slightly, or not at all, affected by 
the same amount of quinine. : ; 

But the protozoa very probably cause epidemic dys- 
entery also. After they were observed by Koch in ex- 

Protozoa Cretions from the intestines of persons who 
in dysen- had died of dysentery in the tropics, Kartulis 
tery. found that amcebee were constantly present in 
this disease in Egypt, and emphasized their pathogenic 
power. Finally, Uplavici, after holding the opimlon for 
a long time that dysentery is a mycotic disease, convinced 
himself that it is caused by amcebe in Europe also.' 


Protozoa 
in malaria. 


341 


schizomycetes. 
Schwalbach, 


Mopes oF AccrpENTAL INFECTION.—The study of 
micro-organisms has thrown much light upon the way in 
which infection takes place in nature. Some organisms 
are capable of causing only diseases of the intestines ; 
another finds conditions favorable to its growth in the 
animal body only upon the mucous membrane of the 
urinary organs, etc., of human beings ; others produce 
disease when introduced merely under the skin ; and still 
others require to be deeply inserted, etc. 

But in many cases the mere presence of the organism 
is not sufficient to produce disease, there must be, besides, 
a predisposition on the part of the animal. It has been 
already stated that the spores of the anthrax bacilli, when 
taken in with the food and drink, cause the disease to start 
from the intestines, whereas the anthrax bacilli, when 
free from spores, are destroyed by the action of the di- 
gestive’ juices. From these facts it is apparent that, on 
the one hand, the power of resistance offered by an or- 
ganism to the action of the gastric juice, and, on the 
other hand, the condition of this juice—as, for example, 
the degree of acidity of the gastric juice—are important 
factors to be considered when infection occurs through 
the alimentary tract. Vegetative bacterial cells are prob- 
ably in most instances killed by the action of the normal 
stomach, so that, before there can be infection beginning 
in the intestines with non-spore-bearing bacilli, or with 
cocci, the function of the stomach must become impaired. 
It follows that all circumstances which impair the diges- 
tion are predisposing causes of infection. Experience has 
shown that what is popularly and vaguely described as a 
lowering of the tone or vitality of the body, whether by un- 
hygienic modes of life or by disease, is, in the case of many 
infectious diseases, an undoubted predisposing factor. 
Furthermore, there are often local predisposing causes of 
infection, such as abrasions, existing foci of disease, the 
presence of stagnating blood or other fluids, the existence 
of so-called dead spaces in wounds, etc. These local 
predisposing influences are of special importance in favor- 
ing infection with organisms which cause suppuration. 

Heredity acts in most cases merely as a predisposing 
cause of disease. In some cases there is a direct trans- 
mission of the organisms from the mother to the.offspring 
(see Bacillus of Sympathetic Anthrax), but this is excep- 
tional, and generally, when the influence of heredity is 
apparent, the offspring inherit a want of resisting power 
which need not be manifested by any anatomical peculi- 
arities, and they are liable to become infected at an early 
period of their existence. If such offspring are placed 
under conditions favorable to their vigorous development, 
the inherited predisposition may undoubtedly in many 
cases be Overcome. 

Although we are able in some instances to point out 
the nature of the predisposing factors, such as those 
already mentioned, it must be admitted that our knowl- 
edge on this point is very imperfect, and that while we 
are compelled to recognize the importance of predisposi- 
tion as an etiological factor, we cannot define the nature 
of this element. It is a curious fact that many races of 
animals have immunity from certain infectious diseases 
as a specific characteristic ; thus Algerian sheep, rats, 
and dogs are scarcely susceptible to anthrax (see also 
Mouse Septicemia, Glanders, etc.). Animals may ac- 
quire immunity from a‘disease by having suffered once 
from an attack of the same. Upon this rests the theory 
of preventive inoculation. It has already been mentioned 
that Pasteur was able to modify the virulence of certain 
organisms to such an extent that their inoculation pro- 
duced no apparent effect, and by carefully regulating 
this process of attenuation he—and others after him— 
have been able to produce such a modification of the 
virus that it is capable of producing only a mild disease, 
which is followed by protection of the animal from in- 
fection by the virulent organism. It has also been 
claimed that inoculation with the poisonous products, or 
ptomaines, produced by a virulent micro-organism, may 
be followed by protection from infection by the organ- 
ism; although this view has been advocated by Pasteur, 
as regards the protective inoculations against hydro- 
phobia, it cannot be considered as proven. 


342 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Pasteur’s anthrax vaccine is obtained by subjecting 
cultures to temperatures varying from 42° C. to 55° C. 
for a length of time, varying in inverse proportion to the 
temperature. According to Toussaint, an exposure to 55° 
C. for ten minutes ; according to Pasteur and Koch, one 
to 42° C. for twenty-eight to thirty days, suffices to de- 
prive the living bacilli of all pathogenic power. Chicken 
cholera, sympathetic anthrax, and Rothlauf cultures have 
all been modified in different ways, so that they could be 
used for protective inoculations. 

The organism of rabies has not been isolated, but Pas- 
teur makes inoculations with parts of the spinal cord of 
rabbits which have been previously inoculated from the 
spinal cord of arabid dog. If pieces of the spinal cord 
of an animal dead from rabies are kept in dry air, they 
gradually lose their virulence, till after seven days they 
can no longer produce the disease in rabbits. 

There is no doubt that preventive inoculations are pos- 
sible, but the methods have not yet been so perfected as 
to be of much practical use, or to find universal adop- 
tion. ; 

In summing up the factors which produce infection, 
it is seen that natural, .or acquired, predisposition is an 
essential condition. The organisms may gain access to 
the body in various ways. They may be introduced 
with the food and water into the alimentary tract, or 
they may be inhaled, or they may find their way through 
lesions in the skin, or they may enter the genito-urinary 
tract. 

As milk is not generally boiled, 7.e., sterilized, it af- 
fords a most dangerous vehicle of infection, along with 
all those articles of food which we are accustomed to 
use in an uncooked state, and those, too, which are left 
standing to be eaten cold. Such articles may easily be- 
come contaminated, and serve as an excellent nutrient 
material for micro-organisms. Water plays an impor- 
tant part, but since the pathogenic micro-organisms 
which have been tested do not multiply, or do so only to 
a limited extent, and for a limited time, in this medium, 
the danger of infection from drinking-water has often 
been exaggerated. This is less true, however, for sewage- 
water. 

Infection from unintentional contact with pathogenic 
micro-organisms, and from want of cleanliness, probably 
occurs much oftener than has been generally supposed. 
Infection from the air, on the other hand, is probably 
less frequent than is usually stated, for micro-organisms 
are specifically heavier than air, and many of them 
are destroyed by drying. Unless they are dry, it has 
been shown that they cannot be taken up into the air. 
Insects may doubtless be carriers of contagion. The 
wound made by a mosquito, which has a short time be- 
fore ted upon a diseased animal, would appear to be a 
most perfect inoculation. 

The mode by which pathogenic micro-organisms are 
eliminated from the body is doubtless of great impor- 

Mode of tance in determining the degree of contagion 
elimination Of infectious diseases. It has been shown by 
from the experiments of Wyssokowitsch that many mi- 
Pony cro-organisms are destroyed within the body, 
and that in general they are eliminated only from ex- 
cretory organs which suffer characteristic lesions from 
the presence of the organisms. It is apparent that when 
the specific micro-organisms are eliminated from the 
body only by the intestinal excreta (cholera, typhoid fe- 
ver), direct contagion is much less likely to occur than 
when the organisms are thrown off from the skin (va- 
riola, scarlatina, etc.). If the organism is not discharged 
at all from the body, as seems to be the case with mala- 
ria, direct contagion cannot well occur. 

We possess little positive knowledge as to the mode of 
action of pathogenic bacteria. Doubtless this action va- 

Mode of ries with different species of bacteria. In this 
action of connection the investigations, particularly those 
pathogenic of Brieger, are of interest which have demon- 
bacteria. —_ strated the production by bacteria of poisonous 
substances, obtained as crystallizable alkaloids, and known 
as ptomaines. ‘Thus Brieger has obtained from impure 
cultures of the tetanus bacillus various alkaloidal sub- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


. Schizomycetes. 
Schwalbach. 


stances which, injected into animals, produce symp- 
toms resembling tetanus (see p. 339). It is believed that 
the cholera bacteria also act through the agency of pto- 
maines. Other injurious effects attributable to the ac- 
tion of bacteria are various local lesions, such as inflam- 
mation, necrosis, hemorrhages, occlusion of ‘blood-ves- 
sels and lymphatics, etc. In certain diseases the bacteria 
are present in the blood and other tissues in such enor- 
mous numbers that there is reason to believe that they 
may destroy life by the appropriation, at the expense of 
the body, of nutriment, particularly of oxygen. 

On the other hand, much interesting work has been 
done to determine in what way the animal body reacts 
against the attack of micro-organisms. Metschnikoff '® 
holds that the white blood-corpuscles eat up the bacteria. 
This view is based upon experiments in which he inocu- 
lated frogs and other animals with anthrax bacilli. He 
found in the warm-blooded animals which were suscep- 
tible, that when virulent material was used only a few leu- 
cocytes took up the bacilli. But, on the contrary, when at- 
tenuated virus was used, or when the animals were insus- 
ceptible (white rats, frogs, and a rabbit, which was found 
to be immune), the leucocytes take up nearly all the ba- 
cilli. This may occur at the seat of inoculation, in the 
blood and in various organs, particularly the spleen and 
the liver. The time required for the leucocytes to take up 
the bacilli was found to vary in different cases. Moreover, 
after the bacilli were taken up by the leucocytes, it was 
observed that the former degenerated and died. These 
experiments were repeated and supplemented by Hess,'® 
who was able to’ substantiate Metschnikoff’s observa- 
tions. Besides inoculations in the usual way, Hess made 
use of a Ziegler cell. This cell consists of a cover-glass 
cemented to a slide of equal size, so that there remains a 
capillary space between, open upon one side. Hess inocu- 
lated cells of this sort with anthrax bacilli, and inserted 
them under the skin of various animals. He noticed, 
in the case of immune animals, that the redness and cde- 
ma at the point of insertion were much more marked than 
in the case of susceptible animals. After allowing the cells 
to remain various lengths of time, Hess removed them, 
and examined them immediately with the microscope. 
He then allowed them to dry, and stained them with- 
out first passing them through the flame. He found that 
in immune animals most of the bacilli had been taken 
up by the white blood-corpuscles, and were more or less 


broken up; the relatively few bacilli which had not been. 


taken up by the leucocytes were unchanged. The bacilli 
contained in leucocytes were never found in chains, they 
were always separate bacilli. This, in brief, is the phago- 
cytosis hypothesis, and it seems very plausible ; for it is 
well known that the leucocytes take up pigment gran- 
ules, etc. But some observers (Wyssokowitsch, Fligge, 
Hanau, Klebs) have come to quite different conclusions. 
They have not been able to find the leucocytes loaded with 
bacteria in such relatively large numbers as have Met- 
schnikoff and Hess, and where they have found them 
they contend that the bacteria have attacked the leuco- 
cytes, and not the reverse. 


LITERATURE. 


The following works may be cited as serviceable for those who wish 
to acquaint themselves with the results and methods of modern bacterio- 
logical work : ; 


Koch: Zur Untersuchung von Pathogenen Organismen. Mittheilungen 
aus dem kaiserlichen Gesundheitsamte, Bd. I. Berlin, 1881. 


Fliigge: Die Mikro-organismen, 2te Auflage. Leipzig, 1886. (The most 
complete work on the subject.) 

Frinkel: Grundriss der Bacterienkunde. Berlin, 1887. 

Hueppe: Die Methoden der Bacterienforschung. Wiesbaden, 1886. 


(This work has been translated into English by Dr. Herman Biggs.) 

Loffler: Vorlesungen wber die geschichtliche Entwickelung der Lehre 
von den Bacterien, Erster Theil. Leipzfg, 1887. 

Cornil et Babes: Les Bactéries, 2me édition. Paris, 1886. 

Duclaux: Chimie Biologique. Paris, 1853. (Contains the methods and 
results of Pasteur’s work. ) 

Crookshank: Manual of Bacteriology, 2d edition. New York, 1887. 

Baumgarten: Jahresbericht tiber die Forschritte in der Lehre von den 
Pathogenen Micro-organismen. Braunschweig. (This report is pub- 
lished annually, beginning with the year 1885.) 

Koch-Fligge: Zeitschrift fiir Hygiene. Leipzig. (This journal was 
founded in 1886, and is devoted mainly to bacteriology. It is pub- 
lished at irregular intervals, about three or four numbers a year.) 

The Centralblatt fiir Bacteriologie und Parasitenkunde, published in 


Jena, and the Annales de l'Institut Pasteur, published in Paris, are 
Dawe devoted to the considevation of bacteriology and of parasitic 
iseases. 


Meade Bolton. 

1 Paul Liborius: Zeitschrift f. Hygiene, Bd. I., p. 115, 1886. 

2 Friedlander ; Microscopische Technik, Berlin, 1884; translated by Coe. 

3 Zeitschrift f. Hygiene, Bd. II., p. 234 et seq. 

4 See Bender et al. in Centralblatt f. Bact., etc., Bd. I., p. 563 and 236. 

5 Zeitschrift f. Hygiene, Bd. I., p. 178 et seq. 

§ Hochsinger : Centralblatt f. Bact. u. Parasitenkunde, Bd. II., p. 177 
et seq. 

7 Bonome ; Fortschritte d. Medicin, November 1, 1887, p. 690 et seq. 

8 Baumgarten’s Jahresbericht, 1886, foot-note, p. 372. 

ices aus d. kaiserlichen Gesundheitsamte, Bd, II. 

id. 

11 Second Annnal Report of the Bureau of Animal Industry for the 
year 1885. Washington, 1886. Also, Salmon and Smith, Am. Monthly 
Micros, Journal, November, 1886. 

12 Zeitschrift f, Hygiene, Bd. I., p. 862, 1886. 

13 Hscherich: Centralblatt f. Bacteriologie, etc., Bd. I., p. 705 et seq. 

‘4 Virchow’s Arch., Bd. CV., Heft 3; also, Centralblatt f. Bacteriologie, 
etc., Bd. I., p. 587 et seq. 

15 Virchow’s Archiv f. Path. Anatomie, Bd. XCVI. u. XCVII. 

LSMbid. 3) Ba. OLX. un Gx. : 


SCHLANGENBAD is a thermal spa in Hesse-Nassau, 
Prussia. It lies in a picturesque valley at an elevation 
of about 1,000 feet above the sea. The water contains a 
very small proportion of mineral constituents, chiefly 
sodium chloride and sodium carbonate. The tempera- 
ture of the different springs varies between 83.5° and 92° 
F. The water is used chiefly for baths, though it is also 
employed occasionally for drinking. Employment is also 
made of goats’ milk, whey, and herb juices. Schlangen- 
bad is visited chiefly by women suffering from uterine 
troubles, and from excessive nervous irritability. The 
season extends from the middle of May to the first of 
October. Pelee 


SCHOOLEY’S MOUNTAIN SPRINGS. Location and 
Post-office, Schooley’s Mountain, Morris County, N. J. 

AccrEss.—By the Delaware, Lackawanna & Western 
Railroad to Hackettstown, thence by stage two and one- 
half miles to the springs. 

Anatysis (C, McIntire, Jr.).—One pint contains : 


Grains, 
Carbonate, of S00 Reins. cecnlen oe eit le teeters eee 0.072 
Carbonate or mapnesia.: sc cscs tee ke eaten a tee eee 0.200 
Garbonatesof iron aca of Sele eee oi ee 0.072 
Carbonate of manganesesy, .. 5s ae sme eases ene eee: cee trace 
Carbonate ob limes jer 2. ne soe er oe eee eee 0.178 
WhlOKideroL SOdi WM ee et eae ete ee ihe ate 0.054 
Snlphate:ofdimere iss eaals com ora eeeetistared sretegarere: 0.210 
PA TUTIN a ie tah eee see ae een Oe ree era 0.018 
AMMONIA Fees A hone eo ecto iva eed ala leters letersi tae ener trace 
SiIGI CACO Fess sie seer eee he eet are en etmoete aioe rant teste 6,092 
Toba let ae cote Saree oe Se ee ee tothe aye oe e ore 0.896. 
Carbonic acid! gasson. oma. ece is ects. not determined. 


THERAPEUTIC PROPERTIES.—This is a very mild alka- 
line-chalybeate-carbonated water. The small proportion 
of salts which it contains, together with the carbonic acid 
gas, renders it a very pleasant and efficient tonic. The 
discharge is small, about thirty gallons per hour. The 
temperature is 50° F. 

These springs are situated among the mountains of 
Northern New Jersey. They have long been a popular 
summer resort, on account of the beauty and healthful- 
ness of their surroundings and their accessibility. There 
are several well-appointed hotels. 

George B. Fowler. 


SCHWALBACH is a spa situated in the province of 
Hesse-Nassau, Prussia. It lies in the valley of the Miin- 
zenbach, about twelve miles from Wiesbaden, and five 
miles from the health-resort Schlangenbad. Its elevation 
is 972 feet above sea-level, and as it is well proteeted 
against all but the southerly winds, its climate is mild 
and well suited for invalids. There are eight mineral 
springs at Schwalbach, known as the Wein-, Stahl-, 
Rosen-, Paulinen-, Ehe-, Neu-, Linden-, and Adelhaid- 
Brunnen. There is but little difference in the compost- 
tion of the waters of these springs. The following is the 


343, 


Schwalibach. 
Sciatica. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


analysis of two of the springs, as made by Fresenius. In 
1,000 parts there are, of 


Weiu-Brunnen. Linden-Brunnen. 


Ferrous bicarbonate.............. 0.057801 (0.009902 
Manganous bicarbonate .......... 0.009085 0.004680 
Sodium bicarbonate. 2....-....0-- 0.245345 ().042317 
Oalcium: bicarbonate en. ee} ee 0.572129 0.429277 
Magnesium bicarbonate ...... ... 0.605120 0.395267 
Ammonium bicarbonate sss... 0.. 0 ces... 0.002205 
Lithiumebicarbonatew ssa: eee eee eee 0.002083 
Strontium bicarbonate ..... Sa aA 0.001048 
Sodium ‘chloride fos ae eee 0.008630 0.017622 
Hodiumisuiphateds cet esete are 0.006193 0.016156 
Potassium sulphate .............. 0.007469 0.006414 
Sodinm nitrate... 2. aperias cane nee eee 0.005541 
Sodium phosphate..............- trace 0.000488 
Alamininm phosphatersisess a eeommae ean = 0.000197 
Siiciciacid access ee ee ee eee 0.046500 0.082821 
Organicumatter, etc inc serene 0.000046 0.000003 
Total Soudse fe ase tee oe ee 1.558818 0.965921 


The gases are carbonic acid and a very small propor- 
tion of sulphuretted hydrogen. 

Schwalbach is a favorite health-resort, and is visited 
by several thousand guests every year. The diseases for 
the relief of which a course of treatment at this spa is rec- 
ommended are anemia and chlorosis, epilepsy, chorea, 
progressive muscular atrophy, neuralgia, neurasthenia, 
hysteria, and other functional and organic nervous disor- 
ders, Bright’s disease, diabetes mellitus, chronic vesical 
catarrh, and various affections of the female sexual or- 
gans. 

The waters are employed externally and internally, 
according to the individual indications, and facilities are 
afforded for pine-needle, mud, vapor, and other baths. 
The season lasts from May to October. There are ex- 
cellent accommodations for visitors. tBAb weh 


SCIATICA. ErroLocy.—Sciatica differs from the large 
majority of neuralgias in the fact that it comparatively 
seldom results from constitutional conditions. 

According to most writers, it is much more frequent 
in men than in women. 
occurred in males, 14 in females. Erb reports 40 males, 
10 females; Eulenburg, 54 males, 17 females. Arnoldi 
is the only one of large experience who arrives at other 
results. Among 388 cases he found 172 males and 166 
females. This experience is entirely exceptional, and 
undoubtedly does not hold good for the general run of 
cases. 

Sciatica is a disease of middle and advanced life. 
Among my 53 dispensary cases 1 was twelve years of 
age; 7 were between twenty and thirty years of age; 10 
between thirty and forty years ; 18 between forty and 
fifty years; 7 between fifty and sixty years; 7 between 
sixty and seventy years ; and 3 between seventy and sev- 
enty-five years of age. If we take into consideration the 
rapidly diminishing number of people after the age of 
fifty years, it is evident that the disease grows relatively 
more frequent beyond this period of life. Prior to the 
age of early manhood, sciatica is one of the most infre- 
quent of all forms of neuralgia, and it began at this time 
in only one of my cases. Caussays reports two cases at 
the ages of seven and eight years, respectively. 

The ordinary predisposing causes of neuralgia have 
comparatively little influence on the development of sci- 
atica. This is particularly true of heredity, usually so 
potent in the etiology of neuroses. Very many writers 
ascribe no influence whatever to this cause, and Anstie 
appears to be almost the only writer who attaches any 
importance to it. In my own experience, a few cases 
have occurred in which the disease appeared to alternate 
with other forms of neuralgia, or in which the patients 
had suffered, at some previous time, from other neuroses ; 
but, on the whole, the neuropathic influence appears to 
have had very little to do with the etiology of the affec- 
tion. 

Anemia and other conditions of exhaustion likewise 
have less effect in the production of sciatica than in that of 
other neuralgias. The patients are often in perfect health 
at the onset of the attack, but the latter often has a de- 
pressing effect*on the general condition if the pain con- 


344 


Among 53 of my own Cases, 39 * 


tinues severe for a long time. In a considerable number 
of cases, however, the sciatica begins at an advanced age, 
when the tissues of the body have begun to undergo se- 
nile involution. Anstie lays stress upon the fact that the 
disease is frequent in those who break down at an early 
period in dife, although they may present the outward 
appearances of excellent health. 

The disease has long been supposed to be intimately 
related to rheumatism—in the narrow as well as in the 
more vague and wider sense—but the fact of such con- 
nection is by no means well established. It is true that 
many of the patients suffer at times from muscular rheu- 
matism, that sciatica begins not infrequently with an at- 
tack of lumbago, and that the supposed causes of ‘‘ rheu- 
matism ” act unfavorably in sciatica; but further than 
this nothing can be said of the connection between the 
two diseases. ) 

The term ‘‘ gouty sciatica” is sometimes applied to the 
disease when it occurs in gouty subjects, and it is said, 
at times, to take the place of the ordinary gouty par- 
oxysm. It is doubtful, however, whether sciatica, when 
it occurs under such circumstances, should not be attrib- 
uted to the portal congestion, constipation, and hzemor- 
rhoids which are so common in gout. 

Infectious diseases are an infrequent cause of sciatica. 
Syphilis is probably the most important factor in this 
category, but it is likewise a rare cause. Sciatica may 
develop during the early or later stages of constitutional 
syphilis, and may or may not be associated with the for- 
mation of gummata along the course of the nerve, or in 
the surrounding tissues. This form is characterized by 
the tendency to nocturnal exacerbations, and by its ready 
amenability to antisyphilitic treatment. We must exer- 
cise caution here, however, inasmuch as non-specific 
sciatica occasionally acts in the same way, and the sus- 
picion of the specific origin of the disease cannot be made 
a certainty unless other evidences of syphilis are present. 
R. W. Taylor, who has gone exhaustively into the litera- 
ture of syphilitic sciatica, has been able to find very few 
authentic cases. He reports four personal cases, in one 
of which sciatica developed during the first year after 
inoculation ; in the second it was associated with gonor- 
rhoeal rheumatism and epididymitis, and was only com- 
plicated with syphilis at a subsequent period ; in the 
third it followed extensive gummata and hemiplegia; in 
the fourth there was gummous infiltration in the gluteal 
region, probably producing compression of the nerve. 
It is not certain, from the history of the latter case, that 
the pain was really neuralgic. 

Malaria is also an infrequent cause of sciatica. Cases 
have been published in which the neuralgic attack re- 
placed the malarial paroxysm. In these cases the pain is 
sometimes confined to a small branch of the nerve. 

A number of cases have been reported after typhoid 
fever, especially during the period of convalescence. In 
one of my patients the neuralgia began during conva- 
lescence from diphtheria, and proved unusually intract- 
able to treatment. 

In rare cases sciatica is one of the symptoms of lead 
or mercurial poisoning. Although I have seen pains in 
the lower limbs develop under such circumstances, no 
case of genuine sciatica due to this cause has come under 
my observation. I have seen violent sciatica so often 
in cases of acute alcoholism that the question has arisen 
whether there is not some causal relation between the 
two conditions. But alcoholism may be attended with 
so many unknown factors which might give rise to sci- 
atica (exposure, compression of the nerve, injury, etc.) 
that I have not been able to arrive at a positive conclu- 
sion. 

External agencies, such as muscular effort, trauma- 
tism, and exposure, possess an unusual degree of influence 
in the development of sciatica as compared with other 
neuralgias. The disease is much more frequent in New 
York City during the damp, wet months, and a relapse 
is also much more apt to occur at such times. For this 
reason it is not uncommon among laborers who work in 
ditches, cab-drivers, and others whose occupation neces- 
sitates constant exposure in all weathers. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Schwalbach, 
Sciatica. 


Muscular effort is sometimes the only ascertainable 
cause of the disease. In some instances it follows the 
muscular strain at once, and may begin with its full se- 
verity. An instance of this kind has come under my ob- 
servation. 

Injuries, in the shape of blows, falls, gunshot wounds, 
etc., may give rise to sciatica, as well as to other forms 
of neuralgia. We may also include under this heading 
all cases in which the disease results from pressure due 
to local processes in any part of the course of the nerve, 
from its spinal origin to its terminal branches. Among 
these may be mentioned the following: Spondylitis de- 
formans, cancer of the vertebre, gummata of the dura 
mater, neuromata within the spinal canal, intrapelvic tu- 
mors, the use of forceps during delivery, exudations into 
the broad ligaments, accumulation of hardened feeces in 
the rectum, pressure upon the nerve by a popliteal aneu- 
rism, neuromata, syphilitic and other tumors of the nerve 
or adjacent parts, etc. 

In very many cases sciatica is associated with chronic 
constipation and hemorrhoids. In such cases it is prob- 
able that the dilatation of the hemorrhoidal veins is a po- 
tent etiological factor. In a patient under my observa- 
tion at the present time, the disease developed under these 
circumstances, the venous congestion being still further 
increased by dilatation of the heart. 

Sciatica is sometimes seen during the course of dia- 
betes, and is then bilateral. Some authors have also no- 
ticed that temporary glycosuria may develop during an 
attack of sciatica. 

In rare cases sciatica is the result of reflex irritation. 
It may accompany various affections of the bladder and 
uterus, orchitis and epididymitis, stricture of the urethra, 
or worms in the intestines. Gonorrhea plays the most 
important part among thisclass. It is often complicated 
with gonorrhceal rheumatism, but sometimes alternates 
with the latter affection. 

But when all is said, we meet with not a few cases in 
which the most patient examination fails to reveal the 
cause of the malady. 

CLINICAL History.—Sciatica is usually preceded by 
prodromal manifestations, though it sometimes begins 
suddenly with full severity. Thus, an individual bend- 
ing over to lift a heavy weight may be seized with the 
pain along the course of the nerve before he has time to 
straighten up. In the large majority of cases, however, 
acute pain does not begin at once. The disease is often 
preceded—sometimes for quite a long time—by an attack 
of ordinary lumbago. Gradually the pain spreads to the 
upper and back part of the thigh, at the same time los- 
ing its myalgic character and becoming sharp and par- 
oxysmal. The limb often feels weak before the pain has 
attained any notable intensity. Perhaps there is slight 
numbness, or a feeling of coldness or weight in the limb. 
After a variable length of time the severity of the pain 
increases, and finally the paroxysms may become intoler- 
able in their intensity. When this stage is reached the 
limb is usually held in a characteristic position. The 
thigh is somewhat flexed on the abdomen, and the leg on 
the thigh; the heel is raised from the floor. A corre- 
sponding position is assumed in bed, the limb being us- 
ually supported upon the opposite one. In walking, the 
limb is moved stiffly and gingerly, the weight being borne 
as much as possible on the opposite limb. 

The duration of the disease may vary from a few days 
(rarely less than a week or two) to twenty or thirty 

ears. 

We will now enter upona more detailed consideration 
of the symptoms. 

Sciatica not only occupies a somewhat isolated posi- 
tion among neuralgias as regards etiology, but the pain 
also differs in certain respects from that of other neural- 
gias. The severity of the pain is generally moderate, 
though in some cases it is unendurable, so that the pa- 
tient writhes upon the bed and screams out in agony. 
As a general thing, however, the sufferer keeps as quiet 
as possible, with the thigh flexed on the abdomen and 
the leg on the thigh. But he is often unable to maintain 
one position for any great length of time, on account of 


an intolerable restlessness in the limb. The pain is gen- 
erally most severe in the back of the thigh and the region 
of the hip. At the height of the paroxysm it is apt to 
radiate into the area of distribution of the crural nerve, 
more rarely into that of the lumbo-abdominal nerve, 
The crural pain is sometimes hardly exceeded in vio- 
lence by the sciatic pain itself. The distribution of the 
nerve to the leg and foot may alone be affected in some 
cases, and among others of the kind which have been 
reported we have also seen a case in which the pain was 
confined to the sole of the foot (plantar neuralgia). 

The pain is of a shooting character, apparently from 
above downward in the majority of cases, though it is 
difficult for the patient to determine its direction. But 
the disease differs markedly from other neuralgias in the 
fact that there are usually pronounced and constant pain 
and tenderness along the course of the nerve. This steady 
pain is sometimes extremely annoying. The tenderness is 
not confined to the painful-points (puncta dolorosa), but 
seems to be located along the entire course of the nerve. 
The following are the locations of the painful points: 1, 
A gluteal point, beneath the gluteal fold, midway be- 
tween the trochanter major and tuber ischii; 2, a point 
at the emergence of the nerve from the sciatic foramen ; 
3, & point at the posterior superior spinous process of the 
ilium ; 4, one or two popliteal points at either side of the 
popliteal space ; 5, a fibular point behind the head of the 
fibula; 6, two malleolar points, one at the posterior part 
of each malleolus. 

The motor symptoms consist of paresis and spasms of 
the limbs. After severe sciatica has lasted for some time, 
the muscles of the entire limb undergo a certain degree 
of atrophy, and in a couple of months the circumference 
of the thigh and calf may be nearly an inch less than that 
of the corresponding parts of the other limb. This ap- 
pears to be the result of the relative disuse of the limb, as 
is shown by the fact that the muscles supplied by the an- 
terior crural nerve are also wasted. In rarer cases the 
limb undergoes a certain degree of rapid atrophy which 
is not explicable in this manner, and is usually attributed 
to an implication of the trophic fibres of the nerve in the 
neuralgic process, or to a reflection of the irritation to the 
large ganglion-cells in the anterior horns of the spinal 
cord, from which the nerve takes its origin. 

In walking, the patient favors the affected limb as 
much as possible, and holds it quite stiffly on account of 
a slight degree of contracture of the muscles. It has 
seemed to me that the limb, as a general thing, is really 
weaker than its fellow, and that there is not merely ap- 
parent weakness due solely to the severity of the pain 
excited by movement. 

Motor spasms do not play a very prominent part in the 
history of the disease. Patients sometimes tell us that 
they suffer, especially at night, from cramps in the calf 
of the leg, and in rarer cases from twitchings of the en- 
tire limb. 

C. Handfield Jones has reported a peculiar case of left 
sciatica of ten years’ standing. At first the knee-jerk was 
absent in both legs. After a time it appeared in the right 
leg, and later, after improvement in the pain had set in, 
it reappeared in the left leg. The patient had become an 
opium-eater. So far as I know, this instance of the dis- 
appearance of the knee-jerk in sciatica is unique, and it 
is impossible to determine whether it stands in any causal 
relation to the neuralgia. 

It has been stated by Eulenburg that the faradic irrita- 
bility of the nerve is often diminished, and that the gal- 
vanic irritability also undergoes changes which may even 
amount to a reversal of the normal formula of contraction. 
Legros and Onimus state that they have observed in- 
creased faradic contractility in recent sciatica, and di- 
minished contractility in old sciatica. Changes of such 
a character do not seem to have been seen by other writ- 
ers, and it is very questionable whether they occur in 
true sciatica. 

Various disturbances of cutaneous sensibility are often 
noticed. In the majority of severe cases tactile sensibil- 
ity is blunted to a slight extent, but marked anesthesia 
is rare. Hyperesthesia is still rarer, and is usually con- 


345 


Sciatica. 
Sclera. 


fined to circumscribed portions of the skin. Both forms 
of disturbed sensibility may be present at the same time. 

The patients often complain of abnormal sensations in 
the skin, such as a feeling of cold, more rarely of heat, 
formication, tingling, etc. These sensations are often pres- 
ent, although tactile sensation is not affected. 

The appearance of the integument is often changed. 
The skin may be pale and anemic; it is frequently colder 
to the touch than the opposite limb ;. perspiration is usu- 
ally diminished, though it is sometimes increased. These 
disturbances are probably the result of vaso-motor 
changes in the affected limb. 

Trophic changes are rare. Apart from the muscular 
atrophy, to which reference has already been made, they 
include increased growth of hair in the area of distribu- 
tion of the affected nerve, and rarely certain cutaneous 
eruptions, such as herpes, erythema, and furuncles. In 
very exceptional instances hypertrophy of the muscles 
of the thigh and calf has been observed. These trophic 
changes play a much less important part in the history 
of sciatica than they do in that of other neuralgias. 

The paroxysms of pain come on at irregular intervals, 
and rarely present the periodicity which is so often a strik- 
ing feature of other neuralgias, even when they are non- 
malarial in origin. They may be brought about by numer- 
ous exciting causes, such as the movements of coughing, 
straining at stool, turning in bed, etc. If the disease lasts 
for any length of time, the paroxysms are apt to occur 
with greater frequency but less severity, until finally the 
patient suffers constantly from pain and the disease en- 
ters the chronic stage. 

DraGeNnosis.—The diagnosis in typical cases is usually 
very easy. The situation and character of the pain, its 
occurrence in paroxysms, the presencé of painful points, 
the slight disturbance, as a rule, of motion and sensation 
—all show clearly the nature of the disease. Lazarevic 
mentions as a pathognomonic sign that there is increased 
pain and tenderness on extending the knee and ankle 
and flexing the thigh on the abdomen. He believes that 
this is owing to the elongation of the nerve produced by 
this manipulation. 

We should not remain satisfied with the mere diag- 
nosis of sciatica, but should at the same time endeavor 
to discover the cause of the attack. In order to do this 
we must go into the previous history of the patient and 
the mode of development of the neuralgia, and, if this is 
unsuccessful, should carefully examine the adjacent or- 
gans along the course of the nerve, bearing in mind the 
various processes, mentioned in the section on etiology, 
which may give rise to the disease. As in all other forms 
of neuralgia, however, we shall meet with not a few cases 
in which it is impossible to ascertain the cause. 

Easy as the diagnosis is in many cases, in others it is 
extremely difficult. Perhaps no condition offers greater 
difficulties in this respect than rheumatoid arthritis of the 
hip-joint. Jonathan Hutchinson even goes so far as to 
claim that nine-tenths of the so-called chronic cases of 
sciatica are really cases of rheumatoid arthritis. Al- 
though I admit that the differential diagnosis may be very 
difficult, and a number of cases of errors in diagnosis have 
come under my own observation, I am convinced that 
Hutchinson’s statement is greatly exaggerated. In rheu- 
matoid arthritis the pain is usually by no means so severe 
as in sciatica, and it is not confined so exclusively to the 
distribution of the sciatic nerve. Equally severe pain is 
felt along the crural, and especially the genito-crural, 
nerve. On making passive motion at the hip-joint, it 
will be found that flexion is limited in amount, and, after 
the limb is bent on the abdomen to a certain extent, fur- 
ther flexion is impossible without tilting the pelvis. Ro- 


tation at the hip-joint is also interfered with. In some 
cases rough creaking can be felt in the joint. The an- 


kylosis in these cases may be either true or false. 

In rare cases sciatica may be mistaken for hysterical 
hip-disease (Brodie’s joint). In the latter disease there 
is remarkable tenderness on the slightest pressure of all 
the parts surrounding the joint, but uniform, strong com- 
pression often feels grateful to the patient. The pain 
is more diffuse than in sciatica, and the patient is gener- 


346 


~ the parts mentioned above. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


ally a young woman who presents other manifest evi- 
dences of hysteria. Brodie’s joint is, moreover, much 
more apt to be mistaken for true morbus coxe than for 
sciatica, 

When the sciatica is bilateral, it must be differentiated 
from locomotor ataxia. The very fact that the disease 
is bilateral should arouse our suspicions. But the pains 
of ataxia possess more of a fulgurating character than 
those of sciatica, are more irregular in their distribution 
and mode of onset, and are generally accompanied by 
more marked sensory disturbances. With very rare ex- 
ceptions, the patellar tendon reflex is absent in ataxia, but 
too much reliance should not be placed on this sign, in- 
asmuch as there are not a few healthy individuals in 
whom this reflex is absent. In addition, the pains of 
ataxia are usually accompanied by some of the other 
symptoms of ataxia (the characteristic gait, bladder dis- 
turbances, cincture feeling, Argyll- Robertson pupil, 
CtG,). 

Myalgia, or ‘‘ rheumatism” of the muscles of the but- 
tock and thigh, must also be excluded. The pain is some- 
times of a darting character, but does not shoot along any 
particular nerve. The characteristic puncta dolorosa of 
sciatica are not present. The patient has, perhaps, often 
suffered from myalgia in other parts of the body. The 
pain is absent when the patient lies down and keeps the 
parts perfectly quiet. Moreover, this condition usually 
is much more amenable to treatment than sciatica. 

Proenosis.—Recovery from sciatica sometimes takes 
place in a few days, but, as a rule, several weeks at least 
elapse before the pain disappears completely. The dis- 
ease also exhibits a very decided tendency to relapse. 
For months, and sometimes even for years, after an at- 
tack of ordinary severity, the patient is liable to have an 
occasional twinge of pain in the limb after any unusuak 
exertion, exposure, or slight injury. In nota few cases. 
the relapses occur at gradually shorter intervals of time, 
and the disease finally becomes chronic. In rarer cases 
the first attack continues for an indefinite period. This 
is’ particularly true of those cases in which the disease 
begins at an advanced period of life, or in which the pa- 
tients exhibit the signs of early senility. But the obsti- 
nacy of the affection does not always appear to depend 
upon impairment of the general condition. It is often 
extremely severe and intractable to treatment in robust 
individuals, who are otherwise apparently in perfect 
health. 

TREATMENT.—AS in all other diseases which exhibit 
a tendency to run an obstinate or even chronic course, 
the number of remedies employed in sciatica is legion. 

Our first object should be to ascertain the cause of the 
attack and to combat the primary disease by appropriate 
measures (antisyphilitic, antirheumatic, antimalarial rem- 
edies, etc.). But in the majority of cases we must adopt 
a purely empirical treatment. It is well to begin by ad- 
ministering a cathartic and by securing sufficient daily 
evacuations from the bowels. 

In my experience electricity, strychnine, and baths 
have been the most effective curative agents. 

Of the various kinds of electricity I now employ only 
galvanism. It is usually applied as the stabile descend- 
ing current, or by the polar method. In the former 
method the anode is placed upon the sacrum or lower 
lumbar vertebre, the cathode to the puncta dolorosa; or 
if none is present, to the most accessible portions of the 
nerve (sciatic foramen, between the trochanter and ischi- 
um, along the thigh, or in the popliteal space). Or the 
anode, instead of being kept on the sacrum throughout 
the entire sitting, is shifted to the part first occupied by 
the cathode at the end of three or four minutes, the 
cathode being moved to the next lower point, and the . 
whole length of the nerve is then traversed in this way. 
I have not noticed any difference in the results, however, 
whether the cathode was applied above or below. In the 
polar method the cathode is applied to the middle of the 
back or front of either thigh, the anode successively to 
The sponges should not be 
too large, and the current must be of sufficient strength 
to cause severe pain. In fact I have found, as a rule, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sciatica. 
Sclera, 


that the stronger the current is, the more marked and 
lasting is the effect. At the end of the sitting the current 
may be interrupted a few times in order to produce mus- 
cular contractions. This is often very effective in dimin- 
ishing the stiffness of the limb. The sittings should last 
about ten minutes, and be held daily, or every other day. 

The faradic current has also been used, either with the 
wire brush applied to the painful points, or as a strong 
current through the entire course of the nerve. In sev- 
eral cases, however, we have seen the pain aggravated by 
this current, and have now abandoned its use. 

Electrical applications often produce prompt and 
marked relief. ‘The pains subside very rapidly, the free- 
dom of motion is very much increased, and in favorable 
cases a permanent cure is effected after a few sittings. 
In very few cases have I failed to obtain at least some 
temporary improvement. 

Strychnine should be given in initial doses of 23 grain 
three times a day, the dose being increased rapidly to the 
point of tolerance by the patient. This drug often pro- 
duces gratifying results if given in sufficiently large 
amounts, but it is by no means as efficacious as galvan- 
ism. It may, or may not, be combined with the use of 
electricity. 

I have always employed, baths in the form of hot sitz- 
baths, and always as an adjuvant to other methods of 
treatment. The water should be as hot as the patient 
can bear, and the baths should last for five or six min- 
utes. They may be repeated once or even twice a day, 
and are often followed by a certain amount of relief. 
If taken at bedtime they may enable the patient to obtain 
refreshing sleep. 

Local irritation is also a valuable adjuvant in some 
cases. It may be produced by blisters, or by the actual 
cautery. Some writers even recommend the production 
of a blister by the application of a sufficiently strong cur- 
rent of galvanism, but this causes an unnecessary amount 
of pain. Itis sometimes advisable to apply the blisters 
in successively lower positions, until the entire upper part 
of the nerve has been treated in this way. The actual 
cautery is to be applied lightly over the course of the 
nerve, since the production of an eschar is not necessary 
to the relief of the pain. 

Among other non-medicinal agents massage has also 
been employed. Schneller has recently reported fifteen 
cases treated in this way with successful results. The 
average period required to effect a cure was two and a 
half weeks. Huenfault reports the cure in two weeks, 
by massage, of a case which had resisted all other meth- 
ods of treatment. 

Favorable results have also been reported from congela- 
tion of the entire limb by means of chloride of methyl. 

Hypodermic injections of various substances, such as 
cold water, ether, nitrate of silver, cocaine, osmic acid 
(3 ss.—j. of a one per cent. solution) into the nerve have 
also been used, but the results are not very gratifying. 
It should be remembered that abscesses occur not infre- 
quently from this method of treatment. 

Numerous drugs are employed occasionally in obstinate 
cases, viz., morphine, arsenic, quinine, iodide of potas- 
sium, aconitine, atropine, gelsemium, and turpentine. 

When the pain is intolerable we are often compelled 
to give a hypodermic injection of morphine in order to 
secure temporary relief. In rare cases a single injection 
is followed by marked permanent benefit. But this rem- 
edy should be used as sparingly as possible, inasmuch as 
we are unable to determine in advance the duration of 
the disease, and the patient may fall into the opium habit 
in consequence of its protracted administration. A case 
of this kind is now under my observation. 

Aconitine sometimes produces excellent results, but its 
effects are far inferior in sciatica to the brilliant results 
so often obtained in trigeminal neuralgia. Arsenic will 
often be found a useful remedy in this disease, especially 
in the chronic cases occurring in old people. The same 
remark may also be made of iodide of potassium. I have 
seen very little benefit from the other remedies mentioned 
above. 

Finally, surgical interference may be resorted to, 


Fayrer reports a case of aggravated sciatica of long 
standing, in which there were fulness and tenderness in 
the course of the nerve near its origin, in the upper part 
of the limb, together with a sense of fluctuation. A long, 
narrow knife was introduced into the swelling, until it 
entered the sheath of the nerve. This gave exit toa 
couple of drachms of clear serous fluid, and was followed 
by immediate relief. Fayrer states that he has seen 
other cases of a similar, but not so well-marked, charac- 
ter. 

Nerve-stretching has also been employed in a large 
number of cases, but the results have not been as good as 
the first reports led us to expect. The stretching may be 
performed subcutaneously, by flexing the thigh forcibly 
on the trunk, while the knee is kept fully extended. 
Woelfler reports one brilliant result from this plan, but 
in thirteen other cases it proved an entire faiiure. 

Stretching of the nerve after its exposure by incision 
has also been successful in a number of obstinate cases, 
and as the operation is unattended with danger it is 
always worthy of trial in desperate cases. 

Leopold Putzel. 


SCLERA, CORNEA, CRYSTALLINE LENS, VITRE- 
OUS BODY, ZONULE OF ZINN, AQUEOUS HU- 
MOR. The sclera (sclerotic) and cornea form the outer, 
so-called hard, membranes of the eyeball which deter- 
mine its shape. While the former is translucent only, 
the latter is transparent, with a refracting index which 
is almost equal to that of water. 

Both the sclera and the cornea in the ideal eyeball form 
portions of a sphere. Generally, however, their cur- 
vature is only approximately spherical. Five-sixths of 
the globe are formed by the sclera, the anterior sixth by 
the cornea, which is inserted like a watch-glass upon the 
sclera, and has a smaller radius of 
curvature (see Fig. 3397). The de- 
pression which is formed in the ., 
sphere by this mode of insertion of ; 
the cornea upon the sclera is called / 
the sulcus sclerew. The diameters of 
the eyeball are not equal in all di- 
rections. The antero-posterior di- 
ameter, the longest, averages 24 
mm., while the vertical one is only 
about 23 mm., the horizonta! diam- 
eter being between these two, or 
about 23.5 mm. The posterior portion of the sclera 
around the optic-nerve entrance is about 1 mm. thick ; 
from this point it gradually tapers off toward the inser- 
tion of the cornea, near which its thickness is reduced to 
0.5 or 0.4 mm. 

The increased thickness in the posterior portion is 
mainly due to the fact that the sheaths of the optic nerve 
here enter the tissue of the sclera and coalesce with it. 
Close behind the insertion of the cornea the sclerotic tis- 
sue is also increased in quantity by the insertions of the 
tendons of the external ocular muscles. 

At the sulcus sclere the translucent tissue of the sclera 
passes over into the transparent tissue of the corned. 
This is done in such a manner that the inner layers be- 
come sooner transparent than the outer ones. This part 
is called the limbus cornew (sclero-corneal junction). The 
translucent tissue reaches farther over the transparent 
tissue at the upper and lower margins of the cornea 
than at the inner and outer ones, and thus the outline of 
the anterior corneal surface is that of an ellipse, while 
that of the posterior surface is circular. The diameters 
of the anterior corneal outline are 11.6 and 11.0 mm., 
respectively. The curvature of the cornea has also been 
said to be elliptical, causing, so to speak, a normal astig- 
matism (Donders, Knapp, and others). However, more 
recently, Aubert has come to somewhat different conclu- 
sions with regard to the curvature of the cornea, which 
he expresses in the following words: ‘‘ We can distin- 
guish between two zones in the cornea, of which one, the 
marginal zone, remains curved in accordance with the 
anatomical shape of the eyeball, while the other, the polar 
zone, serves the optical requirements. The shape of the 


347 


ee 
Fra. 33897.—Outline of the 
Sclera and Cornea. 


Sclera. 
Sclera. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


eyeball is such that the part defined by the sclerotic is 
almost spherical, with a radius of from 11 to 12 mm. 
The margin of the cornea has almost the same curvature 
as the sclerotic, of which it is a direct contihuation. 
This portion then passes gradually over into a part of 
the cornea of a stronger curvature—a zone of the cornea 
which is immaterial for optical purposes, since the rays 
which fall upon it are kept from entering the interior of 
the eyeball by the iris. It is only where this sclerotic cur- 
vature of the eyeball is totally changed that the part of 
the cornea begins which 
is material for vision, 
and which forms an 
area of from twelve to 
sixteen degrees around 
the optical axis. The 
curvature of this part 
is such as torefract the 
rays of light falling 
upon it in a manner to 
unite them upon the 
retina. We may, there- 
fore, speak of two zones 
(of curvature) in the 
cornea, of which the 
one, the polar, is the 
optical zone, while the 
other, the marginal, 
may be called its scle- 
ral zone. Their limits are given by the iris and pupil.” 

The cornea is thicker at its periphery than in its cen- 
tral portion, the thicknesses being 1.1 mm. and 0.9 mm., 
respectively. 

Close to the inner surface of the sclerotic (cf. art. Iris) 
lies the uveal tract, and upon this (cf. art. Optic Nerve 
and Retina) is the expansion of the optic nerve, the retina. 
The fibres of the optic nerve enter the posterior pole of 
the sclerotic, somewhat to the nasal side, by numerous 
openings, which give this portion of the sclerotic the ap- 
pearance of asieve. From this it has been called the 
lamina cribrosa of the sclera. On its outer surface the 
sclera is surrounded by Tenon’s capsule, from which it is 
separated by Tenon’s space, a lymph-space. 

The large cavity surrounded by the sclera (and choroid 
and retina) is filled with the vitreous body, a transparent, 
gelatinous substance. The general shape of the vitreous 
body is spherical. Its 
anterior surface, how- 
ever, which lies at the 
level of the ciliary pro- 
cesses, has a central de- 
pression (fossa /patel- 
larts) in which lies the 
crystalline lens. Its 
posterior surface is also 
slightly changed from 
the spherical, by reason 
of its filling the physio- 
logical excavation of 
the‘optic papilla. 

In front of the vitre- 
ous body lies the crys- 
talline lens, with its 
suspensory ligament 
(zonule of Zinn). The 
crystalline lens is a perfectly transparent, lens-shaped 
body. It lies posteriorly in the fossa patellaris of the vit- 
reous body ; anteriorly it touches the pupillary edge of 
the iris. It is biconvex, and its equator lies at the level 
of the highest prominence of the ciliary processes. The 
curvature of its surfaces is unequal, the posterior surface 
having a stronger curvature than the anterior one. The 
equatorial diameter of the lens is from 9 to 10 mm., 
while the antero-posterior diameter is on an average 3.7 
mm. It consists of a transparent capsule and the lens- 
substance proper. On both surfaces of the lens star-like 
figures may be seen, as are represented in Figs. 3398, 
3399, and 38400. In the new-born we find three radii 
which, starting from the anterior and posterior poles, form 


Fig. 8398.—Adult Lens, Anterior Surface. 
(Arnold.) 


face. 


(Arnold. ) 


348 


angles of about 120°. While, on the anterior surface, one 
of these radii goes upward, and the remaining two 
downward and to the sides, these directions are reversed 
on the posterior surface. 
reach the equator. 


These radii never seem to 
In the adult the radii branch off, and 
their number is considerably 
increased. These radii have 
been called the sutures of the 
lens. (See Figs. 3398, 3399, 
and 3400.) 

The curvature changes 
with age, the lens being more 
1 convex in childhood and be- 
; coming gradually flatter. Its 
colorless structure also grad- 
ually takes on a yellowish 
amber tint with age. Its con- 
sistency is much firmer than 
that of the vitreous body. 

The lens is held in its po- 
sition by fibres which come 
Fia. 3400.—Lens of the Newly- from the ciliary processes, 

hy from the Side. (Ar- ond attach themselves on the 

; anterior and posterior surfaces 
of the capsule of the lens, close to its equator. These 
fibres together form the suspensory ligament (zonule of 
Zinn, zonula ciliaris). They come from the vitreous 
body (Arnold), and after having closely followed all the 
windings of the inner surface of the ciliary processes, 
they are bent almost at right angles toward the axis of 
the eyeball, and then attach themselves to the capsule of 
the crystalline lens. It was formerly thought that a tri- 
angular space could be demonstrated between those fibres 
that go to the posterior, and those that go to the ante- 
rior, lens-capsule, and this was given the name of canal 
of Petit. 

The anterior chamber (the space which is bounded by 
the cornea, anterior surface of the iris, and as much of the 
anterior surface of the lens as lies in the pupillary space), 
and also the posterior chamber (the prismatic space 
bounded by the posterior surface of the iris, the zonule 
of Zinn, and the remaining portion of the anterior sur- 
face of the lens), are filled with a fluid called the aqueous 
humor. This water-like fluid closely resembles serum, 
but contains but little albumen. 

MrcroscopicAL ANATOMY.—Cornea.—The cornea con- 
sists of the anterior epithelium, Bowman’s membrane 
(Reichert?s membrane, membrana elastica anterior), the 
parenchyma or the corneal tissue proper, Descemet’s mem- 
brane (membrana Duddeliana, Demoursti, humoris aquet, 
lamina elastica posterior), and the endothelium (posterior 
epithelial layer). (See Fig. 3401.) 

The epithelium of the cornea is made up of a large 
number of layers like that of the skin, with the difference, 
however, that the cells of eventhe most superficiai layer 
are never changed into horny scales, but have a nucleus ~ 
like the cells of mucous membranes. (See Fig. 3401.) The 
innermost layer of the epithelium is, as a rule, a single 
layer, and consists of long cylindrical or club-shaped cells 
with an oval nucleus. Although these are in a general 
way the types of shape of these cells, they show all sorts 
of varieties in shape, into which they mould each other 
during their growth. It is not rare to find cells of two 
nuclei among them, which fact has led Waldeyer to the 
opinion that from this basal layer all other layers are 
derived. 

Outward from the basal layer are several layers of cells 
which are more broad than they are high, and are poly- 
morphous. These are characterized by two or more 
offsets, by which they are inserted in the interstices be- 
tween the cells of the underlying layer. Their nucleus 
is rather spherical, and their shape depends on the press- 
ure they exert on each other. Outward from these lay- 
ers there follow two or three layers of serrated cells, that 
is, cells which have in all directions minute prick-like 
offsets by which they anastomose with each other. The 
most superficial portion of the epithelium consists of a 
number of layers of cells, becoming gradually more and 
more flattened, and having a-.flat nucleus, around which 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sclera. 
Sclera. 


the cells are slightly thickened. (See Fig. 3403.) Viewed 
from the surface these cells constitute a delicate mosaic. 

All of these cells and layers are firmly bound together 
by a small amount of cementing substance. 

The parenchyma of the cornea, that is, the corneal tis- 
sue proper (substantia propria), consists of the stroma, in 
which are embedded a system of canals (corneal canals) 
with cellular elements, a large number of nerves, and at 
its periphery a wreath of blood-vessels. 

The stroma consists of very fine connective-tissue fibril- 
le, which are somewhat wavy and intersect each other 


—= 


——s 


Fre. 3401.—Section through Human Cornea. 


met’s membrane ; 5, endothelial layer. 
proper of the cornea, fibres going to Bowman's layer. 
to each other. 


and therefore appearing homogencous; e, é, sclero-corneal junction. 


at varying angles. A cementing substance unites them 
with each other, and into fasciculi. Several fasciculi to- 
gether are by the same cementing substance united into 
lamelle, which, in turn, are bound together more or less 
parallel to the surfaces of the cornea. These lamelle are 
thinner and more closely packed in the anterior portions 
of the cornea than they are near its posterior surface. 
Between these fibrillee, fasciculi, and lamelle of the 
stroma of the cornea, and within the substance which ce- 
ments them -together as a whole, we find a system of 
canals which have received the name of Von Reckling- 
hausen’s corneal canals. (See Fig. 3404.) These canals, 
differing in width, intersect and communicate with 
each other at different angles. Here and there they 


(Waldeyer.) 1, Epithelium; 2, 
Reichert’s or Bowman’s membrane ; 38, parenchyma of the cornea; 4, Desce- 
a, Anterior layers of the substance 
The canals are closer 
b, Points which represent transversely cut fibres and fasciculi ; 
¢, corneal corpuscles, appearing fusiform in section; d, fasciculi cut lengthwise, 


have an enlargement which is called a lacuna. These 
lacunz are especially found in the interlamellar canals, 
where they are seen to lie in rows parallel with the la- 
melle. They are flattened in 
an antero-posterior direction, 
and therefore, in sections, 
they appear spindle-shaped. 
In a plane view they vary ex- 
tremely in shape, according 
to the number of canals which 
are connected with each of 
them. As the lamelle 
of the corneal stroma 
differ in thickness, so 
the canals and lacunze 
differ in calibre in such 
a way that the canals 
and lacune are smaller 
and narrower in the an- 
terior portions of the 
cornea than in the pos- 
terior ones. These 
canals and lacune are 
easily demonstrated by 
staining the corneal stro- 
ma by means of nitrate 
of silver or chloride of 
gold, or by injecting 
some colored fluid into 
them. (See Fig. 3404.) 
Within the lacune 
(see Fig. 3405) lie the so- 
called fixed corneal cells me! ee oe agin 
(corneal corpuacies),) wtoughiiie Comes of the Calf, 
When isolated they are {Wvaldever.) @, Flattened, epi 
found to be flat proto- ec, polymorphous cells; d, basal 
plasmic bodies, with a yee of eee Peer e, 
round or oval nucleus  jtantia propris of ehh 
and _ several offsets. 
These cells never wholly fill the lacuna in which 
they lie. Usually they are seen to adhere to one 
wall of it, and 
to fill about two- 
thirds of its cavity. 
Their offsets can 
generally be traced 
fora short distance 
within the canals 


which communi- 
cate with their la- 
cune. Although 


called fixed cells, 
they are not so in 
the full sense of 
the word, and they 
have been observed 
to change their po- 
sition within the 
lacuna. Near the 
sclero-corneal 
juncture, and es- 
pecially in the eye 
of the negro, these 
cells contain some- 
times a granular 
brown pigment ,which 
is enclosed within their 
protoplasm, leaving the 
nucleus free. 

While some authors 
(Kuehne and _ others) 
hold the opinion that 
the corneal canals and 
lacunze are filled with 
protoplasm, thus form- 
ing a solid network 
within the connective tissue of the cornea, the large ma- 
jority of authors consider them to be lymphatic canals. 

In these canals we find, further, a limited number of 


349 


Fra. 3403.—Isolated Cells of the Corneal 
Epithelium. (Waldeyer.) A, from the 


basal layer; B, polymorphous cells ; 
C, prickle-cells; D, flattened cells; D,, 
plane view; Dg, side view; 2, Zo, 
#,, young cells from the middle layers ; 
#,, cell undergoing division; 2g, cells 
with one nucleus; #3, cells with sey- 
eral nuclei. 


Sclera. 
Sclera. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


lymph-cells (wandering cells), which differ, of course, in 
nothing from the lymph-cells found in other tissues. 

Another system of canals which is in communication 
: with the lymph-canal 
system, but which lies 
almost at right angles to 
the latter, consists of 
the canals in which the 
nerves of the cornea are 
situated. 

The anterior surface 
of the parenchyma of 
the cornea is formed by 
a layer which, varying 
in thickness in different 
eyes, with a moderate 
magnifying power ap- 
pears structureless, and 
very much resembles a 
vitreous membrane. 
This is called Bowman’s, 
or Retchert’s, layer. (See 
Fig. 3398.) With a 
higher magnifying pow- 
er this membrane is seen 
to be striated, and there- 
fore to consist also of different layers, and to be, in fact, 
only condensed corneal tissue. Fibres are seen to go to 


Fig. 3404.—Interfibrillar and Interla- 
mellar Canals, and one Nerve-canal 
Injected. They all communicate with 
each other. The lines of the inter- 
fibrillar canals are wrongly drawn as 
straight lines in the cut. They are in 
reality wavy. 


Fra. 3405.—Cornea, stained with Nitrate of Silver. 
cune are white. 


The canals and la- 
In some of the latter fixed corneal cells are seen. 


it from the adjacent layers of the corneal parenchyma, 


and to join it at varying angles. With the proper agents 
it can be split into layers, and even 


—_ 


layer of epithelial (endothelial) cells. (See Fig. 3406.) 
These cells vary considerably in height in different eyes, 
and in shape in one and the same eye. In sections they 
appear cuboid, in surface views they are hexagonal, 
rhomboid, or square, or, in general, have a shape which 
is dependent on the pressure which the different cells ex- 
ert upon each other during their growth. They have 
generally a round nucleus, and are held together by a 
small amount of cementing substance. 

Between these endothelial cells we find very frequently, 
perhaps oftener in old eyes than in young ones, a vary- 
ing number of roundish transparent bodies which some- 
times coalesce with each other. (See Fig. 3409.) They 
are usually situated near the periphery of Descemet’s 
membrane, very much resemble the 
colloid excrescences on the lamina 
vitrea of the choroid, and crowd the 
surrounding endothelial cells aside. 
They are usually called v¢treous warts 
of Descemet’s membrane (Hassal): 

The corneal parenchyma does not 
contain any blood-vessels, except in a 
portion of from one to three mm. in 
width at the corneo-scleral junction. 
The arteries going to this wreath of 
blood-vessels come from the anterior 
ciliary arteries, either directly, or in- 
directly by way of the conjunctival arteries. They are 
found in loops, which unite to form a narrow network of 
capillaries. The veins are of a rather large calibre. (See 
Fig. 3407.) Several authors have described two separate 
wreaths of blood-vessels, one of which is said to lie closer 
to the anterior, the other closer to the posterior, surface 
of the cornea. The loops formed by the capillaries often 
show a number of teat-like projections toward the centre 
of the cornea. 

At its periphery the cornea is entered by from forty to 
forty-eight larger nerve branches. which come from the 
anterior ciliary nerves of the sclerotic and conjunctiva. 
After having entered the cornea these nerves very soon 
lose their double contour, branch off dichotomously, and 
thus form a network within the stroma of the cornea. (See 
Fig. 3408.) From this network branches go forward at 
different angles toward Bowman’s layer, and near it form 
another network. At this part the axes-fibrille and axes- 
cylinders pierce Bowman’s layer almost at right angles, 
form one network around the basal cells, and another 
between the more superficial layers, from which fine 
branches can be traced into the most superficial layer. 
Whether they end in these cells or protrude on the sur- 


Fie. 3406.— Endothelial 
Cells of Descemet’s 
Membrane. (Wal- 
deyer. ) 


fibrille. Close upon its outer sur- P 
face lies the corneal epithelium, a ee 2 
and some authors have described a pea a =< 


y 


ridges on it into which the epithe- 
lial cells are said to fit. 


purpraell 


_ 


mt! 


=¢ 
EN 
The posterior surface of the cor- Fay 
neal parenchyma is bound by 


a thinner, double-contoured, 


} 


elastic vitreous membrane, 
which seems to have more 
claims to be regarded as an 
independent membrane. This 
is commonly called Desce- 
mets membrane. (See Fig. 
3398.) Some authors consid- 
er this membrane also to be 
only a condensation of the 
corneal tissue. It can, how- 
ever—and this often happens 
in pathological conditions— 
be perfectly detached from 
the parenchyma. This is not 
the case with Bowman’s layer. 
The fact that it is an elastic 


ZN 
p> | i 
— e) he 
rf hy iy hy 
) kh 


cA 


membrane, and rolls itself up 
when freed from its adhesion 


to the corneal parenchyma, seems no longer to be doubted. 
On its inner surface Descemet’s membrane carries one 


350 


Fra, 3407.—The Loops of Blood-vessels found in the Periphery of the Cornea. A, Region of the bulbar con- 


junctiva ; B, region of the cornea; C, line of junction between cornea and sclera. 1, Arteries; 2, veins; 3, 
marginal loops; 4, lacuna-like enlargements where several loops join each other and the veins. (Waldeyer.) 


face and form special nervous corpuscles there (Cohn- 
heim), is, as yet, an unsettled question. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Selera, 
Sclera,. 


As has been already stated, the nerves lie in canals, 
which communicate with the lymphatic canals of von 
Recklinghausen and can be injected. These nerve-canals 
seem to have a layer of endothelial cells. 

At the corneo-scleral junction the corneal epithelium 
goes directly over into the conjunctival epithelium. 


Ee Ee Ts Re eee Eee ee 
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A CANS Pi COEv Orage ce Hesoae ah eats os a 
GOVE SoS Ioana Ora wails bos Vo Wau abandon gt INS Sect ARO GK Cornea ee cierenO 
LEAIRSOP DEER NCCES On i Beeb oeceen Ss aspo ce daneeae 
x oy, onSaaaiaior eo [i e We 'SaQd0GGG (tA Be 
‘ 7 real 


Fie. 3408.—Oblique Section through Human Cornea stained with Chlo- 
ride of Gold. (Waldeyer.) A, epithelium with intra-epithelial nerve- 
plexus ; B, substantia propria of the cornea; C, nerve branching off 
dichotomously ; D, axes-cylinders; 1 and 2, anastomosing axes-fibrille. 


Bowman’s layer and the anterior layers of the corneal 
parenchyma pass over into the conjunctival tissue, and 
the bulk of the parenchyma of the cornea becomes scleral 
tissue. The membrane of Descemet and the adjacent 
layers form a network of fibres which lies on the inner 
surface of the tendon of the ciliary muscle, and is called 
ligamentum pectinatum (pectineum). (See Fig. 3409.) In 
accordance with this arrangement, the anterior portion 
of the cornea has been called the conjunctival, the mid- 


Fic. 3409.—A Portion of Descemet’s Membrane and the Ligamentum 
Pectinatum. On Descemet’s membrane may be seen some endothelial 
cells, and between them a number of glassy warts. 


dle the scleral, and the posterior the choroidal, portion 
of the cornea. 

The fibres of the ligamentum pectinatum, when de- 
tached, appear as tough vitreous fibres to which a num- 
ber of endothelial cells adhere. These fibres form a 
network, the meshes of which (Fontana’s spaces) are in 
communication with a system of lymphatic spaces which 


lie between the inner fibres of the corneo-scleral junction 
and go to Schlemm’s canal. 

The fibres of the ligamentum pectinatum are lost in the 
tissue of the ciliary body and iris. 

The tissue of the sclera, like that of the cornea, consists 
of very fine connective-tissue fibrille, which are, how- 
ever, not quite so transparent, and differ from the corneal 
fibrille in their chemical character. It contains, more- 
over, some elastic fibres. The scleral fibrille, like those 
of the cornea, are bound together by a cementing sub- 
stance, and thus form fasciculi. The scleral fasciculi 
are not arranged in more or less parallel lamella, but are 
interwoven at different angles. In a general way, the 
fasciculi in the sclera run in a meridional (longitudinal) 
direction. An equatorial (circular) arrangement of the 
fasciculi, however, is found constantly around the optic- 
nerve entrance and near the corneo-scleral junction, be- 
hind the ligamentum pectinatum. 

Between the fasciculi of the sclera, and within the ce- 
menting substance, we find a network of lymphatic 
canals similar to those of the cornea. Their arrange- 
ment is, however, very irregular, and resembles more 
the arrangement found, for instance, in the tissue of 
larger tendons. This system of lymphatic canals is read- 
ily demonstrated by staining with nitrate of silver or 
chloride of gold, or by injection. We find then that the 
scleral system of canals has also lacune, like the corneal 
ones, and embedded in these lacunez are stellated cells, 
the analogue of the fixed corneal cells. They resemble 
the latter in shape, are protoplasmic bodies with a num- 
ber of offsets and a round or oval nucleus. Near the 
corneo-scleral junction, and around the optic-nerve en- 
trance, these cells are often found to contain a granular 
brownish pigment. This is especially the case in ne- 
groes’ eyes. A smal] number of lymphatic (wandering) 
cells are also found in the canals of the sclerotic. 

At the optic-nerve entrance (see article Optic Nerve 
and Retina) the sheaths of the optic nerve merge into the 
tissue of the sclerotic, the dura-mater sheath joining the 
outer layers, the pia mater mingling with the inner lay- 
ers of this membrane. The intervaginal space reaches 
into the sclera to a varying depth, sometimes splitting 
this membrane for a short distance into two portions. 
The fibres of the sheaths of the optic nerve make a part 
of the equatorial (circular) fibres of the sclera found 
around the optic-nerve entrance. 

The tendons of the six extra-ocular muscles are in- 
serted upon the sclera at very acute angles. Their fibres 
are seen to enter the scleral tissue, and may be traced for 
some distance, when they are gradually lost. According 
to Loewig, the fibres of the tendons of the recti muscles 
form longitudinal (meridional) fibres in the sclera, while 
the fibres of the oblique muscles form circular (equa- 
torial) fibres. 

As we stated above, the optic nerve is not admitted 
into the eyeball by one large round opening in the sclera, 
but in such a manner that its bundles enter the eyeball 
separated from each other by a sieve-like network of fas- 
ciculi of the sclera (lamina cribrosa). 

The outer and inner surfaces of the sclera are covered 
with a layer of flat endothelial cells, of a more or less 
rhomboid shape. These cells can be easily demonstrated 
by staining with nitrate of silver. On the inner surface 
of the sclera the endothelial lining is pierced by numer- 
ous fibres, which unite the choroid with the sclera and 
form the lamina fusca. 

This name has been given to the network of fibres, in- 
termingled with pigmented stellate cells, which remain 
adherent to the sclera when the choroid is torn from it. 
On the outer surface of the sclera a similar condition 
obtains, the endothelial layer being pierced by many 
fibres, which form the loose episcleral tissue, and join the 
conjunctiva anteriorly and posteriorly to Tenon’s cap- 
sule. Endothelial cells are also found adhering to these 
fibres. 

The whole thickness of the sclera is pierced in a num- 
ber of places by blood-vessels and nerves, which in this 
manner enter the eyeball and go to the uveal tract or 
come from it. These are the ciliary arteries and nerves, 


351 


Sclera. 
Sclera. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, 


and the ven vorticose. Blood-vessels and nerves are 
surrounded by a lymphatic space with an endothelial 
membrane. ‘The posterior ciliary arteries and nerves fre- 
quently lie together in one such sheath. By these sheaths 
the suprachoroidal lymph-space directly communicates 
with Tenon’s space. 

During their passage through the sclera both the ante- 
rior and posterior ciliary arteries give off branches for 
this membrane. The same is done by the nerves. 

The anterior ciliary arteries enter the sclerotic with the 
tendons of the recti muscles. 

At the corneo-scleral junction we find always a larger 
number of blood-vessels of an arterial character. Aside 
from these there is a venous plexus (Leber) which sur- 
rounds the periphery of the cornea, lying near the inner 
surface of the corneo-scleral junction. There is, further- 
more, always a large canal to be found in this tissue just 
to the outer side of the insertion of the tendon of the 
ciliary muscle and the ligamentum pectinatum, which 
seems to be a lymphatic canal, and goes by the name of 
Schiemm’s canal. In longitudinal sections it appears as 
an elongated opening with an endothelial lining. Its in- 
ner wall is perforated, and by means of Fontana’s spaces 
and the lymph-fissures in the tendon of the ciliary mus- 
cle, Schlemm’s canal seems to communicate with the an- 
terior chamber. Leber contends that what by others is 
maintained to be a lymphatic canal, is 
the very venous plexus so well described 
by him. Iam of the opinion that there 
is a venous plexus, and, aside from it, 
also a lymphatic canal, which latter 
corresponds to what has been called 
Schlemm’s canal. 

The crystalline lens consists of the lens- 

W's capsule (anterior and posterior), the in- 

tra-capsular epithelium, and the lens-sub- 
stance (lens-fibres, lens-bands). 

The lens-capsule forms a hyaline sac, 
so to speak, in which the remainder of 
the constituents of the lens are inclosed. 
It is one continuous membrane. From 
the clinical distinction between an ante- 
rior and a posterior capsule, it might seem 
to follow that we have to deal with two 
different membranes, but this is not the 
case. There is, however, a distinct dif- 
ference between that part of the capsule 
which covers the anterior surface of the 
lens and the portion which covers the 
posterior surface, in so far as the former 
is considerably thicker than the latter. 
The reduction in thickness takes place 
near the equator of thelens. This differ- 
ence in thickness seems to be mainly due 
to the fact that a much larger number of 
the fibres of the zonule of Zinn (suspensory ligament) 
merge into the capsule in front of the equator of the lens 
than behind it. 

The lens-capsule is an elastic hyaline membrane. In 
a plane view it appears homogeneous. Its transverse 
section, with a very high magnifying power and after 
the use of certain reagents, shows a fine striation. Its 
elastic nature is proven by the fact that it rolls up when 
severed from the lens-substance. 

The inner surface of the anterior lens-capsule is lined 
by a single layer of epithelial ceils. In a plane view they 
appear more or less hexagonal. In transverse sections 
their height is about that of the thickness of the lens- 
capsule ; yet their size and shape vary in different eyes. 
They are held together by a small quantity of cement- 
substance. Their nucleus is round or oval. This epi- 
thelial layer does not reach beyond the equator of the 
lens, and near it we find that the cells become elongated, 
cylindrical, and gradually assume the form of lens-fibres. 
The view which is maintained by almost all investigators 
on this subject, that the continued formation of new lens- 
fibres takes place at the equator, has of late been declared 
absolutely incorrect by Robinski. The opinion advanced 
by him is that new cells are formed all over in the epi- 


AIS 


Fa TINIAN SS 


—— = 
“WWW 


FeO TTDI IDA AS: 


== SSR RASAN SASS SEES 


Fria. 3410.—Isolat- 
ed Lens - fibres 
stained with Ni- 
trate-of Silver. 
(Arnold. ) 


352 


thelial layer by karyokinesis, and that the process is 


therefore not confined to the equator. 
The posterior capsule has no epithelial lining. 
The lens-substance consists of the so-called lens-fibres 
(lens-bands, lens-tubes). Iso- 


Ue SS ELE RLU CAT! lated Jens-fibres appear as flat 
ay Y ! NIN bodies with a very fine longi- 
| | tudinal striation (see Fig. 
Ni “, 3410), and in rare cases also a 


transverse one. When they 
happen to lie on edge they 
appear much thinner. In 
transverse sections they are 
seen to be in reality hexagonal 
prisms (see Fig. 3411), which 
are smaller and thinner when 


Uy | taken from the nucleus of the 


Lea 
Odes 


Du 


( 


if MW ni lens than when taken from its 


Fie. 3411.—Section through a periphery. While the younger 
Frozen Lens stained with Ni- and peripheral lens-fibres have 
trate of Silver, showing Hexa- gn oval nucleus somewhere in 
Pasecy of Lens-fibres. their protoplasmatic body, the 

older and central lens-fibres 
have none for the most part. 

The lens-fibres have also been called lens-tubes, since 
they evidently consist of a tough peripheral substance 
and a more fluid one within this. The latter is called 
liquor Morgagnt. This fact is es- 
pecially evident in the young lens- 
fibres near the periphery. As we 
come nearer to the centre of the 
lens, the Morgagnian fluid disap- 
pears gradually, and the fibres 
grow flatter and harder. The out- 
lines of the fibres in the nucleus of 
the lens are rough and indented, 
and their lines.of union with each 
other resemble bone-sutures. All 
the fibres are held together by a 
small quantity of cementing sub- 
stance. 

From the foregoing it will be 
seen that in the lens-substance we 
find layer upon layer of lens-fibres | 
arranged in a more or less con- 
centric manner. The _ peripheral 
fibres are the youngest ones, the 
central fibres are the oldest ones. 
The latter form the nucleus of the 
lens. The whole of the lens-tissue 
is epithelial in nature, and the old 
nuclear lens-fibres. correspond to 
the oldest epidermic cells which 
have undergone a horny metamor- 
phosis. In a meridional section 
through the poles of the lens, the 
nuclei of the lens-fibres are seen to 
be arranged in a convex line, with 
the convexity toward the capsular 
epithelium and near it. (See Fig. 
3412.) 

According to J. Arnold, the pe- 
ripheral lens-fibres are from 0.010 to 0.012 mm. in breadth, 

: and from 0.0045 to 0.0055 mm. 
in thickness ; while the central 

ones are but 0.007 to 0.008 mm. 

in breadth, and from 0.0022 to 

0.0021 mm. in thickness. Their 

length, according to Robinski, 

averages in the eye of the newly- 
born 5.5 mm., while in the eye 

of the adult it varies from 7.18 

to 10.64 mm. 

Fig. 3413.—Equatorial Sec- The vitreous body, which fills 
ea Uinerpabeng ge 7 aha about the posterior two-thirds of 
Fluid. (Schwalbe. ) the eyeball, consists of a more 

solid mucoid part.and a thin fluid 
one, which runs off when the vitreous body is taken from 

the eyeball. The firmer portion amounts to 0.021 to 0.07 


Section through Lens of 
the Embryo of the Calf. 
(Arnold.) Shows the ar- 
rangement of the nuclei 
of the lens-fibres. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Selera ° 
Sclera. 


parts in 100 parts of vitreous body, according to Loh- 
meyer. This substance seems to form a number of very 
thin meridional and equato- 
/ rial septa in which the fluid 
portion of the vitreous body 
(vitrina ocularis) is held con- 
fined. (See Fig. 3413.) 


~ It is very difficult to 
x j}demonstrate these 
7 septa, yet their exist- 

* ence seems to be gen- 
erally admitted. Con- 

centric (equatorial) 

septa seem to be want- 

ing in the more homo- 
geneous central por- 

tion of the vitreous 

body, while they appear to be very 
numerous in its periphery. Prob- 
ably for this reason the peripheral 
portion of the vitreous body is 
denser and firmer than are its cen- 
tral portions. From the lymphatic 
canals of the optic nerve a central 
Fie, 3414,—Cells from the canal in the vitreous body may be 
wreate ody injected, which reaches from the 
optic papilla to the fossa patellaris. In this canal (canalis 
hyaloideus) during foetal life the hyaloid blood-vessels go 
to the crystalline lens, After birth these blood-vessels 


Fre. 3415.—Zonula Ciliaris (Suspensory Ligament of the Crystalline Lens). 


Plane View. The pigment of the ciliary processes remains lying on the 
pars non-plicata (a) of the zonule; the fibres of the pars plicata (b) go 


to the lens-capsule (c) and merge into it. (Arnold.) 


no longer exist, excepting in a few cases in which persist- 
ent hyaloid blood-vessels may be found as an anomaly. 
A number of authors have described a separate mem- 


Vou, VL—23 


brane, as membrana hyaloidea, which was said to cover 
the whole of the vitreous body, and thus to lie between it 
and the inner surface of the retina. Others contend that 
no such separate hyaloid membrane exists. The latter 
seems to be the correct opinion. 

The vitreous body always contains a number of cellu- 
lar elements, but their mass in the normal condition is 
but small in comparison to the bulk of the vitreous body. 
There are usually more cells to be found in its peripheral 
parts than in the central ones. The nature of all of these 
cells is that of lymph (wandering) cells, which enter the 
vitreous body from the surrounding membranes. (See 
Fig. 3414.) 

With regard to their shape these cells (like all wander- 
ing cells) differ very greatly. There are simple round 
cells with one or more nuclei; there are round cells con- 
taining one or more vacuole, which sometimes crowd the 
nucleus aside so as to give the cell the appearance of a 
seal ring; there are, furthermore, cells with one or more 
offsets, some of which are very long. 

Fibres, which by some investigators have been found 
in the vitreous body, seem to be pathological in nature. 

The suspensory ligament of the crystalline lens (zonule 
of Zinn) springs from the vitreous body near the ora ser- 
rata of the retina. (See article Optic Nerve and Retina.) 
It lies at first close to the retinal (inmost) portion of the 
ciliary body, and has, therefore, here a pars non-plicata 
and a pars plicata just like the ciliary body. At the level 
of the ciliary processes the suspensory ligament is bent 
toward the axis of the eyeball, and is inserted into the 
lens close to itsequator. This ligament consists of tough 
glassy fibres which sometimes show a fine transverse stria- 
tion. They are held together in the manner of a mem- 
brane by a very small amount of a homogeneous cement- 
substance. From the ciliary processes these fibres are 
seen to go in the main to the anterior capsule of the lens, 
while a few go to the posterior capsule, and some return 
to the vitreous body. It was formerly thought that there 
was a triangular space bounded by the two portions of 
the suspensory ligament and the equator of the lens (cana- 
lis Petiti). Such a single large space does not actually 
exist, but the fibres crossing each other on their way in 
different directions leave a multitude of small spaces be- 
tween them. At their point of insertion upon the lens- 
capsule the fibres of the suspensory ligament are lost in 
the tissue of the capsule. The cells which are sometimes 
found lying upon and between the fibres are lymph-cells. 

Adolf Alt. 


SCLERA, DISEASES OF THE. Although the sclera 
becomes secondarily involved in various morbid processes 
originating in other parts of the eyeball, primary disease 
of this structure is comparatively rare. Scleritis, or in- 
flammation of the sclerotic, as a primary affection, is rec- 
ognized only as originating in a narrow zone of the 
sclera, bounded in front by the cornea and behind by the - 
insertion of the recti muscles. In this situation we meet 
with two varieties of scleritis—simple and complicated. 

SIMPLE SCLERITIS (episcleritis) commences as a local- 
ized subconjunctival hyperemia at a short distance from 
the corneal margin. As the episcleral tissue becomes in- 
filtrated, a smooth swelling appears, which is but slightly 
elevated above the surrounding surface, and is usually of 
a dingy yellowish-red color, sometimes resembling a pust- 
ular formation, though ulceration or loss of ‘substance 
never occurs. The conjunctival vessels over and around 
the swollen part are more or less engorged, but the con- 
junctiva in general remains normal. After a few days 
or weeks the nodule assumes a dull violet hue and be- 
comes flatter, in which form it may remain stationary 
for a long time, or may gradually disappear, leaving a 
more or less permanent dull gray or ash-colored spot. 
Occasionally two or more such nodules are present at the 
same time, or as one disappears others may develop. 
The slow progress and tendency to recurrence of these 
nodules frequently render the disease tedious and pro- 
tracted. One or both eyes may be affected, or as one re- 
covers the other may undergo the same process. 

The subjective symptoms are seldom severe ; they con- 


303: 


Sclera. 
Scleroderma, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES: 


sist in an unpleasant sensation of weight or pressure in 
the eye, undue sensitiveness to light or cold, and perhaps 
slight headache ; rarely there may be considerable photo- 
phobia and sharp pain. This disease belongs almost ex- 
clusively to adult life, and is most common in elderly 
people. The gouty, the rheumatic, and the scrofulous 
diatheses are all credited with lending a predisposition to 
this form of scleritis. 

Treatment.—Any special dyscrasia on the part of the 
patient must be taken into account and suitably dealt 
with ; and while exercise in the open air is to be enjoined, 
the eye must be protected from strong light and from 
sudden changes of temperature. The local use of sul- 
phate of atropine is allowable in the early stages, espe- 
cially if there be marked symptoms of irritation. In the 
absence of these, instillations of solution of eserine—gr. 
ij. ad %j. (eserine, 0.10 ; water, 25.00)—twice daily, are 
often very efficacious. Massage, with the employment 
of oxide of mercury ointment (amorphous yellow oxide 
of mercury, 1 part, and fat or vaseline, 25-50 parts), has 
been highly recommended. Dry or moist heat, applied 
to the eye in the usual way, several times daily, may be 
beneficial. 

In regard to internal medication the choice of remedies 
will depend on various circumstances. Mineral waters, 
iodide of potassium, salicylate of soda, proto-iodide of 
mercury, hypodermic injections of pilocarpine, and many 
other remedies have been used with more or less success, 
according to the special indications present in the individ- 
ual case. 

COMPLICATED SCLERITIS (sclero-keratitis, scrofulous 
scleratitis)—This is a much more serious affection, 
owing to the involvement of the cornea, iris, and ciliary 
region in the inflammatory process, and also to the ten- 
dency which exists to disastrous 
changes in any or all of these 
parts. Sclero- keratitis, com- 
\X\\ mencing on the sclerotic, begins 
\\\) With one or more dusky infiltra- 

tions of the sclerotic, as in sim- 
ple scleritis, but close to the 
corneal margin, the cornea be- 
ing involved from the first, or 
after the scleral affection has 
existed only a short time; the 
pericorneal tissues are more 
deeply and more generally in- 
volved than in simple scleritis, and in some cases the 
cornea becomes extensively opaque ; sooner or later the 
iris may participate in the inflammation, as is shown by 
visible changes in its appearance and by the presence of 
posterior synechia, or the entire ciliary region may be- 
come intensely congested and sensitive (irido-cyclitis). 
The special dangers to which the eye is subjected in any 
given case may be approximately estimated by the se- 
verity of the disease in the several parts affected—ex- 
tensive changes in the cornea threatening permanent 

opacity of this structure ; in the iris, more or less com- 
_ plete posterior synechia, and in the ciliary region, cil- 
lary staphyloma. ‘There may be one or more foci of in- 
flammation ; when there are several of these, the entire 
pericorneal zone may be involved, or the same thing may 
happen more slowly through repeated relapses, each time 
a different area of this zone being attacked. The low 
dusky swelling of the sclerotic, continuous with a patchy 
opacity, of the adjacent cornea, is the characteristic ob- 
jective sign of this disease, which, as a rule, is subacute 
in all its manifestations. Occasionally, however, the in- 
flammatory process is more active, and there are intense 
photophobia, considerable lachrymation, and severe pain. 
The disease may at any time subside, leaving a dull 
grayish, thickened appearance of the sclerotic, and a cor- 
responding irregular marginal opacity of the cornea. If 
several foci have been present, the cornea will have the 
appearance of being irregularly encroached upon by the 
sclerotic. With the subsidence of the inflammatory pro- 
cess the dull slaty-gray sclerotic may present a zone of 
thickened tissue around the cornea, which sometimes 
looks as if it were pushed forward, giving the anterior 


Za \ ih 
é WH 


Fia. 3416. 


354 


part of the eyeball an elongated appearance ; or, more 
frequently, the sclerotic immediately around the cornea 
yields in certain places, and an irregular, nodular-looking 
projection is formed behind the cornea. This nodule is 
sharply defined anteriorly, but becomes gradually flat- 
tened toward the level of the normal sclerotic posteriorly. 
After repeated attacks of inflammation the staphyloma- 
tous bulging may involve the entire circumcorneal zone 
of the sclerotic, giving rise to great enlargement and dis- 
tortion of the anterior part of the eyeball (Fig. 3416); at 
the same time the iris may become expanded from the 
periphery, and the anterior chamber is often considerably 
enlarged. The development of staphyloma from this cause 
does not often depend on increased intraocular tension, 
but on a gradual expansion of the softened sclerotic, and 
the most extensive changes in the form and appearance 
of the eyeball are not inconsistent with fairly good vision. 

The subjects of this disease are usually young adults, 
and it affects women far more frequently than men. ‘‘It 
is not known to be associated with any special dyscrasia, 
but it generally goes along with a feeble circulation and 
a liability to ‘catch cold ;’ in some cases there is a defi- 
nite family history of scrofula or phthisis”’ (Nettleship). 

Treatment.—During the irritative stages soothing rem- 
edies are indicated. Protection from cold air and strong 
light is always advisable, warm fomentations are gener- 
ally beneficial, and instillations of atropine are useful 
if there is much irritation, especially if the iris is at all 
involved. 

In the more acute forms of this disease the writer has 
seen great improvement follow the use of antipyrine in 
doses of fifteen grains several times daily. Mercury may 
be used in moderation if the patient is not too anemic. 
Iridectomy may be performed if there are extensive ad- 
hesions of the iris and a tendency to the development of 
staphyloma. If vision is destroyed and the eyeball is 
greatly enlarged, an operation for the removal of the 
staphyloma may be indicated. 

Staphyloma of the sclera (ectasia) occurs under the 
most varied conditions, but usually as the result of pro- 
longed increase of intraocular tension. 

As a congenital anomaly of rare occurrence there is 
sometimes a partial bulging of the sclerotic, associated 
with congenital coloboma of the choroid (scleral protu- 
berance of Von Ammon). There may also be a general 
uniform bulging of the sclerotic, associated with enlarge- 
ment of the cornea, existing from the earliest infancy, 
and known as congenital ‘‘ buphthalmus ;” it commonly 
affects both eyes. Nothing is known of the etiology of 
this rare affection. 

Extensive destruction of the cornea from suppurative 
keratitis is commonly followed by more or less complete 
corneal staphyloma, and this may extend to the sclera, 
giving rise to more or less general enlargement of the eye- 
ball. Irido-cyclitis and irido-choroiditis, followed by 
occlusion of the pupil, give rise to increased tension of 
the eyeball, which, in the course of time, if not relieved, 
causes scleral staphyloma, usually in the ciliary region. 
Protracted increased tension from neglected glaucoma 
(glaucoma consummatum), or from dislocation of the 
lens, is a common cause of scleral staphyloma. Under 
these circumstances the bulging is usually far back, be- 
hind or between the insertion of the recti muscles. 

In an ectasia following inflammatory or glaucomatous 
processes the protruding part is lined by a corresponding 
portion of the stretched and attenuated uveal tract. Bulg- 
ing of the sclerotic may occur at any part, during the 
course of suppurative panophthalmitis, prior to rupture 
of this tunic and the escape of the contained pus. 

Intraocular growths likewise cause bulging of the 
sclerotic, either by softening of the tunic in the vicinity 
of an intraocular growth, by the increased tension which 
such growths induce, or by simple expansion from ex- 
cessive development of the growth. For the diagnosis 
of these conditions, see article Eye, Tumors of the. 

Ectasia of the sclerotic at the posterior pole (sclero- 
ectasia posterior), as met with in axial myopia, is a condi- 
tion of frequent occurrence. (See Myopia.) Its presence is 
easily determined, by means of the ophthalmoscope, by 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the existence of a crescent or irregular circle of choroidal 
atrophy, which nearly always commences at the temporal 
side of the optic papilla. F. Buller. 


SCLEREMA NEONATORUM. This rare affection isin 
no way connected with scleroderma, although the latter 
was at one time called sclerema of adults. It usually 
shows itself in the first days of extra-uterine life, having 
in all probability begun in foetal life. 

The first marked symptoms are commonly observed 
from the third to the sixth day after birth, when the lower 
extremities are seen to show considerable areas of shin- 
ing, tense, white skin, sometimes tinged with red, or of a 
dirty-brown or yellowish color.. The tissues are cedema- 
tous, pitting on pressure with the finger, while the skin 
is so much thickened that it cannot be pinched into folds 
between the thumb and fingers. Beginning in the calf, 
the disease soon extends to the thigh, spreads over the 
abdomen, up the trunk, involves the head and upper ex- 
tremities, and, in fine, after a brief period (three hours to 
- three days) invades the entire body. Of course we can 
know nothing of the subjective symptoms, but the rapid 
fall in body-temperature, the frigidity of the affected 
parts, and the general depression of functional activity 
point to a serious general condition. 

The infant’s bodily movements are imperfect and re- 
strained ; it lies numb and stiff, usually with closed eyes 
and wrapped in lethargic slumber ; it declines food, partly 
on account of mental hebetude and partly because of the 
difficulty of making the movements of the mouth neces- 
sary to nursing. The heart is weak, and the pulse is 
rapid and sometimes almost imperceptible. The respi- 
rations are irregular and shallow, with occasional rales. 
The patient occasionally utters a complaining whine. 
The urine and stools are diminished in quantity. 

The symptoms mentioned usually increase in severity 
with continually falling bodily temperature and increas- 
ing weakness, until death ends the scene at the end of 
from four to ten days. 

Sclerema neonatorum is almost invariably fatal, though 
recovery has been noted in a few cases where the disease 
was not extensive. The cause of the disease seems to lie 
in an extensive implication of the blood-vessels. Atelec- 
tasis of the lungs, congenital disease of the heart, or 
other constitutional anomalies have been brought for- 
ward as explanatory of the origin of the disease. Sur- 
rounding and pre-natal conditions of an unfavorable hy- 
gienic character—want, privation, etc.—appear to have 
some influence in the causation of the disease. 

Anatomical examination shows deep involvement of all 
strata of the cutaneous envelope. The widespread infil- 
tration of the subcutaneous tissues allows the easy separa- 
tion of these layers from the deeper layers of muscles 
and the fascia. On section a yellowish-white serous fluid, 
mostly composed of oil-globules, exudes. Of the inter- 
nal organs, the lungs and kidneys are usually hyper- 
zmic, while the brain and the serous membranes are 
usually cedematous. The brief duration of the affection, 
however, usually allows only the earlier stages of these 
changes to be observed. 

The treatment of sclerema neonatorum is of a roborant 
and restorative nature, and should be undertaken at the 
earliest possible moment. Rubbing with hot blankets, 
etc., and the internal administration of restoratives may 
relieve the patient, and, if begun in time, may work a 
cure. 

(The above article is based upon that of Schwimmer, 
“«Ziemssen’s Handbuch,” Vierzehnter Bd., Erste Halfte, 
8. 451.) Arthur Van Harlingen. 


SCLERODERMA. An affection of the skin chiefly 
characterized by changes in the color and density of the 
integument, and in some cases accompanied by marked 
deformity. 

Two varieties are usually described, Scleroderma dif- 
Susa and Scleroderma localis. 

SCLERODERMA DirrusA.— This is the affection de- 
scribed first, under the name of sclérémie des adultes, by 
Alibert, in 1817. The affection occurs most commonly 


Sclera. 
Scleroderma, 


in women and in adult life. No previous ailment seems 
to exercise a predisposing influence, unless it be rheuma- 
tism. The immediate cause in many cases has been ex- 
posure to dampness and cold. 

The induration, which is so marked a symptom of the 
affection under consideration, is variously described in 
different cases, and writers seem to vie with one another 
in their attempts to express vividly the peculiar sensa- 
tions offered to the sight and touch. 

In some cases the skin is described as being of stony 
or board-like hardness, or feeling like that of a frozen 
corpse, without the sensation of cold. In other cases it 
is compared to brawn or leather. Adherence of the skin 
to subjacent tissues is not uncommon—‘“ hide bound,” or 
‘‘perfectly immovable,” are the expressions used. In a 
case coming under the writer’s personal observation, the 
skin over the forearms was so bound down that the limbs 
seemed as if carved out of wood. The underlying mus- 
cles, particularly those of the limbs, are generally more 
or less wasted. 

One of the most distinctive characteristics of this vari- 
ety of scleroderma is symmetry and diffusion as distin- 
guished from localization. Commencing, as in most of 
the cases reported, on the back of the neck, the disease 
spreads equally on either side of the median line ; or, 
when it begins in the limbs, both are usually attacked at 
once. 

The surface covered is almost invariably large ; those 
cases reported in which the disease seems to tend toward 
localization, are usually to be regarded as, in all probabil- 
ity, belonging to the other variety of the disease. 

A marked characteristic of this variety of scleroderma 
is that no distinct boundary exists to the affected areas ; 
they seem to melt imperceptibly into the surrounding 
skin. 

The color of the affected skin varies much in different 
cases. In many cases pigmentation exists to various 
degrees, while in othef cases the skin either retains its 
normal tint, or becomes pale-yellowish or waxy in color. 
A curious fact is that the pigmentation seems much 
deeper in the immediate neighborhood of the sebaceous 
follicles. In a certain number of cases, it is said that 
spots or patches of pigmentation at various points pre- 
cede and presage the induration of the skin in these 
localities. This, however, is more likely to occur in the 
circumscribed and localized form of scleroderma. 

Neither fever nor local inflammatory reaction of any 
kind ushers in, accompanies, or follows the appearance 
of the disease in any typical case. Oidema is rarely, if 
ever, observed in diffuse scleroderma. Occasionally swell- 
ing of the hands or feet has been observed as a result of 
mechanical interference with the circulation. 

The rapidity with which the disease attacks and spreads 
over the skin varies in different cases. In some, large 
areas of skin become indurated in a very short time; in 
others, the onset is slow and insidious. 

In no case is there any marked elevation of the indu- 
rated skin above the level of the surrounding and unaf- 
fected parts, though tubercular elevations have occasion- 
ally been observed. Where the tightened skin plays over 
prominent bony parts, as the knuckles, a tendency to 
ulceration is often observed. 

Cutaneous sensibility in most cases remains unaltered. — 
The appendages to the skin, the glands and hair, are 
rarely affected. 

Scleroderma diffusa runs a very chronic course ; many 
cases may be under observation for years with little or 
no change apparent, and this under the persistent em- 
ployment of decided and varied treatment. The exist- 
ence of. scleroderma does not necessarily exclude that 
of other skin diseases; acne, comedo, and eczema have 
been observed simultaneously, and in the same localities. 

Scleroderma diffusa is not in itself a fatal.affection. 
In the few cases in which death has occurred while the 
patient has been under observation, it has usually oc- 
curred from some intercurrent disease, totally uncon- 
nected with the scleroderma. It is true that, in one case 
recorded, death was hastened by the extremely inflexible 
condition of the facial integument, which interfered 


355 


Scleroderma, 
Scurvy. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


greatly with deglutition, while in some others respiration 
was much impeded through immobility of the thoracic 
walls. . 

The pathological anatomy of scleroderma diffusa is 
simply that of a hyperplasia of the fibrous element of the 
papillary layer and corium, with decrease of subcutane- 
ous fat and increase in pigment deposit. 

SCLERODERMA Locatis.—The symptoms and course 
of this disease, or form of disease, are very different 
from those of scleroderma diffusa. The affection is 
sometimes preceded by nervous symptoms, neuralgic 
pains, rheumatism, etc. At other times there are no gen- 
eral prodromes. The advent of the local symptoms is 
usually insidious, so that they are not often observed 
until the disease has made considerable progress. The 
most prominent skin symptoms are the appearance of 
parchment-like patches, with sclerotic strie. In a typi- 
cal case described by Bésnier the patches were irreg- 
ular in shape, usually elongated in the direction of the 
axis of the body and members, isolated or confluent, 
sometimes symmetric, sometimes asymmetric. At first 
sight these patches can be distinguished from the sur- 
rounding skin only by their deeper color, their finely stri- 
ated surface, slightly depressed beneath the level of the 
surrounding skin, and particularly by a lilac border com- 
posed of fine blood-vessels. 

To the touch the affected patches seem slightly rough, 
dry, parchment-like, and superficially indurated, so that 
the skin can be pinched up only in thick folds. Sensa- 
tion is in no way altered. ) 

The striated patches are sometimes fine and diffuse, 
and hard to recognize, at other times they are united, 
forming large patches of convergent stripes. | 

The localized patches of scleroderma may be observed 
in any part of the body, but are more common on the 
trunk. The cases which have been observed by the writer 
have presented only the parchment patches (morphea) 
with lilac areola, and have been observed about the clavi- 
cles and on the face. 

In addition to the more characteristic patches above 
described, keloidal lesions and areas of pigmentation are 
observed at times. Occasionally also ecchymoses and 
phlyctenular lesions occur, and hyperesthetic points, but 
these are usually evanescent. In some cases deep-seated 
and superficial neuralgic pains precede and accompany 
the appearance of the lesions, occurring in attacks often 
nocturnal, In other cases no such symptoms are present. 

Accompanying the skin symptoms, rheumatic pains 
with articular symptoms, anchyloses, and even osseous 
degenerations have been reported. The hands and fin- 
gers, in particular, are said to be involved. The disease 
runs a very chronic course, and but few cases have been 
followed through their entire evolution. It will be seen 
from the above description that scleroderma, whether of 
the diffuse or localized form, presents itself in so many 
varieties as to make it difficult of definition. As to the 
nature of the localized form, all the evidence points to- 
ward a tropho-neurotic origin. 

- Arthur Van Harlingen. 


SCROFULODERMA. There are a number of skin dis- 
eases so Closely connected with the condition of the system 
_ called scrofulous as to be properly designated scrofulo- 
dermata. Of these, one of the commonest is that which 
begins in one or more of the superficial lymphatic glands, 
especially under the jaw, about the neck and clavicular 
region. The glands become enlarged and the process ex- 
tends to the skin overlying them, which becomes red and 
infiltrated. Finally a cold abscess forms, and is dis- 
charged through the skin, and an ulcer of slow progress, 
with undermined violaceous berder, results. 

Bésnier calls scrofulous nodes, especially when they 
occur superficially, ‘‘ scrofulous gummata,” on account 
of their resemblance to syphilitic gummata. The most 
superficial of these gummata begins as a small infiltra- 
tion or node in the skin, of a livid red color. Increasing 
in size, slowly at first, and later more rapidly, it some- 
times extends in one or more directions, involving the en- 
tire skin, and softening at one or more points to form 


356 


small ulcers, with burrowing sinuses extending from one 
to another. The discharge from these ulcers is usually 
sero-purulent or sanious, and occasionally bloody, and 
the skin may be undermined by numerous communicat- 
ing galleries. Occasionally the disease takes on a diffuse, 
infiltrating form, spreading in an irregular patch over 
the skin, involving its entire surface, and giving rise to 
serpiginous shallow ulcers. 

The scrofulous ulcer never shows any disposition to 
heal. It may look as if it were on the very verge of cica- 
trization, but it does not actually scar over, or, if it does, 
a week or two later the cicatrix may open in one place 
while forming in another. 

In addition to the localities above mentioned, this form 
of scrofuloderma may occur over the cap of the shoulder, 
in the groin, and elsewhere. It is generally accompanied 
by other signs of the scrofulous condition, by old scars, 
etc. 

This form of scrofuloderma is to be distinguished from 
lupus vulgaris and from syphilis by the concomitant gen- 
eral symptoms of scrofulosis and by the peculiar features 
of the lesions, which differ materially from those of lupus 
and syphilis. The characters of the primary lesions, the 
form of the ulcers and their course, and the amount of 
crusting differ materially. Where the diagnosis between 
scrofuloderma and syphilis is difficult, the history in 
some cases will aid. 

Another and rarer form of scrofuloderma is character- 
ized by the formation of papillary, wart-like, or fungous 
growths of a pale, bright, dusky, or violaceous red color. 
The surface of these growths soon ulcerates, with a thin 
discharge and some crusting. These lesions are apt to 
occur upon the backs of the hands, and may extend to 
such depth as to lead to bone-changes. The course of 
this form of scrofuloderma is exceedingly chronic. 

A fourth variety of scrofuloderma may be referred to, 
which shows itself in the form of small, hard, scattered, 
flat papules with a raised violaceous areola. The lesions 
may occur upon any part of the body, but are usually 
met with upon the forearms, legs, and face. At first 
they look like the pustular syphiloderm, but crust over 
after some weeks, leaving a depressed pit-like cavity, 
of a size to receive the head of a pin, in the lesion. Fi- 
nally the lesion disappears, leaving a punched-out scar 
like that of small-pox. This form of scrofuloderma is 
chronic to an extreme degree. New lesions form while 
the old ones are cicatrizing ; and while the affection does 
not give rise to any pain or other annoying sensation, it 
is very rebellious to treatment. 

The treatment of scrofuloderma is both general and 
local. Cod-liver oil, iodine—usually in the form of iodide 
of potassium, or of Blancard’s pills of iodide of iron—and 
iron alone, are most frequently serviceable. Milton has 
reported excellent results from the administration of 
calomel or gray powder, two or three times a week at 
bedtime for a fortnight, with a saline every morning, 
so as to produce a daily action of the bowels. Then the 
mercurial is suspended for from a fortnight to a month, 
the saline being continued. If the appetite fails, bitters 
and mineral acids are to be given. Locally a mild zinc 
ointment is applied. Milton lauds this treatment as cur- 
ing where all else fails. 

Locally the ulcers are to be treated, as a general thing, 
with stimulating ointments, preferably those containing 
mercury. Ointments and powders of iodoform are also 
useful. .Tincture of iron and chlorinated soda solution 
may also be used. Where the disease is extensive, scrap- 
ing with the curette or sharp spoon, to remove the mor- 
bid tissue, as in lupus, is the quickest method. 

[TUBERCULOSIS OF THE SKIN. — Our knowledge of 
tuberculosis of the skin is of recent date, and even now 
but little is known of this affection on account of its 
comparative rarity. 

Tuberculosis of the skin usually shows itself as a single 
roundish or oval ulcer, which soon becomes crusted over, 
giving rise to little pain. On removal of the crust a 
reddish-yellow granular surface, bleeding easily, is ob- 
served. The walls of the ulcer are only slightly infil- 
trated, soft, not undermined, though sometimes movable 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, 


Scleroderma, 
Scurvy. 


over the subjacent tissues. The edges are not smooth, 
but irregular and eroded, with occasional pits filled with 
pus. It is extremely rare to find any miliary tubercles. 

The ulcer grows by gradual destruction of the edges in 
an irregular way, presenting occasionally a serpiginous 
appearance. The tuberculous ulcer is never large, rarely 
exceeding the area of ten to twenty square centimetres. 
It shows no tendency whatever to heal. The seat of the 
ulcer is almost always about some mucous orifice, as the 
mouth, anus, or vulva, or on the glans penis. The diag- 
nosis is to be made by exclusion. 

The treatment, in addition to that described above un- 
der scrofuloderma, consists in scraping and applying py- 
rogallic acid. The prognosis is usually unfavorable. 

Arthur Van Harlingen. 


SCULLCAP (Scutellaria, U. S. Ph.), Scutellaria lateri- 
flora Linn.; order, Labiate. This genus consists of scent- 
less bitter perennials, destitute of the aromatic properties 
found in most species of this large order, and further 
distinguished by a peculiar helmet-like development of 
the upper sepal, to which it owes its name. Calyx two- 
lipped, persistent ; closed-in fruit until maturity, when 
it splits and opens widely. Corolla labiate, ascending ; 
stamens four, also ascending, and under the upper lip 


of the corolla ; lower anthers one-celled. Leaves oppo- 


site, petiolate ; flowers axillary, usually solitary, some- 
times in apparent spikes or racemes. There are about 
ninety species, forming a very distinct and natural genus, 
distributed over nearly the whole north temperate zone. 
There are about a dozen in the United States. The 
above-named species is a branching herb, from one to 
two feet high, with small flowers arranged in one-sided 
racemes, whose floral leaves are reduced, excepting those 
near the base, to small bracts. It has opposite, ovate-ob- 
long or lanceolate, coarsely serrate, pointed leaves about 
two inches long. Stems squarish. 

The commercial Scullcap is the entire herb, or the 
leaves and branches, dried. It has but little odor, and 
a bitterish taste. Both this and other species of Scutel- 
laria have had from time to time some transient or pop- 
ular reputation in medicine for the cure of mad-dog bites, 
chorea, epilepsy, or other nervous diseases ; also as ton- 
ics, antiperiodics, etc. The present species, S. lateriflora, 
is considerably used by the Eclectic school of practition- 
ers, and in home medication. It is reputed to be anti- 
spasmodic, anticonvulsant, etc., and is given for restless- 
ness and wakefulness. Its composition has not been 
determined, and there is nothing in its obvious action to 
indicate that it has any particular value. Dose from 
five to ten grams (3 j. ad 3 iij.). 

ALLIED PLANTS, ETC.—See PEPPERMINT. Lycopus 
resembles it in properties. W. P. Bolles. 


SCURVY, or SCORBUTUS. Philologically consid- 
ered, the word ‘‘ scurvy” appears to be of North country 
or Scandinavian origin, being derived from the Swedish 
skérbjugg, or the Danish skojwerbug, signifying soft or re- 
laxed stomach, the relaxation of the abdomen being one 
of the characters of this malady. The German scharbock 
and English scurvy have the same sense. As the disease, 
scurvy, prevailed among the ancient Danes, it is prob- 
able that they have given us the word, which, together 
with numerous other technical terms applied to naviga- 
tion, has left an imprint on our language showing plainly 
the Viking influence. 

Symptomatic definitions of scurvy are almost too well 
known to require repetition. On running over a number 
of them, selected at random from standard works, three 
distinct points are fixed in the mind, namely: 1, Skin 
and muscle lesions ; 2, mouth and gum phenomena ; and, 
8, physical, physiological, and psychical depression. Be- 
sides this, the definitions agree in attributing the alteration 
of the blood to a defective alimentation. Many writers 
speak of scurvy as a nosohemia of the same nature as 
purpura, from which it differs in greater intensity only. 
However strange the statement may seem, scurvy should 
properly be classed with the condition of multiple neu- 
ritis known as beriberi. The two diseases do not resem- 


ble each other in all essential points, yet we see in beri- 
beri the result of insufficient alimentation brought about 
by the abuse of a vegetable regimen, and the absence of 
meat, salt, and fat, and one that is best treated by butter, 
cocoanut oil, and fat meats ; while scurvy, which origi- 
nates from the abuse of an animal regimen and the ab- 
sence of fresh vegetable matter, is cured most readily by 
a diet of fresh succulent vegetables. 

Few diseases have been more observed and written 
about than scurvy, and few have so exercised the sagacity, 
and sometimes the imagination, of medical writers. The 
bibliography of the disease is enormous, and, so far from 
settling mooted points in the pathology of scurvy, it only 
adds to the confusion. 

To write the history of scurvy would almost be to 
write the history of medicine and to chronicle the sani- 
tary circumstances of most human events, since the dis- 
ease has occurred from time immemorial both on sea and 
on land. (See Army Diseases.) To pass in chronological 
review the various epidemics of scurvy of which a record 
is preserved would serve no good purpose. The disease 
was often described, but the first use which we find of 
the present name was in the sixteenth century, when a 
learned botanist, Enricus Cordus,! says of an antiscorbu- 
tic, the Chelidonium majus, ‘‘Saxones vero Scharbock’s- 
Kraut (eam nominant), quod forte morbo quod illi Schar- 
bock nominant medeatur.” From this period clinical 
pictures of scurvy, more or less exact, occur in various 
publications up to the time of the appearance of the mag- 
nificent works of Lind, of Krebel, and of Mahé. The 
word ‘‘ scurvy ” is no longer on the ‘‘ Statistical Reports of 
the British Navy,” and Sir Thomas Brassey says that the 
disease has been unknown for eighty years in the Royal 
Navy, or in the better class of merchant ships.?, With 
the opening of the Suez Canal, the recent improvements 
in steam machinery, and better methods of preserving 
food, it is certainly humiliating to find that scurvy 
should occur in the merchant marine, as it has occasion- 
ally done within the last decade. The English Govern- 
ment has made energetic efforts to diminish and stamp 
out scurvy from its commercial marine, and these efforts 
have been nobly upheld by The Lancet and the English 
medical press generally. Yet the high naval authority 
quoted above informs us that of late scurvy has been by 
no means rare in the British merchant service. A naval 
medical officer tells me that he knows of the occurrence 
of a number of cases of scurvy on board a British man- 
of-war on the South Pacific station, and that he has seen 
one case in the United States Navy. Dr. Guillemard re- 
ports the death of the boatswain, from scurvy, on board 
a well-found English yacht cruising in the Malay Archi- 
pelago in 1883.* Cases of scurvy have also lately come to 
the notice of the United States Marine Hospital Service. 
Four cases are reported from the Marine Hospital at San 
Francisco, in 1880, with one death, and another death 
from the same cause is reported in 1881. Both cases 
were complicated with pneumonia. Six cases were re- 
ceived into the Contract Hospital at Astoria, Ore., in 1881, 
and in 1885 the barkentine William Phillips, from Iloilo, 
Philippine Islands, arrived at Norfolk, Va., with scurvy 
on board. During the year ending June 30, 1887, the 
following cases of scurvy were treated in the United 
States Marine Hospitals: At Boston, 6; Chicago, 1; Port 
Townsend, 1; San Francisco, 4; Vineyard Haven, 2; 
and Wilmington, N. C.,1. Of this number 12 recovered 
and 3 improved. Only a few years since I had an op- 
portunity to study, in the Baltimore Infirmary, a number 
of cases from a vessel that had come around Cape Horn, 
In the spring of the year 1887, in the remote parish of 
Hornstrandir, Iceland, 62 out of 400 died from typhoid 
fever. After the fever had worn itself out, Hornstrandir 
was attacked by scurvy, with several fatal cases. 

While the existence of beriberi corresponds more or. 
less to the geography of insufficient alimentation, scurvy 
may be said to have no distinct geographical limits, since 
its symptoms are likely to appear on land or at sea, in the 
tropics or at the poles, under diametrically opposite me- 
teorological states, when the conditions necessary for its 
development are present. The polar regions have long 


307 


Scurvy. 
Scurvy. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


been regarded as the principal home of scurvy; but 
the geographical voyages of Kotzebue through Behring 
Strait (1815, 1818) ; that of Sir John Ross to the Arctic, 
accomplished without the loss of a man ; and that of the 
late circumpolar expeditions, among which scurvy did 
not appear, are an evidence of what sanitary and prevent- 
ive measures may do to ward off the effects of extreme 
polar cold. On the other hand, numerous facts attest 
the existence of scurvy in such warm places as India, 
Aden, Hindustan, Brazil, Egypt, Algeria, and Senegal. 
In thearid plains on the way to California, before the 
days of the Union Pacific Railway, emigrants were often 
attacked with scurvy, and entire caravans would perish 
‘from this cause. In late years almost the same thing 
has occurred in Australia. I have also seen it on the 
Rio Grande River in Texas, among persons whose diet 
was mainly beef and black coffee. In fact, having to 
subsist for some time upon the same diet, I had personal 
experience of the premonitory symptoms. Although we 
were surrounded by thousands of cattle, milk was not to 
be had, and we were also wholly deprived of fresh veg- 
etables, on account of the extreme heat and dryness. 

The foregoing observations show that this disease is by 
no means extinct, and that it may again become active 
whenever the conditions are favorable to its development. 
Nor is it confined wholly to the higher order of animals. 
I have seen. the experiment of feeding two rabbits, one 
exclusively on meat, the other on vegetable diet. After 
a few weeks the animal fed on meat developed symptoms 
of scurvy, while the other was sleek and fat. Hogs, 
though growing fat on an exclusive animal regimen, be- 
come scorbutic. It has also been observed that mon- 
keys and gorillas on board ship become scorbutic at the 
same time that the sailors are affected. It would be sur- 
prising, then, if the African should escape scurvy, as he 
was formerly supposed to do, when placed under the 
same conditions as his white brother. The fact is that 
the negro victims on board the slavers lived principally 
on vegetable diet, such as manioc, while the crew lived 
on salt provisions, and in addition had to contend with 
the circumstances of a previous voyage. The blacks, 
when subjected to the same dietetic causes as the whites, 
contract scurvy with them, as is shown by the history of 
sieges when both races had to live on the same food. 
Scurvy, therefore, is impartial in the selection of its vic- 
tims ; nevertheless, it would seem to be a disease of civ- 
ilization rather than of primitive life, since it appears to 
spare degraded savages who subsist on roots and grubs, 
and Eskimos and Kamschatdales, whose diet is highly 
nitrogeneous.* Properly speaking, scurvy is not a dis- 
ease of famine. ‘The Terra del Fuegan and the African 
negro may starve from want of vegetable food, but they 
do not die from scurvy. On the other hand, according 
to Parkes, men fed on a uniform diet of fat have gained 
in weight but have become scorbutic. 

Regarding the etiology of scurvy two sets of opinions 
prevail. ‘The first admits but one cause in the production 
of the malady, viz., the prolonged deprivation of fresh 
vegetable food; the second admits a variety of causes— 
physical, moral, and dietetic—which may produce scurvy 
when combined, or when one or the other of them is asso- 
ciated with some adjuvant cause of a different nature. 

Generally speaking, scurvy is engendered by the per- 
sistent and prolonged action of causes susceptible of 
weakening the metabolism of the general nutrition. And 
eae there are many causes which may contribute 
to this. 

Among physical causes may be enumerated the rota- 
tion of the seasons, overcrowding, and excessive fatigue, 
or its opposite, enforced immobility. Other considera- 
tions being equal, humidity of the atmosphere favors 
the development of scurvy. Numerous reports by differ- 
ent authors show that dampness and atmospheric changes 
constitute the most invariable elements among the pre- 
disposing and exciting causes of scurvy. Epidemics of 


* It has been suggested that the marked absence of salt may account 
for this immunity. Having spent two seasons among the Eskimos of 
Behring Strait, [ have been impressed with the fact of their aversion to all 
salted articles of food. 


308 


scurvy have prevailed among soldiers living in cold, 
damp casemates, though provided with a suitable ration ; 
it has appeared on board ships and in fleets where fresh 
provisions abounded—for instance, in the squadron of 
Admiral Martin cruising in the English Channel; and 
the bad weather experienced in doubling the Cape of 
Good Hope or Cape Horn has, for a long time, been recog- 
nized as one of the causes of scurvy. Of course it would 
be imprudent to say that cold and damp, overcrowd- 
ing, or any one of the forementioned causes is an indis- 
pensable factor in the outbreak of scurvy. They may 
have acted like sparks in lighting up the effects of a train 


of previously existing unhygienic circumstances. 


Fatigue is mentioned by most writers as an adjuvant 
cause. The assertion finds its application in the instances 
of overworked and underfed prisoners, in the disastrous 
retreats of armies, during sieges, in shipwrecks and dis- 
asters at sea. Among recent examples is the outbreak 
of scurvy among the enfeebled men of the Spanish squad- 
ron returning from the bombardment of Callao. 

Immobility or inaction, whether forced or voluntary, 
takes a part in the genesis of scurvy. It has often been 
observed in prisons and asylums. The crews of ships 
doing blockade duty have been attacked with scurvy, 
which has disappeared as if by magic on making prepa- 
ration for an engagement or on going into battle. Ac- 
cording to Dr. Charles Smart, United States Army, the 
average annual rate of cases of scurvy reported to the 
War Office during the eighteen years before the Civil 
War was 23.3 per thousand of strength, or nearly twice 
as large as that which prevailed among our white troops 
during the years of the war.°® 

To these causes may be added those referable to de- 
fects in lodging, bedding, clothing, and antecedent. physi- 
cal state. We may mention the filthy bedding in such 
dark, ill-ventilated places as the forecastle of most mer- 
chant ships as perhaps concerned in the causation, and 
it is well known that the excesses in which men indulge 
when ashore furnish a strong predisposing cause, so that 
men leaving port on a long-distance sailing ship, after a 
debauch, are more likely to acquire a scorbutic taint than 
those who have kept sober. 

Next to the physical are the mental and moral causes. 
Psychological misery and moral depression in prisoners 
have long been looked upon as preponderating causes, 
and in years gone by nostalgia was thought to have 
caused scurvy on board French ships. A comparatively 
recent example, in which the alimentary origin cannot 
be admitted, is the outbreak of scurvy among French 
prisoners at Ingolstadt (1871), who, according to report, 
received excellent rations of fresh meat and potatoes. In 
this instance the malady was thought to be owing to the 
damp cold of the casemates, to inactivity, and to mental 
depression. Deported convicts and prisoners on board 
ships have also suffered from scurvy, though receiving 
the same ration as the crew. Notable instances of late 
years are the epidemics of scurvy on board the French 
transports which conveyed political convicts to Caledonia 
in 1873. On board the Var and the Orne the food of 
these unfortunates is said to have been irreproachable as 
to quantity and quality ; they received exactly the same 
ration as the crew and the free passengers, except that 
they had only half a ration of wine and no brandy ; the 
drinking water was excellent, and clothing and bed- 
ding were sufficient. But chagrin, want of employment, 
ennui, and painful preoccupation affected the prisoners, 
and they slept in a vitiated atmosphere that was damp 
and hot. Recent travellers also speak of the prevalence 
of scurvy among Siberian prisoners. 

Physical and moral causes may together engender 
scurvy, more particularly after prolonged and uniform 
usage of salt provisions that have undergone an isomeric 
modification that causes a loss of their reparative prop- 
erties. Salt in itself is, however, not a cause of scurvy. 
The experiment of drinking sea-water for a month has 
been followed by harmless results, and numerous in- 
stances are reported in which the prolonged use of salt 
provisions has not been followed by scurvy. On the 
other hand, we have examples of the outbreak of the mal- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Scurvy. 
Scurvy. 


~ady in cases in which salt food has not been employed. 
Yet it cannot be denied that the chief cause of scurvy is to 
be found in the absence or the insufficient quantity of 
certain materials or principles necessary to good alimen- 
tation, and notoriously in the prolonged deprivation of 
milk, and of fresh vegetable food. Epidemics of scurvy 
in English and Scotch prisons have often been attrib- 
uted to the privation, or to the suspension, of the ordi- 
nary ration of milk served to the prisoners. The uni- 
formity and monotony of the diet in most merchant ships 
are not conducive to the preservation of health. Sir 
Thomas Brassey says the allowance differs little, except in 
quantity, from the dietary in use during the last century; 
and this notwithstanding the great improvements in the 
preservation of meats and vegetables. The abuse of to- 
bacco is also claimed to be a pathogenic factor in scurvy. 

For convenience of description the ordinary phenom- 
ena of scurvy may be divided into three degrees or pe- 
riods. The first period, that of. evolution, is marked 
by general adynamia. The physiognomy is expressive ; 
the characteristic pale-yellow tint of the skin being dis- 
tinct from that of icterus, or of any other cachexia. Ex- 
treme lassitude, with an undefinable sensation of ma- 
laise in the voluntary muscular system, is accompanied 
by a sad and downcast air, disturbance of the appetite, 
dyspnoea, insomnia, hebetude, and other indications of 
diminished vitality. These are followed usually, though 
not always, by gingivo-buccal symptoms. At the margin 
of the gums, and in the intervals of the teeth, appears 
a change of color and consistency, owing to alteration 
of the capillaries ; the gums become livid, soft, and bleed- 
ing; and the breath has a characteristic earthy, fetid 
odor. Pains occur in different parts of. the body, more 
particularly in the lower limbs, and extravasation of 
blood in the outer skin and other tissues causes small 
purpuric spots that often assume a large size and induce 
a brawny hardness in the cellular tissue of the legs. 

In the second period these symptoms are greatly ag- 
gravated. The purpuric spots become true ecchymoses, 
varying in color from yellow-brown to blue-black; the 
sanguineous infiltration, affecting the muscles of the 
calf and thigh, causes a characteristic induration ; the 
loosened teeth sometimes fall out ; and the alteration may 
extend to the osseous system, causing detachment of the 
epiphyses, if the subject is young, and sometimes exos- 
tosis and periosteitis. In addition to these, there may 
be bleeding from the mucous membranes, painful dysp- 
noea, a relaxed and pendulous condition of the abdo- 
men, and fever. 

In the third or last period the aspect of the patient is 
that of a breathing cadaver. In addition to the fever and 
other symptoms already described, there follows a gen- 
eral prostration, with septic or putrid hemorrhages ; the 
legs assume a sphacelated appearance ; phlyctenz are 
followed by rapidly extending and spontaneous ulcera- 
tions of the skin ; fractures which have long been united 
again separate ; necrosis of the tibia and bones of the foot 
occurs, and marasmus supervenes. Death occurs from 
extensive suppuration, from the intensity of the hectic 
fever, or by hemorrhage, visceral lesion, or syncope. 

So little is known of the pathological lesions of scurvy 
that the subject may be dismissed in a few words. Al- 
though the disease is dependent upon some chemical 
alteration in the quality of the blood, it cannot be said 
that we know positively of any morphological modifica- 
tion of this fluid that is proper to scurvy. ‘The same 
may be said of the other morbid changes that have 
been noted. Beyond the sanguineous effusions into the 
splanchnic cavities ; softening, or more often hardening, 
of the muscles ; the occasional cartilaginous detachment 
of the ribs, and caries of the bones, scurvy has no ana- 
tomical characteristics that are not common to many 
other diseases. 

It is rather in the complications of scurvy that the 
more marked anatomical lesions are to be found. To 
study even the more immediate of these complications 
would require systematic examination of most of the or- 
gans of the body, since pleurisy, pneumonia, pericarditis, 
etc., are morbid processes occurring side by side with 


scurvy under the influence of accessory causes; and 
many great epidemics of disease, especially in armies, 
have been preceded, accompanied, or followed by scurvy. 
In fact, scurvy may color or modify many diseases or 
accidents, prolong convalescence, and increase mortality 
to a serious extent. The most common complications of 
scurvy are dysentery, diarrhoea, and malarial fever, which 
some regard as epiphenomena of the disease. Hemeral- 
opia and nyctalopia have a like origin with scurvy, and 
the pathological annals of navigation of the last two cen- 
turies are filled with the disastrous associations of the fore- 
mentioned diseases. 

If properly treated an uncomplicated case of scurvy 
leaves no trace. Many ex-soldiers are, however, borne 


| on the Invalid Pension List on account of the results of 


scurvy incurred in the late Civil War. In these cases 
the chief sequele are loss of teeth, scars from extensive 
ulcers, and occasional lesions of one or more of the tho- 
racic or abdominal organs. ° 

Simple, uncomplicated cases of scurvy often disappear, 
as if by magic, on removal of the cause ; but the repara- 
tive process is ordinarily slow, and severe cases require 
two months’ treatment. The patient may be considered 
out of danger if, after several days of treatment, he re- 
gains the use of his limbs and has no dysentery, chest 
complication, or bleeding at the nose. An improved 
state of the skin is also a favorable indication. The prog- 
nosis, however, depends on the intensity of the symp- 
toms; upon previous or concomitant diseases, such as 
fevers and lesions of the digestive organs ; upon pro- 
longed treatment for syphilis ; upon malarial poisoning ; 
upon the fact of a previous attack ; and upon atmospheric 
and climatic conditions. 

The diagnosis of scurvy is a matter of no difficulty. 
Perhaps some distinction should be made between it and 
purpura and Alpine pellagra, in order to avoid nosologi- 
cal confusion. The only morbid conditions with which 
scurvy is likely to be confounded are the different ane- 
mias and spangzemias, hematophilia, beriberi, and the 
cachectic condition brought about by dirt-eating. (See 
Appetite. ) 

No disease is more easily prevented, and none is more 
amenable to treatment than scurvy. The means of its 
prevention are now so well understood that an outbreak 
of scurvy among soldiers, sailors, prisoners, or the in- 
mates of an asylum, or among any other persons subjected 
to discipline or restraint, is, in most cases, presumptive 
evidence of neglect on the part of somebody. The law 
takes cognizance of this neglect, as is shown in Sections 
4.569 and 4,570 of the Revised Statutes. 

The prophylaxis of scurvy is so apparent, after its 
causes are known, that to particularize the details would 
be to repeat unnecessarily. 

Regarding the prevention of scurvy, the most effica- 
cious hygienic precepts are now a matter of common 
knowledge. The principal ones that bear emphasizing 
are the enforcement of dryness and cleanliness, especially 
on the berth-deck or forecastle of a ship, and the use of 
so-called antiscorbutics. We have no rational explana- 
tion of the power of the latter as a preventive ; their use 
being in the large and true sense purely empirical. New 
Bedford whalers cruising in the Pacific Arctic provide 
themselves with a sufficient supply of live pigs, cocoa- 
nuts, pickled cabbages, onions, and potatoes. From the 
captain of a Russian fur-trading vessel I learned of an 
excellent antiscorbutic in the use of cranberries, espe- 
cially the little ones that grow in Alaska and the Aleutian 
Islands. Lime-juice, in great renown with the English, 
has won for them the sobriquet of ‘‘ lime-juicers” from 
Yankee sailors. It is, however, very unpopular among 
many sailors, because they think the use of lime-juice 
causes impotency ; and it is doubtful whether it be as 
effective as a liberal allowance of potatoes, onions, sauer- 
kraut, and condensed milk, or the occasional issue of beer, 
cheap light wine, or even wine of absinthe, the three lat- 
ter being regarded by Lind as antiscorbutics of the first 
order. The same authority also recommends eating a bit 
of raw onion every morning before exposure on deck. 
When practicable, cider may be added to the dietary, and 


309 


Scurvy. 
Sea-Sickness, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the daily use of lemonade at dinner is to be highly com- 
mended. 

The curative treatment of scurvy being almost entirely 
hygienic, but little is to be done in a therapeutic way. 
Admirable results may be obtained from a good dietary 
consisting chiefly of milk, vegetables, and fruit. (See 
Grape Cure.) A chlorinated or an antiseptic mouth- 
wash ; an alcoholic or a camphorated lotion for the pur- 
puric spots; the administration of brandy or quinine to 
overcome adynamia and cardiac insufficiency ; and rest 
in a horizontal or sitting position, in order to avoid pos- 
sible syncope, are the salient and essential therapeutic 
points to be observed in ordinary cases. The treatment 
of complications and sequel should be mainly directed 
against the asthenic condition, and so the economy should 
be fortified against a return of the disease, which may 
happen on the slightest provocation. 

For the future observer there still remains much to be 
done in clearing up points of disagreement and in filling 
up the gaps left in the pathological anatomy of scurvy. 
To this end the newer experimental methods of investi- 
gation—chemical, clinical, and histological—should be 
made to take the place of the old hypotheses and sterile 
reasonings of our forefathers. In spite of numerous 
efforts, much remains to be done in the way of investi- 
gations bearing upon the component elements of the 
blood, such as a rigorous enumeration of the red globules, 
the amount of hemoglobine in the corpuscles, and the 
chemical analyses of the globules themselves. In addi- 
tion, it is desirable to know the proportions of iron and 
potassium, as well as of the principal substances elimi- 
nated by the excretions, particularly the urine. A_bet- 
ter and more extended study of the state of the capillary 
system in the principal organs and tissues is a desideratum, 
and the same may be said of the study of the patholog- 
ical anatomy of the principal viscera of the abdominal 
cavity. On the side of the nerve-centres almost nothing 
has been pointed out up to the present in the patho- 
logical anatomy of scurvy, and we are equally ignorant 
of the anatomical changes that occur within the organs 
of sight. Irving C. Rosse. 

1 Botanologicon. Colon, 1534. 

? The British Navy: Its Strength, Resources, and Administration, 
vol. v., p. 174. London, 1883. 

3 Cruise of the Marchesa, vol. ii., p. 8353, London, 1886. 

4 See writer's ‘‘ Cruise of the Corwin to Alaska and the Northwest Arc- 


tic Ocean.” Washington, 1881. 
5 Medical and Surgical History cf the War of the Rebellion. 


SEAL, GOLDEN (Hydrastis, U. S. Ph., Yellow Puc- 
coon, Yellow Root, ete.). The rhizome and rootlets of 
Hydrastis canadensis Linn. ; order, Ranunculacew. This 
is a low perennial herb, with a tuberculated, crooked, 
yellow rhizome, marked along its upper surface with 
frequent scars (seals) of fallen stems, and bearing numer- 
ous wiry, wavy, or crooked, yellow roots. The aérial 
stem, situated at the extremity of the rhizome, and sur- 
rounded at the base by a few brown scales, is upright, 
from two to three decimetres long, and bearing two un- 
equal five- or seven-lobed leaves. The lower of these is 
the larger, and petiolate ; the upper is sessile; flower 
solitary, terminal, about as large as a buttercup ; it con- 
sists of three fugacious, greenish-white sepals, numerous 
stamens, and about a dozen pistils ; fruit a raspberry-like 
cluster of red berries. Hydrastis grows abundantly in 
the northern and western parts of the United States and 
inCanada. In New England, and the Middle and South- 
ern States it is more scarce. It was originally used by 
the Indians as a dye and medicine, and has been known 
to us about a hundred years. 

DEsCRIPTION.—It comes in pieces four or five centi- 
metres long, slightly branched, or simple, covered with 
rather numerous rootlets, yellowish-gray outside, bright 
yellow within ; the rhizome is slightly wrinkled longi- 
tudinally ; odor strong; taste very bitter. The principal 
active derivatives of Hydrastis are the alkaloid berberine, 
the same as that found in Barberry Bark and other 
plants, and hydrastine. This latter substance, discov- 
ered about 1852, crystallizes in brilliant, white, four- 
sided prisms, soluble in alcohol, chloroform, and ether, 


360 


but scarcely at all in water. No odor; taste, in solu- 
tion, bitter. A third alkaloid, vanthopuccine, appears 
to exist in the drug, but is less fully known than the 
others. The proportion of hydrastine in the dried root 
is about one anda half percent. An odorous principle 
and a resin have not yet been isolated. © 

Action AND Use.—It is difficult to find in Hydrastis 
anything more than the usual tonic qualities of the der- 
berine-yielding drugs; in small doses they all are thought 
to improve the appetite and promote assimilation ; in 
large ones they derange the stomach. It is given in in- 
termittent and other fevers, and for the various uses to 
which quinine is put—sweating, typhoid, diarrheea, etc. 
Locally used, Hydrastis is in considerable favor as an in-. 
gredient of urethral and vaginal injections, as well as for 
washes for other surgical cases—ulcers, heemorrhoids, 
vegetations, etc. * 

ADMINISTRATION.—Hydrastis is not often given in sub- 
stance ; the dose would be from three to ten grams. A 
Fluid Extract (Hztractum Hydrastis Fluidum) and Tinct- 
ure (Tinctura Hydrastis, 4) are officinal. An infusion 
may be also made. For a wash or injection hydrastine 
and berberine are both to be had ; doses from two to ten 
decigrams. ‘‘ Hydrastin” is an impure preparation ob- 
tained in the usual way for ‘‘resinoids;” it is a combi- 
nation of the three alkaloids and some resinous substance. 
Dose about three decigrams. 

ALLIED PLANTs.—See ACONITE. 

ALLIED DRuGs.—CopPTis, BARBERRY, COLUMBO, etc. 

W. P. Bolles. 


SEA-SICKNESS. The assemblage of morbid symp- 
toms denominated sea-sickness, or more properly sea-ill- 
ness, is too well known to require formal definition, since 
there are but few that have not had both subjective and 
objective experience of the malady. 

In spite of the distressing character of sea-sickness it 
fails to elicit much pity from others. It is also strange 
that the unpleasant phenomena of sea-sickness have been 
so little elucidated; such little advancement having 
been made in the study of the subject that ‘it is practi- 
cally a fresh one with an unlimited field of observation, 
and he that succeeds in working it will reap the re- 
ward of a public benefactor. The great medical writ-. 
ers of antiquity scarcely allude to sea-sickness, and the 
published observations of sea-going surgeons are most 
meagre. The majority of writers on the subject have 
been landsmen who knew but little of the sea, and 
sailors who knew less of medicine. In fact, the subject 
has been so little scrutinized by physicians, that it pre- 
sents the remarkable anomaly of the existence of an ail- 
ment almost without a medical bibliography, the two 
hundred or more references to this subject consisting 
chiefly of a few theses or inaugural dissertations and 
short journal articles. It is rather to general literature 
that one must turn to find illustrations of the subject. 
Plutarch appears to be the first author to describe its 
symptoms and treatment. The malady is also mentioned 
by Suetonius and Juvenal, and every school-boy knows 
of Cicero’s desperate resolve to fall into the hands of his 
executioner rather than endure longer the horror of sea- 
sickness. In Burton’s ‘‘ Anatomy of Melancholy” sea- 
sickness is mentioned as being very good at times; in 
Boswell’s ‘‘ Johnson” the great doctor recommends the 
salutary effects of a smart sea-sickness ; Goldsmith inter- 
ested himself to the extent of attempting to invent a ma- 
chine for its prevention ; in ‘‘ Tristram Shandy ” the cere- 
bral effects of the malady are felicitously described; and so 
citations might be extended indefinitely from the ‘‘ quite, 
quite down” of Shakespeare to Browning’s ‘‘swooning 
sickness on the dismal sea,” not to mention the com- 
ments of Rabelais and Montaigne. : 

Most of the attempted explanations of sea-sickness are 
pure figments of the mind, that of the greatest German 
savant being, in point of fact, but little above that of the 
humblest fisherman. It is, however, generally conceded 
that the symptoms are owing to the influence of the mo- 
tions of the ship, which admit of infinite variation, as 
anyone may observe while sitting on the quarter-deck, or 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Scurvy. 
Sea-Sickness, 


when lying in a bunk, during rough weather. In en- 
deavoring to balance or right itself, the ship rolls, pitches, 
seems to pause, and then darts with a side motion fore- 
and-aft, or, in more precise language, a variety of oscilla- 
tions take place around both the transverse and the longi- 
tudinal axes of the ship. These motions alone are the 
cause of sea-illness, and bad smells, heat, sight of the 
waves, fear, ‘‘ biliousness,”’ and other alleged causes are 
mere accessories. The same idea, aphoristically expressed 
more than two thousand years ago, does not admit of 
greater refinement, notwithstanding the advanced knowl- 
edge of the day. 

There are, however, certain unusual and disorderly 
movements that may cause phenomena similar to those 
of sea-illness, such as the trembling of the earth during a 
volcanic. eruption or an earthquake, experiences of the 
kind having been common during the late seismic dis- 
turbances at Charleston and Mentone. Riding backward 
in a railway train, going up and down in a lift or ina 
balloon, the act of swinging, riding a camel or a drome- 
dary, rapid gyratory movements of the body, the concus- 
sion experienced by workmen in riveting boiler-plates, 
or, in short, any series of unusual and disorderly shocks 
that disturb the cerebro-spinal or the ganglionic nervous 
system may bring on this peculiar functional disturb- 
ance. 

It is estimated that of those who go to sea about three 
per cent. are never sick, and three per cent. are never 
well. Others, after temporary illness, recover rapidly ; a 
few are prostrated for weeks, and, in rare instances, some 
delicate or susceptible persons may never recover. There 
is also much that is odd and enigmatical regarding indi- 
vidual susceptibility to sea-sickness. Although women 
are more subject than men, it sometimes happens that a 
delicate, hysterical girl will escape illness, while a strong 
man is prostrated. Champion pugilists during a voyage 
at sea have been overcome, while many of the weaker 
passengers were exempt. One of the greatest sufferers 
I have ever known was a celebrated member of the Lon- 
don Athletic Club. The liability to illness is much af- 
fected by the class of ship and by certain motions. Many 

' persons will cross the Atlantic with impunity, and yet get 
ill on a Channel steamer. The sensibility of others is 
such that travel on a comparatively smooth river or lake 
causes unpleasant sensations. As a rule, navigation is 
easiest on a sailing-ship; the tendency to illness is in- 
‘creased on board a paddle-wheel steamer, and it is great- 
est on board a screw steamer. If the force of the wind 
should cause a list in the steamer to one or the other side, 
the tendency to become ill is greater. I have often no- 
ticed, in a transatlantic steamer, that passengers who had 
recovered from an illness incurred during a fore-and-aft 
motion of the ship, with the wind astern or off the quar- 
ter, would invariably become ill again when the wind 
shifted so as to cause a beam-sea, which changed the di- 
rection of the ship’s oscillations. Owing to the greater 
amplitude of the oscillations experienced in going aloft, I 
have often seen boys become ill on board a training-ship, 
who kept well as long as they remained on deck. After 
staying ashore for some time, the inuring process of get- 
ting one’s sea-legs has often to be repeated, even in ‘‘ old 
sea-dogs.” Sonve years since, in a gale on the Pacific, just 
after quitting the Golden Gate, I was a fellow-sufferer 
with an old Nantucket whaling captain ; and though hav- 
ing personal claims to being something of a sea-rover, I 
lately became squeamish on board a steam yacht while 
witnessing a race. Nothing dampens enthusiasm like 
sea-sickness. Men full of military ardor start on an ex- 
pedition, and after a day or two at sea on board a trans- 
port suddenly come to the conclusion that there is really 
no cause for war. History tells how Bonaparte’s sea-sick- 
ness paralyzed and brought to naught his grand enter- 
prise of invading England. 

Many professional sailors suffer greatly from sea-sick- 
ness, and even Nelson was a martyr to this cause. I 
know of several naval officers who are great sufferers ; 
one, a fleet captain, tells me that he often, in his cabin, 
suffers agony on this account. With many persons the 
susceptibility is so great that the sensorial perversions 


—~ 


continue for days after going ashore, and in others any- 
thing suggestive of the sea causes unpleasant sensations. 
I have known such to be caused by a boatswain’s whis- 
tle. A naval officer of my acquaintance, who is sorely 

troubled by this form of illness, has all the premonitory } 
symptoms on the reception of his orders for sea duty, 
and I know an old lady in New Bedford who is unable 
to look at the heaving figure of a ship on the face of an 
old-fashioned clock without becoming ill. Another in- 
stance, in which the mere recollection of the occurrence 
caused renewal of the nausea, is that of the late Henry 
Ward Beecher, who relates that, many years after his 
first voyage across the Atlantic, he heard some sailors in 
a Brooklyn dock singing the same old ‘‘chanty” song 
that he had heard when ill at sea, and that the mere lis- 
tening to this song produced symptoms of sea-sickness. 

That something less than perverted sensation may 
arouse the unpleasant associations of sea-sickness is evi- 
denced by the effects upon a highly susceptible person 
on reading one of Clark Russell’s novels, say, ‘‘ Wreck 
of the Grosvenor” or ‘‘Sailor’s Sweetheart.” Carried 
almost beyond the realms of fancy, one sees a complete 
nautical picture in his mind’s eye; he hears the thud of 
the sea and the sounds of the running rigging; smells 
the tarred rope and bilge, and feels the close atmosphere 
and nauseating roll of the ship. 

The cerebral action which recalls such phenomena can 
hardly be said to exist in the lower order of animals— 
such as birds, dogs, sheep, horses, and elephants—who 
often suffer greatly from sea-sickness. It is easier to 
look for a mechanical or physical cause in the disturb- 
ance of the cerebro-spinal tluid from the effects of a cen- 
trifugal force, analogous to the change that takes place in 
such a liquid substance as milk when placed in the tubes 
of a whirling machine for testing. 

Similar effects of cerebro-spinal disturbance appear in 
a tumbler-pigeon, which seems lifeless after being whirled 
around for afew moments with the head under its wing; 
gulls, Mother Carey’s chickens, and other aquatic birds, 
when placed on a ship’s deck become nauseated from 
the rolling and pitching, that is to say, from the great 
oscillations of the ship around its axes; and many per- 
sons have observed the phenomena of sea-sickness in chil- 
dren who have ridden too long on a merry-go-round. 

The many explanations that are offered to account for 
the symptoms of sea-illness differ one from another, and 
are all more or less objectionable. One of the causes as- 
signed to account for the nausea is neither the motion in 
itself nor the appearance of motion, but the violation of 
the habitual conceptions of contrasted effects of motion, 
which may obtain not only in those having sight, but in 
the blind. The motions of the ship cause mental con- 
cepts totally at variance with the ordinary experience. 

Dr. William James, of Boston, states that deaf-mutes, 
as a class, are exempt from sea-sickness, and for that rea- 
son it is suggested that the malady does not occur in the 
ease of destruction either of the auditory nerves or of 
their labyrinthine terminations, and that the semicircular 
canals are the probable starting-point of the affection. 
An illustrative instance is mentioned in which a person 
much subject to sea-sickness was entirely cured after re- 
ceiving a blow on the head which crushed the mastoid 
process and caused deafness. 

That there is some connection between aural defects 
and certain symptoms simulating those of sea-illness ap- 
pears to be the fact. Such symptoms are at times ob- 
served when the Eustachian tube is obstructed, and still 
more commonly when there has been concussion of the 
labyrinth, or when the structures contained within this 
cavity have undergone pathological changes as the result 
of cerebro-spinal meningitis. . ; 

Whether the nausea be owing to irritation in certain 
states of defective aural mechanism ; to irritation of the 
nerves of the eye caused by the apparent instability of 
all surrounding objects; to agitation of the abdominal 
viscera ; to the continuity of the muscular contractions 
necessary for the maintenance of the equilibrium ; to the 
pumping motion of the liquids of the body, analogous to 
the rise and fall of the mercury in a barometer ; to reflex 


361 


Sea-Sickness,. 
Secretion. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


action disturbing the medulla, the spinal cord, the solar 
plexus, and the splanchnic nerves, or to concussive 1m- 
pact resulting in cerebral anemia and diminution of the 
brain mass, we are not in a position definitely to say. 
These are questions too subtile and problematical, but it 
is possible that there is more or less truth in each, and 
that the symptoms vary accordingly as the cerebral, the 
spinal, or the visceral contents are most acted on; so 
that in some, whose cerebro-spinal system is less resistant, 
the trouble experienced is headache, giddiness, and un- 
steadiness, rather than the vomiting and loss of appetite 
of others, whose organic nervous system is principally 
affected. 

No illness is less harmful and sooner forgotten than is 
this. Ordinarily it passes off in a few days, leaving the 
patient none the worse for his experience. In fact, it is 
highly beneficial in many ailments, as affections of the 
liver and digestive organs, melancholia, certain kinds 
of mental alienation, and obstinate intermittent fever, 
which I have known to be broken up by this curative 
means alone when all others had failed ; and were it not 
for the rare occurrence of death in persons suffering from 
some antecedent malady, and the alarming weakness and 
erethism produced in other delicate subjects, the matter 
of deciding whether there is any effective prophylactic 
or any infallible treatment that may ward off, alleviate, 
and abate the ravages and woes of this unpleasant ad- 
junct of sea-travel, would scarcely occupy the serious 
attention of the physician. 

As arule, sea-sickness is dangerous in organic disease 
of the stomach, brain, heart, or lungs, and to pregnant 
women. All such should avoid sea-voyages. Heemor- 
rhages and hernia may occasionally result from the 
straining caused by the frequent vomiting, and defective 
nutrition may bring about great wasting of the body. 
Obstinate constipation, marked diminution of the urine, 
and occasional spasmodic contraction of the urethra, are 
among what may be called the complications of sea-sick- 
ness. In addition to these, sugar is sometimes found in 
the urine, owing to irritation of the diabetic centre in the 
medulla; convulsions may occur in some cases, and in- 
stances of temporary insanity from this cause are re- 
ported. I have seen one such case in a Frenchman in 
crossing the English Channel from Dieppe. Dr. Rey- 
nolds states that he has seen three cases.! 

Pretended specifics for sea-sickness have not been want- 
ing from the earliest times, and most of them, from old 
women’s remedies down to the sort of liver-pad praised 
by Bacon, are as worthless as they are foolish. We do 
not know the contents of the box of which Shakespeare 
says, ‘‘If you are sick at sea, a dram of this will drive 
away distemper” (‘‘ Cymbeline,” act iii., scene 4.) Nor 
was it perhaps so effective as the rope’s-end formerly 
used on green midshipmen in the British navy ; or the 
bucket of cold water that is usually dashed over sea-sick 
men on board whaling-vessels ; or the treatment pursued 
in the case of boys on training-ships, who are supported 
by two other persons, if necessary, and made to walk the 
deck and swallow occasional spoonfuls of hot soup until 
they get well. Such heroic measures, of course, cannot 
be resorted to when dealing with delicate, susceptible 
people, invalids, and pregnant women, who make up the 
larger part of the passenger list of an ocean steamer ; so 
recourse is often had to such drugs as chloral, opium, 
chloroform, amyl nitrite, and numerous other sedatives, 
most of which are of little more value than the colored 
spectacles, supposed to prevent sea-sickness, which were 
sold in large quantities, a few years since, by an enter- 
prising individual in Cadiz to Spanish soldiers embark- 
ing for Cuba. 

Although like advising a sufferer from toothache to be 
philosophical, it is best, if one must go to sea, to exercise 
his courage and force of will. He must keep up and 
show his stoicism by remaining in the open air, and eat- 
ing at usual hours, regardless of the fact that the food 
is vomited. The vomiting, which, by the way, is not 
one and the same thing with sea-sickness, is often al- 
layed by lying down and by swallowing crushed ice or 
small quantities of iced champagne. According to Dr. 


362 


Coniat, of the Compagnie Générale Transatlantique, the 
rebellious vomiting is arrested with ‘‘ prompt and evi- 
dent success” after faradization of the epigastric region, 
combined with the external employment of a solution 
of atropia, the intensity of the current being graduated 
according to the susceptibility of the person and the ob- 
stinacy of the vomiting.’ The debilitated stomach is soon- 
est brought back to its normal state after drinking a little 
bitter beer, or eating an orange, a lemon, or other bland 
and delicate food ; but, as a rule, all spirits, liquids, and 
sweets should be avoided, as they disturb the stomach 
and irritate the gastric mucous membrane to the extent 
of causing a predisposition to illness. A teaspoonful 
of Worcestershire sauce is often excellent in the earlier 
stages ; and fat bacon, smoked herring, and curry will 
often stay down when other things are vomited. , 

Mechanical contrivances against sea-sickness, as tight 
belts, swinging beds, the Bessemer saloon, and the proj- 
ect of affording greater amplitude by connecting two 
or four vessels after the manner of a catamaran, have 
proved inoperative. 

A course of exercise in a swing, with a view to pre- 
paring for a voyage, has proved as futile as the habit of 
taking medicine previously to embarking. No malady, 
in fact, has afforded a more ample field for polyphar- 
macy, and none is more rebellious to treatment. In fact, 
there is no remedy for sea-sickness, and as long as men 
go to sea, so long will they be liable to suffer from this 
distressing malady. Irving C. Rosse. 

1 Lancet, 1884, i., 1161. London. 
2 Archiy. Méd. Navale, November, 1868. 


SEBACEOUS CYST, or ‘‘wen,” as it is popularly 
called, appears as a variously sized, firm or soft, round- 
ish tumor, seated in the skin or subcutaneous connective 
tissue. The skin covering the tumor is natural in color, 
or whitish from stretching. The tumors may occur singly 
or in great numbers, and may vary from the size of a pea 
to that of a walnut, or larger. They are usually firm, but 
sometimes doughy, and are generally freely movable and 
painless. Their usual seat is upon the scalp, face, back, 
and scrotum, though they may be met with anywhere, 
even on the soles, it is said. They may last for years un- 
changed, but sometimes break down and ulcerate. They 
may degenerate into epithelioma in old persons. Some 
sebaceous cysts are flat, with a minute hole in the centre, 
others tend to rise above the surface of the skin and be- 
come semiglobular. The latter are those commonly 
found upon the scalp, when they are devoid of hair. 

The contents of sebaceous cysts may be milky or 
cheesy in consistence, and are often decomposed and 
fetid. The tumors are, in fact, nothing more than enor- 
mously distended sebaceous ducts and glands, the walls 
of which have become hypertrophied until they form a 
tough sac. 

The treatment of sebaceous cyst is excision. The cyst- 
wall should be carefully dissected out, as otherwise the 
disease is apt to recur. Arthur Van Harlingen. 


SEBORRHGEA. A disease of the sebaceous glands of 
the skin, characterized by an increase in the quantity of 
sebum poured out ; and also, in most cases, by an altera- 
tion in quality of the secretion. There are two varieties 
— seborrhea oleosa and seborrhea sicca. 

Seborrhea oleosa appears in the form of an oily coating 
upon the skin, giving it an unctuous and greasy feel. 
Its most common seat is on the scalp and about the face, 
particularly the nose and forehead, where it appears as a 
greasy coating, containing more or less dust and dirt, 
and looking as though the skin had been smeared with a 
dirty ointment. In the scalp it collects on the hair, giv- 
ing it a dark, limp look, as if it had been freely oiled, or, 
when the scalp is bald, looking as if oil had been poured 
over it. 

Seborrhea sicca, or dry seborrhea, occurs in infants as 
vermx caseosa, or smegma of the new-born. Here it is 
almost physiological, and is usually soon removed. If 
it remains it becomes a diseased condition, and as such 
is often seen upon the scalp. Dry seborrhea shows 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sea-Sickmness, 
Secretion. 


itself on both the hairy and non-hairy portions of the 
body as a more or less greasy mass of scales, of a dirty 
yellowish color, and somewhat adherent to the skin. On 
the scalp these masses are larger and oilier, tending to 
cling to the skin in thick plates, and leaving, when picked 
off, a smooth, grayish, moist or oily surface beneath. In 
old persons the scalp, and sometimes the region of the 
beard, is covered to a greater or less extent with a brown, 
adherent greasy coating, which is essentially seborrhceic 
in character. 

Seborrhcea of the scalp, like pityriasis, with which it 
is sometimes confounded (see Pityriasis simplex), is some- 
times followed in the young by premature baldness. If 
taken in time, however, baldness from this cause can be 
prevented, and it is desirable in all cases to remove the 
seborrheeic condition, even if it gives rise to little or no 
annoyance. 

Seborrhcea of the foreskin and glans penis is an abnor- 
mal flow of the normal secretion of this part, known as 
smegma preputit. If not attended to, it leads to balanitis, 
from the irritation of its rapidly decomposing sebaceous 
products, 

Seborrhcea is induced by a variety of causes, promi- 
nent among which is the chlorotic or anemic state. It 
is more apt to occur about puberty or in early adult age. 
It may occur in persons otherwise healthy. In such 
cases it is usually curable by local measures. 

The diagnosis of seborrhcea is usually not a matter of 
much difficulty, the evidently sebaceous character of the 
products of disease pointing out its nature with sufficient 
certainty. The treatment of seborrhea should usually be 
both constitutional and local. Fresh air and exercise, espe- 
cially in the case of young women, is to be insisted upon. 
Attention should also be paid to diet. The history should 
be looked into, and any functional irregularities corrected 
when possible. Success in treatment often depends upon 
ascertaining and meeting the exciting cause in the indi- 
vidual. Cod-liver oil, iron, and arsenic are the most 
generally useful remedies. Iron may be given in the 
form of the tincture of the chloride alone, or with phos- 
phoric acid. Arsenic is best given as Fowler’s solution, 
in the dose of four or five minims, thrice daily, in wine of 
iron. Cod-liver oil is particularly beneficial in cases in 
which oily seborrhcea is accompanied by acne, particu- 
larly acne indurata in strumous subjects. 

The local treatment of the disease is very important. 
In seborrheea of the scalp the scales and crusts must first 
be removed. If they are hard and caked, as is sometimes 
the case in old people, the scalp should be soaked in 
olive- or almond-oil overnight. Hot water and soap will 
then remove the softened crusts. 

An excellent means of removing the crusts and scales 
is by means of the spiritus saponis kalinus, an alcoholic 
solution of Hebra’s green soap. A tablespoonful of this 
may be applied to the scalp with a sponge and a consid- 
erable quantity of warm water added, so as to make a 
lather. After yigorously shampooing the scalp for a few 
minutes, the soapy matters are to be washed away with 
an abundance of clear warm water, and the scalp dried 
quickly with a soft towel, when it is ready for the appli- 
cation of the more strictly remedial agents, usually in 
the form of medicated oils. An excellent formula is the 


following : 
Bev ACIdLeArpolicin 20 e.2+ Gm. 38 (gr. xlv.) 
CU pe PLO OI sions sina hte Gm. 4(f3j.) 
CL ALMODIS odie « henn « we Gm. 2(f38s.) 
Aq. cologniensis ...... ad Gm. 64 (f 2 ij. 


On the bald scalp and other places where there is no 
hair an ointment of one part of sulphur to eight parts of 
cosmoline may be employed. 


The prognosis of seborrhea is generally favorable. . 


The oily variety is that which is most apt to be stubborn 
under treatment. Arthur Van Harlingen. 


SECRETION, PHYSIOLOGY OF. Secretion in gen- 
eral may be defined as the separation of certain prod- 
ucts from the blood, usually in a liquid form, which are 
poured out on the free epithelial surface of the secreting 


organ. When the secreting surface happens to have a 
somewhat complicated structure it is usually spoken of 
as a gland. Simple epithelial membranes, such as the 
pleura or peritoneum, may, and often do, form secretions 
from the blood, and though not ordinarily described as 
glands, there is, nevertheless, no fundamental distinction 
between the process of secretion in them and in the 
more complicated secreting organs, such as the salivary 
glands. That is, in both cases we have to deal with se- 
cretions, as defined above, and though the secondary 
differences between the two are many, they are, perhaps, 
not more numerous than those which exist among the 
glands, usually described as such, in the body. Indeed, 
the phenomena shown in the action of the different 
glands are often so diverse that some physiologists are 
inclined to doubt whether any general theory of secretion 
will ever be obtained ; but these differences, as well as 
the resemblances, will be better appreciated after the ac- 
tion of the various glands has been described. 

Defining a gland as a secretory organ, the simplest 
form of gland that 
we have to consider ry) 
consists of three es- 
sential parts, viz., 
(1) a simple base- 
ment-membrane, or 
membrana propria, 
supporting on one 
side a layer (2) of secreting cells, nucleated epithelial 
cells, and on the other side (3) a network of blood-capil- 
laries, as shown in the diagram (Fig. 3417). 

All the secreting organs of the body are constructed 
essentially on this plan; and the serous, mucous, and 
synovial membranes furnish examples of this simplest 
form of secreting apparatus. It is obvious, however, 
that if all secreting organs were constructed exactly in 
this way, as plain surfaces, the extent of the secreting 
surface would be greatly limited. The various compli- 
cations of structure that we meet with in the different 
glands seem to have for their primary purpose economy 
of space. 

A plain secreting membrane, such as that described, 
may have its surface increased, without occupying more 
space, in one of two ways. First, by protrusion in the 
form of folds. These folds or processes may be either 


Fie. 8417.—Typical Secreting Surface. a 
Basement-membrane ; 0, secreting cells; ¢ 
capillary network. 


’ 


] 


simple or compound, according to the extent of surface 
demanded, as shown in Fig. 3418. Examples of this 


oun 


Fie. 3418.—Increase of Secreting Surface by Protrusion. ; a, Basement- 
membrane ; b, epithelial cells; ¢c, network of blood-vessels. 


method of increasing the surface are found in the villi 
of the mucous membrane of the small intestines, and in 
other places, though this method seems to be one that is 
not generally used. Second, by a denting in of the sur- 
face to form a crypt or follicle. The cavity thus formed 
may be either tubular or saccular. Most of the glands 
of the body are formed on this plan, and may, therefore, 
be divided into two great classes—the tubular glands and 
the saccular, or, as they are more commonly called, the 
racemose glands (from racemus, a cluster of grapes). The 
invagination of the membrane may form only a simple 
tube or sac, making what is known as a simple tubular 
or racemose gland—as in the crypts of Lieberkiihn of 
the small intestine, the sweat-glands, and some mucous 
crypts. Diagrams of this form of gland are shown in 
Fig. 8419. The increase in the extent of surface in these 
cases is not very great, unless, as in the sweat-ducts, the 
simple tube is very much elongated and twisted into a 
compact knot. The invagination, however, instead of 


363 


Secretion. 
Secretion. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


being a simple tube or sac, may be variously compounded, 
forming what are called compound glands, of which 
again we have two kinds—compound tubular and com- 
pound racemose glands—diagrammatic representations 
of which are given in Figs, 3420 and 3421. 

In the compound racemose gland the separate little 


ao ppDLeLnp 


Fie. 3419.—Increase of Secreting Surface by In- 
vagination. A and CU, forms of simple tubular - 
glands; B, simple racemose gland. 


sacs are spoken of as alveoli or acini, and they open into 
canals or ducts which finally unite into one or more com- 
mon secretory ducts. The salivary glands and pancreas 
are good examples of this type of gland, the secreting 
surface being enormously increased without any great 
loss of space. The different alveoli are united into lob- 
ules, and these, bound together by connective tissue, form 

. the gland. 
The actual 
secreting 
cells are found in 
the alveoli, while 
the epithelial cells 
lining the ducts 
have, _ probably, 
simply a protective 
function. Exam- 
ples of the com- 
pound tubular 
glands are found in 
the kidneys and testes, and to a less marked extent in the 
gastric tubules of the stomach. In the kidney and testes, 
by this subdivision of the tubular gland, a really vast ex- 
tent of secreting surface is obtained within a very limited 
space. In such glands we can also distinguish a portion 
in which the epithelial cells have an active secretory func- 
tion, from that known as the duct of the gland, in which 
the epithelial cells seem to form sim- 
ply a protective covering. 

It was formerly customary to di- 
vide the secretions into two great 
classes, viz., excretions and secre- 
tions proper. Johannes Miiller, in 
his ‘‘ Physiology,” defined these two 
classes in this way: Excretions are 
substances which exist already 
formed in the blood, and are merely 
eliminated by the gland without be- 
ing changed in the process—the urea / 
of urine, for instancé ; while the se- 
cretions proper are substances which 
do not previously exist in the blood, 
but are first manufactured from it 
by the cells of the secreting gland— 
a good example of this type is found 
in the milk produced by the mam- 
mary gland. | 
_ It has as yet been found impossi- 
ble, however, to establish any such 
distinction as this. Even in the case 
of urea it has long been doubted 
whether the kidneys simply eliminate 
this substance from the blood after 


-J-Je-J- 


Fre. 3420.—Compound Racemose Gland. 


it has been formed in other tissues, '1% ,242!.— Compound - 


Tubul 
many contending that the cells of ate a 


the uriniferous tubules take part in the formation of the 
urea. Indeed, the question may still be regarded as an 
open one, needing further investigation before decisive 
statements can be made. 

The more usual conception of an excretion as a prod- 


364 


uct, formed in a gland, which is of no further use in 
the animal economy, and is simply eliminated from the 
body as waste matter, while sometimes a convenient ex- 
pression, is also inadmissible from a scientific standpoint. 
In the first place, we have secretions, such as the bile, 
which contain both waste products, of which no further 
use can be made, and also true secretory products of 
great functional importance in the body. In the 
second place, the method of formation of these so- 
called excretions—the urine, for instance—cannot 
be clearly separated from the processes of ordinary 
secretion. It will be better, then, to abandon any 
attempt to make a distinction between secretions 
and excretions, and to describe the processes in 
both cases under the general term of secretion, as 
is done in the best text-books of physiology at the 
present time. 

Another classification of secretions that has been 
suggested divides them into transudations and se- 
cretions proper. By transudations we mean those secre- 
tions which can be conceived as derived from the blood 
by the simple physical processes of filtration and diffusion. 
Examples of this are found in the secretions formed on 
serous membranes—the pericardial liquid, or that in the 
tunica vaginalis of the scrotum, for instance. These liq- 
uids contain no specific elements, such as we find in 
most secretions, but have a chemical composition similar 
to that of the blood from which they are derived. It 
would seem very probable, then, at’ first glance, that such 
secretions are formed as the products of filtration and 
diffusion. The plasma of the blood in the capillaries is 
under greater pressure than the lymph impregnating the 
tissues, so that we should expect a steady filtration of 
the plasma through the capillaries into the lymph of the 
tissues, and, in turn, « transudation of this lymph upon 
the free surface of membranes, such as the ordinary se- 
rous membranes. According to this view the epithelial 
cells of such a membrane. take no active part in the for- 
mation of the transudation or secretion, whichever we 
choose to call it. Since in all secretions, even those in 
which we have a specific element characterizing the se- 
cretion, and undoubtedly formed de novo by the meta- 
bolic activity of the gland-cells, we have also certain 
products, the water and salts, which may.be considered 
as derived directly from the blood by the physical pro- 
cesses mentioned, it will be necessary to distinguish in 
each secretion two kinds of substances—one manufact- 
ured by the cells of the gland from nutritive material 
furnished by the blood, or, more correctly speaking, the 
lymph ; and one derived from the lymph by filtration 
and diffusion—that is, transudation-substances—w hose 
formation is not dependent upon the life-processes of the 
gland-cells. Some such distinctign is actually made at 
present by physiologists, as we shall see when describing 
the secretion of the salivary glands. But the distinction 
is not usually drawn as sharply as indicated above, for 
the reason that many facts are known which seem to 
show that the formation of even the water and salts of 
secretions is in some way connected with the activity of 
the secreting cells. 

To illustrate the difficulties encountered in explaining 
transudations by referring them to the physical processes 
of filtration and diffusion, some recent experiments of 
Tigerstedt and Santesson! may be quoted. These ex- 
perimenters found that while filtration takes place read- 
ily through dead animal membranes, nevertheless, when 
living membranes were used, such, for instance, as the 
lung of a frog, and filtration was attempted under the 
same pressure, with serum or normal salt solution, no fil- 
trate at all was obtained. If the living lung-tissue that 
allowed no liquid to filter through it was killed by heat, 
or by any other means, filtration quickly commenced. 
Similar results were obtained with the frog’s intestines 
and abdominal wall; and if we were justified in applying 
these results to the other membranes of the body, it 
would be necessary to explain transudations by some- 
thing more than simple physical laws. The authors cite 
many facts to show that even the formation of lymph, 
which has always been regarded as caused by the filtra- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, 


tion of blood-plasma through the thin walls of the capil- 
laries, is apparently independent of the blood-pressure, 
in many cases at least ; for, if produced by filtration, the 
amount of lymph obtained ought to increase with in- 
crease of blood-pressure. They conclude from their ex- 
periments that the transudation of the blood-plasma to 
form the lymph is caused by the activity of the cells 
composing the capillary walls, and this conclusion, if 
correct, will apply @ fortdort to transudations of the 
lymph through the basement-membrane and epithelial 
covering of glandular walls. Investigations like this 
compel us to be cautious in explaining the simplest phe- 
nomenon of the animal body by physical laws obtained 
from the study of dead matter. It may be convenient to 
speak of transudations as opposed to secretions proper. 
The distinction has some basis in the fact that in transu- 
dations the chemical constituents are qualitatively the 
same as those of the blood or lymph from which the 
transudation is derived, while the secretions proper are 
characterized by the presence of certain constituents not 
normally contained in the blood, but manufactured in 
the glandular cells in consequence of their metabolic pro- 
cesses ; nevertheless it would be gratuitous, at present, 
to assume that in transudations the epithelial cells act 
simply as a filter or membrane through which certain 
things pass in consequence of a greater pressure on one 
side. It is certainly possible that the epithelial cells 
may take an active part in the production of the water 
and salts of a secretion, as well as in the formation of 
mucin or specific ferments. As long as the word transu- 
dation has the significance it possesses at present, a divis- 
ion of the secretions into transudations and secretions 
proper has, perhaps, as little right to acceptance as the 
old separation into excretions and secretions. 

The facts known and the theories maintained, with re- 
gard to secretion, can be best presented by a description 
of the physiology of the salivary glands and the pancreas, 
from the study of which most of our knowledge on this 
subject has been obtained. But before passing on to the 
physiology of these glands it will be well to review 
briefly the principal theories of secretion held by physi- 
ologists from the time of Haller, since the relative im- 
portance of the facts which we now possess can be more 
clearly emphasized by such a comparison. Though Hal- 
ler is credited with being one of the chief opponents of 
the old mechanical school of physiologists, the physiol- 
~ ogy of secretion as given by him is almost entirely 
mechanical. He divided the secretions into four classes, 
and held that the substances composing these secretions 
all pre-existed in the blood, from which they were sepa- 
rated by various mechanical means. The alveoli of the 
glands were supposed to be formed of ‘‘ arteries and 
veins, divided and subdivided,” and the arteries were 
connected directly with the ducts of the glands by pores 
or canals of varying sizes. This belief in the connection 
between the arteries and ducts was a deduction from the 
heroic injections of those days, or what Haller calls “‘ the 
superlative art of great anatomists,” by which wax In- 
jections were forced from the arteries into the gland- 
ducts. The fact that the different secretions, although 
derived from the same source, the blood, possess marked 
and constant differences of composition was explained 
by supposing that the pores or canals connecting the ar- 
teries and ducts were of different sizes; none of them 
were large enough to allow the unchanged blood with its 
corpuscles to pass through, but some were smaller than 
others and allowed only the lightest and most volatile 
particles of the blood to pass, while the larger pores gave 
passage to the grosser particles. Additional factors In 
causing the differences in the different secretions were 
found in the angle, whether acute or a right angle, which 
the artery supplying the gland made with the main 
trunk, and also in the difference in velocity of the blood- 
stream in the secreting arteries, depending on the width 
of the artery, distance from the heart, etc. Similar me- 
chanical views were held well into the nineteenth cen- 
tury, until the masterly work of Johannes Miller, on the 
structure and physiology of secreting glands, laid a true 
foundation for modern views. 


Secretion. 
Secretion. 


Miiller proved that no pores of communication exist 
between the arteries and ducts of the gland ; he described 
the anatomy of the glands and the relations of the blood- 
vessels to them, and showed that the nature of the secre- 
tion was not dependent on the gross structure of the 
gland, nor on the way in which its vascular supply was 
obtained. ‘‘ The nature of the secretion depends solely 
on the peculiar vital properties of the organic substance 
which forms the secreting canals,” is his final conclusion, 
and he states his belief that ‘‘the variety of secretion is 
due to the same cause as the variety of the formation 
and vital properties of organs generally ; the only differ- 
ence being that, in nutrition, the part of the blood which 
has undergone the peculiar change is incorporated with 
the organ itself, while in secretion it is eliminated from 
it.”? The extensive researches of modern times have 
added very much to our knowledge of the histology and 
chemistry of secreting tissues; but, as Heidenhain re- 
marks, if we substitute the term ‘‘cells” for ‘‘ living 
substance,” or ‘‘ organic substance,” the words of Miller 
just quoted express the conclusion to which modern 
physiologists have come, and but little can be added to 
them. 

The most important advances made since Miiller’s 
work have .been connected with the cell-theory of 
Schwann, and the discovery of the laws of diffusion 
through membranes by Dutrochet. Schwann’s concep- 
tion of the cellular structure of the animal body was fol- 
lowed by careful histological investigations of the struct- 
ure of glands as well as of other organs. The glandular 
epithelium was described, though the physiology of se- 
cretion was not at first directly benefited by this discov- 
ery. The laws of diffusion of liquids through mem- 
branes seemed to promise great things for the physiology 
of secretion, and investigations upon this basis were 
eagerly taken up by some of the best physiologists. As 
a consequence of this, the physical theories of secretion 
again came to the front, and have since occupied an impor- 
tant position in the explanation of secretory phenomena. 
Ludwig, in his ‘‘ Physiology” (vol. ii., 1861), develops 
in detail the conceptions of filtration and diffusion in 
their application to the processes of secretion. According 
to him, the forces concerned in the production of secre- 
tions are filtration, diffusion, and also the action of stim- 
ulated nerves, though he was careful to say that other 
forces still might contribute to this result. Ludwig knew, 
of course, at the time of the publication of his ‘‘ Physiol- 
ogy,’ that the organic material found in the secretions of 
the salivary gland, etc., was not obtained directly from 
the blood, but was made in the gland itself ; but it is im- 
portant to notice that, by the aid of the simple physical 
phenomena of diffusion and filtration, he was able to 
build up a theory of secretion that to a large extent ac- 
counted for the specific differences found in the secre- 
tion of different glands. The discovery by Ludwig that 
some of the glands—the submaxillary gland, for example 
—give a secretion when the nerve-fibres going to them 
are stimulated, was an extremely important addition to 
our knowledge of secretion, and has played a large part 
in recent theories of the physiology of glands. The re- 
searches of the same distinguished physiologist proved 
that the secretion in this case is not owing to simple fil- 
tration from the blood, even if the water and salts alone 
of the secretion are considered ; for it was found that in 
some cases the pressure in the gland might rise to nearly 
double the mean pressure of the blood in the carotid 
artery. An equally important observation, also made 
by Ludwig, was that the temperature of the gland and 
of its secretion increases during the act of secretion, a 
fact which would seem to indicate that active chemical 
changes take place. 

At about this same period, also, Claude Bernard found 
that during stimulation of the nerve going to the submax- 
illary gland the blood-flow through the gland is greatly in- 
creased, suggesting again an increased nutritive activity 
of the gland in secretion. If Ludwig, at the time his 
‘‘ Physiology ” was published, laid too much emphasis on 
the purely physical factors in secretion, it is neverthe- 
less mainly owing to the important discoveries made by 


365 


Secretion. 
Secretion. 


himself and his pupils that these physical forces have 
been found to be insufficient. The numerous researches 
of the last twenty years have shown that, in many of the 
glands we have true secretory nerves, comparable in their 
functions to the motor nerves of muscles. Just as stim- 
ulation of the nerve of a muscle causes the muscle to 
enter into functional activity, to contract, so the stimula- 
tion of the secretory nerve causes the gland to enter into 
functional activity, and form its proper secretion. Chem- 
ical examination of these secretions has shown that, in 
some glands at least, the most distinctive constituents of 
their secretion do not exist at allin the blood, but are 
formed within the gland. 

This dependence of secretion on nervous influences, 
and the undoubted chemical changes which take place in 
the gland during its period of activity, have forced us 
back again to the position held by Miiller, that the nat- 
ure of the secretion depends upon the properties of the 
living substance which forms the glands. This living 
substance we now know consists of glandular epithe- 
lium cell's, and it is to-day the most difficult problem in 
the study of secretion to understand the properties of 
these secreting cells. As Miller pointed out, it is only a 
particular case of the wider problem of nutrition shown 
by all living cells. <A satisfactory theory of secretion 
must give us some conception of the metabolic changes 
undergone by the gland-cells at rest and during activ- 
ity, and the way in which nervous influences affect these 
changes. We are indebted to no one more than to 
Heidenhain for what we know at present with regard to 
the action of the nerves on secretion, and the histolog- 
ical changes shown by the gland cells during rest and 
activity. His study of the cells of the glands, together 
with similar work by Kiihne, Langley, and others, forms 
the most important contribution of recent times to this 
difficult problem. We are far, as yet, from having suffi- 
cient data for the construction of a general theory of 
secretion applicable to all glands, but a large number of 
facts tending in this direction have been accumulated, 
especially in the case of the salivary glands and the pan- 
creas. A detailed account of the physiology of secre- 
tion in these glands, therefore, will best show the nature 
and importance of the views now held. The knowledge 
that has been gained of the physiological processes in- 
volved in the secretion of these glands is more complete 
than for the other glands of the body, though the views 
presented may be, and are, looked upon as the founda- 
tion for a general theory of secretion. But the appli- 
cation of the views derived from the study of these 
glands to the secretions formed by other glands, is in 
many cases simply a matter of inference, and Jacks any 
experimental basis. 

SALIVARY GLANDs.— Wecan take it for granted that the 
gross anatomy of these glands is sufficiently well known, 
and that we may pass at once to a description of their 
histology, as far as it is necessary to an understanding of 
their functional activity. Heidenhain distinguishes in 
the salivary glands two different types of secreting cells, 
characterized both by the nature of the secretion formed 
and by the histological appearances of the cells. Glands 
containing cells of the first type give a thin, watery se- 
cretion containing, in addition to the water, only albu- 
minates, salts, and, in some cases, a diastatic ferment. 
He speaks of them as albuminous (or serous) glands, and 
examples of this class are found in the parotid gland of 
man and the mammalia generally, and in the. submaxil- 
lary gland of the rabbit. Glands of the second type he 
names mucous glands ; the secretion which they form is 
thicker and more mucilaginous, containing mucin as its 
principal constituent, in addition to a certain amount of 
salts and albuminates. Thesubmaxillary gland, in most 
mammalia, and the sublingual belong to this type. The 
submaxillary gland of man is of a mixed character, 
Most of the alveoli contain only granular albuminous 
cells ; some contain only mucous cells, and others have 
partly albuminous and partly mucous cells. The sub- 
lingual of man is also a mixed gland, but approaches 
more nearly the type of mucous glands than the sub- 
maxillary. 


566 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


The alveoli of the albuminous glands consist of a base- 
ment membrane, or tunica propria, covered with the 
glandular epithelial cells. The basement membrane it- 
self is formed of a number of flattened and branched 
connective-tissue cells, 
the branches fusing with 
one another to form a 
network, while the spaces 
between the branches are 
filled up by a structure- 
less membrane or matrix. 
The gland-cells are of a 
polygonal or cuboidal 
shape, and are character- 
ized by their very gran- 
“AY ular structure. On this 
eere@\ account the boundary 
) Cen line between the different 
cells is seen with some 
difficulty. Each cell 
LS: shows a distinct nucle- 
Fie, 8422.—Albuminous Gland (Rest- us often of an irregular 
ai sated of the Dog. (After shape, and a number of 

amen dark granules in the body 
of the cell, which are colored by the different staining re- 
agents, such as borax carmine and Heidenhain’s hema- 
toxylin. An example of this type of gland is shown in 
Fig, 3422, The alveoli of the mucous glands have a 


Sou 


Fie. 3423.—Mucous Gland. Submaxillary of Dog. Resting stage. (From 
a camera-lucida drawing of a gland stained in Heidenhain’s hzema- 
toxylin.) 


basement membrane of the same structure as in the al- 
buminous glands, but the secreting cells upon it are of 
quite different appearance, as shown in Fig. 3423. They 
are large, clear, and possess few granules; each has a 


Fie. 3424.—Human Submaxillary Gland. (From acamera-lucida draw- 
ing of a gland stained in Heidenhain’s hematoxylin. ) 


distinct nucleus which lies toward the base of the cell. 
The clear substance making up the body of the cell does 
not stain, and gives the micro-chemical reactions of mu- 
cin, In perfectly typical mucous glands there are often 


REFERENCE HANDBOOK OF 


Secretion. 
Secretion. 


THE MEDICAL SCIENCES. 


found cells of another character, granular protoplasmic 
cells, lying between the mucous cells and the basement 
membrane. These cells are usually spoken of as the dem- 
tlune cells of Giannuzet, and play an important part in 
the functional activity of the gland. (See Fig. 3425.) 
The secretory ducts in both types of glands show about 
the same structure. The larger ducts are lined by a 


Fie, 3425.—Submaxillary Gland of Cat, showing the Demilune Cells. 
; drawing. 


simple columnar epithelium, which, in all probability, has 
only a protective function, and cannot be considered as 
a secreting surface. The smaller ducts leading to the 
alveoli have also a layer of columnar or cuboidal epithe- 
lial cells, which show toward the base, where they sit 
upon the basement membrane, a striking longitudinal 
fibrillation. These small ducts are united to the acini 
by what are known as the ‘‘ intermediate piece ’—ducts 
of the finest calibre—which in the mucous glands are 
lined by short cuboidal cells, that, at the junction of the 
tube with the acinus, pass suddenly into the large, clear, 
secreting cells of the gland. ‘The 
cells of the intermediate piece in the 
_albuminous glands are said to be more 
elongated and spindle-shaped, and 
project some distance into the alveo- 
lus. The salivary glands are supplied 
with nerve-fibres from the sympa- 
thetic and cranial nerves, and histo- - 
logical examination of ‘the gland 
shows a rich network of nerve-fibres 
and ganglia between the lobes and 
acini. Some of these fibres are vaso- 
motor, and are distributed to the blood-ves- 
sels of the glands; others are undoubtedly 
secretory, and in some way connected with 
the secreting cells. The way in which the 
secretory fibres end in the cells has not yet 
been determined satisfactorily. Some years 
ago Pfliiger published several papers in which 
he described in detail how the nerve-fibres 
penetrated into the cells of the alveoli and 
ducts, and the axis-cylinder broke up into | 
fibrils which were lost in the cell. But these 
results have not been confirmed by later his- 
tologists, so that we are not justified in accepting 
them, although-the facts known with regard to the 
physiology of secretion seem to demand some such 
connection between the cells and nerve-fibres as that 
described by Pfliiger. 

Influence of the Nerves on the Secretion of the Sati- 
vary Glands.—In 1851 Ludwig discovered that after 
continuous stimulation of the chorda tympani nerve 
going to the submaxillary gland, in the dog, the saliva 
secreted suffered a change in its chemical composi- 
tion of such a nature that the percentage of solid constit- 
uents, especially of the organic substances, was dimin- 
ished. Heidenhain afterward took up the same line of 
experiments, and to his thorough and thoughtful work 
we owe most of our knowledge on this subject. An 
account of his experiments may be found in Pfliiger’s 


Camera-lucida 


Fic, 8426.—Diagram of Nerve-supply to Submaxillary Gland. 
‘* Physiology,” slightly changed.) a. car., Carotid artery ; ch. t., chorda tym- 
pani nerve ; gl. cer. s., superior cervical ganglion ; 7. 2., lingual nerve ; sm. 
gl., submaxillary gland ; 
illary duct; ¢., tongue; v. sym., vago-sympathetic trunk; 7. sym., sympa- 
thetic branches to the gland. 


Archiv fiir die gesammte Physiologie, vol. xvii., p. 1, from 
which the following account is chiefly taken. His ex- 
periments were made upon the submaxillary gland of the 
dog, and the parotid gland of the dog and the rabbit. 
The submaxillary gland of the dog derives its nerve- 
fibres from two sources: First, cerebral fibres which orig- 
inate in the facial nerve, but afterward leave this nerve 
in the Fallopian canal to join the chorda tympani; this 
latter nerve, after running for some distance with the 
lingual branch of the fifth cranial nerve, leaves it at the 
point where the lingual crosses the duct of the gland, and 
running along the duct reaches the gland. At the point 
where the chorda tympani leaves the lingual there is a 
small ganglion—the submaxillary ganglion. 
Second, sympathetic fibres which leave the 
sympathetic trunk above the first cervical gan- 
glion, and pass to the gland along the two 
branches of the facial artery which supply the 
gland with blood. 

If the chorda tympani is stimulated by weak 
induction shocks the gland almost immediately 
begins to secrete, and this secretion, by proper 
regulation of the stimuli, may be kept up for 
hours. The secretion obtained in this way is 
comparatively thin and watery, and contains 
not more than one or two per cent. of solids 
when evaporated to dryness. If the sympa- 
thetic fibres are stimulated in the same way, 
quite a different result is obtained. The secretion in this 
case is relatively small in amount, and flows very slowly. 
Instead of being thin and clear, like that obtained by 
stimulating the chorda, it is thick and turbid, and may 
contain as much as six per cent. of total solids after 
evaporation to dryness. The results of stimulation of the 
two sets of fibres show other differences, especially in the 
circulatory changes in the gland. During stimulation of 
the chorda the abundant flow of saliva is accompanied 
by a greatly increased flow of blood through the gland; 
the whole gland becomes of a reddish hue; the veins 
passing off from it are distended by the increased flow of 
blood through them, and, if they are cut, the blood flows 
from them in a much stronger stream than in the resting 
gland, of a redder color, and often with a decided pulse. 
We must suppose, then, that the 
chorda contains, in addition to \ | 
secretory fibres belonging directly 
to the gland, also vaso-dilator fibres 
passing to its blood-vessels. Dur- = 
ing stimulation of the sympathetic 


vo, Syma. 


(From Foster’s 


sm, gil., submaxillary ganglion ; sm. d., suabmax- 


we get an opposite set of phenomena, the gland becomes 
pale, and if the veins returning from it are cut the blood 
flows out in single drops, or ceases altogether. The 
sympathetic branches, in other words, contain, In addi- 
tion to secretory fibres proper, also vaso-constrictor fibres 
going to the blood-vessels. 


367 


Secretion. 
Secretion. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Influence of the Strength of the Nerve Stimulation upon 
the Chemical Composition of the Secretion.—If the stimu- 
lus applied to the chorda be gradually increased in 
strength, care being taken not to exhaust the gland, the 
chemical composition of the secretion is found to change 
with regard to the relative amounts of the water, the 
salts, and the organic constituents. The water and salts 
of the secretion increase with increased strength of stim- 
ulus up to a certain maximal limit, although the increase 
in the two does not run along exactly parallel lines. 
After the maximal percentage of salts has been reached, 
further increase in strength of stimulus has no effect, 
the percentage remaining practically constant, as shown 
in the accompanying diagram (Fig. 3427). 

It is of special importance to notice that these results 
are obtained from the gland in all cases, no matter what 
its previous condition was—whether it had been formerly 
stimulated, or whether it had been in a state of rest. 
With regard to the organic constituents the results are 
different. If previous to the stimulation the gland was 
in a resting condition and unfatigued, then increased 
strength of stimulation is followed at first by a rise in the 
percentage of organic constituents ; and, indeed, this rise 
is in the beginning more marked than in the case of the 


salts. Butas the gland becomes more and more fatigued, . 


the relative increase in the organic constituents becomes 


Fie. 3427.—Diagram Illustrating the Changes in the Chemical Constituents 
of the Saliva with gradually Increasing Strength of Stimulation. 


less and less, falling behind that of the salts, and, finally, 
the percentage begins actually to diminish, although the 
strength of stimulation is still increased. If the gland 
had been previously fatigued by long-continued activity, 
then the stimulation, while it would increase the amounts 
of water and salts as in the fresh gland, might have either 
no effect at all on the organic portions of the secretion, 
or cause only a temporary increase, quickly followed by 
a fall. The accompanying diagram (Fig. 3427) repre- 
sents the relative increase in these three components of 
the secretion, in an unfatigued gland, as the stimula- 
tion is made stronger. An examination of the diagram 
shows that the water and salts, though not increasing in 
exactly the same ratio, have much in common, whereas 
the curve of increase of organic constituents runs an en- 
tirely independent course. These facts lead us to believe 
that the conditions determining the secretion of the or- 
ganic substances are different from those affecting the 
water and salts, and this view is confirmed by the results 
of stimulation of the sympathetic fibres. Stimulation of 
the sympathetic fibres going to the submaxillary gland 
causes a vaso-constriction of the blood-vessels and a flow 
of saliva. But the stream of saliva is very different from 
that obtained by stimulation of the chorda tympani; it is 
very slow, and the saliva, instead of being clear and wa- 
tery, is thick and turbid. Chemical analysis of the saliva 
secreted after stimulation of the sympathetic shows that 
it contains a much larger percentage of organic matter 
than that following stimulation of the chorda tympani. 
This also indicates that the secretion of the organic con- 


368 


stituents and that of the water and salts depend upon 
different conditions. This difference is brought out even 
more distinctly in Heidenhain’s experiments upon the 
parotid gland. 

The parotid gland, like the submaxillary, is supplied 
by nerve-fibres which are derived from the cerebral 
nerves, and by sympathetic nerve-fibres. The cerebral 
fibres have a complicated course; arising first in the 
glosso-pharyngeal nerve, they leave this trunk by the 
tympanic branch of the petrous ganglion, or the nerve of 
Jacobson ; from this nerve they branch off in the small 
petrosal nerve to reach the otic ganglion, and from the 
otic ganglion they pass to the parotid gland through 
branches of the auriculo-temporal nerve. Stimulation, 
then, either of the nerve of Jacobson while in the tympanic 
cavity, or of the auriculo-temporal nerve, will enable us 
to determine the effect of these fibres on the parotid se- 
cretion. The sympathetic fibres of the parotid reach the 
gland along the branches of the carotid artery, and may 
be stimulated while still in the cervical sympathetic. 

When the cerebral fibres of the parotid are stimulated, 
results are obtained similar to those given for the sub- 
maxillary gland : the saliva begins to flow at once in large 
quantities, and is of a clear, watery appearance, while at 
the same time the circulation through the gland is in- 
creased. If the strength of the stimulation is increased, 
the velocity of the secreted saliva becomes greater, and 
along with this there is an increase in the quantity of sol- 
uble salts, up to a maximal limit. This happens in all 
cases, whether or not the gland had previously been in 
functional activity. As in the case of the submaxillary 
gland, the amount of organic constituents present in this 
more abundant flow of saliva depends on the previous 
condition of the gland. If before the stimulation the 
gland had been secreting actively for some time, then the 
percentage of organic constituents, instead of increasing, 


' may, on the contrary, begin to fall; while, if the gland 


had been resting, the organic constituents at first in- 
crease, but soon begin to decrease, showing, as in the 
case of the saliva, that the conditions govern- 
_ ing their secretion are different from those 
under which the water and salts are formed. 

This difference is made still more striking by the fol- 
lowing observations. If the sympathetic fibres of the 
parotid gland are stimulated, usually no secretion at 
all is produced ; although the stimulus may be applied 
for hours, the column of saliva in the cannula placed 
in the parotid duct remains stationary, provided, of 
course, the nerve of Jacobson is first cut to prevent any 
possible reflex stimulation of the gland by this means. 
Though no secretion flows from the cannula, neverthe- 
less stimulation of the sympathetic has a very important 
action on the gland, for if shortly afterward, or at the 
same time, the nerve of Jacobson is stimulated, the saliva 
obtained differs markedly from that obtained by stimula- 
tion of the nerve of Jacobson alone, inasmuch as the or- 
ganic constituents are greatly increased. In some cases 
Heidenhain stimulated at the same time the cerebral fibres 


_ going to each of the parotid glands, and on one side stim- 


ulated simultaneously the sympathetic fibres going to one 
of the glands; asa result of this the secretion from the 
latter gland was found to be very much richer in organic 
constituents. While the organic substances are thus 
largely increased by stimulation of the sympathetic fibres 
—the secretion sometimes containing tenfold the amount 
of organic matter—nevertheless the percentage of salts 
in the secretion is not affected by the action of the sym- 
pathetic fibres. Very weighty evidence is thus obtained 
showing that the nerve-fibres which cause the formation 
of the organic portion of the secretion are distinct from 
those which bring about the separation of the water and 
salts. Heidenhain’s theory to account for these facts is 
as follows: 

Theory of Secretory and Trophic Nerve-fibres.—The fact 
that the increased flow of saliva in both the submaxillary 
and parotid glands of the dog, when the cerebral fibres 
are stimulated, is accompanied by active vaso-dilatation 
of the blood-vessels of the gland, while the diminished 
secretion in both cases from stimulation of the sympa- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Secretion. 
Secretion. 


thetic fibres is associated with strong vaso-constriction of 
the blood-vessels of the gland, would lead one naturally to 
the supposition that the amount of secretion in each case 
was dependent on the quantity of blood flowing through 
the organ. On the hypothesis that the secretion is the 
result of filtration and diffusion from the blood, the in- 
creased flow in one instance, and the diminished flow in 
the other, would seem to find a sufficient explanation in 
the changes in the blood-supply. But we possess very 
complete proofs that this supposition is erroneous, and 
that the secretion is independent of any increase or dim- 
flash, in the quantity of blood flowing through the 
gland. 

Ludwig first showed that if a mercury manometer is 
connected with the duct of the submaxillary gland, and 
the chorda tympani is then stimulated for a certain time, 
the pressure in the ducts of the gland, as shown by the 
manometer, may become much greater than the blood- 
pressure of the animal, the excess of pressure in the gland 
being in some cases as much as 100 mm. of mercury. 
This pressure in the ducts is, of course, continued back- 
ward into the alveoli, and it is not possible to conceive, 
under these circumstances, that the secretion is a filtration 
product from the blood and lymph of the gland, since 
the filtration stream always proceeds from a place of 
higher to one of lower pressure. So it has been observed 
that if the blood-supply is completely shut off from the 
gland by clamping the arteries, stimulation of the chorda 
will still excite a secretion for a short time. The neatest 
and most conclusive experiments that have been brought 
forward to demonstrate that the flow of saliva is indepen- 
dent of the changes in the quantity or pressure of the 
blood, are those obtained from the action of atropine and 
the hydrochlorate of quininé upon the gland. Kenchel 
(Dorpat, 1868, ‘‘ Das Atropin und die Hemmungsner- 
ven”) showed that atropine injected into the blood, or 
directly into the gland, completely prevents the secretory 
action of the chorda tympani; nevertheless stimulation of 
the chorda® causes vaso-dilatation of the arteries of the 
gland, just as it does without the previous administration 
of atropine. That is, the atropine paralyzes the secretory 
fibres of the chorda, while it does not affect the vaso-mo- 
tor fibres, and the gland in this case will not secrete a 
drop, although the quantity of blood flowing through it 
is largely increased, and the pressure in the capillaries is 
mueh greater than in the resting gland. The action of 
quinine is even more conclusive. Heidenhain found 
(Hermann’s ‘‘ Handbuch der Physiologie,” vol. v., p. 45) 
that if he mixed 10 c.c. of saliva, secreted under stimula- 
tion of the chorda tympani, with 2 c.c. of a saturated so- 
lution of hydrochlorate of quinine, diluted this neutral 
mixture to 20c.c., and then injected a few cubic centime- 
tres into the duct of the salivary gland, he got a greatly 
increased flow of blood in the gland, but no trace of a secre- 
tion. Nevertheless, if the chorda was stimulated a rich 
flow of saliva was obtained. In this experiment the secre- 
tory fibres were not paralyzed, but remained perfectly irri- 
table, while the strong vaso-dilatation caused by the qui- 
nine, without simultaneous stimulation of the secretory 
fibres, was powerless to produce any secretion, From 
these experiments we are forced to conclude that, as far 
as the submaxillary gland is concerned at least, the se- 
cretion is not caused by a simple increase in the quantity 
and pressure of the blood in the gland capillaries. On 
the contrary, we must recognize the existence of true se- 
cretory fibres, which exert their action upon the gland- 
cells directly, and not indirectly by alterations of the 
blood-stream. i 

From the experiments upon the parotid and submaxil- 
lary glands given above, Heidenhain concludes that we 
can divide these secretory fibres into two classes, one of 
which he calls trophic fibres and the other secretory 
fibres ; stimulation of the latter causes the secretion of 
water and salts, while stimulation of the trophic fibres 
causes the formation of soluble organic products in the 
protoplasm of the gland-cells, and these products are 
then dissolved in the water of the secretion. Upon this 
hypothesis we can explain the action of the secretory 
nerves upon the parotid and submaxillary glands in the 


VoL. VI.—24 


following way: The sympathetic nerve-branches going 
to the parotid gland (of the dog) contain only trophic 
fibres, so that stimulation of this nerve, while it causes 
important changes in the gland, and the formation of the 
organic constituents of the secretion, gives no percepti- 
ble secretion, because there is no stream of water to dis- 
solve and carry out these products. The nerve of Jacob- 
son, on the other hand, contains mainly secretory fibres, 
and but few trophic fibres, so that stimulation of this 
nerve will give an abundant flow of saliva, which, how- 
ever, will be poor in organic material. In the same way, 
the chorda-tympani nerve may be considered as com- 
posed mainly of secretory fibres, while the sympathetic 
branches to the submaxillary contain many trophic 
fibres, together with a sufficient number of secretory 
fibres to give a slow flow of saliva, rich in organic prod- 
ucts, when these nerves are stimulated. Granting that 
we have two such classes of fibres, how can we conceive 
their action to take place? In what way do the secre- 
tory fibres bring about the secretion of water and salts, 
and the trophic fibres cause the formation of the organic 
material of the secretion? These are difficult questions 
to answer, and it is impossible, with the knowledge we 
now possess, to give any really satisfactory explanation 
of these phenomena, The action of the trophic fibres is 
perhaps better understood, so that we may consider them 
first. Our ideas of the way in which the trophic fibres 
act rest partly upon the chemical changes caused by their 
stimulation, and partly upon the simultaneous morpho- 
logical changes which can be detected in the gland. The 
former have been mentioned already ; the changes in the 
histological appearance of the gland have been described 
by Heidenhain from preparations of the hardened gland, 
and by Langley from observations upon the living gland. 
The most important results may be briefly stated as fol- 
lows: 

Histological Changes in the Active Gland as Evidence for 
the Huistence of Trophic Fibres.—If a resting albuminous 
gland—the parotid of the 
dog, for instance—is har- 


Fic. 3428.—-Albuminous Gland, 
after Strong Secretion. Paro- 
tid of the Dog. (After Heiden- 
hain.) 


[F1ie. 3422.—Albuminons Gland (Rest- 
ing). Parotid of the Dog. (After 
Heidenhain. )] 


dened in alcohol and then stained in carmine, or, better 
still, if stained in Heidenhain’s hematoxylin, we see that 
the cells are more or less compactly filled with fine gran- 
ules, which receive a stain from the hematoxylin, and 
are embedded in a clear ground-substance which does not 
stain. The nucleus of each cell, according to Heidenhain, 
is small and of irregular outline, If, now, the nerve of 
Jacobson is stimulated in another gland, and the gland 
is then hardened in alcohol and stained, very little, if 
any change will be observed in it, unless the stimulation 
has been very strong and continued for many hours. 
But if, at the same time, the sympathetic fibres had been 
stimulated also for a comparatively short time, very 
marked changes will be noticed. The cells are distinctly 
smaller, the nucleus becomes rounder and shows nucle- 
oli, while the cells present a more granular appearance, 
owing to the diminution in the amount of clear ground- 
substance contained in them. The diminution in the 
size of the cells, and the different relative quantities of 
clear substance and granules, show that the organic ma- 


369 


Secretion. 
Secretion. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


terial of the secretion, which, as we have seen in the case 
of the parotid, is so largely increased by stimulation of 
the trophic fibres in the sympathetic, must have been 
derived from the substance-of the cells. In some way 
the action of these fibres causes metabolic changes in the 
cell protoplasm and the formation of the organic portion 
of the secretion. If the gland is again allowed to rest, 
the proportion of clear substance to granular material in- 
creases, and the cells become larger. Heidenhain con- 
cludes, therefore, that the clear substance is the material 
from which the organic products of the secretion are di- 
rectly formed, and that during secretory activity it is 
converted into these products and washed out of the cell 
by the stream of secreted fluids; while in periods of rest 
the protoplasmic substance of the cell is first regenerated 
from the food-material given by the blood, and then con- 
verted into this clear ground-substance ; the latter may 
be looked upon, not as the organic material of the secre- 
tion, but as the substance from which this material is 
formed, in consequence of metabolic changes set up in it 
at the moment of secretion by the action of the trophic 
nerve-fibres. 

Langley’s experiments upon the changes during secre- 
tion in the albuminous glands* yielded him somewhat 
different results. His experiments were made upon the 
fresh living gland, either by cutting out bits of the gland 
during rest and activity, or, in the case of the parotid of 
the rabbit, a portion of the gland, while still in the body, 
was placed under the microscope, and its appearance ob- 
served while the blood was circulating freely through it. 
He found that, when the animal was in a fasting condi- 


tion, the cells of these glands 
had a granular appearance 
throughout their substance, the 
outlines of the different cells 
constituting an alveolus being 
faintly marked by light lines. 
When, however, the gland was 
made to secrete, by giving the 
animal food, by injecting pilo- 
carpin, or by stimulating the 
sympathetic nerve-fibres going 
to it, the granules began to dis- 
appear from the outer borders 
of the cells—that is, from the 
border turned toward the base- 
ment membrane—so that each 
cell now showed an outer clear 
border and an inner granular 
portion. After prolonged se- 
cretion very few granules were left in the cell, and these 
formed a thin layer at its inner portion bordering upon 
the lumen, and stretched outward fora greater or less 
distance along the sides of the cells. During secretion, 
also, the cells separated slightly from one another at the 
lumen, and this, with a distinct diminution in the size of 
the individual cells, caused the lumen in each alveolus 
to become more manifest. He found that these appear- 
ances could not be preserved by hardening the gland in 
alcohol or osmic acid, so that probably Heidenhain’s ob- 
servations on the hardened gland do not accurately rep- 
resent the changes that take place in the living gland. 
From these results we must believe that in the albu- 
minous glands, as we shall find to be the case in the pan- 
creas, the granules represent the substance from which 
the organic constituents, and especially its specific fer- 


Fie. 3429.—From Langley’s pa- 
per. A, Cells of parotid gland 
of rabbit in resting condition ; 
B and C, after strong secre- 
tion, showing the disappear- 
ance of the granules. 


370 


ment, are formed, and that stimulation of the trophic 
nerves causes the expulsion of these granules. It is not 
believed that the granules are forced out as such in the 
secretion-streain, but that they represent the material 
from which the organic products of the secretion are 
formed, at the moment of secretion, under the influence 
of the trophic nerves. -Following the analogy of the 
pancreas, this preliminary material may be spoken of as 
a zymogen. It is formed from the protoplasmic contents 
of the cells, and deposited in the form of granules, which, 
in turn, are dissolved and changed into ptyalin and the 
organic products of the secretion during the period of 
glandular activity. We know nothing of the chemical 
reactions that occur in this process; but from analogy 
with what we know to take place when other tissues— 
muscles, for instance—enter into functional activity, it is 
most probable that these chemical changes are of the 
nature of destructive metabolisms or katabolisms. The 
term trophic, which Heidenhain has used to characterize 
the nerve-fibres causing these changes, is, as Gaskell has 
pointed out, somewhat unfortunate. Trophic or nutri- 
tive nerves are usually understood to be those whose ac- 
tion leads to a constructive metabolism or anabolism in 
the tissue to which they are distributed. A better des- 
ignation for these gland-nerves, then, would be that sug- 
gested by Gaskell, viz., katabolic nerves. However, 
Heidenhain believes that the nerves in question, when 
stimulated, cause changes in the gland-cells of a twofold 
character.. On one hand, the zymogen—the substance 
from which the ptyalin and organic products in the se- 
cretion are directly formed, and which in this case is 
stored up in the cells in the form of granules—undergoes 
katabolic changes, with the production of the character- 
istic elements of the secretion ; while, on the other hand, 
active constructive metabolisms are in progress, which 
result in the formation of new material in the cell from 
the food furnished by the lymph. This new material 
can be recognized in the living cell as the clear non- 
granular substance, which in the active gland makes a 
distinct zone at the base of the cell. This, in turn, is 
changed into the granular material, but whether this 
change is katabolic or anabolic cannot be determined 
with certainty. We must recognize that these two pro- 
cesses go on simultaneously in the cell, and the diminu- 
tion in size of the cell during activity is from the excess 
of the destructive over the constructive changes, while 
the growth of the cell during the period of rest is owing 
to the greater constructive metabolisms. If these pro- 
cesses all result from the action of the gland-nerves, then 
these nerves are, in part at least, truly trophic or ana- 
bolic ; but the change which we know most definitely to 
be the result of their influence, the final change from 
the zymogen to the organic material found in the secre- 
tion, is most probably of a katabolic nature, and Gaskell’s 
term would seem, therefore, to be the most appropriate. 

In presenting the theories of the action of the trophic 
fibres, the phenomena shown by the albuminous or se- 
rous glands have alone been considered, but we have 
equally strong evidence that similar changes occur in the 
mucous glands. In some respects, indeed, the changes 
in these glands are more decided, and, fortunately, we 
have good observations upon both the hardened and the 
fresh gland in its different conditions of rest and activity. 
Most of our information is derived from Heidenhain’s 
and Lavdovsky’s work upon the hardened glands. Ac- 
cording to their descriptions, the mucous cells of the al- 
veoli in the resting gland are large, clear, with flattened 
nuclei well toward the base of the cells. The demilune 
cells of Gianuzzi, placed between the basement mem- 
brane and the mucous cells, are smaller and of a granu- 
lar, protoplasmic nature. The clear substance of the 
mucous cells has all the micro-chemical reactions of 
mucigen, and seems to be undoubtedly the substance 
from which the mucus of the secretion is directly formed. 
When the.gland becomes active, from stimulation of the 
nerve, for instance, the nuclei of the mucous cells be- 
come more spherical, show distinct nuclei, and advance 
more toward the middle of the cells. The cells mean- 
while become smaller, because of the transformation of 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the mucigen into mucus and its elimination from. the 
cells. If the stimulation is strong and continued for a 
long time, more important changes take place. Accord- 
ing to Heidenhain, the mucous cells break down com- 
pletely, and are carried off in the secretion, while the 
demilune, or border cells, grow and form new mucus- 
secreting cells similar to those destroyed. Such results are 
obtained, of course, only from excessive artificial stimu- 
lation, but Heidenhain believes that this represents a nor- 
mal physiological process. The individual mucous cells 
may continue for a time to secrete mucus, and then be re- 
generated by the formation, first, of protoplasm from the 
food of the lymph, and the transformation of this into 
mucigen, but sooner or later the cell is destroyed, and 
its place is supplied by one of the demilune cells. That 
we do not see any evidence of this in sections of mucous 
glands, not submitted to artificial stimulation, is owing 
to the fact that the change only affects individual cells, 
and would necessarily be inconspicuous under normal 


[F1e, 3423.—Mucous Gland. Submaxillary of Dog. Resting Fie. 3430.—Submaxillary Gland of Dog after eight hours’ 
Stimulation of the Chorda Tympani. 
lucida drawing.) 


stage. 
in Heidenhain’s hematoxylin. )] 


conditions, since probably only a few cells in the gland 
would be undergoing this change at the same time. 

More recently Langley® has made experiments upon 
the fresh gland with regard to its histological appearance 
during rest and activity, using the submaxillary and the 

sublingual glands of the dog. He finds that in the rest- 

ing gland, when treated with dilute solutions of neutral 
or alkaline salts, he could detect, along with the hyaline 
material in the cells, a number of granules, both inclosed 
in a network stretching throughout the cell. The gran- 
ules extend through the cell, and during secretion both 
the hyaline substance and the granules are ‘‘ turned out 
of the cells; after prolonged secretion the cells consist 
of an outer zone, chiefly of freshly formed substance, 
and of an inner zone of network, hyaline substance, and 
granules.” Langley does not agree with Heidenhain 
and Lavdovsky in believing that the mucous cells disin- 
tegrate during secretion and are replaced by the demi- 
lunes. On the contrary, he thinks that the demilunes 
are secreting cells of a different nature, belonging to the 
albuminous type, and that the mucous cells, after their 
period of activity is over, grow again to their original 
size in a way closely comparable to that described as oc- 
curring in the parotid gland and the pancreas. 

Action of Secretory Fibres.—The term secretory fibres 
is applied here in a restricted sense to those fibres whose 
stimulation excites a secretion of water and salts. This 
name also seems somewhat unfortunate, as it would be 
more convenient to speak of all the glandular nerve- 
fibres as secretory, as, indeed, is usually done. It has 
been suggested that transudatory fibres would be a better 
designation, and it would certainly be a more convenient 
one, inasmuch as it would enable us-to speak of two 
different things by different names. The term, how- 
ever, is not entirely free from objection. By transuda- 
tions we are accustomed to understand fluids formed by 
filtration or diffusion through membranes in the body. 
It is more than doubtful whether the action of the fibres 
in question can be considered of this character—that is, 


Secretion. 
Secretion, 


as simply increasing or permitting the filtration and dif- 
fusion of water and salts from the lymph through the 
basement-membrane and cells into the lumen of the al- 
veolus. As was shown in the beginning of this article, 
there seems to be an accumulation of evidence forcing us 
to the belief that transudation through living membranes 
is quite a different thing from filtration or diffusion 
through dead membranes. If we use the word transu- 
datory simply to indicate the fact of the production of 
water and salts in the secretion, without any reference to 
the manner in which they are formed, the term will be 
a useful one; but inasmuch as this conception of filtra- 
tion and diffusion is generally attached to the word, it 
will be better for us to use the non-committal term secre- 
tory, in the sense. in which it is employed by Heiden- 
hain. 

How the water of the secretions is formed has always 
been a difficult question to decide. Quite a number of 
theories have been proposed from time to time, but none 
of them are really satisfactory, and on this point, as on 
many others in physiology, we must await future histo- 
logical and physiological researches. We know that at 
bottom the stream of 
water in secretion is 
caused by chemical 
and physical agen- 
cies, but what the 
nature of these phe- 
nomena is remains to 
be discovered. We 
have abundant proof, 
part of which has 
already been given, 
that it is not a case 
of simple filtration 
or diffusion from the 
blood in the capilla- 
ries; we know that 
changes in the press- 
ure in the capillaries 
have no direct effect on the quantity of water in the secre- 
tion. Gianuzzi divided the process of water-secretion into 
two different and independent stages : First, the filtration 
of the water through the blood-capillaries into the lymph- 
spaces; second, the transference of this water from the 
lymph to the lumen of the alveolus through the activity 
of the cells. Heidenhain has shown that this hypothesis, 
the first part of it at least, is contradicted by facts, and it 
introduces a new difficulty in the way of understanding 
how these two processes are regulated with respect to 
each other. Another theory, suggested by Hering, is that 
—in the submaxillary gland, for instance—stimulation 
of the secretory nerves causes the formation within the 
cells of a colloidal substance, mucin, which has a great 
attraction for water, and that, as a result of the imbibi- 
tion-power of this mucin, water is carried into the cells, 
and there forms with the mucin a solution which makes 
the secretion. If this theory were correct, then those 
glands which contain the most mucin ought to show the 
most active secretion. Asa matter of fact, this is not the 
case—the sublingual is richer in mucin than the submax- 
illary, but the secretion-stream in the former is much 
less rapid than it is in the latter ; so also the organic sub- 
stances in the parotid saliva may sink to avery small 
percentage, and yet the secretion may be very active. 

Heidenhain’s own theory to account for the produc- 
tion of the water as the result of nerve-stimulation is 
also far from conclusive. He starts from the funda- 
mental fact that no more water leaves the blood-capilla- 
ries than appears afterward in the secretion—that is, no 
matter how long the secretion continues, the gland is 
never cedematous, nor is the velocity of the lymph in the 
lymphatics of the gland increased. This being the case, 
we must suppose that the water-stream is regulated by 
the secretion—that is, by the activity of the cells of the 
gland. If, now, we conceive that the substance of these 
cells, or some constituent of them, has an attraction for 
water, then while the gland is in the resting state water 
will be absorbed first from the basement-membrane ; 


371 


(From a camera- 


Secretion. 
Secretion. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


this membrane makes good its loss by subtracting water 
from the lymph of the tissue, and this, finally, from the 
blood of the capillaries. The water in the cells increases, 
and its tension becomes greater, until, finally, the endos- 
motic power of the cell-substance is held in equilibrium, 
and the diffusion-stream between the blood in the capil- 
laries and the cells comes to a stand-still. The water 
held in the substance of the cells cannot escape into the 
lumen of the alveolus, which would be the natural path 
for it to take, since there the water is under little or no 
pressure, because the border of the cell-protoplasm is so 
constructed as to offer a great resistance to filtration. So 
the water may be held in the cell under great tension, 
and yet not be able to filter through this limiting layer 
into the lumen. The action of the nerves consists in so 
changing the structure of this resisting layer that it may 
offer little resistance to filtration, and the water of the 
cell then filters out into the ducts; its own endosmotic 
power, no longer held in equilibrium, again draws water 
from the lymph, etc., and a filtration-stream is started, 
the moving force of which is this endosmotic power of 
the cell-substance. In what way the nerves cause a 
change in the nature of the resisting layer of the cell 
can only be a matter of speculation. The author of the 
theory thinks that there is a molecular change or re- 
arrangement in its structure, of such a character that it 
no longer offers a resistance to the passage of water from 
a point of high pressure within the cell to one of lower 
pressure outside of the cell. It is possible, also, that ac- 
tive contractions of the cell-substance may facilitate the 
secretion of liquid. The whole theory goes far beyond the 
facts which are known; but it is, perhaps, the best that 
has been offered, and may be adopted provisionally until 
future researches give us more data to speculate upon. 

Heidenhain says little about the secretion of salts in- 
dependently of the water in which they are dissolved. 
Presumably, on his theory, the salts are carried directly 
in the diffusion-stream, passing from the blood of the 
capillaries to the cells of the alveoli, and depend no more 
for their secretion upon metabolisms in the cells than the 
water does. In accordance with this view, Heidenhain 
found that the maximum amount of inorganic salts in 
the submaxillary saliva lay between 0.5 and 0.6 per 
cent., or, according to the later experiments of Werther, 
may reach 0.77 per cent.; increased velocity of the secre- 
tion-stream beyond this point caused no increase in 
the percentage of salts. This percentage of salts is still 
below that of the blood, and calls for no especial secre- 
tory activity of the cell to explain its production. In 
other glands of the body, however, we meet with what 
seems to be a true secretion of salts—that is, the salts 
cannot be considered as filtering or diffusing through the 
gland-cells with the stream of water, but exist in such 
quantities that they must have been collected from the 
blood by the secreting cells in some way, and are the di- 
rect products of the metabolic activity of these cells. In 
the mammary gland, for instance, Bunge ® finds that the 
salts of the milk not only differ widely in percentage- 
value from the same salts in the blood, from which they 
are ultimately derived, but exist in the same percentage 
by weight as in the ash of the sucking animal for whose 
food the milk is intended—that is, the epithelial cells pick 
out from the blood certain salts in the quantities needed 
for the growth of the young animal. For the proof of 
this interesting statement Bunge submits the following 
table of analyses : 


Sucking animal. 4 3 E 

TH Ss fe 

100 parts of ash contain : a 2 2 

2 wa rs 

Rabbit. | Dog. | Cat bo pe oo 

A A A 

Wg Os Rese rk ie alec i aarti 10.8 Sib OED TOT AS 2.4 
Ning Oss Bere wich tote tits 6.0 8.2 8.8 | 6.1 | 45.6 | 52.1 
Caliente aceise Ge 35.0 | 35.8 | 341 | 344 | 09 | 24 
MeO v2 $n ck aoe once 2.2 1.6 NES ha as 0.4 0.5 
HEAO SS ee eke. Sion 0.23 | 0.34| 0.24 0.14] 9:4 | O12 
0,925, Bie Mees 41.9 | 398 | 40.2 | 37.5 | 13.2 | 6.9 
Glo ara/s techs te ta see an 4.9 7.3 V1 | 12.4 | 35.6 | 47.6 


There can be no question of simple diffusion and filtra- 
tion in this case. While the blood of the mother con- 
tains in its ash less than one per cent. of CaO, the milk 
holds over thirty-four per cent., and, on the other hand, 
the blood contains a large percentage of Na2O and Cl, 
while the ash of the milk contains very much less. 

Similar results have been obtained from the kidney by 
Munk.? This observer experimented upon kidneys of 
dogs taken from the body and kept alive by an artifi- 
cial circulation of defibrinated blood, usually diluted with 
one-half to one volume of water or normal salt solution. 
Under these conditions the kidney continued to secrete 
urine steadily, and the characteristic salts of the secretion 
always existed in a higher percentage in the secretion 
than in the blood which was circulating through the 
gland. The NaCl, for instance, was found without ex- 
ception to be greater in the secretion than in the blood, 
the excess varying between eighteen and sixty-seven per 
cent. Even when by addition of NaCl to the circulating 
blood the percentage of this salt was raised to 2.28, the 
weight of NaCl found in the secretion was always from 
twelve to sixty per cent. higher. The same resuits were 
obtained with NazSO, and NasHPO,, and here, again, 
the secretion of the salts is undoubtedly connected with 
the activity of the secreting cells, and is not a passive 
phenomenon. Munk’s success in getting a true secre- 
tion of urine from a kidney with artificial circulation 
is opposed to the experience of other observers, and his 
results need corroboration before they can be fully ac- 
cepted. 

Stricker and Spina have advocated a different theory 
of secretion, founded upon some observations made 
upon the simple racemose glands contained in the skin 
of the frog.* In these simple glands the lining epithe- 
lium forms a more or less flattened layer upon the al- 
veolar wall, leaving a relatively large lumen. When the 
gland is stimulated by electricity, either directly or 
through nerves, two things happen. In the first place, 
the whole gland becomes smaller, from a contraction of 
the external surface, and, secondly, the cells of the alyeo- 
lus dilate and completely close up the lumen. After 
the stimulation has ceased, the cells and gland return 
again to their former condition. As far as the first of 
these phenomena is concerned, it is probably owing to 
the contraction of muscular elements in the periphery 
of the gland. The enlargement of the gland-cells that 
follows stimulation may be explained either as an active 
dilatation, or aS a passive dilatation from the imbibi- 
tion of water. The authors hold to the first of these 
views ; they see no reason why nerve-stimulation should 
not lead to an active dilatation of the cells as well as to 
a contraction, and believe that the object of the dilata- 
tion is twofold. On the one hand, by obliterating the 
lumen the cells drive out the secretion which was stand- 
ing in it, and, on the other, their enlargement creates a 
negative pressure within the cells, in consequence of 
which water is drawn into them from the surrounding 
lymph. When the stimulation ceases the cells return to 
their normal size and squeeze out this water into the 
lumen. According to this theory the cells act both as a 
mechanical force-pump and as a suction-pump, drawing 
the water into themselves, and again forcing it out into 
the duct. Stricker and Spina have attempted to apply 
this theory to similar glands—the salivary glands, for 
instance—but the attempt is hardly worthy of serious 
consideration. As Heidenhain says, the enlargement of 
the cells in these glands during secretion, which un- 
doubtedly takes place, is in reality a secondary phenom- 
enon ; the stream of water which results from the stimu- 
lation causing changes in the cells is the primary 
phenomenon, and the cells swell up from imbibition of 
this water. Why stimulation of the nerves should set 
up a secretion-stream through the gland is the same 
problem that we have discussed already with reference 
to the salivary glands, and Heidenhain’s hypothesis ap- 
plies as well in one case as in the other. 

Action of Atropine and Pilocarpine on the Salivary 
Glands.—The action of a number of different poisons on 
the salivary secretion has been determined more or less 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


completely. Of these poisons, atropine and pilocarpine, 
from their decided and antagonistic effects, have always 
been regarded with peculiar interest. It has long been 
known that when atropine in minimal doses is injected 
either into the blood or directly into the gland through 
its duct, the secretion of the gland very quickly stops, 
and in the submaxillary gland, upon which most of the 
experiments have been made, stimulation of the chorda 
no longer has any effect upon the gland-secretion, al- 
though the dilatation of the blood-vessels follows as in 
the unpoisoned gland. This action of the atropine is not 
exerted upon the nerve-centres in the cerebro-spinal sys- 
tem, but directly upon the glands. The same effects 
may be obtained when all nervous connections between 
the glands and the nerve-centres are severed. The atro- 
pine must act either upon the secreting cells directly, or 
else upon the termination of the nerves in the gland. 
The second of these views seems to be the probable one, 
for the reason that when atropine is injected into the 
blood of a dog the chorda-fibres going to the submaxil- 
lary gland are completely paralyzed—no amount of stim- 
ulation will cause them to excite a secretion. But even 
very strong doses will not paralyze the action of the sym- 
pathetic fibres of the same gland. Hence the gland-cells 
themselves must be capable of functional activity. What 
the atropine has done is to prevent the action of the 
chorda-impulses on these cells. The connection between 
the nerve-fibres and gland-cells is unknown, and it re- 
mains an open question whether the atropine affects this 
connection, or possibly acts upon the local centres, small 
ganglia, which exist in the substance of the gland, and 
with which, presumably, the chorda-fibres are first con- 
nected before passing to the secreting cells. The action 
of pilocarpine is of the opposite kind. Very small doses 
(0.001 Gm.), injected into the blood, cause an active se- 
cretion of the gland (submaxillary), a secretion which 
may be increased by simultaneous stimulation of the 
chorda-fibres. If, however, the dose of pilocarpine is 
too strong, the gland is paralyzed, as in the case of atro- 
pine-poisoning. 

Most of our knowledge of the action of these drugs is 
derived from Langley’s work.’ With regard to their an- 
tagonistic action, he states that they have an imperfect 
mutual antagonism. As long as the dose of pilocarpine 
is sufficiently small to cause secretion of the gland, the 
antagonism of atropine for it is perfect—that is, the secre- 
tion of the gland can be stopped by injection of atropine. 
The antagonism of pilocarpine for atropine, however, is 
less perfect, and is more complete the smaller the dose of 


atropine—that is, the paralyzing action of the atropine, . 


if the dose is not too great, may be removed by injection 
of pilocarpine. While the atropine may be regarded as 
acting upon the peripheral nerve-endings in the gland in 
such a way as to paralyze them, the pilocarpine in small 
doses may be supposed to stimulate these nerve-endings, 
and in larger doses to paralyze them. These facts give us 
but little aid in understanding the physiological mechan- 
ism of secretion, though any theory that is proposed 
must take them into consideration. 

The Secretion-centre.—The salivary glands in the nor- 
mal relations of the body are set into action, not by direct 
stimulation of the secretory nerves supplied to them, but 
reflexly from stimulation of sensory nerves of the tongue, 
of the buccal cavity, of the alimentary canal in general, 
etc. The position of the secretory centre through which 
these reflexes are made has been placed in the medulla, 
at about the nuclei of origin of the facial and glosso-pha- 
ryngeal nerves. Bernard attempted to show that the little 
submaxillary ganglion placed in the angle between the 
lingual and chorda-tympani nerves might serve as a re- 
flex centre for stimulation of the endings of the lingual 
in the tongue. Experiments made by other observers 
have discredited this theory, and we cannot at present 
state what the function of this ganglion is with reference 
to the submaxillary gland. The secretory centre in the 
medulla can be excited by stimulation of the sciatic or the 
splanchnic nerve, and can also be stimulated directly by 
mechanical or electrical means. In strong dyspnoea this 
centre is usually thrown into action by the stimulating 


Secretion, 
Secretion. 


action of the venous blood in the medulla. The secre- 
tory centre may also be stimulated by impulses descend- 
ing from the higher centres in the brain. As is well 
known, the mere thought of pleasant food may cause a 
reflex secretion of saliva. On the other hand, the action 
of this centre may be inhibited either by afferent im- 
pulses from various nerves of the body, or by impulses 
descending from higher centres in the brain. The well- 
known fact that terror, anxiety, etc., frequently stop the 
flow of saliva is sufficient proof of this latter statement. 

Paralytie Secretion. —Claude Bernard discovered, in 
1864, that if the chorda-tympani fibres of the submaxillary 
glands are cut, the gland ceases to secrete, because the 
efferent path from the secretory centre is now cut off. 
Nevertheless, from one to three days after the section of 
the nerve a slow secretion begins in the gland, and keeps 
up continuously for several weeks. As a final result of 
the section, the gland undergoes complete atrophy unless 
the chorda-fibres again grow out. The cause of this par- 
alytic secretion is very obscure. Heidenhain thought 
that it was owing, perhaps, to the stagnation of saliva in 
the ducts, certain products being formed which stimulated 
the gland. Langley has recently studied the subject with 
more success than other observers.!® He has both added 
new facts to those already known with regard to the 
results of this section, and has suggested a plausible 
theory of the cause of the paralytic secretion. Section of 
the chorda tympani in the cat, according to Langley, is 
followed by a continuous secretion of watery saliva from 
the submaxillary gland on -both the cut and the uncut 
side, that on the cut side being the more abundant. The 
secretion of the gland on the side on which the nerve 
was cut he calls the paralytic secretion, and that from 
the gland on the other side, the antiparalytic or antilytic 
secretion. The primary cause of these secretions he con- 
siders to be an increase in the irritability of the cells of 
the secretory centre. When the chorda on one side is 
cut, the central secretory nerve-cells become more irrita- 
ble, and finally the blood flowing through the centre, 
which is normally somewhat venous, but not enough so 
to stimulate the centre, becomes now a sufficient stimulus 
to this more irritable centre, and the impulses pass to the 
gland on the cut side through the sympathetic fibres 
which remain uncut, thus exciting the paralytic secre- 
tion ; while on the other side the impulses descend through 
both the chorda and the sympathetic, causing the anti- 
lytic secretion. Confirmatory of this view he finds that 
the paralytic secretion may be stopped in its first stages 
by section of the sympathetic fibres of the same side. In 
later stages, however, section of the sympathetic fibres, 
while it mayslow the secretion, will not stop it alto- 
gether. Langley explains this by supposing that now 
the local centres in the gland itself have become affected, 
that is, become more irritable, and are being stimulated 
continually by the blood flowing through the gland, so 
that it is possible to get a paralytic secretion from the 
gland after all nervous connection with the medullary 
centre is cut off ; the secretion in this case would proba- 
bly take a longer time to develop, as the local centres 
undergo this change in irritability more slowly than the 
general centre in the medulla. As a confirmation of 
this view, Langley points out that in the sweat-glands, 
in which no peripheral nerve-cells, local centres, are 
known to exist, no paralytic secretion can be obtained 
when the nerves of the glands are cut; while in the sal- 
ivary glands and the pancreas, in which these peripheral 
nerve-cells have been found, a. paralytic secretion is ob- 
tained when all the nerves supplying the gland are cut. 
This theory seems to meet all the facts in the case, and is 
certainly a great advance on any hitherto offered, though 
it is somewhat difficult to see why section of the chorda 
should be attended by an increase in irritability of the 
central nerve-cells of the medulla. | 

SECRETION IN THE PancrEAs.—In some respects the 
study of the process of secretion, as exhibited in the pan- 
creas, has been of more service in throwing light upon 
the phenomena of secretion in general than the study of 
the salivary gland. This is especially true with respect 
to the histological changes undergone by the cells during 


373 


Secretion. 
Secretion. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


secretion. Observations upon the hardened gland, in dif- 
ferent stages of activity, by Heidenhain, and confirmatory 
experiments upon the living pancreas of the rabbit, by 
Kiihne and Lea, have given us a pretty clear conception 
of the mechanism of the secretion of the organic constit- 
uents. In other respects, however, the work upon the 
pancreas has been less successful. Little or nothing is 
known of the effect of direct nerve stimulation upon the 
character of the pancreatic secretion, so that the evidence 
for the presence of different kinds of secretory nerves in 
this gland is not so direct as in those already described. 
An account of the physiology of secretion in the pancreas 
will add, then, but little to the data already given, as far 
as any general theory of secretion is concerned. But it 
will serve toshow that in many points the process exhib- 
its a fundamental similarity in the two sets of glands, 
giving us some hope that certain general statements with 
regard to gland activity may yet be formulated. From 
what has been said of salivary secretion it is very evident 
that our knowledge of the real nature of the process is 
very fragmentary and insufficient, and this is even more 
conspicuous in the case of the pancreas. The theories in 
the one case, as far as they have been developed, apply 
fairly well in the other; but in neither case are the facts 
sufficient for the construction of a theory of secretion that 
does not force us to use hypotheses for the truth of which 
there is little positive proof. Glands so similar in struct- 
ure as the pancreas and salivary glands must function 
in essentially the same way, and it seems allowable to 
supplement the facts known with regard to one by the 
results obtained, under more favorable conditions, from 
experiments upon the other. What we have to say 
about pancreatic secretion, then, will be made as brief as 
possible, since the general deductions that might be made 
from its study alone have already been presented in 
speaking of the salivary glands. 

The pancreatic secretion, as obtained from a tempor- 
ary fistula in the duct of a dog, is a clear, thick, sticky 
liquid that coagulates in the cold, and shows an alkaline 
reaction. It contains a large percentage of organic ma- 
terial, which appears to consist chiefly of albuminous 
bodies, alkali albuminate, and the usual salts, among 
which the sodium salts are especially abundant. Owing 
to its large amount of albuminous material the secretion 
gives a strong precipitate or coagulum when heated. 
W hat especially characterizes the secretion, however, is 
the presence of at least three unformed ferments, or en- 
zymes, which have the power of causing digestive changes 
in the three chief classes of alimentary principles. These 
three enzymes are, (1) A diastatic ferment capable of con- 
verting starch into sugar; (2) a ferment capable of con- 
verting albumins into peptones and amido-acids ; (3) a 
ferment capable of splitting neutral fat into glycerine 
and the corresponding fatty acid. The physiological ac- 
tion of these ferments does not interest us in this con- 
nection ; we are concerned only with the way in which 
they are formed within the cells of the gland, together 
with the other products of secretion, and with the mech- 
anism by which they are forced out of the cells into the 
secretory ducts. In cases of permanent pancreatic fistula, 
where the secretion has been long continued, its charac- 
ters differ in degree from those given above; the secre- 
tion becomes much thinner, and the percentage of solid 
constituents may sink to a very low level, one or two per 
cent., while in the fresh gland it may be nine to ten per 
cent. So all gradations may be obtained according to 
the condition of the gland. It is evident that the chemi- 


cal constitution of this secretion places the gland in the | 


albuminous type, and the morphological changes in its 
structure during rest and activity also suggest strongly 
the appearances found in salivary glands of this type, 
é.g., the parotid. 

The secretion of pancreatic juice in the dog is not con- 
tinuous, but intermittent. After the reception of food 
and the commencement of gastric digestion the pancre- 
atic juice begins to flow out of the duct into the intes- 
tine, and continues to be secreted with varying velocity 
for several hours. By making a pancreatic fistula, and 
measuring directly the amount of pancreatic secretion 


374 


that flowed from it, Bernstein,!! and afterward Heiden- 
hain,!? have been able to determine the variations in the 
secretion in the hours following digestion. The curves 
given by the two investigators agree very well, and the 
general result, as stated by Heidenhain, is as follows: 
Immediately after the reception of food the secretion 
begins, and increases in velocity up to a certain maximum, 
which it reaches from the first to the third hour after di- 
gestion has begun. The velocity then falls quickly un- 


ae ee 


WN EZ 
Vale tla 8 
ia Fiala 8 


Fie. 3431.—The upper figure represents the curve of secretion of pan- 
creas. The lower figure gives the percentage of solid matter in the 
secretion. The hours are marked off on the abscissa, and the ordinates 
represent the quantity of the secretion, the unit being 0.1 c.c. 
Heidenhain.) 


(After 
til the fifth or sixth hour, after which there is a second 
increase of velocity up to the ninth or the eleventh 
hour. This second increased velocity is never so great 
as that which occurs in the first few hours. The flow of 
secretion then diminishes slowly until the sixteenth or 
seventeenth hour after digestion, when it again comes 
back practically to zero. Two of the curves obtained 
by Heidenhain are given in the upper portion of the ac- 
companying figure. Heidenhain determined at the same 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Secretion. 
Secretione 


time the percentage of solid constituents in the secretion 
at the different hours, and the results are represented in 
the lower curves of the figure. An examination of these 
curves shows that as the velocity of the secretion in- 
creased the percentage of solid matter decreased, in this 
respect differing very much from the salivary secretion. 
The solid matter of the secretion is composed partly of 
organic constitutents and partly of salts; the variations 
given here are presumably varia- 
tionsin the organic material chiefly, 
though no analyses are given, so 
that the external characters of the 
secretion change during the hours 
of its flow; at first 
thick and coagulable, 
it becomes afterward 
thinner and more like 
the weak secretion 
:) from long-established 
fistulas, while toward 
the end of its 
flow— when 
the velocity 
is again very 
small—the 
percentage 
of organic 
constitu-: 
ents increases, giving again 
a secretion like that usually 
described as normal. 

Morphological Appearance 
of the Gland in Rest and 
Activity. — Together with 
these changes in the flow of 
the secretion certain well-marked differences in the his- 
tological appearance of the gland have been noticed. A 
resting gland from a dog that has fasted for twenty-four 
hours or more, if hardened in alcohol and stained in 
carmine or Heidenhain’s hematoxylin, shows in sec- 
tions appearances represented in Fig. 3482. The cells of 
the alveoli show two distinct zones—an outer non-granu- 
lar zone, which stains readily and contains the nucleus, 
and an inner granular zone facing the lumen; the ma- 
trix containing these granules does not stain at all, and 
is differentiated clearly from the stained outer layer. 
Heidenhain has shown, also, that in the outer non-granu- 
lar zone the cells show a distinct striation, the 
lines disappearing at the commencement of the 
granular portion. If, now, the pancreas from a 
dog recently fed is treated in the same way with- 
in the first six or ten hours after digestion, marked 
changes in the relations of the two zones will be 
found to occur. The non-staining granular in- 
ner zone becomes smaller and smaller 
during this period, until in some of 
the alveoli it may entirely disappear. 
Together with this disappearance of 
the granular zone there is a corre- 
sponding increase in the staining 
non-granular portion, which becomes 
wider and wider, and may finally ex- 
tend over the whole cell from base- 
ment membrane to Jumen. The in- 
crease of the outer zone, however, 
does not quite keep pace with the consumption of the | 
granular zone, so that during this period the cells and 
the alveoli or tubes of the gland become decidedly 
smaller, a condition of things represented in Fig. 3483. 

During the second stage of digestion, within the tenth 
to the twentieth hour after feeding, the gland again 
comes back gradually to its resting condition. The cells 
increase in size, the inner granular zone is regenerated, 
and the outer clear zone of staining protoplasm forms 
now only a thin layer on the outer or basement mem- 
brane side of the cells. 

The observations of Heidenhain on the hardened pan- 
creas of the dog have been confirmed and extended by 


Cy 


as 


Fig. 3432.—Pancreas of Dog. (From 
Heidenhain. ) 


eae 
Bia seein 


experiments of Kahne and Lea'* upon the pancreas of a 


living rabbit. The secretion of the pancreas in the rab- 
bit appears to be continuous, owing to the different char- 
acter of the food and the time required for its digestion. 
When a portion of the pancreas in the living animal is 
examined under the microscope, two different kinds of 
alveoli or tubes may be seen, either in one field or in 
different parts of the specimen. In one represented in A, 
Fig. 3434, the outlines of the alveolus are smooth and 
even, the individual cells are not clearly distinguished 
from one another, and two zones can be seen—a clear 
homogeneous outer zone toward the basement membrane, 
and a granular inner zone toward the lumen. In the 
other, represented in B, Fig. 3484, the outlines of the 


Fic. 3433.—Pancreas of Dog; six to ten hours after digestion has be- 
gun. (From Heidenhain.) 


alveolus are notched or indented, and the division be- 
tween the individual cells becomes more or less distinct 
in consequence of spaces or lines which appear between 
them. In the alveoli, also, the granular layer or zone is 
less conspicuous and the outer zone relatively greater. 
Kihne and Lea were able to show that this latter appear- 
ance represents the condition of activity, while the for- 
mer, A, shows the resting state. When the gland was 
actively secreting, the notched alveoli were most numer- 
ous ; and, furthermore, drugs which excite the secretion, 
jaborandi, ¢.g., caused the alveoli to assume this shape, 
while atropine, which inhibits the secretion, brought about 
the smooth outline. When indifferent solutions, like 
normal salt solution or defibrinated blood, were forced 
into the duct of the gland under a low pressure, the 
liquid could be followed back, in the latter case, by the 
blood-corpuscles, into the small ducts and lumens of 


Eo 


Fic. 3434.—Living Pancreas of Rabbit. (From Kiihne and Lea.) 


the alveoli; if the pressure was now taken off, the secre- 
tion of the cells forced back the defibrinated blood from 
the lumens, and in cases in which this occurred the alve- 
oli assumed the notched appearance. For these reasons 
this latter condition may be considered as the state of ac- 
tivity. They saw alveoli pass from a state of rest to one 
of activity, and were able to determine that there was a 
movement of the granules toward the lumen. In the 
state of activity it was noticed, also, that the external 
zone of the cells, the non-granular zone, became distinctly 
striated, and if the stria# were seen during the resting: 
stage they became more distinct in the state of activity. 
These experiments, together with those of Heidenhain,, 
leave no doubt that the organic material of the secretion, 


37D) 


Secretion. 
Secretion, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


is formed from the granules of the inner zone, and that 
these in turn are derived from the protoplasmic material 
of the outer zone directly or indirectly ; while during 
the act of secretion active changes of form take place 
in the cells, owing either to a contraction of the substance 
of the cells themselves or of some other element of the 
alveoli or tubes composing the gland. 

Some recent experiments of Ogata! have given the 
same results with regard to the changes in the granular 
zone and size of the cells during rest and activity. 
Ogata’s chief results, however, relate to the changes in 
the nucleus of the cell during rest and secretion, and the 
way in which the pancreatic cells that may be destroyed 
during the secretory.process are replaced. Briefly pre- 
sented, his results are as follows: He distinguishes in 
the nucleus of the resting cell two kinds of nucleoli—one 
staining with hematoxylin, like the nuclear membrane 
which he calls karyosmen, and of these there may be one 
or several; the other kind, usually a single nucleolus, 
he calls a plasmasoma, and it stains readily with eosin. 
In the cell outside of the nucleus he describes the two 
layers, granular and non-granular, already spoken of. 
In the inner granular layer the zymogen-granules are 
embedded in a clear, structureless matrix, which also ex- 
tends throughout the non-granular zone, and forms what 
he calls the cell-stroma. In the external zone of the cell 
this cell-stroma contains granules of another kind from 
those of the inner zone ; they are very fine and stain 
readily in nigrosin, and Ogata speaks of them as proto- 
plasm. When the gland is stimulated in any way—by 
feeding, by stimulation of the medulla, or, best of all, by 
the injection of pilocarpin—very marked changes take 
place in the cell. The zymogen-granules disappear and 
the cells become smaller, as already described, but in ad- 
dition to this a new body appears in the cell just outside 
of the nucleus ; this he calls a ‘‘ Nebenkern ” (accessory 
nucleus) after Gaule, and he finds that it is formed by 
the passage of the plasmasoma out of the nucleus into 
the cell-body. One of two things may happen to this 
‘‘Nebenkern.” It may grow and finally be converted 
into zymogen-granules, to replace those used up in secre- 
tion, or it may develop an entirely new cell, with gran- 
ules, nucleus, nucleoli, ete., and thus indirectly furnish 
new zymogen-granules, As the new pancreas-cell de- 
velops from the ‘‘ Nebenkern,” which in this case is a 
veritable cytoblast, the old cell dies away and finally dis- 
appears. These experiments of Ogata on the develop- 
ment of the new cell are in the line of recent researches 
on cell-growth and the function of the nucleus, but are 
too new to be accepted at present without further con- 
firmation. 

Formation of the Pancreatic Ferments.—Though the ex- 
periments just given indicate clearly that the ferments 
are derived from the granular material of the cells, we 
know that these granules do not themselves contain the 
ferments, but are composed of a material which proba- 
bly at the moment of secretion suffers changes that result 
in the production of the ferments and other organic sub- 
stances. This mother substance, from which the fer- 
ments or enzymes are formed, is spoken of usually as 
zymogen, but it is not easy to prove its existence. Ifa 
dog which has fasted for twenty-four hours—at which 
time, from what has been said, we know that the gland 
contains a large proportion of the granular material in 
the inner zone of the cells—is killed, and immediately 
after death a glycerine-extract is made of the pancreas, 
very little or no trypsin will be obtained from it. But if 
the gland is first allowed to remain in the air, in a warm 
place, for twenty-four hours, or treated with dilute acctic 
acid, then a glycerine-extract will be found to have a 
powerful tryptic action. The fresh gland then contains 
no trypsin ready-made, or only very small quantities of 
it, but a substance (zymogen) which can be readily con- 
verted into trypsin. The zymogen of the fresh gland is 
readily extracted by glycerine, and the zymogen of this 
extract can then be easily changed to trypsin by any one 
of a number of different methods—by simple dilution 
with water, by the passage of a stream of oxygen through 
it, by shaking with finely divided platinum-black, ete. 


376 


The amount of trypsin or zymogen contained in the pan- 
creas is found to vary according to the number of hours 
that have elapsed after digestion before the extract is 
made, and these variations are in the direction we should 
expect if the zymogen is contained in the granular ma- 
terial of the gland. Heidenhain has made a number of 
such experiments upon dogs, using in all cases a glyce- 
rine-extract of the gland, and has found that immediately 
after digestion the amount of zymogen or trypsin begins 
to sink, and reaches its minimum from the sixth to the 
tenth hour after the food has been taken, just the time at 
which, according to microscopical examination, the gran- 
ular material of the inner zone is least abundant. After 
this the amount of ferment that can be extracted begins 
to increase, together with the increase of granular mate- 
rial that. has been shown to take place in the gland, 
reaches its maximum at about the sixteenth hour, and 
then remains practically constant until the next meal is 
taken. Similar results have been obtained with the dias- 
tatic and fatty actd ferments. Griitzner ® found that both 
reached their minimum at about the sixth hour of diges- 
tion, and then slowly increased, the diastatic ferment 
reaching its maximum at the fourteenth hour, while the 
fatty acid ferment gradually increased in quantity until 
the fortieth hour. In the pancreatic gland, then, we are 
able to trace the genesis of the ferments, by microscopical 
and chemical means, more satisfactorily than in the sali- 
vary glands. ‘The similarity in the appearance of the 
resting and active conditions of the living pancreatic and 
the living parotid gland lead us to believe that what has 
been ascertained for the former will hold good for the 
latter. On the contrary, what we know of the action of 
the nerves on the secretory activity of a gland has been 
derived almost entirely from a study of the salivary 
glands, and can be applied only by inference to the pan- 
creas. 

Action of the Nerves on the Pancreatic Secretion.—The 
secretion of the. pancreas is, under normal ‘conditions, 
probably a reflex act; it begins as soon as food has been 
received into the stomach, but the path of the reflex has 
not been determined. The centre for the reflex probably 
lies in the medulla, since direct stimulation of this organ 
increases the velocity of the secretion, and, furthermore, 
the secretion may be inhibited by the stimulation of cer- 
tain afferent nerves, the vagus, for instance. Neverthe- 
less the pancreas seems to be, to a large extent, an auto- 
matic organ, even more so than the salivary glands. The 
ganglia found in its substance act as local centres, which 
excite secretion in the gland after all nervous connection 
with the higher medullary centre has been severed. This 
secretion of the pancreas, after as complete section as 
possible of all nerves going to it, is of the nature of a 
paralytic secretion, and the views of Langley as to the 
mechanism of the paralytic secretion in the salivary 
gland will doubtless apply to the pancreas also. It is 
difficult to remove the pancreas from all nervous influ- 
ence, since its nerve-branches are derived from the plexus 
hepaticus, lienalis, and mesentericus superior, and reach 
the gland along the walls of its blood-vessels, and are 
therefore less easily isolated than in the case of the sali- 
vary gland. For the same reason no satisfactory experi- 
ments, comparable to those given for the submaxillary 
and parotid glands, have yet been made upon the effect 
of direct stimulation of the secretory nerves of the pan- 
creas. ‘The best that can be done is to stimulate the se- 
cretory centre in the medulla and observe the effects. 
Experiments of this kind have shown that not only is the 
velocity of the secretion increased as the result of stimu- 
lation, but there is also an increase in the percentage of 
organic matter contained in it. These results indicate 
that here, as in the salivary glands, we have to deal with 
two kinds of nerve-fibres—secretory fibres, which regulate 
the velocity of the secretion, that is, the amount of water 
which passes out in a given time; and trophic fibres, 
whose business it is to form the organic materials of the 
secretion from the zymogen-granules, and at the same 
time start constructive metabolic processes in the cell, 
which result in the formation of new protoplasm and 
new zymogen-granules to take the place of those secreted. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Secretion, 
Secretion. 


The experimental evidence for the existence of these 
fibres is not very conclusive, though there is nothing to 
oppose such a view, and the analogy of the salivary 
glands, as before stated, leads us to believe that the ner- 
vous mechanism is essentially the same in both cases. 

SECRETION IN OTHER GLANDS.—The most important 
outcome of modern researches on the phenomena of se- 
cretion, as illustrated in the salivary glands and pancreas, 
relates to the part taken by the extrinsic nerves of the 
gland in regulating and modifying the flow of the secre- 
tion, and to the histological changes which can be ob- 
served in the gland during its periods of rest and activity. 
It will be interesting to summarize briefly our knowl- 
edge of these two processes in some of the other glands 
of the body. 

Stomach.—As far as the nervous mechanism of the se- 
cretion in the stomach is concerned, the results of investi- 
gations are very meagre. There is some evidence that 
the secretion of the gastric gland is under the influence 
of extrinsic nerves. For instance, it is stated that in cases 
of gastric fistula the mere sight of food has been observed 
to start the secretion of gastric juice. Unfortunately 
this observation has not been satisfactorily confirmed, 
and the flow of gastric juice, if it took place under such 
circumstances, might be an indirect result of reflex move- 
ments of the stomach, so that it cannot be considered as 
conclusive proof that the stomach can be reflexly excited 
to secretion. The well-known observation of Richet, 
who found that, in a man with a completely obstructed 
cesophagus, the chewing of sapid substances, sugar, cit- 
ron, etc., caused a reflex flow of gastric juice, is also 
unsatisfactory, especially as similar experiments upon 
dogs have given negative results. On the other hand, 
direct stimulation of the vagus, or of the sympathetic 
branches to the stomach, has given only negative results. 
So, also, section of all the extrinsic nerves going to the 
stomach seems to have no direct influence on the secre- 
tion, and we are forced to believe that the intrinsic ner- 
vous apparatus, plexuses of Auerbach and of Meissner, 
are sufficient to regulate the normal secretion of these 
glands. 

With regard to the histological changes in the gastric 
glands during secretion, our knowiedge is much more sat- 
isfactory. From the microscopical study of. glands taken 
from dogs in different stages of digestion, and hardened 
in alcohol, Heidenhain has been able to show that certain 
_ definite changes in the size and appearance of the cells 
can be observed. More detailed and trustworthy obser- 
vations upon the living glands have been made by Lang- 
ley and Sewall,'® and Langley.!" The experiments of 
these investigators were made upon the cesophageal and 
gastric glands of the frog and related animals. As is 
well known, the pepsin of the gastric secretion in the 
frog is chiefly formed in the cesophageal glands, and it 
has been found that these glands suffer changes during 
secretion which are very similar to those already de- 
scribed as occurring in the parotid gland and the pancreas. 
If these glands are made to secrete, either by mechanical 
stimulation or by the action of food, the cells, which in 
the resting condition were granular throughout, begin to 
lose their granules. The disappearance takes place from 
the periphery inward, so that soon the cells show an outer 
non-granular, and an inner granular, zone, owing to the 
fact that the granules toward the exterior travel inward 
to the lumen, as those formerly occupying that position 
are used up in making the secretion. The secretion of 
pepsin goes on as long as digestion continues, and Lang- 
ley has proved that during the Jatter half or two-thirds 
of the digestive period the granules begin to increase in 
number, showing that two processes ate going on simul- 
taneously, viz., the conversion of the zymogen granules 
into pepsin and its discharge into the duct of the gland, 
and the manufacture of new zymogen granules from the 
protoplasm of the cell. It may be assumed that these 
two processes go on throughout the whole period of ac- 
tivity, and that in addition there is a continual formation 
of new protoplasm in the cell from the food offered by 
the lymph, this being a necessary preliminary step to the 
formation of new zymogen granules. In the first stages 


of digestion it is probable that the conversion of zymogen, 
or pepsinogen as it is called in this particular case, to pep- 
sin overbalances the other processes, and the cells there- 
fore diminish in size. The other two processes, however, 
soon equalize this loss of substance, and in the later 
stages of digestion lead to an actual increase in the size of 
the cells. The cells, therefore, do not have to wait until 
the period of activity is passed to make up the loss of 
substance suffered during secretion, but the restorative 
processes go on simultaneously with the secretion, so that 
at the end of digestion the gland-cells are nearly or quite 
as large as the resting cell. 

Kidney.—We have no satisfactory evidence of the ex- 
istence of secretory nerves in the kidney. Eckhard held 
such a view,’? and thought that these fibres have their 
origin from a secretory centre in the medulla, pass down 
the cord, and reach the sympathetic chain by the commu- 
nicating branches in the-upper thoracic region. Their 
path from the sympathetic trunk to the kidneys was not 
definitely known, but Eckhard supposed it to be through 
the circumvascular plexus around the aorta. He was led 
to this conclusion chiefly from the fact that, after separa- 
tion of all the nerves going to the kidneys, as far as they 
could be distinguished anatomically, stimulation of the 
medulla still caused an increased secretion of urine. The 
explanation of this he found in the stimulation of sécre- 
tory nerves, since the only other theory which could ac- 
count for it, namely, variations in arterial pressure from 
the stimulation of the vaso-motor centre, was shown by 
him to be insufficient, the variations in arterial pressure 
not being constant. 

As far as Eckhard’s work has been repeated by later 
observers, the result has been to weaken his theory of 
special secretory nerves. The results obtained from sec- 
tion of the cord, stimulation of the medulla, etc., find a 
simpler explanation in the vaso-motor changes which fol- 
low such experiments, and the variations in the quantity 
of secretion are now usually believed to be the result of 
the increased or diminished blood-flow through the kid- 
neys. 

With regard to the mechanism of the secretion of 
urine, at least two different views are held at present 
among physiologists. According to the theory of Lud- 
wig, the secretion of urine is the result of simple filtra- 
tion and diffusion. In the blood-vessels of the glomeruli 
the conditions are such that not only is there a filtration 
of water and salts, but also of the specific elements of 
the secretion from the blood into the kidney tubules, and 
this diluted urine in its passage along the uriniferous 
tubules, by diffusion with the surrounding lymph, be- 
comes concentrated to its normal. strength. According 
to the other theory, first advocated by Bowman, and 
since upheld by Heidenhain, the secretion of water and 
salts takes place in the glomeruli, while the specific ele- 
ments of the secretion are eliminated from the blood by 
the epithelial cells of the tubules. According to Heiden- 
hain, we have to deal in both cases with a functional activ- 
ity of the epithelial cells of the kidney, a true secretion 
as opposed to Ludwig’s idea of a simple physical process 
in which the cells take no active part. The question of 
the truth or error of Ludwig’s view seems to turn mainly 
on the effect of variations in arterial pressure in the kid- 
neys on the quantity of the urine formed. According to 
his theory an increase in the arterial pressure should al- 
ways be accompanied by an increased secretion, and vzce 
versa. Heidenhain contends that this is not true, that 
in some cases increased pressure in the kidney-vessels is 
not followed by increased secretion, that all the numer- 
ous experiments made by Ludwig and his pupils to dem- 
onstrate this point simply show that the quantity of the 
secretion (quantity of water secreted) depends, not on va- 
riations in pressure in the arteries of the kidney, but 
upon variations in the velocity of the blood-flow, an iIn- 
creased velocity of the blood being accompanied invari- 
ably by a greater secretion. The labors of Heidenhain, 
especially his well-known experiments on the secretion 
of indigo-carmine, have pretty well established the second 


-part of Bowman’s theory, that the secretion of the spe- 


cific elements of the urine takes place through the action 


377 


Secretion. 
Segmentation. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


of the cells of the uriniferous tubules; and there is a 
continually increasing amount of evidence, from various 
sources, Which goes to support the first part of the theory 
as modified by Heidenhain, viz., that the secretion of the 
water is also the result of the functional activity of the 
epithelial cells, most probably those of the glomeruli. 
There is no evidence of any histological changes in the 
appearance of the gland-cells during rest and activity of 
the kind described for the salivary glands, the pancreas, 
and the glands of the stomach. — 

Mammary Glands.—Without going into the details of 
the discussion as to the action of nerves in the produc- 
tion of the mammary secretion, it can be stated that we 
have abundant evidence that this secretion is, to some ex- 
tent, capable of being influenced by the nerves. But 
whether the effect of the nerves is a direct one upon the 
secreting cells, making them true secretory nerves, or 
whether it is an indirect effect through modifications of 
the blood-flow, as in the kidney, is an entirely unsettled 
question, and we have no positive evidence one way or 
the other. 

Well-defined histological changes of the glandular epi- 
thelium, in different stages of activity, have been de- 
scribed by Heidenhain. ‘The changes, however, seem to 
lie chiefly in the direction of variations in the size of the 
cells lining the alveoli, and in the amount of fat present 
in them ; so that, while we are justified in believing that 
the organic products of the secretion, at least, are the re- 
sult of metabolic changes in the gland-cells, there is 
nothing in the mechanism of the formation of these 
products, such as the production of zymogen granules, 
which would bring this process into close relation with 
the metabolic changes in other glands. The inorganic 
constituents of the mammary secretion, as already stated 
from the analysis of Bunge, differ very widely from 
those of the blood in percentage proportion, the differ- 
ence being most marked in the proportion of CaO, P2Os, 
and Naz.O. In the ash of dog’s blood there is 45.6 per 
cent. Na.O, 0.9 per cent. CaO, and 13.2 per cent. P.O; ; 
while in the ash of dog’s milk there is 6.1 per cent. 
Na.O, 34.4 per cent. CaO, and 37.5 per cent. P:O0;—a 
difference which would seem to indicate an active secre- 
tion on the part of the gland-cells. 

Sweat-glands.—It has been demonstrated beyond doubt 
that the sweat-glands are provided with proper secretory 
nerves. Stimulation of the sciatic or brachial plexus in 
the lower animals causes drops of sweat to form on the 
balls of the feet. It has been clearly shown that this is 
not owing to vaso-dilatation, or to any contraction of the 
tissue simply pressing out the sweat from the gland- 
ducts. The secretion may be obtained as long as twenty 
minutes after amputation of the leg, or after clamping 
the femoral artery, and Luchsinger has shown that the 
glands may be made to secrete continuously from nerve 
stimulation for many hours. The nerves of the glands 
may be stimulated either directly, or reflexly through the 
central nervous system, and it has been found that pilo- 
carpine and atropine act upon the secretion of these 
glands just as they do upon the salivary glands. 

The precise path of the secretory fibres for the balls of 
the feet, in cats and dogs, has not been determined. It 
seems most probable that—for the lower limbs—they 
leave the spinal cord through the rami communicantes of 
the three lower dorsal and four upper lumbar nerves, and 
reach their destination through the sympathetic sys- 
tem. Whether or not there is a general secretory centre 
for all the sweat-secreting nerves of the body, is unknown ; 
according to Luchsinger the evidence at hand indicates 
a number of spinal centres as the points of origin of the 
secretory nerve-fibres. According to Ott!® the cells show 
histological changes, after profuse secretion, similar to 
those found to occur in the salivary glands. From the 
study of specimens hardened in alcohol after stimulation 
for two hours and a half, he states that the cells are 
smaller, more granular, and stain more readily in carmine 
than those of the resting gland. The increase in the 
number of granules, as in the case of the salivary glands 
after hardening’in alcohol, is probably the result of the 
action of the alcohol, and it is possible that if these glands 


378 


were studied while fresh, the production of -secreting 
material in the form of granules which dissolve and dis- 
appear during secretion, as in the pancreas and salivary 
glands, might be demonstrated. A general survey of the 
action of the glands of the body, other than the salivary 
glands and pancreas, teaches us, in fact, that the general 
theory of secretion, as obtained from the study of these 
glands, which has been presented in some detail in this 
article, is not generally applicable. After a careful com- 
parison of the physiology of the different glands, as far 
as is known, one is forced to the conclusion of Heidenhain, 
that a general theory of secretion cannot be made at pres- 
ent, if indeed it is possible at all. As he points out, we can 
make a general theory of the physiology of muscular or 
contractile substance. Some of the common properties 
upon which sucha thing can be based may be mentioned 
briefly. When stimulated, a contraction or shortening 
always results, never a dilatation, as might seem theoreti- 
cally possible. The chemical changes which accompany 
the contraction are doubtless closely related. The meta- . 
bolic changes in voluntary and involuntary muscles, if not 
identical, must be very similar, and it is not going too 
far, perhaps, to say that the chemical changes in the sub- 
stance of the contracting amceba are of essentially the 
same character as those in the voluntary muscles. So, 
too, we have theories of the ultimate structure of con- 
tractile substance, such as that of Engelmann, and of the 
mechanism of its action in contraction, which are appli- 
cable to the contractile material in protoplasms wherever 
found. If we seek for any such common properties 
among the secreting tissues, the search will be in vain. 
As far as the secretions of our own bodies go, the two 
most general characteristics that have been established, 
are, that the secretion is the result of metabolic changes 
in the gland-cells, as shown by chemical and histological 
examination of the secretion and of the cells ; and further- 
more, that the action of the cells is under the influence of 
the nerves. But as we have already seen in some of the 
glands, we cannot prove the existence of secretory nerves, 
or perhaps the evidence is entirely against their existence ; 
while, on the other hand, the generous definition of secre- 
tion includes certain liquids, such as the serous transuda- 
tions or the lymph, the formation of which, according to 
general belief, is not dependent upon any functional 
activity of epithelial cells, although evidence has been 
given in this article to show that this general belief may 
be erroneous. Indeed, the very definition of secretion as 
given in the beginning of this article, the definition gen- 
erally accepted, is an artificial one, which does not clearly 
characterize or differentiate secretion from other physio- 
logical processes. 'Thesecond part of the definition, viz., 
that the secreted substance, after its separation from the 
blood, is poured out on a free epithelial surface, seems to 
be an arbitrary distinction. In the liver, for instance, 
we have an example of a gland which forms a true secre- 
tion, bile, according to the definition. The materials for 
the secretion are prepared in the liver-cells, and poured 
out on the free epithelial surface of the bile-ducts. But 
the liver-cells also prepare another substance, glycogen, 
which is finally poured out into the blood-vessels, and 
the processes in the two cases would seem to be essentially 
the same, though no one speaks of the latter as a secretion. 
If it be urged in this particular case that the glycogen is 
of direct nutritive value to the body-cells, food-matter, 
in fact, while the bile is only of secondary value in its 
action on the food-stuffs in the intestine, such a distinction 
cannot be accepted as general. For in some of the un- 
doubted secretions, such as saliva and pancreatic juice. 
we have albumins present which must finally be absorbed 
from the alimentary canal, and serve as nutritive material. 
The formation of the organic products of the secre- 
tions, whenever such products occur, is essentially simi- 
lar to the ordinary nutritive processes in all the cells. 
The food-material given by the lymph is assimilated into 
new protoplasm of the kind characteristic of the cell, and 
this then undergoes retrograde changes of a katabolic 
nature, which result finally in the production of the zy- 
mogen material. Perhaps an essential difference between 
the metabolism in gland-cells and the nutritive changes 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Secretion. 
Segmentation, 


in the cells of the tissues generally, may lie in the fact 
that, whereas in the cells generally the end products of 
katabolism are COs, H.O, and some simple nitrogenous 
residue, in the gland-cells the series of katabolic changes, 
at least in those glands which are distinguished by the 
formation of organic material in their secretions, ends in 
the formation of these more complex products ; the oxi- 
dations or dissociations are less complete. In those 
glands, like the kidney, in which the cells seem only to 
pick the secreted material out of the blood, we have no 
theory at all of the means by which this is accomplished, 
nor do we know whether or not the process is associated 
with any metabolic changes in the cells themselves. With 
regard to the active secretion of water and of salts by 
gland-cells, or epithelial cells of any kind, no satisfactory 
theory is yet offered. Heidenhain’s view of the action of 
the secretory fibres in the salivary glands, to account for 
this process, will not apply at all to the similar process 
of water formation in the kidney, nor to the formation of 
lymph by the endothelial cells of the capillaries, if this is 
demonstrated to be true. W. H. Howell. 


1 Hinige Betrachtungen und Versuche itiber die Filtration im ihrer Be- 
deutung fiir die Transudationsprocesse im Thierkérper. Stockholm, 
1886. 2 Miller, J.: Elements of Physiology. Translated by Baly. 

3 Heidenhain: Arch. f. d. ges. Physiol., 1872, v. 

4 Journal of Physiology, vol. ii., p. 261. 

5 Proceedings of Royal Society, 1886, vol. xl., No. 244: 

§ Archiv f. Anat. u. Physiol., 1886, S. 539. 

7 Centralblatt f. d. Med. Wiss., 1886, No. 27. 

8 Wiener Sitzungsber., Ixxx., 3. Abth., 1879. 

9 Journal of Physiology, 1878, vol. i. 

10 Tbid., vol. vi., p. 71. 11 Tudwig’s Arbeiten, 1869. 

12 Hermann's Handiuch der Physiologie, vol. v., p. 183. 

13 Untersuchungen «a. d. physiol. Inst. d. Univers. Heidelberg, vol. ii., 
p. 470. 14 Du Bois-Reymond’s Archiv, 1883, p. 405. 

15 Pfluger’s Archiv, 1876. vol. xii. 

16 Journal of Physiol., vol. ii., p. 283. 

18 Beitrage zur Anatomie und Physiologie. 

19 Studies from the Biological Laboratory, Johns Hopkins Univ., vol. i. 


SEDATIVES. There is a class of remedies called sed- 
atives, or depressants, the action of which is to quiet over- 
excitement of an organ or group of organs. Like all 
other divisions of therapeutic agents, that of the seda- 
tives cannot be strictly defined, as it embraces many rem- 
-edies which exert a sedative action only in certain cases 
and upon certain organs. Thus digitalis is a vascular 
sedative, while at the same time it is a powerful cardiac 
tonic. Again, a remedy may be either an excitant or a 
sedative, according to the dose, or to the length of time 
that has elapsed since its administration. Opium, for 
example, may be employed as either a stimulant or a 
sedative, according to the dose, or the condition or idio- 
syncrasy of the patient. 

The group of remedies which may be given to produce 
sedation is a very large one, and may be divided into sub- 
classes according to the mode and degree of action of the 
medicaments comprised therein, or to the special organ 
or group of organs acted upon. Thus we have nervous 
sedatives, emollients, analgesics, anesthetics, anaphro- 
disiacs, hypnotics, etc. We shall here consider briefly 
the nervous, respiratory, circulatory, gastric, urinary, 
and local sedatives. Fora further consideration of the 
remedies embraced in this class, the reader may consult 
the articles Anodynes, Antispasmodics, Anaphrodisiacs, 
Anesthetics, and Hypnotics, in the earlier volumes of 
this HANDBOOK. 

Nervous SEDATIVES.—These remedies are employed 
to quiet abnormal excitability of the brain and spinal 
cord, either directly by their action upon the nervous 
centres, or indirectly by stilling pain or removing any 
other cause of the exalted nervous state. Among the 
general sedatives may be mentioned rest, warm baths, 
alcohol in small doses, especially in the form of malt 
liquors, tobacco smoke in moderate quantity, for those 
who are habituated to its use, valerian, camphor, hyoscy- 
amus, the bromides, chloral, opium, and all the hyp- 
notics and anodynes. Among spinal sedatives gelsemi- 
um and calabar bean are familiar examples. 

RESPIRATORY SEDATIVES.—These are remedies which 
serve to relieve dyspnoea and quiet cough. These effects 
may be obtained by removing the cause, whether it be in 
ithe lungs, the liver, the heart, the larynx, or the ear, by 


17 Phil. Trans., pt. iii., 1881. 


obtunding the respiratory centre, or by reducing the irri- 
tability of the terminal nervous filaments. Belladonna, 
opium, oxalate of cerium, quebracho, and the expecto- 
rants generally, may be mentioned as examples of the 
respiratory sedatives. 

CIRCULATORY SEDATIVES are agents which reduce the 
frequency and the strength of the cardiac action, and di- 
minish the volume of blood in the vessels. Some reme- 
dies, like digitalis, increase the strength of the cardiac 
pulsations, while they reduce the tlow of blood in tlre 
vessels. These are called vascular, as distinguished from 
cardiac, sedatives. The principal circulatory sedatives 
are cold, veratrum viride, aconite, ergot, digitalis, and 
opium. 

GASTRIC SEDATIVES are employed to relieve pain and 
vomiting. They act by reducing local irritation in the 
stomach itself, or by a direct effect upon the vomiting 
centre. The most important are cold, opium, bismuth, 
oxalate of cerium, chloroform, creasote, atropine, hydro- 
cyanic acid, and ipecac, calomel, or arsenious acid in 
minute doses. 

URINARY SEDATIVES.—These are agents which render 
the urine bland and unirritating, or which lessen pain 
and irritability of the bladder. Alkalies, water in large 
amounts, copaiba, thymol, belladonna, opium, and warm 
sitz-baths are some of the remedies of this class. 

Loca SEDATIVES.—In this class are all those reme- 
dies which act directly upon the terminal nerve-filaments 
in any locality, diminishing their sensibility. Many of 
the gastric and urinary sedatives, already referred to, are 
examples of this class of agents ; but the term, in its more 
commonly understood application, refers to remedies act- 
ing upon the skin and accessible mucous membranes. 
These agents are employed to relieve pain and itching 
of the parts to which they are applied. Aconite, bella- 
donna, opium, chloral-camphor, carbolic acid, hydro- 
cyanic acid, chloroform, lead-water, cocaine, and cold, 
in the form of ice or evaporating lotions, are familiar 
examples of this class of remedies. fil) 84 5 


SEGMENTATION OF THE BODY. As stated in the 
article Foetus, vol. iii., p. 177, the segmentation of the 
body depends primarily upon the divisions of the mus- 
cles to which the segmental divisions and arrangements 
of the other parts are secondary. The evidence we at 
present possess in regard to the evolution of vertebrates 
indicates that they were derived from forms allied to the 
segmented worms (Annelida). These animals are, in 
fact, the only ones besides the vertebrates whose bodies 
have a segmentation. In the annelides all the segments 
are decidedly similar, and though we see, here ard there, 
a group of them modified, all in a like manner, as for 
instance in the clitellus of the earth-worm, yet we do not 
see anything strictly comparable to the division of the 
segments in vertebrates into two main groups, one com- 
prising the segments of the head, the other the segments 
of therump. Consequently, we must say that the pos- 
session of a head developed by the condensation of a 
number of segments is a feature exclusively pertaining to 
vertebrates. This involves the corollary that no inverte- 
brate possesses a true head, if we take the definition of 
that term from vertebrates. The homologous parts, or, 
to be more precise, the segments homologous with those 
of the vertebrate head were, of course, present in the in- 
vertebrate ancestral form. 

These considerations render it evident that to elucidate 
the segmentation of the higher types we have to deter- 
mine, first, the primitive character of the segments ; second, 
the number and modifications of the segments in the 
head ; and third, the number and modifications of those 
in the rump. It is impossible to enter here upon a full 
discussion of this abstruse problem. We can only state 
briefly the essential results at present known. 

First. As to the primitive arrangement. We must 
assume that in the ancestral type of vertebrates the body 
cavity was continuous ventrally throughout both the re- 
gion of the head and of the rump. The dorsal portion 
of the body cavity was divided into the muscular seg- 
ments or myotomes. » Each pair of myotomes, of course, 


O79 


Segmentation. 
Segmentation. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


represented a single segment. For each segment there 
were four nerves, two on each side; of these two, one 
sprang from the ventral side of the nervous system and 
passed to innervate the myotome of that side ; this nerve 
persists, in man, in the series of spinal nerves as the an- 
terior motor root ; the other nerve of the same side sprang 
from the dorsal part of the central nervous system, passed 
outside of the myotome, and innervated both the walls of 
the body cavity and also an epidermal sense-organ upon 
the surface of the segment. This nerve is represented 
in man by the sensory root of a spinal nerve. 

The evolution of a heart upon the ventral side of the 
body may be regarded as having been, presumably, the 
first definite step toward the evolution of the head, be- 
cause the heart lay a little distance behind the mouth, 
so that there were a few segments in front of the heart 
and an indefinite series behind it. But the heart was so 
constructed that it pumped the blood forward ; it must 
have been advantageous for the blood to be purified be- 
fore it reached the tissues to which it was forwarded by 
the heart ; certainly the purifying apparatus eas actually 
developed in the segments in front of the heart, for they 
only were gill-bearing. These respiratory needs were 
satisfied by the development of gill-clefts, which permitted 
a freer circulation of water and an increased exposure 
of the superficial blood-vessels of the branchiz, and so 
effected a more perfect aeration of the blood. The divis- 
ion of the body into a gill-bearing and a not gill-bearing 
region may be designated as the second step in the evolu- 
tion of the head. In fact, the branchiate segments are the 
head segments. The presence of gill-clefts has led to 
many modifications of the primitive segmental arrange- 
ments, and these complications have been greatly in- 
creased by the extreme condensation of the head seg- 
ments and also by the displacement of certain parts, as 
well as by the disappearance of others, and, finally, 
through the annexation by the head of three or four seg- 
ments properly belonging to the rump. 

Second. Number and characteristics of the cephalic 
segments. The determination of the number of seg- 
ments in the vertebrate head has long occupied the atten- 
tion of naturalists. In the beginning of this century the 
vertebree were usually taken as the means of counting 
segments, for at that time the fact that segmentation de- 
pends on the myotomes, and that therefore the vertebre 
are parts of the inter-segmental structures, had not been 
ascertained. Hence, in this period, we find discussion 
turning upon the number of supposed vertebre in the 
head. The earliest suggestion of a vertebral theory of the 
skull, known to me, is that of Burdin, independently made 
about the same time by Heilmeyer. These authors com- 
pared the skull to a single complex vertebra. The first 
to announce the modern theory of there being several 
segments in the head, was Oken, who conceived that 
there were four cranial vertebre. Goethe adopted this 
hypothesis with some infelicitous modifications of his 
own. He counted six vertebree, of which three belonged 
to the facial apparatus. As to the number of vertebra, 
there is a very extensive literature, which possesses an 
interest purely historical. Let it suffice, therefore, to 
state aphoristically that three vertebrae were advocated 
by Spix, Meckel, Burdach, and Carus; four by Oken, 
Bojanus, and Owen; six by McClise; and seven by 
Geoffroy. 

The discovery of the real segmentation was started by 
Gegenbaur, continued by Balfour, and elaborated by 
Marshall, Spencer, Dohrn, van Wijhe, Froriep, Beard, 
and others. Gegenbaur recognized the segmental ar- 
rangement of the cranial nerves, and endeavored to as- 
certain their primitive number and arrangement. This 
was a great step in the right direction. Subsequent 
writers have studied in more detail the development of 
the cranial nerves, giving especial attention to their re- 
lation to the primitive segments or myotomes, which 
embryology shows to be temporarily present in the head. 
These researches have led to the conclusion that the 
two nerves, on each side of each segment, have remained 
distinct, whereas in the rump they are transformed into 
roots which unite into one nerve. he dorsal or sensory 


380 


nerve in the head runs to a sensory organ in the integu- 
ment, which organ is situated just above the opening of 
the branchial cleft of the same segment. This nerve 
also possessed three branches, one running above the 
cleft, one in front of it, and one behind it. The ventral 
or motor nerve ran to the myotome of its segment. The 
number of myotomes, in at least all the higher verte- 
brates, to be found in the head of the embryo is twelve, 
and there is some reason for thinking that there may 
once have been a thirteenth in front of those which we 
can still detect. Now, the majority of these myotomes 
disappear very early, and the nerves which belong to 
them have disappeared also. In fact, no trace of the 
nerves of several of the myotomes has been observed. 
We see that the majority of the branchial sense-organs 
are also only temporary embryonic structures. But the 
sensory nerves, as they have other branches than those 
to the branchial sense-organs, are left with functions to 
perform, and accordingly are preserved in the adult. It 
is a misnomer to call the ventral cephalic nerves sen- 
sory only, because they carry motor fibres likewise, 
which supply the muscles developed in the gill-arches 
independently of the myotomes. <A brief explanation is 
requisite in regard to the three posterior segments of the 
head, and in regard to the seventh, eighth, ninth, and 
tenth segments. These two sets of myotomes have each 
a single nerve only. The seventh to tenth segments cor- 
respond in our enumeration to the sixth to ninth myo- 
tomes, one myotome being supposed to have been lost 
in front. The nerve of these segments is shown by its 
development in the embryo to be the product of the 
fusion of four nerves; it is known to anatomists as the 
vagus. The nerve of the eleventh to thirteenth segments 
(tenth to twelfth myotomes) is the hypoglossus, which is 
produced by the fusion of three distinct nerves, each of 
which has two roots, and possesses in the embryo all the 
essential features of a true spinal nerve. It follows that 
the three corresponding segments are not truly cephalic, 
but have been annexed from the region of the rump 
by the head, and added to the occipital region. Since 
the differentiation of the head commenced with the evo- 
lution of branchial clefts, it has resulted in the evolution 
of the head preceding that of the vertebre ; hence there 
is no trace whatever of vertebre in the head, except in 
the hypoglossal region. 

The table on the next page presents, in a compact form, 
all the essential facts yet gathered in regard to. the seg- 
mental disposition of the organs of the head. 

The characteristics of the head segments are, first, the 
development of gill-clefts; second, the fact that the 
dorsal and ventral nerves do not become roots, but re- 
main distinct; third, the absence of vertebre. There 
are many other peculiarities which might be signalized, 
but the three named seem to me the most essential. 
There are very numerous secondary modifications, which 
are in large part indicated in the following table. 

Third. Rump segments. The number of segments in 
the rump is very variable. In man there are thirty-seven 
or thirty-eight, of which four or five constitute the tem- 
porary tail, and disappear during the second month of 
foetal life. ‘The characteristics of the ramp may be said 
to be the conversion of the nerves into roots; the devel- 
opment of true vertebre ; the great development of my- 
otomes, which produce the skeleton muscles ; and, finally, 
the segmental organs or excretory tubules, which consti- 
tute the primitive kidney or so-called Wolffian body, and 
of which there is, at: first, at least one pair in each seg- 
ment. It must be added that not every rump segment 
appears to necessarily have segmental organs. 


LITERATURE. 


Balfour : Development of Elasmobranchs. 

Beard, John: The System of Branchial Sense-organs and their Associ- 
ated Ganglia in Icthyopsida. A Contribution to the Ancestral History 
of Vertebrates. Quart. Journ. Microsc. Sci., xxvi., 95-156. Pls. viii., 


ix. 

Blate, Julius: Untersuchungen iiber den Bau der Nasenschleimhaut 
bei Fischen und Amphibien, namentlich ber Endknospen als Endap- 
parate des Nervus olfactorius. His’ Arch., 1884, 231-309. Tafn. xii.- 
xiv. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Segmentation. 
Segmentation. 


Dohrn, Anton: A Series of Papers on the Evolution of Vertebrates in the 
Mittheil. ZoGl, Stat., Naples, ; 

Froriep, A.: Ueber Anlagen von Sinnesorganen am Facialis, Glosso- 
pharyngeus und Vagus, und iiber die genetische Stellung des Vagus 
zum Hypoglossus und uber die Herkunft der Zungenmusculatur, Arch. 
Anat. Phys., Anat, Abth., 1885, 1-55, 2 Taf. ; 

Froriep, A.: Zur Entwickelungsgeschichte der Wirbelsiule, insbesondere 
des Atlas und Epistropheus und der Occipitalregion. II. Beobachtung 
an Séugethierembryonen. His’ Archiv fur 1886, 69-150, Taf. 1-3. 

Gegenbaur, C.: Das Kopfskelett der Selachier, 4to. Leipzig, 1872. 

McClise: Art. Skeleton, in Todd’s Cyclopedia. 


Marshall, A. Milnes: The Development of the Cranial Nerves in the 
Chick, Quart. Journ. Micr. Sci., 1878, xviii., Pls. ii., iii. 

Marshall, A. Milnes: The Morphology of the Vertebrate Olfactory Organ, 
Quart. Journ. Micr. Sci., 1879, xix., 300-340, Pls. xiii., xiv. 

Marshall, A. Milnes: On the Head Cavities and Associated Nerves in the 
Elasmobranchs, Quart. Journ. Micros. Sci., xxi. 

Spencer and Marshall: Observations on the Cranial Nerves of Scyllium, 
Quart. Journ. Micros. Sci., xxi. 

Wijhe, J. W. van: Ueber die Mesodermsegmente und die Entwickelung 
der Nerven des Selachierkopfes, Verh. k. Akad. Wetens: Amsterdam, 
xxii., 1883, 50, Taf. 1-4. 


TABULAR ANALYSIS OF THE SEGMENTATION OF THE VERTEBRATE HEAD. 


1 


ee beth Cleft. Sense-organ. Ganglion. Dorsal nerve. See Ente Ventral nerve. Muscles, 
ra} ENON Ob are sak rac ee: Olfactory, #00 ee Olfactoryy ye see Olfactonyy cee 0. Nonei: Sorel eo... INONG); ).. >) Sores None. 
Ta 1 | None (or Hyphy- | Branchial* ...... IBILIRL Yee ache) Radix longa of cil- | Ophthalmicus | Motor oculi ...... Recti super. in- 
sis?) jary gang]. profundus, ter, and inf. and 
obliq.inf. of eye. 
1B Te iS Mont big esis. Branchial * ...... Gasserian........ Trigeminus..... Ophthalmicus su- | Trochlear........ ‘Muscle of mouth. 
i perficialis sine obliq. sup. of eye, 
port. facialis, 
EVE Da TELVOIGE tata hdaee 5 - Branchial *—. 7.7. HaClaleysteyacs west JREOONDE hae he ae Part.facialofoph- | Abducens........ Rectus. externus. 
thal. sup. and 
ramus buccalis. 
Ve ENON Guay tee y ieer ieke AQIGibOry 45-042 0% ATIGHEOLY: sie ns cle PATICIUONY, 4.9 do cre: INOMO% eee ect INONG Aye once . | None, 
Viet vo First branchial...| Branchial* ...... Glosso-pharyn- | Glosso-pharyn- | Supra-temporal...| None ........ None. 
geal. geus. | 
Val Ucreee Onlclatec spam dry Omen kere oie aan eG Ae GL Mn SRamO MRE celle lt ee el aye Supra-temporal ../ None ............ None. 
‘ iG i Second to fifth | Branchial*...... Vagus i. to iv....| Vagus, to iv ....| (Of vag. ii. to iv.. | None ........... | None, 
xX 9° branchial. lateral nerve? ?) 
; a 
RGR kt ) | ° 
RET alec dep CIN OMG de yeni ne, UN ONG ea aati pyres ADOERINOF a nies. PA DOLLLVeE1OOtsias alt NODC). ..5 jocanie Hypoglossus ..... None. 
MITL. +3 19'} 
* Aborts. 


+ Dohrn and Beard regard the facial nerve as double, and think that one myotome and one cleft are lost between the mouth and hyoid cleft. 


SEGMENTATION OF THE OVUM. There follows 
upon the impregnation of the ovum aremarkable process 
known as the segmentation, This term is used to desig- 
nate the series of divisions of the impregnated ovum into 
a number of cells, of which all the cells of the future ani- 
mal are the direct descendants. Common usage applies 
the term only up to the time of development, when the two 

primitive germ-layers are clearly differentiated and the first 
distinct organs are beginning to appear. The word was 
introduced before the masses into which the ovum di- 
vides were known to be cells. The cleavage of the ovum 
was described by Prevost and Dumas, and again by 
Rusconi in 1836.27 Since then it has been investigated 
very frequently. The cell doctrine dates from 1839. 

As stated in the article on Impregnation (vol. iv., p. 5), 
the nucleus of the impregnated ovum ts formed by the union 
of the male and female pronuclet. Van Beneden had af- 
firmed that there was no real union in the eggs of Ascaris, 
but Carnoy '? has shown that Van Beneden’s observations 
were incomplete, and Zacharias*® states that they were 
so very defective as to be fundamentally erroneous, and 
that in reality the eggs of Ascaris offer another proof of 
the actual union of the pronuclei. It seems to me safe 
to accept the generalization just made as to the origin of 
the first or segmentation nucleus. 

The position of this nucleus is determined, first, by the 
form of the egg; second, by the distribution of the for- 
mative (ectodermal) and nutritive (entodermal) yolk. In 
round eggs, with very little yolk—alecithal ova—such as 
those of Echinoderms, the nucleus lies nearly in the cen- 
tre. It is commonly stated to lie exactly in the centre, but 
I must question the accuracy of such statements. When 
there is an evident differentiation of nutritive and forma- 
tive yolk—telolecithal ova—the nucleus is always eccen- 
tric and its eccentricity increases with the amount of 
yolk, for it always tends to approach the so-called ‘‘ ani- 
mal” pole, where the protoplasmatic or formative yolk 
is accumulated. In oval eggs with little yolk the nucleus 
lies in the middle of the long axis, as in Nematod eggs, 
but whenever there is differentiation of an animal pole 
the nucleus tends to approach it. In brief, we may say 
that the segmentation nucleus takes the most central posi- 
tion possible with regard to the protoplasm of the ovum. 
The vitelline granules are not regarded as protoplasm, 
hence, when they accumulate they may increase the bulk 


Charles Sedgwick Minot, 


on one side of the nucleus without otherwise disturbing 
the radial distribution of the protoplasm around it. 

After the segmentation nucleus is formed there occurs 
a pause, which lasts, according to observations on several 
invertebrates, from half to three-quarters of an hour. 
During this period the yolk gradually expands again 
(having contracted during impregnation), and also ac- 
quires a radiating appearanee starting from the nucleus 
as acentre. The radiation is due to the arrangement of 
the protoplasmatic network, and the conforming distri- 
bution of the yolk granules. The physiological mechan- 
ism is unknown which causes this radiation and the other 
radiations of protoplasm which appear during cell di- 
visions. Morphologists often speak loosely of nuclear 
attraction as the cause, but it need hardly be pointed out 
that this notion is, physiologically speaking, vague and 
crude. The monocentric radiation soon disappears and 
is replaced by a dicentric radiation, which marks the end 
of the period of repose, and the commencement of the 
first division of the ovum. For figures see Hertwig’s 
memoirs. !*® 19 

The external appearances of segmentation in the living 
ova vary, of course, especially according to the amount 
and distribution of the yolk material. The appearances 
in holoblastic ova with very little yolk are well exem- 
plified by Limax campestris. Mark’s description * is, 
nearly in his own words, as follows: In Limax, after im- 
pregnation, the region of the segmentation nucleus re- 
mains more clear, but all that can be distinguished is a 
more or less circular, ill-defined area, which is less opaque 
than the surrounding portions of the vitellus. After a 
few moments this area grows less distinct. It finally ap- 
pears elongated. Very soon this lengthening results in 
two light spots, which are inconspicuous at first, but 
which increase in size and distinctness, and presently 
become oval. If the outline of the egg be carefully 
watched, it is now seen to lengthen gradually in a direc- 
tion corresponding to the line which joins the spots. As 
the latter enlarge, the lengthening of the ovum increases, 
though not very conspicuously. Soon a slight flattening 
of the surface appears just under the polar globules ; the 
flattening changes to a depression (Fig. 3485), which 
grows deeper and becomes angular. A little later the 
furrow is seen to have extended around on the sides of 
the yolk as a shallow depression, reaching something 


381 


Sezmentation. 
Segmentation. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


more than half-way toward the vegetable or inferior pole, 
and in four or five minutes after its appearance the de- 
pression extends completely around the yolk. This an- 
nular constriction now deepens on all sides, but most 
: ae rapidly at the animal pole; as 
it deepens it becomes narrower, 
almost a fissure. By the further 
deepening of the constriction on 
all sides, there are formed two 
equal masses, connected by only 
a slender thread of protoplasm, 
situated nearer the vegetative 
than the animal pole, and which 
soon becomes more attenuated, 
and finally parts. The first 
; cleavage is now accomplished. 
Fia. 3435. — Ovum of Limax Both segments undergo changes 
Campestris during the First 
Magnified 200 ai- Of form ; they approach and flat- 


Cleavage. : 
ameters. The envelopes are ten out against each other, and 
Sata in, (After E. L. after a certain time themselves 


divide. 

The division of al? ova, so far as at present known, is 
indirect (karyokinesis, mitosis), there being nuclear spin- 
dles, amphiasters, etc. The dicentric radiation just men- 
tioned marks the appearance of the first amphiaster. 

The plane of the first division determines those of the 
subsequent divisions, and also of all the axes of the em- 
bryo ;* it is itself determined by the position of the long 
axis of the first amphiaster or nuclear spindle, to which 
it isat right angles. It, therefore, is a matter of great in- 
terest to ascertain what factors determine the position of 
the first spindle, or, in other words, the axis of elonga- 
tion of the segmentation nucleus. So far as at present 
known, there are two factors: 1, Relation to the axis of 
the ovum ; 2, position of the path taken by male pronu- 
cleus to approach the female pronucleus. The axis of 
the ovum is fixed before impregnation ; it passes through 
the centre of the animal, and that of the vegetable pole. 
Usually the nuclear spindle which leads to the formation 
of the polar globule has its long axis coincident with that 
of the ovum, hence the point of exit of the polar glob- 
ule marks one end of the ovic axis. The first amphias- 
ter or spindle ts always at right angles to the ovie axis, 
This, however, leaves the meridian plane undetermined. 
Roux,*4 from a series of interesting experiments on 
frogs’ ova, concludes that the plane is fixed by the path 
of the spermatozoon. So far as I know, this idea was 
first suggested by Selenka, in 1878, in his paper on ‘‘The 
Development of Toxopneustes Variegatus ;” compare 
also Mark, JU. ¢., p. 500. In the frog’s egg the path of 
the male pronucleus is marked by a line of pigment, as 
was first described by Van Bambecke,”* and has been well 
figured by O. Hertwig.’?? The pigment renders it easy to 
ascertain the position of the male road, even after the 
first cleavage of the ovum. This Roux has done in sec- 
tioned ova, and from his experiments and observations 
reaches this result: The long axis of the first segmentation 
spindle lies in a plane, which passes through the axis of the 
ovum and the path of the male pronucleus. If Roux’s con- 
clusion is confirmed, it will become of fundamental im- 
portance. Yet there must be other factors which can 
at least replace the male pronucleus in this special réle, 
since the development of parthenogenetic ova, in which 
there is no male pronucleus at all, is equally determinate. 
It is probable that the distribution of the protoplasm is 
the real cause determining the position of the nucleus ; 
thus in oval eggs the spindle lies in the direction of the 
long axis ; it is quite probable that if the male pronucleus 
has the effect ascribed to it by Roux, it produces it in- 
directly by altering the distribution of the protoplasm 
within the ovum; that such alteration takes place is in- 
dicated by the occurrence of the male aster. 

After the spindle is formed it divides, and the daughter 


* In certain cases, notably in birds, as described below, the segmenta- 
tion is irregular ; and it is therefore not known yet whether the scheme 
of arrangement of the cleavage planes here given can be applied to all 
ova or not. We may say, however, that the scheme is the primitive one, 
from which any modifications arose phylogenetically, The best discus- 
sion of the subject is by Whitman.! 


382 


nuclei form the centres of two segmentation spheres or 
cells. Each of these cells again divides in the meridional 
plane at right angles to the first. The third cleavage is 
at right angles to both the first. If an egg is placed with 
its axis vertical, the planes of the first and second 
divisions both will be vertical, but that of the third will 
be horizontal. ; 

Segmentation occurs with many variations, according 
to the manifold modifications of ova, and these varieties 
we must now briefly consider. 

It has long been customary to describe the various 
modifications of segmentation as belonging to three 
types: 1, regular or equal; 2, unequal; 8, partial. It 
has become traditional to state that the first type is found 
in the Echinoderms, etc., and is characterized by the 
regular and uniform division of the cells (segments), so 
that there are first two, then four, eight, sixteen, thirty- 
two, sixty-four, and so forth, cells. But this statement 
is fundamentally erroneous. The frog’s ovum is taken as 
the example of the second type, and the bird’s ovum of 
the third. This classification is most unfortunate, for it 
leads attention off from the essential feature of the process 
of segmentation, as first pointed out by Minot in 1877. 
Minot” established the generalization that in all animals 
the yolk undergoes a total segmentation, during which the 
cells of the ectoderm divide faster and become smaller than 
the cells of the entoderm 
(Fig. 8436). There are, 
however, a small, and 
it seems diminishing, 
number of cases where 
the process of segmen- 
tation and the forma- 
tion of the germ-layers 
is imperfectly under- 
stood, and which can- 
not yet be shown to 
conform to this gener- 
alization. ‘‘ All the 
known variations in the 
process of segmentation 
depend merely upon: 

ee : : 1, The degree of differ- 
Fra. 8436.—Ovum of Amphioxus Lanceo- ence in size between the 


latus during Segmentation ; stage with two sets of cells: 2. the 
88 celis. Magnified 280 diameters. (After time Gv heneihe ; alfaie 


Hatschek.) One pole is occupied by 
ence appears; 38, the 


large, the other by smaller, cells. 

mode of development, 
whether polar or by delamination,* either of which may 
or may not be accompanied by axial infolding. In Gas- 
teropods, Planarians, Calcispongize, Gephyrea, Annelida, 
fish, birds, and Arthropods the difference is great and ap- 
pears early. In Echinoderms, most Coelenterates, some 
sponges, in Nematods, Amphibians, etc., it is less marked 
and appears later” (Minot, J. ¢.). 

In most cases the entodermic cells are very decidedly 
larger and less numerous than those of the ectoderm. 
This distinction is obviously necessary on account of the 
mutual relations of the two primitive layers. The ecto- 
derm has to grow around the entoderm, which it can do 
only by acquiring a greater superficial extension—this 
the ectoderm accomplishes by dividing very quickly at 
first into small cells. After the entoderm is fully en- 
veloped it may then continue to grow until its superficies 
is much greater than that of the outer layer, within 
which, however, it still finds room by forming numerous 
folds; thus is gradually reached the condition in the 
higher adult animals, where the intestine sometimes has 
an enormous surface, but is nevertheless contained in 
body-walls covered by ectoderm presenting much less 
surface. It is, therefore, only during the early stages of 
segmentation that we find the entoderm expanding more 
slowly than the ectoderm. 

The degree of difference in size between the ectoderm and 


* There is notasingle satisfactory description of the process of delami- 
nation known to me, and one cannot avoid hesitating to accept it as an 
actual occurrence. It is certainly at most a very rare, and probably 
secondary, modification of segmentation. It does not occur among verte- 
brates. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Segmentation. 
Segmentation. 


entoderm cells depends upon the amount of yolk present. 
The yolk-granules are s¢twated, not quite exclusively but 
almost so, in those parts of the ovum out of which the 
entodermal cells are formed. Hence, when there is a 
great deal of yolk, the Anlage of the entoderm in the 
ovum becomes bulky, and the entoder- 
mal cells correspondingly big, as may 
be seen very plainly in amphibian ova. 
On the other hand, when the amount 
of yolk is very small, as in the eggs of 
echinoderms, the difference in size of 
the two kinds of cells is very slight at 
the start of segmentation ; but, as the 
cleavage process continues, the ecto- 
dermal cells, in consequence of their 
more rapid divisions, become marked- 
ly smaller than their entodermal fel- 
lows. Thesame may be said in regard 
to mammalian ova, the segmentation 
of which is described more fully be- 
low. Besides its effect upon the vol- 

(After Bobretzky.) Ume of the entoderm, the yolk matter 

Nuclei are seen scat- seems to actually retard the develop- 

tered through the ment of the inner germ-layer, by im- 

ee peding the division of cells. This ef- 
fect was pointed out many years ago, and is one of the 
familiar principles of embryology.* This is well exem- 
plified in the bird’s egg, in which the nuclei divide in the 
entoderm, but only gradually gather distinct cell-bodies 
about themselves, and in consequence the ventral side of 
the primitive entodermic cay- 
ity is bounded by a mass of 
protoplasm with scattered nu- 
clei and numerous yolk-gran-, 
ules; and as these last are 
transformed into protoplasm, 
the cells are completed as 
separate individualities. The 
proliferation of the nuclei 
without part passu separation 
of the cells occurs in similar 
manner in elasmobranchs, and 
comparable phenomena occur 
in many invertebrates, notably 
among the arthropods (Fig. 
3437), with the so-called su- 
perficial segmentation. 

The terms holoblastic and 
meroblastic are applied to ova 
according to their manner of 
segmentation. The first is 
employed for those ova in 
which there is either very little 
or only a moderate amount of 
yolk, so that the whole of the 
ovum splits up into distinct 
masses (cells), which enter 
into the composition’ of the 
embryo. The second desig- 
nates ova with a very large 
amount of yolk, so that while 
the protoplasm from which 
the ectoderm arises divides 
rapidly into distinct cells, the 
entodermal portion merely de- 
velops nuclei at first, with the 
result that while one portion 
of the egg is ‘‘ segmenting,” 
another portion (the entoder- 
mal) remains unsegmented, so 
far as the external appearances 
are concerned. Eggs, then, 
with much yolk undergo the so-called partial segmenta- 
tion ; hence the adjective meroblastic. 

The result of segmentation is to produce two kinds of 
cells, ectodermal and entodermal ; the latter are the larger 


Fia. 3487.—Section of 
the Egg of a Moth. 


* It is not a little curious that two embryologists have recently discussed 
this principle as if it were quite a new discovery of their own. 


and contain most of the yolk-granules ; the entodermal 
cells may be represented for a certain period, partly or 
wholly, by a mass of yolk with scattered nuclei (Fig. 
3437). The cells are arranged so as to form, each kind, a 
layer of epithelium. The two epithelia are joined at their 
edges ; the line of junction is the ectental line. (See Fetus.) 
Between the two layers, ectoderm and entoderm, is a 
space known as the segmentation cavity, and which varies 
in farm and size according to the species of ovum. 
Among radiates it approaches a spherical shape, and the 
two epithelia make a hollow sphere ; this arrangement is 
known as the Siastula form, and by some writers has been 
considered the primitive type of structure resulting from 
segmentation. In other cases the segmentation cavity is 
a mere slit between the entoderm distended with yolk 
and the ectoderm. (See the figures in the article on the 
Blastoderm.) Ultimately, the segmentation cavity is in- 
vaded by cells, which enter into the composition of the 
mesoderm (see Germ-layers, Gastrula, and Foetus, develop- 
ment of), and by which the cavity is ultimately filled up. 
The body cavity arises subsequently in the mesoderm. 
(See Ceelom.) The segmentation cavity is very much re- 
duced in amniote ova, and in birds is obliterated so early 
by the precocious thickening of the ectoderm that it 
scarcely can be said to appear. 

The best-known example of a meroblastic ovum is the 
hen’s egg. Its segmentation commences while it is pass- 
ing through the lower part of the oviduct, and shortly 
before the shell has begun to be formed. 

Viewed from above, a furrow is seen to make its appear- 


Fia. 3438.—Four Stages of the Segmentation-of the Hen’s Ovum. Only the germinal disk, seen from above, 
and part of the surrounding yellow yolk are represented. 


(After Coste.) 


ance, running across the germinal disk, though not for 
its whole breadth, and dividing it into two halves ; this 
furrow is developed in accompaniment with the division 
of the first segmentation nucleus. The primary furrow 
is succeeded by a second, nearly at right angles to itself. 
The surface thus becomes divided into four segments or 
quadrants (Fig. 3488, A), which are not at first separated 


383 


Segmentation. 
Seminal Incont’nece, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


from the underlying substance. The number of radiating 
furrows, of which there are now four, increases to from 
seven to nine, when there occur a series of cross-furrows 
by which the central portion of each segment is cut off 
from the peripheral portion, giving rise to the appearance 
of a number of small central segments surrounded by more 
external elongated segments. Division of the segments 
now proceeds rapidly by means of furrows running in 
various directions. 
Not only are the small 
central segments di- 
vided into still smaller 
ones (Fig. 8438, D), 
but also their number 
is increased by the 
addition of more seg- 
ments cut off from 
the peripheral ones. 
Sections of the hard- 
ened blastoderm show 
that segmentation is 
not confined to the 
surface, but extends 
through the mass, 
there being also hori- 
zontal furrows, 7.¢., 
furrows parallel tothe 
surface of the ovum. According to Duval,!® whose ac- 
count of the segmenting hen’s ovum is, on the whole, the 
most satisfactory, when quite a small number of cells 
are separated off there is a small space between them and 
the yolk, as shown in his Figs. 2, 8, 4,5, and 6 of PI. L. ; 
this space he calls the segmentation cavity ; but this can 
hardly be, as the cells formed below it make part of the 
ectoderm (primitive blastoderm) ; the cells referred to are 
those marked 7m in Fig. 8 of the same plate; the space 
there lettered cg is the entodermal cavity. We can now 
speak of the primitive blastoderm (compare the article 
Blastoderm, vol. i., p. 528). The several-layered mass of 
cells represents the ectoderm ; it has only traces of the 
segmentation cavity. The yolk represents the entoderm. 
At this stage the ectoderm is not completely separated 


Fre. 3439.—Ovum of a Rabbit of Twenty- 
four Hours; the first cleavage has been 
completed. (After Coste.) 


Fie. 3440.—Ovum of Vespertilio Murina, with Four Cleavage Spheres, 
(After Van Beneden and Julin.) 


off, but still receives peripheral accretions from what 
may be called the segmenting zone around the blastoderm. 
For the further history see Blastoderm, and the first sec- 
tion of the article Foetus, where the differentiation of the 
cellular entoderm is described. 

The ovum of the placental mammalia is called holo- 
blastic, because it contains very little yolk and under- 
goes ‘‘ total” segmentation. Its segmentation was first 
clearly recognized by Bischoff, though it had been pre- 
viously seen and misinterpreted by Barry.? Very beau- 
tiful figures are given by Coste.!4 A number of more re- 
cent writers have dealt with the subject, among whom 
Hensen deserves especial mention. Reference may 


384 


—— 


also be made to Heape’s observations on the mole ;!* to 
Kupffer’s on rodents ; to Selenka’s on rodents and the opos- 
sum in his ‘‘ Embryologische Studien ;” to Van Beneden 
and Julin’s on bats,® and to Van Beneden’s on the rab- 
bit ;** but of these last the entire accuracy may be 
doubted. The ovum is discharged from the ovary sur- 
rounded by the so-called corona radiata, which is com- 
posed of cells of the discus proligerus. It passes quite 
rapidly through the first half or two-thirds of the ovi- 
duct, and during this period is impregnated and loses 
the corona radiata. In the lower half, or third, of the 
oviduct segmentation begins, and may be wholly or 
only partially completed when the ovum passes into the 
uterus. The ovum spends about seventy hours in the 
oviduct in the rabbit, and about eight days in the dog. 
The first cleavage plane passes through the axis of ex- 
trusion of the polar globules (Fig. 3439); the two seg- 
mentation spheres flatten out against one another. The 
second cleavage plane is probably also meridional, as is 
indicated by Selenka’s observations on the opossum ; 
and there are four equivalent cells as the result. Van 
Beneden asserts, however, that the cells are unlike, two 
being smaller than the others (Fig. 3440). These smaller 
cells he regards as the representatives of the ectoderm. 
The successive cleavages have never been followed ac- 
curately, but after a time there appear an outer layer of 


Fie. 8441.—Rabbit’s Ovum in an Advanced Stage of Segmentation. Z, 
zona pellucida; Hc., ectoderm of authors ; im., inner mass of cells, 


cells (Fig. 3441), He., forming an epithelium under the 
zona pellucida, Z, and an inner mass of cells, 7m., of 
darker appearance, which at first completely fill the 
space within the epithelium. During all these early 
stages the cells (segmentation spheres) are all naked, 
7.e., Without any membrane; the nuclei, when not in 
karyokinetic stages, are large, clear, and vesicular; the 
yolk granules are small, highly refractile, and more or 
less nearly spherical; they show a marked tendency to 
lie in the egg, half-way between the nucleus and zona, 
or, when the cells are-large, around the nucleus, but a 
little distance from it. The outer layer of cells is not 
complete, but interrupted at one point, where the inner 
mass (Fig. 3441, im.) comes through to the surface. By 
the continued division of the cells of the subzonal layer, 
that membrane forms a larger vesicle, and there arises a 
space between the outer epithelium and the inner mass, 
as shown in Fig. 421, Vol. I. The cavity, I think, is 
probably the true segmentation cavity ; the outer layer 
is the entoderm, and not the ectoderm, as commonly de- 
scribed ; and the inner massis the true ectoderm. For 
the reasons of this interpretation see Blastoderm. 


LITERATURE, 


The literature upon Segmentation is very extensive. I cite a few of 
the principal articles, giving the majority of those which deal with the 
mammalia. There is no research published on mammalian segmenta- 
tion which meets the present requirements of embryology. 

1 Agassiz, A., and Whitman, C. O.: On the Development of some 
Pelagic Fish-eggs. Preliminary notice. Proceedings of the American 
Academy, xx., 23-75, Pl. i., 1884. 


‘ 


Seminal Inecont’nce. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, Seementation. 


2 Barry: Researches on Embryology, Series I., Philosophical Trans- 
actions, 1888, 301-341, Pls. v.-viii.; Series II., Philosophical Transactions, 
1839, 807-880, Pls. v.-ix.; Series III., Philosophical Transactions, 1840, 
529-612, Pls. xxix.-xxx. 

3 Beneden, E. van: La Maturation de l’Ciuf, la Fécondation, et les 
premiéres Phases du Développement embryonnaire des Mammiféres, 
d’aprés des Recherches faites chez le Lapin, Journ. Zool., 1876, v., 
10-56. e 

4 Beneden, H. van: Recherches sur ’?Embryologie des Mammiféres, 
I.a_-Formation des Feuillets chez le Lapin. Arch. biol., 1880, i., 136-224, 
Pls. iv.-vi. 

5 Beneden, E. van, and Julin, Charles: Observations sur la Matura- 
tion, la Fécondation et la Segmentation de ];Giuf chez les Cheiroptéres, 
Arch. Biol., i., 551-571, Pls. xxii.-xxiii. (Abstract in Bull. Acad. royale 
de Belgique, xlix.) 

6 Bischoff, T. L. W. : Entwicklungsgeschichte des Hunde-Hies, 134, 15 
Taf. Braunschweig, 1845. 

7 Bischoff, T. L. W.: Entwicklungsgeschichte des Meerschweinchens, 
4to, 56, 8 Taf. Giessen, 1852. 

8 Bischoff, T. L. W.: Entwicklungsgeschichte des Rehes, 4to, 36, 8 
Taf. Giessen, 1854. 

9 Bischoff, T. IL. W.: Ueber die Bildung des Saugethier-Hies und seine 
Stellung in der Zellenlehre, Sitzb. k. bayr. Akad. Miinchen, 1863, i., 
242-264, 1 Taf. 

10 Bischoff, T. L. W.: Ueber die Ranzzeit des Fuchses, und die erste 
Entwicklung seines Eies, Sitzb. k. bayr. Akad. Munchen, 1863, ii., 44—- 
55 


11 Bischoff, T. L. W.: Neue Beobachtungen zur Entwicklungsge- 
schichte des Meerschweinchens, Abh. bayr. Akad., 1870, Ch. ii., x., 
115-166, Taf. 7-10. 

12 Bonnet, R.: Beitrége zur Embryologie der Wiederkiéuer, gewonnen 
am Schafei, Arch. f. Anat. u. Entwicklungsgeschichte, Anat. Abth., 
1884, 170-230, Taf. 9-11. 

13 Carnoy, J. B.: La Segmentation chez les Nématodes (La Cyto- 
diérése de ’Guf, etc., Seconde partie). ‘‘La Cellule,” iii., 1-108, Pls. 
v.-viii., 1886. 

14 Coste, J. J. M. O. V.: Histoire générale et particuliére du Déve- 
loppement des Corps organis¢és. Paris, 4°, tome i., 1847; tome ii., 
1859. Atlas, fol., 50 Pls. 

15 Duval, M.: De ia Formation du Blastoderme dans l'Giuf d’Oiseau, 
Ann. Sci. Nat. Zool., 1884, xviii., 1-208, Pls. i,-v. 

16 Heape, Walter: The Development of the Mole (T'alpa Europea), 
the Ovarian Ovum, and the Segmentation of the Ovum, Q. J. M.S8., 
xxvi,, 157-174, Pl. xi. Reprinted in Sedgwick’s Studies, ii., 201-218, 
PAS SOxT 

17 Hensen, Victor von: Beobachtungen tiber die Befruchtung und 
Entwicklung des Kaninchens und des Meerschweinchens, Z. Anat. u. 
Entwicklungsgeschichte, 1876, i., 211-353. 

18 Hertwig, O.: Beitrage zur Kenntniss der Bildung, Befruchtung und 
Theilung des thierischen Hies, Morph. Jahrb., 1875, i., Taf. 10-13. 

19 Hertwig, O. : Beitrége zur Kenntniss der Bildung, Befruchtung und 
cheene des thierischen Hies, Morph. Jahrb., 1878, iv., 177-218, Taf. 

20 Hatschek: Studien uber Entwickiung des Amphioxus, Arb. Zool. 
Inst. Univ. Wien, 1881, iv., 1-88, Taf. 1-9. 

21 His, W.: Untersuchungen ber die erste anlage des Wirbelthier- 
leibes. Die erste Entwicklung des Hilmchensim Hi. Leipzig, 4°, 237, 
12 Taf., 1868. 

22 Mark, E, L.: Maturation, Fecundation, and Segmentation of 
Limax campestris, Binney: Bull. M. OC. Z., 1881, vi., 178-625, Pls. 
i.-v. 

23 Minot, C. 8. : Recent Investigations of Embryologists, Proc. Boston 
Soc. Nat. Hist., 1877, xix., 165-171. 

24 Roux, Wilhelm: Beitrige zur Entwicklungsmechanik des Embryo. 
No. 4. Die Richtungsbestimmung der Medianebene des Froschembryo 
durch die Kopulationsrichtung des Hikernes und des Spermakernes, 
Arch. f. mikr. Anat., 1887, xxix., 157-218, Taf. 10. 

25 Schafer, E. A.: Description of a Mammalian Ovum in an Early 
Condition of Development, Proc. Roy. Soc., 1876, xxiv., 399-403, Pl. x. 

26 Zacharias : Arch. Mikrosk. Anat., 1887, xxx. 

27 Rusconi: Ann. Sci. Nat. Zool., tome v., p. 304. 

oe Bambecke: Bulletin Académie royale de Belgique, 1870, xxx., 
Dp: 65; 

29 Hertwig, O.: Morph. Jb., iii., Pl. v., Figs, 4 and 5. 


Charles Sedgwick Minot. 


SELTERS is a village in the province of Hesse-Nas- 
sau, Prussia, near which is a spring which is the source 
of the well-known Selters or Seltzer-water. The follow- 
ing is the composition of this water. In one thousand 
parts of water there are: 


Calcinnibicarbona tere onthe rs ocak ch bee eioes 0.550 
Magnesium: bicarbanateryg we). nis 4455 h 0s felde' viens (4 OF210 
arrous: bicaroonatarn tite.) a teirelatwetc cat cee «cle 0,080 
OGM sR PNAte emer Hs. ee aes Coase pat ce cisins a 6 ee 0.150 
Sodiunitphorphates then tiehe se cees adds oes lobes 0.040 
Podtmm.chicride te» ian? Ler S hahah Saree eee es 2.040 
HR OURBETIIINY. CL OTIC Ou, <'cahoe:sleseiere’ =: alel otros tagttoms Mate averacshchow 0.001 
Bilics’and alnminitim, ..<-..s0e.0.. pit Cea. 25 0.050 

IOLA ae Bey eee Os Ped She Se seats eT ore Raney 4,092 


Selters-water is exported in large quantities, very little 
use being made of it at the spring itself. It is recom- 
mended in the treatment of dyspepsia and catarrhal 
troubles of the respiratory organs. Its chief employ- 
ment, however, is as a beverage, 1 as? 


Vou. VI.—25 


SELTZER SPRINGS. Location and Post-office, Men- 
docino County, Cal. 

Access.—By San Francisco & North Pacific Rail- 
road to Cloverdaie ; thence by stage. 

AwnaLysis (H. G. Hanks).—One pint contains (61° 
Fahr.) : 


Carbonvateiol SOUR ras. cee eek etter oie alt Hoa renee seers 
Carbonaterol MAPNesIa mle. 4 is ss ne se See ante oe 10.118 


Oarbounte Ohlimess 3) 8. cee. oe ee eee eS 1.938 
Carbonate ordronts Wises ete cee che tanned eet eee 0.567 
Chloride GiasOduMiiastare reer. ceed on Waele oe eek 1.478 
IIA Ree ye ce By ee carte ge SEES Ae cae SR ae tn rene I 0.075 
SRO NCE Re th ig ey eu AR MOR LA ICAL dion 5 aaa rete Me Rae 0.729 
PLOtales ths serde: tees. eku Ashes ote. MAST Eason ie ee Ue 

Gas. Cub. in 
Garbonic'acid) ay. cy. a6 asia ekee ae es. Hee ee ee 45 

Goliad. 


SEMINAL INCONTINENCE. Derrinrrion.—By this is 
meant the involuntary loss of seminal fluid, whether one 
is asleep or awake, by ejaculations or passive flow. The 
term spermatorrhea has commonly been applied to this 
condition, but not with uniform significance. By some 
writers this word is made to signify only the passive flow 
of semen, according to its etymology (omépya, semen, and 
pew, I flow); and losses accompanying erections, spas- 
modic ejaculations, and orgasms, are styled pollutions. 
Some make a distinction between nocturnal and diurnal 
pollutions, or those in sleeping and waking hours, and 
so have three forms of the malady. Those who apply 
the term spermatorrheea to all forms of seminal inconti- 
nence, speak of true and false spermatorrheea, but here 
the distinction is not uniform. With some the irwe va- 
riety means emissions with erection and orgasm, while 
others restrict its use to cases in which the emissions con- 
tain spermatozoa. This last distinction is lacking in 
both precision and convenience, for the presence of sper- 
matozoa must be determined by microscopical examina- 
tion, and in the same case they may at one time be pre- 
sent, and at another time absent, according to frequency 
of emissions. In this article seminal incontinence will 
express all forms of involuntary seminal emission; the 
word spermatorrhea will be restricted to that form in 
which erection, spasmodic ejaculation, and orgasm are 
absent ; and other forms will be styled nocturnal and di- 
urnal pollutions, according as they occur in sleeping or 
in waking hours. 

NATURAL History.—It is to be premised that seminal 
incontinence may be physiological or pathological. Most 
men in vigorous health, who do not indulge in sexual 
intercourse, have occasional nocturnal emissions, and 
they may occur once in two weeks, once a week, or even 
oftener, without any impairment to health. It is only 
when they are followed by a sense of muscular exhaus- 
tion, pain in the head and back, mental hebetude, and de- 
pression of spirits, that they become morbid and require 
measures for theirarrest. In health the testicles, prostate 
gland, and seminal vesicles are in the constant exercise 
of their functions, from the period of puberty to the de- 
cay of old age, and their secretions are commonly re- 
dundant, that is to say, more than the absorbents can take 
up and carry off in the general circulation. This redun- 
dancy is relieved by a due amount of sexual intercourse, 
or by occasional involuntary emissions. Excessive stimu- 
lation and use of these organs result in seminal inconti- 
nence, and later in impotence. It is unnecessary to re- 
peat here what is described in other articles about the 
anatomy of the male sexual organs and their functions. 

Most cases of morbid seminal incontinence begin with 
nocturnal pollutions, which become more and more fre- 
quent unless the exciting causes be discontinued. In 
neglected cases the malady is aggravated, gradually the 
pollutions become more frequent, they begin to occur In 
waking hours from indulgence in libidinous thoughts, 
from the friction of the clothing, especially in horseback- 
riding, from toying with women, from perusal of inde- 
cent books or pictures, and frequently during defecation 
and urination. The erections and orgasm diminish, until 
the complaint runs into the third stage, when they cease, 


385: 


Seminal Inconvnces REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Senega. 


and the flow is passive, sometimes intermittent and some- 
times constant. There are instances, however, in which 
the emissions are passive from the beginning, but these 
result from gonorrhcea and are exceptional. As the pollu- 
tions become more frequent, they contain fewer sperma- 
tozoa, which are immature, have little or no motion, and 
finally are absent. In consequence of catarrh of the pros- 
tate gland and seminal vesicles the spermatic fluid loses 
viscidity and becomes watery. In some cases digestion is 
much impaired and the bowels become constipated. In 
an advanced stage the moral depression is the most seri- 
ous feature ; for the unhappy subject is usually ashamed 
to seek relief, as he would in ordinary complaints, and is 
apt to fall into the hands of those rapacious quacks who 
hire the services of a venal press to promote their nefari- 
ous business of exciting groundless fears and delusive 
hopes, by which victims are attracted to their toils, to be 
plucked without mercy. 

An analysis of 175 cases by Professor 8S. W. Gross, 
M.D.,! shows the relative frequency of a large number 
of symptoms, as follows: Anxious and depressed condi- 
tion of mind, 72; constant dwelling on sexual matters, 
72; hypochondria, 14; mental dejection after intercourse 
or emission, 60; impairment of memory, 55; incapacity 
for prolonged mental exertion, 68; headache, 69 ; vertigo, 
30; broken sleep, 15; insomnia, 6; drowsiness, 11; iras- 
cibility, 2 ; asthenopia or musce volitantes, 31; noises in 
the ears, 26; muscular weakness of the limbs and fatigue, 
118; trembling of the limbs, 10; temporary reflex para- 
plegia, 1; pain in the back, 95; oppressed breathing, 7; 
pain in the chest, 3; constipation, 61 ; dyspepsia, 40 ; pal- 
pitation of the heart, 26; subjective sensation of cold, 
11 ; and of heat, 4; loss of flesh, 9 ; pallor of the face, 15 ; 
feebleness of erection, with premature ejaculation, 38 ; 
irritable weakness, 29; total failure of erection, 10; 
elongation of the prepuce, 29; relaxation of the scrotum, 
19; irritable testis, 9; varicocele, 6; hemorrhoids, 5; 
coldness of genitalia, 8 ; sensation of heat in genitalia, 3 ; 
painful ejaculation on intercourse, 3; bloody ejaculation, 
1; irritability of the bladder, 8. 

As the emissions become more frequent, the erection 
and the orgasm are less pronounced, and the ejaculation 
is premature. There is pain in the head and back, with 
muscular fatigue and indisposition for mental effort. 
Then follow vertigo, loss of memory, depression of 
spirits, aversion to company, especially that of females, 
asthenopia, trembling, palpitation, shortness of breath, 
indigestion, and constipation. Finally there result im- 
potence, hypochondria, insomnia, neuralgia, cold ex- 
tremities, and a peculiar expression of shame. This is 
the usual course in neglected or ill-managed cases. 

Morsip ANATOMY AND PatHoLocy.—In the early 
stage of seminal incontinence there is preternatural ir- 
ritability of the ejaculatory muscles and of the ducts of 
the seminal vesicles, together with excessive sensibility 
of this part of the urethra from undue excitation. As 
the case progresses the canal becomes inflamed and its 
walls are thickened, with narrowing of its calibre, par- 
ticularly in the prostatic portion and near the meatus. Of 
1538 masturbators who became subjects of seminal incon- 
tinence, Professor 8. W. Gross found that 127 had one 
or more strictures, of rather moderate narrowing in most 
instances, and 22 other cases not traced to masturbation 
all had stricture, with a single exception. Hyperesthe- 
sia of the urethra existed in all but 11 cases. In an 
advanced stage the ducts of the seminal vesicles are en- 
larged and lose their sensibility. Inflammation of the 
epididymis, or of the seminal vesicles, may occur, and in 
the latter case is accompanied with painful purulent or 
bloody emissions. 

Errotoegy.—In a large number of instances a neurotic 
temperament may be regarded as a predisposing cause, 
and this view will be confirmed by the discovery of other 
neuroses in the same subject, or among his near rela- 
tives. It might be more correct to say that this tem- 
perament induces the habit of masturbation. Undoubt- 
edly ascarides, or a long and narrow prepuce, with a mass 
of imprisoned smegma and an irritable and herpetic glans 
penis, will lead to early masturbation. Habitual consti- 


386 


conditions. 


pation, piles; fissures, and pruritus ani have the same ef- 
fect in later years. Inquiry into the previous history will 
show that a considerable number have been subjects of 
nocturnal incontinence of urine in early childhood. In- 
dulgence in erotic thoughts, and perusal of lascivious 
books, also lead directly or indirectly to seminal inconti- 
nence. The concurrence of seminal emissions with tabes 
dorsalis is explained by the diminished inhibitory control 
of the spinal cord in the functions over which it presides. 
Its occasional concurrence in the early stage of pulmo- 
nary phthisis, in variola, typhus fever, and chronic al- 
coholism, is probably to be accounted for on the same 
ground, but the connection is less apparent. 

In the 175 cases analyzed by S. W. Gross, the exciting 
cause was found to be masturbation, 153 times ; gonor- 
rhea, 7 times; masturbation and gonorrheea, 11 times ; 
toying with women, 1; cause obscure, 3 times. It was 
attributed to inherited predisposition once only. In the 
same list 154 were unmarried, 18 married, and 3 were 
widowers. Twenty-two occurred under twenty years of 
age; 103 between twenty and thirty years of age ; 36 be- 
tween thirty and forty years of age; and 14 between 
forty and fifty-four years of age. All the married men 
indulged excessively in sexual intercourse. 

DraGnosis.— Whenever the emissions take place with 
erection and orgasm, there can be no question that they 
are seminal. In cases which have begun in this way 
the presumption is strong to the same effect. The detec- 
tion of spermatozoa requires a microscopic power of four 
hundred diameters, but they may be absent in chronic 
and aggravated cases of seminal incontinence. With 
a history of gonorrhcea rather than of masturbation, 
and with emissions without erection or orgasm from the 
beginning, diagnosis of gleet or prostatorrhcea would be 
presumptive, to be confirmed by absence of spermatozoa. 

Proenosis is favorable in cases which have not ad- 
vanced to protracted impotence, and are not attended 
with profound hypochondria. <A neurotic diathesis and 
chronic inflammation of the seminal vesicles are serious 
Seminal incontinence resulting from gonor- 
rhoea or sexual excesses is more amenable to treatment 
than when arising from masturbation. The worst effects 
of the latter result from early indulgence in the habit. It 
is necessary in any case that the patient should be thor- 
oughly obedient and tractable, and persevere with treat- 
ment uninterruptedly. 

TREATMENT.—An indispensable condition to recovery 
is removal or discontinuance of all the etiological factors, 
and here is the great difficulty. Masturbation and sexual 
intercourse must be prohibited; erotic thoughts and 
whatever might suggest them must be banished ; stimu- 
lating food and drinks must be eschewed ; the bladder 
should be emptied before the hour of rest, and once or 
more times during the night; the bed should be rather 
hard, and the cover barely sufficient for comfort; the 
dorsal decubitus should always be avoided; both mind 
and body should be sufficiently occupied to prevent 
dwelling upon the complaint and indulging in any of its 
causes. A close inspection must be made of the external 
genitals and anus for sources of irritation. A redundant 
prepuce calls for circumcision. Herpes of the glans or 
prepuce may be relieved by the application of dry calo- 
mel or a weak solution of lunar caustic. Stricture of the 
urethra requires dilatation or division, and it must not 
be allowed to contract again. The hyperesthesia of the 
canal in the early stage is best overcome by the passage 
of a steel sound, as large as it will admit, two or three 
times a week, remaining from five to twenty minutes. 
In case of excessive irritability its sensibility may be ob- 
tunded, prior to the introduction of the sound, by the injec- 
tion of a solution of cocaine. In some cases an exquisitely 
sensitive, inflamed tract may be found in the prostatic por- 
tion by exploration with an acorn-pointed bougie. This 
having been accurately located, is best treated by a local 
application of lunar caustic solution, ten to thirty grains 
to the ounce, by a catheter syringe; or by projecting 
from a porte-remede a small quantity of cocoa butter, in- 
corporated with about one-eighth of a grain of silver 
nitrate. A short frenum should be divided. External 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, S°™minal Incontnce. 


piles may be injected with carbolic acid, and internal 
piles be removed by the ligature or the écrasewr. Pru- 
ritus may be relieved by a lotion of corrosive sublimate, 
two or three grains to the ounce, or a five per cent. solu- 
tion of carbolic acid. Constipation may be relieved by a 
pill containing resin. podophylli, gr. 4; extract. bella- 
don., gr. $; extr. nucis vom., gr. 4; pulv. aloes, gr. iij., 
taken at first every night, and then every other night, 
till the habit is overcome. 

Internal medication for this malady must be adapted 
to the stage andthesymptoms. In the stage of nocturnal 
pollutions the object is to diminish the excitability of the 

nervous tract which presides over the genitalia. The 
bromide of potassium and atropine are the agents of 
greatest value. Twenty to thirty grains of the former 
may be given three times a day, and one-sixtieth of a 
grain of the latter at bedtime. If the patient be weak 
and anemic, it is preferable to give quinine and iron 
during the day, and sixty grains of the bromide with the 
atropine at night. In case of diurnal pollutions, a similar 
medication is appropriate. In the stage of spermator- 
rlhoea, when the spermatic ducts are relaxed and there is 
atony of the ejaculatory muscles, a combination of ergot 
and strychnine will be found useful, say one-half drachm 
of the fluid extract of the former with one-twentieth 
grain of the latter, after meals, three times a day; or, 
in an anemic condition, twenty drops of the muriated 
tincture of iron with five drops of the tincture of cantha- 
rides. These remedies may be supplemented by the 
constant galvanic current, with the positive rheophore on 
the perineum and the negative in the rectum, commenc- 
ing with an application for two or three minutes and 
gradually increasing the duration, according to toleration. 
The strength of the current, at the beginning, should be 
such as the operator can pass through his own temporal 
region. 

Abstinence from sexual indulgence and from all excite- 
ment of the organs must be enforced until the anatomical 
lesions are entirely healed and the functional derange- 
ment has ceased. Subsequent moderation is to be en- 

_ joined with the married, and the unmarried, if their 
circumstances warrant, may then be counselled to essay 
matrimony. S. 8. Herrick. 

1 Disorders of the Male Sexual Organs. 


_ SENEGA, U. S. Ph. (Senege Radiz, Br. Ph.; Radix 
Senege, Ph. G.; Polygale de Virginie, Codex Med.). 
The root of Polygala Seneya Linn., order Polygalacce. 
A delicate-looking perennial herb, with a rather thick, 
knotty, somewhat branched crown, from which numer- 
ous slender, wiry, generally simple, smooth, upright stems, 
twenty or thirty centimetres long arise, and one or two 
rather stout, crooked, branching woody roots descend ; 
leaves lanceolate, two or three centimetres long, alter- 
nate, smooth. Flowers small, pinkish-white, in terminal 
spikes. Calyx irregular, of three small green, and two 
(lateral) large, petaloid sepals, the latter concave and in- 
closing the corolla. This consists of three partly united 
petals, of which the lower is concave and ornamented with 
a crest of papilla. Stamens eight, diadelphous (4 x 4). 
Ovary transversely two-celled. Style single. Senega has 
a wide range in the United States from western New 
England and the Middle and Western States southward. 
It is now mostly collected in the West and South. P. 8. 
latifolia is a larger form with broader leaves. 

The plant takes its common name, Seneca Snakeroot, 
from the Seneca Indians, by whom it is reported to have 
been used as a remedy for snake-bites. It was introduced 
into modern medicine by Dr. Tennent, of Virginia, about 
1734, for pleurisy and pneumonia (Fliickiger), and has 
had times since then of very great popularity. | 

The root is about four inches (10 centimetres) long, 
with a very knotty crown, and spreading, tortuous 
branches, keeled when dry, fleshy and round after hav- 
ing been soaked in water ; externally yellowish-gray, or 
brownish-yellow ; bark thick, whitish within, inclosing 
an irregular, porous, yellowish wood ; odor slight but un- 
pleasant ; taste sweetish, afterward acrid. The woody 
column of Senega root is very irregular; near the crown 


Senega. 


it is cylindrical, but lower down markedly excentric, 
semicylindrical, or with wide vacant gaps, or clefts, of 
parenchymatous tissue. ° 

Composition.—The special interest of Senega lies in 
the substance originally called Senegin, later polygalic 
acid, and by some considered to be the same as saponin, 
to which it is undoubtedly related. It is amorphous, so- 
luble in water, making a frothy solution ; it is also sternu- 
tatory. It is, moreover, a glucoside, separable into sapo- 
gentn and sugar. The yield is about two per cent. O71, 


(Baillon.) 


One-half natural size. 


Fra. 8442.—Senega, Root and Stems. 


resin, gum, and other unimportant matters are also found 
in it. 

ACTION AND Use.—Senega in large doses is an irritant 
and nauseating emetic, also a purgative; in medicinal 
ones it is reputed to be a stimulating expectorant. It has 
been extensively employed in chronic bronchitis and 
other diseases accompanied by cough. As an ingredient 
of cough preparations it has probably its most extensive 
use, but is much less valued than formerly ; as an em- 
menagogue and diuretic it is obsolete. 

ADMINISTRATION. —Dose of Senega is about one gram 
(1 Gm. = gr. xv.). The preparations are Abstract (Ad- 


387 


Senega. 
Senna. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


stractum Senege, U. S. Ph.), strength +, and the Fluid 
Extract (Hetractum Senege Fluidum, U. 8. Ph.). It is 
also in the Compound Syrup of Squills (Syrupus Scille 
Compositum, U.S. Ph.). 

ALLIED PLANTS.—See RHATANY. W. P. Bolles. 


SENILITY. In old age there normally occur certain 
changes in the tissues, and, as sequele, anatomical and 
physiological alterations of the senescent body. The 
changes are principally atrophic and degenerative. 

Senile atrophy involves especially the muscles and 
glands, but also affects other soft parts. The cellular 
elements diminish in size progressively, but without ap- 
parently presenting any essential modification in their 
structure. Thus the muscular fibres become small, and, 
it is said, more uniform in size; the spleen and lym- 
phatic glands undergo a remarkable diminution in vol- 
ume and weight, which increases with the advance of 
age. In the digestive tract the glandular parts and villi 
are somewhat shrunken. Where there has been an accu- 
mulation of fat, it gradually wastes away. 

Senile degeneration begins somewhat later than the 
atrophy. The elements become the seat of fatty or pig- 
mentary infiltrations, or calcareous incrustations. ‘The 
fatty degeneration occurs, for instance, in the striped mus- 
cle-fibres, both the voluntary and cardiac ; in the smooth 
muscles ; in the blood-vessels, especially in the cerebral 
arterioles, and probably also in the nerve-cells and the 
parenchyma of glandular organs. The pigmentary infil- 
trations are much rarer. Calcareous deposits occur, es- 
pecially in the tendons, ligaments, and cartilages, also in 
the pineal gland. In the central nervous system the neu- 
roglia tends to predominate over the nervous elements 
proper, and tends to become permeated by a greater or 
less number of amylaceous bodies ; the tissue of the brain 
undergoes a chemical change—the fatty constituents are 
diminished, while the amounts of water and phosphorus 
are increased. 

In consequence of these changes the weight and height 
of the body as a whole is lessened, and the size of most 
of its parts is lessened also; this holds true of the mus- 
cles, skeletal structures, brain, spinal cord, nerve-trunks, 
lungs, liver, spleen, etc.; but it does not apply to the 
heart or kidneys, the heart being often hypertrophied 
and the kidneys retaining the size of middle life. The 
skin becomes dry and wrinkled, the hair scanty and 
white, the gums toothless, the body crooked and sunken. 

Physiologically there is a general impairment of the 
vigor, resulting from the atrophy and degeneration. 
There is great muscular enfeeblement; the amount of 
carbonic acid exhaled is diminished, as is also the vital 
capacity of the lungs; but, on the other hand, the respir- 
atory rhythm is quickened. The secretions are dimin- 
ished. ‘There is less urine. The rate of the heart-beats 
rises. 

Such, categorically given, are the changes in old age. 
Unfortunately, there is no thorough and satisfactory 
compilation of these data, which, though very numerous, 
are scattered through a vast literature. Until this century 
old age scarcely received scientific consideration ; those 
who wrote upon it wrote like Cicero, in his De Senectute, 
from a contemplative literary standpoint. It was not 
until 1839 that anything very serious from the medical 
side was attempted. In that year Canstatt published, at 
Erlangen, his treatise on the diseases of old age. Since 
then there have been a number of manuals of similar 
scope, but in none of them, so far as I know, is there to 
be found a thorough and comprehensive review of the 
normal changes in old age, although such a review is ur- 
gently needed. The preceding paragraphs follow Char- 
cot closely. (See Tuke’s translation, Sydenham Society, 
1881.) Charles Sedgwick Minot. 


SENNA, U.S. Ph. (Folia Senne, Ph. G.; Sené, Codex 
Med. ; Senna Alexandrina and S. Indica, Br. Ph. ; Alex- 
andria and Tinnivelly (Indian) Sennas). The leaflets 
of several, at present mostly of two, species of Cassia, 
order Leguminose@ (Cesalpinee), growing wild in Nubia, 
Upper Egypt and Arabia, or cultivated in Southern 


388 


India. In the United States; German, and French Phar- 
macopeeias the general term covers both the principal 
varieties ; in the British, the Alexandrian and Tinnivelly 
Sennas are distinguished by name; they are always en- 
tirely distinct in the market. 

The genus Cassia is a very large one, numbering three 
or four hundred species, many of which produce hand- 
some ornamental flowers; it is also the type of a tribe 
(Cassie) including nine or ten other genera, of which 
nothing need be said from a medical point of view. 
Ceratontia (St. John’s 
Bread) is one of them. 
The Cassias are herbs, 
shrubs, or trees, with ab- - 
ruptly pinnate leaves, 
usually showy yellow 
flowers in axillary or ter- 
minal racemes or panicles, 
and, in the section to which 
the above Sennas belong, 
extremely flat pods. The 
following two species sup- 
ply nearly all the Senna 
of modern commerce. 

_ 1. @. acutifolia Delile,. 
Fig. 3443, — Cassia Acutifolia, the B m7 small - shrub about 
source of Alexandria Senna, leaf and SIXty centimetres (two 
pod; about natural size. (Baillon.) feet) high, with pale, slen- 
der, round or slightly 
angled, branching, somewhat zigzag, smooth (at least 
when old) stems, alternate leaves of four or five pairs, 
and rather small flowers. Calyx imbricated, of five ob- 
long, blunt sepals. Corolla subregular, of five, obo- 
vate, yellow petals, the lateral and lower ones larger than 
the upper. Stamens ten, the three upper abortive, the 
two lower lateral ones very large, the others subequal ; 
anthers opening by terminal pores. Pistil one, a simple 
carpel raised upon a short stalk, and, like the longer sta- 
mens, curved upward. Pod broad, flat, coriaceous, slight- 
ly curved, rounded and oblique at the ends, containing 
about half a dozen seeds. This species has a wide and 
unknown range in Central Africa, it is abundant in 
Nubia, Kordofan, Sennaar, etc., and is said to be found 
in Timbuctoo. 

2. C. angustifolia Vahl., is also a small shrub, a good 
deal like the preceding, but it has larger flowers and 
larger, more numerously paired leaflets. Its pod is nar- 
rower and straighter than that of C. acutifolia, and con- 
tains about eight seeds. It is a native of Arabia, and in 
the wild state supplies an 
inferior, carelessly collected 
variety of Senna (Arabian). 
It is also said to be found 
in the Somali Land. This 
is the species cultivated in 
the south of India (where 
it is not indigenous) as the 
source of Tinnivelly Senna. 
The leaves, under cultiva- 
tion, are increased in size 
and improved in quality. 

- 0. obovata Colladon, is an 
herbaceous or semi-shrubby 
perennial, of very much the 
same general habits as the 
above, but whose leaflets are 
broader, obovate, with blunt 
apex and base, the former, 
however, mucronate, and 
about two and a half centi- 
metres long. Flowers large 
and handsome, much like 
the others, pod considerably curved. It grows over the 
same range as (. acutifolia, but also extends to West 
Africa and India; it has been introduced into Southern 
Europe, and formerly furnished the European or Italian 
Senna. This species formerly supplied a considerable 
part of the Alexandria Senna, being mixed with the leaf- 
lets of C. acutifolia ; but at present it seldom appears 


Fig. 3444,—Leaf and Pod of Cassia 
Angustifolia; about natural size, 
The leaf is Tinnivelly Senna. 
(Baillon. ) 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


' Senega. 
Senna, 


in any shape. 
jected. 

C. brevipes of Central America, C. Schimper of Abys- 
sinia, and several other species of both hemispheres, have 
been proposed as substitutes for Senna, but have at 
present no commercial existence. 

Senna appears to have been introduced into European 
use in the ninth or tenth century ; the pods were used as 
well as the leaves, and even preferred to them. 

Collection: This, in the wild districts of Nubia and 
Arabia, is done in the coarsest and most primitive manner. 
The shrubs are cut down and exposed to the sun until 
the leaves are dry, when they are stripped off bringing 
leaf-stalks, twigs, flowers, and pods with them. They 


It is of inferior quality and should be re- 


Fic. 8445.—Cassia Obovata, the Source of an Inferior Variety of Senna. 
(Baillon.) 


must be afterward cleaned and sorted before they are 
fit for use. Tinnivelly Senna is always clean. 
DescrreTion.—Alexandria Senna is usually described 
with great care as consisting of a pretty uniform mixture 
of the leaflets of C. acutifolia, C. obovata, and one or two 
other leaves or leaflets of plants not Cassias at all (Solen- 
ostemma Argel Hayne,, order Asclepiadacew, Tephrosia, 
Colutea, Coriaria, etc.), but this applies only to the past, 
as the Senna of recent years is improved in quality and ap- 
pearance, and consists almost entirely of the leaflets of the 
desirable C. acutifolia, with stems and pods of the same. 
The following is the officinal description: ‘‘ Alexandrian 
Senna consists of leaflets about one inch (twenty-five 
millimetres) long, lanceolate or lanceoval, subcoriaceous, 
brittle, rather pointed, unequally oblique at the base, 
entire, grayish-green, nearly smooth, of a peculiar odor, 
and a nauseous, bitter taste. It should be freed from 
stalks and from argel leaves (the leaves of Solenostemma 
Argel Hayne), which are frequently present ; these leaves 
are thicker, one-veined, glaucous, and even at the base. 
India Senna consists of leaflets nearly two inches (five 
centimetres) long, acute, unequally oblique at the base, 
entire, dull green, slightly pubescent, of a peculiar odor 
and a mucilaginous, bitter taste. It should be freed 
from stalks, discolored leaves, and other admixtures.” 
The leaves of Alexandria Senna are always considerably 
broken, those of Tinnivelly generally whole. The former 
commands the higher price; there appears to be no 
“medicinal difference between them. Besides these two 


varieties there is Arabian, often called ‘‘ Indian,” Senna, 
because imported through Indian ports, whose leaves 
have the same shape, etc., described above as Indian 
Senna, but are smaller. It is a cheap, poor, and usually 
very dirty article, seldom used here. Senna pods form a 
separate article in continental shops ; they have the shape, 
size, etc., figured above, and the same properties as the 
leaflets. 

ComPposiITion.—Sennacrol and sennapicrin are two bit- 
ter and acrid substances, separable from senna by treat- 
ment with alcohol. The former is, the latter is not, 
soluble in ether. Neither of them is the valuable part 
of senna. This is principally found in cathartic acid, 
an uncrystallizable, dark brown, astringent-tasting sub- 
stance of decidedly cathartic qualities. It is soluble in 
warm diluted alcohol, but is nearly insoluble in strong 
alcohol or water. Cathartic acid is a glucoside yielding 
by decomposition ‘‘ cathartogenic acid.” A coloring mat- 
ter, chrysophan, also found in rhubarb, etc., and a sugar, 
catharto-mannit, are the remaining constituents. Cathar- 
tic acid is also found in the bark of Frangula and other 
Rhamni. 

Action AND Use.—This is one of the most satisfac- 
tory and generally useful of simple cathartics, usually 
emptying the bowels thoroughly in ten or twelve hours, 
with but little depression or other untoward effects, ex- 
cepting a variable amount of griping ; it acts principally 
upon the small intestine, and the amount of effect pro- 
duced can generally be pretty accurately regulated, by 
the dose, from the mildest laxative to a brisk cathartic. 
It is in universal domestic use, and is the foundation of 
numerous proprietary laxatives. By combination with 
salines its activity is considerably augmented ; in small 
doses it does not readily lose its efficiency. It appears to 
be partially excreted in the milk, when taken by nursing 
women. 

ADMINISTRATION.—A. few Senna leaves chewed every 
day are a favorite habitual laxative with many people, 
who find them to act efficiently, without griping and 
without producing after-sluggishness of the bowels. One 
or two dozen leaves usually display some effect. In large 
doses (six or eight grams [ 3 jss.] or more), as required for 
thorough action, it is apt to produce colic, unless modi- 
fied by aromatics or salines. A strong alcoholic extract 
is inert ; a watery extract, made from the residue after 
exhausting by alcohol, is active and much pleasanter than 
one made without this previous treatment. Infusion 
with hot water extracts the active principle (salts of ca- 
thartic acid), and makes a good form for administration, 
but prolonged boiling destroys it, as do also mineral 
acids and alkalies, by decomposing the cathartic acid. 
Bitters are said to increase its action. 

The officinal preparations are numerous and good. 
The Fluid Extract (Hetractum Senne Fluidum, U. 8. 
Ph.), made with weak alcohol, represents the leaves 
weight for weight. It is not often given alone, but is 
eligible for mixture with other medicines, The Com- 
pound Infusion, Black Draught (Infusum Senne Com- 
positum, U. 8. Ph.), consists of : 

Senna, 6 parts. 

Manna, 12 parts. 

Sulphate of Magnesium, 12 parts. 

Fennel, bruised, 2 parts. 

Boiling water, 100 parts. 


Macerate and strain; then add water to make 100 
parts. It is six per cent. senna, and twelve each of 
manna and Epsom salts. The Syrup (Syrupus Senne, 
U. 8. Ph.) consists of 33 parts of senna with a little oil 
of coriander. The Compound Licorice Powder (Pu/vis 
Glycyrrhize Composita) is one of the most extensively 
used laxatives ; it is composed as follows : 


Senna, 18 parts. 

Licorice, 16 parts. 

Fennel, 8 parts. 

Washed sulphur, 8 parts. 

Sugar, 50 parts. 

The ingredients should be finely powdered and thor- 
oughly mixed. One of the most elegant preparations In 


389 


Senna, 
Sensation. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the Pharmacopceia is the Confection of Senna (Confectio 
Senne, U. 8. Ph.): 

Senna, 10 parts. 

Coriander, 6 parts. 

Cassia fistula, 16 parts. 

Tamarind, 10 parts. 

Prune, 7 parts. 

Fig, 12 parts. 

Sugar, 50 parts. 

Water, 60 parts. 

It is a black extractiform mass, of pilular consistency, 
with a mawkish, but not disagreeable, sweet taste. Con- 
fection of senna is an appropriate remedy for chronic 
constipation, and is especially useful in the case of chil- 
dren, who will often take it as a candy. The Compound 
Syrup of Sarsaparilla contains twelve parts of Senna in a 
thousand. 

ALLIED PLANts.—Of the three hundred or more Cas- 
stas but few have medical importance, although many 
are probably cathartic. C. mardlandica Linn., a peren- 
nial herb of the United States, is a moderately active, 
safe cathartic in somewhat larger doses than the Eastern 
Sennas; the leaves, stems, and flowers are usually col- 
lected together. C. fistula Linn. (see CasstA, PURGING), 
a large East Indian tree, with striking cylindrical fruits 
half a metre long, is a mild laxative, used in the compo- 
sition of Confection of Senna. The order Leguminose 
is one of the largest in the botanical kingdom, and in- 
cludes numerous very interesting, useful, and beautiful 
plants, as the following partial list will show : 

Baptista tinctoria, our yellow False Indigo. 

Lupinus, Laburnums, ornamental flowers. 

Genista, Dyers’ Weed. 

Oytisus Scoparius Link, Broom Tops. 

Trigonella Fenum grecum Linn., Fenugreek. 

Melilotus, Sweet Clovers. 

Trifolium, Clovers, 

Indigofera tinctoria, Indigo. 

Wistaria sinensis, Wistaria. 

Robinia, Locusts, etc. 

Astragalus, sp. var. Tragacanth. 

Glycyrrhiza glabra Linn., Licorice. 

Arachis hypogea Linn., Peanuts. 

Vicia, Lens, Pisum, etc., Peas, lentils, etc. 

Abrus precatorius Linn. 

Mucuna pruriens D. C., Cowhage. 

Butea frondosa, a source of kino. 

Physostigma venenosum Balfour, Calabar Bean. 

Phaseolus, sp. var. Garden Beans. 

Pterocarpus Marsupium Roxb., Kino. 

Pterocarpus Santaltinus Linn., f. Red Saunders. 

Piscidia erythrina, Jamaica Dogwood. 

Myroxyion Toluifera H. B. K., Balsam of Tolu. 

Myroxylon Pereire Klotzsch, Balsam of Peru. 

Haemaioxrylon Campechianum Linn., Logwood. 

Cassia, sp. var. Senna, etc., Purging Cassia. 

Ceratonta siliqua, St. John’s Bread. 

Tamarindicus Indica Linn., Tamarinds. 

Copaifera, sp. var. Copaiba. 

Acacia, sp. var. Gum Arabic, Catechu; and many 
others of the most diverse properties. 

“ALLIED Drucs.— The nearest related cathartics to 
Senna are probably the Rkamni and Rhubarb. See also 
Aloes, Jalap, ete. W. P. Bolles. 


SENSATION, DISORDERS OF. The disorders of the 
special senses will be found discussed under the diseases 
of the organs to which they refer. We shall here dis- 
cuss the other modes of sensation and their pathological 
relations, beginning with cutaneous sensibility. 

All the different modalities of sensation may be af- 
fected, either singly or in various combinations, as the 
result of morbid processes occurring in the terminations 
of the sensory fibres in the integument, in their course 
from the periphery along the nerve-trunks, or at their 
central origin in the brainand spinal cord. In the major- 
ity of cases we are able to determine the site of the le- 
sion by the sensory disturbances themselves, or by the 
associated symptoms, 


390) 


Cutaneous sensibility includes tactile sensibility in the 
general sense, and common sensations. The former in- 
cludes the sense of touch, the sense of location, the sense 
of pressure, and the sense of temperature. At the pres- 
ent time these different sensory qualities are commonly 
supposed to be inherent in different kinds of nerve ter- 
minations and fibres, but the discussion of this question 
must be left to the physiologist. 

The common sensations include the sense of pain, 
pruritus, tickling, sexual feeling, and electro-cutaneous 
sensibility. : 

The sense of touch is tested by applying different ob- 
jects gently to the skin, the patient’s eyes being kept 
closed during the experiment. He is then asked to state 
whether he has felt anything or not, and to describe the 
surface of the object (sharp, blunt, rough, smooth) which 
is brought in contact with the skin. In ordinary ex- 
aminations it is sufficient to use the head and point of 
a pin, the tip of one of the fingers, or the point of a 
lead-pencil. This should be applied gently, in order to 
avoid producing pain and thus confusing the sensations 
in the mind of the patient. As in the tests for all other 
forms of sensibility, the experiment must be repeated 
over and over again ; the patient must sometimes be asked 
as to his sensations, although nothing has been applied 
to the skin; and, above all, similar tests should be made 
on the corresponding healthy part of the integument of 
the opposite side of the body, or, if this is not practi- 
cable, on some other part of the body. It is also very 
often advisable for the physician to repeat the various 
tests upon himself, in order that he may be able to com- 
pare the sensations produced in himself with the state- 
ments made by the patient. There are very few points 
in symptomatology with regard to which the patient, and 
therefore the physician, are so apt to. be led astray as in 
the tests for disorders of sensation. This is often true, 
even when the patient is very intelligent ; but with the 
ignorant we are frequently compelled to abandon all hope 
of arriving even at the approximate truth. The results 
of such examinations are almost zd in children—except 
with regard to the sense of pain—because, even though 
they are able to speak, they are unable to analyze their 
sensations. 

The sense of localization is tested in two ways: first, by 
touching the skin with any small object and then direct- 
ing the patient (with closed eyes) to indicate with the 
finger the part of the skin which has been touched. It is 
also tested by deter- 
mining the smallest 
distance at which 
two sharp points can 
be distinguished sep- 
arately. This is done by means of an instrument known 
as an esthesiometer. Sieveking’s esthesiometer (Fig. 
3446) consists of a metallic rod, divided into millimetres, 
with two pointed arms given off at right angles to the 
rod. One arm is fixed to the end of the rod, the other 
can be moved along its whole length. Both points are 
applied repeatedly to the part to be tested, until we find 
the shortest distance (which is read off upon the scale) 
at which they are felt as two distinct points. The aver- 
age distances at which this takes place in adults, and in 
a boy of twelve years, are shown in Landois’ table: 


Fia. 2446. 


Adult. Boy. 
Mm. Mm. 
TH OLMt her tone ie aaa... eieteeis fslere oe eae ee Ee ee fst. tt 
Third phalanx of the finger (anterior) ............ 2.3 ile 
SVieriiiion poLaer, OL; tne lips erie eee ace cee 4.5 3.9 
Second phalanx of the finger (anterior)............ 4.5 3.9 
Third phalanx of the finger (posterior)............ 6.8 4.5 
EI pyOLSENE MOSS eis 7 mhctat alat cictanite ae alee ein 6.5 4.5 
Head of the metacarpus (palmar)................. 6.8 4.5 
Dorsum of the tongue... 
MWY U EERO (5) DUNO) cf AA RS eh) EE cy ON tap 9.0 6.8 
Metacarpus of the thumb. 
Great.toe(plantar).\.) 0 aces oe oe ee ets 11.3 6.8- 
Second phalanx of finger (posterior).............. 11.3 9.0 
GHECKRR SA ace erate. fhe AG CR cee BR ie ae HS 9.0 
My clic Retcravicves ees Aapiles, ersinte ot ae cane oie be 11.8 9.0 
Hard palates(middie)..: ta. 4.< 0.25 cee ee 13.5 11,3 
Malariponevanterioriy) (Gee. nek cme ome ee eee 15.8 11.3 
Metatarsus hallucis (plantar)........2¢.<0.-s.0-0- 15.8 9.0 
First phalanx of finger (posterior)............ eee 2S 9.0 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Senna. 
Sensation. 


Adult. Boy. 
Mm. Mm. 
Head of metacarpus (posterior)................00. 18.9 13.5 
Innerigideotlipnsegiee: fe.c hoes sees SRR ihe ie ae 13.5 
Malar bone (posteriorly) 15.8 
(Horeheads (below) rae sacichiicsatea se © cl: Ge des ossee ; 18.0 
ELEOL (MOSLEMONI Va) mmaraeeyn © cisicieSrata perk octal icp aia ; 20.3 
WCEIPUEs (MELO My) erretete Nese. eicie.c.c a.scrs ious mat Gee ceed ts 22.6 
POrsunMOL Nand nreme tee ee te se he oat, : 22.6 
ORI tener asec teas ao teeke he oS se cheb 3. 22.6 
WGK Sa Sead Tet ghee ea, DAR aOn ce Lena. Mame 3. 22.6 
ALCL Gee en MOINS Meds reas csr eee ees cise os bison see : 31.6 
ACrt inte eres é 
Micatee | a oe a oct! 33.8 
i ate ek gle ial OTe 40.6 36.1 
Dorsum of foot near the toes.................0.0ee 40.6 36,1 
DPOUIUB teria erecta eit eolals Serhan ae ees 45.1 33.8 
Neckathiohinp) icduce ota cme eis eee Shae fe, ee 54.1 36.1 
Spine (fifth dorsal vertebra, dorsal and lumbar re- 
ZION) Goer mee ee ee ary ine ev ecinoe cots 54.1 
Neches (middle) Pe moe cmameneulsuiccs cites oe tees name 67.7, anes 
AYIee eee § 31.6 
ANSE a) gL Sine Sp eto Ort cris SO PRICE ene ober 67.7 to 
Middle of back. | 40.6 


Any marked deviation from these distances, on one side 
or the other, is an evidence of a morbid state. In using 
the esthesiometer care must be taken 
that the two points are applied to the 
skin at the same time, and with the 
same degree of force (not sufficient 
to produee pain), and that they pos- 
sess approximately the temperature 
of the skin. In making this test we 
must be especially on our guard 
against unintentional deception on 
the part of the patient, and must 
verify the results by repeated ‘‘ con- 
trol”’ tests. 

The sense of pressure is tested by 
applying, successively, different 
weights to the part examined, the 
latter being firmly supported in or- 
der to exclude the muscular sense. 
Eulenburg constructed a_bareesthe- 
siometer for the purpose of testing 
- this sense. It consists (Fig. 3447) of 
a rod connected with a spring, and a 


dial-plate, upon which is registered Fria: 3447. 
the amount of force exerted by the 
rod, that is brought in contact with the skin. Eulenburg 


found, with the aid of this instrument, that the following 
increments of pressure could be appreciated on the differ- 
ent parts of the body: 


pate iclinehanehs. ct ] Phalanges of the fingers. } 

Ee eRe i ae ae | HOC GAPE ee weve ste otets | 

Dorsum of the tongue. }1/49-1/39 Hand Wasi 0 
Cheeks = he er ae a eae vies ee ee ee ee ee er ay J 
VOCINDICO eee eRe oe GEES My eT OR ee er i 


Goltz devised an apparatus for the determination of 
the minimum amount of pressure which could be appre- 
ciated. It consists of a rubber tube, which is brought in 
contact with the integument, and through which waves 
of fluid of a known amount of force are passed. 

A simple test consists in placing a coin or other weight 
upon the skin, and then adding others until the patient 
appreciates the increase. The proportion between the 
original weight and the added weight necessary to pro- 
duce an appreciable difference, is the minimum appre- 
ciable increment. , 

The sense of temperature may be tested by Eulenburg’s 
thermesthesiometer. This consists simply of a trans- 
verse rod, to which are fastened two surface thermom- 
eters. The latter are heated to different degrees, and 
applied to the skin. We then note the minimum differ- 
ence between the two thermometers which can be appre- 
ciated by the patient. Eulenburg found that this sense 
was most acute between 27° and 33° C. (80.6° and 91.4° 
F.). Upon the arms the minimum appreciable difference 
of temperature was found to be 0.2° ; on the cheeks, 0.2° 
to 0.4°; on the temples, 0.3° to 0.4° ; on the back of the 
hand, 0.8° ; on the palm of the hand and dorsum of the 
foot, 0.4° ; on the leg, 0.5° to 0.6° C. 

A coarser method of testing the temperature sense is 


the application to the skin of test-tubes containing water 
at different degrees of heat, or placing the part alternately 
in warm and cold water, and noting whether the patient 
is able to detect the difference. hen employing the 
latter methods we should always make the same experi- 
ment on ourselves. 

Goldscheider comes to the conclusion, from his experi- 
ments, that there are special nerve-fibres for the percep- 
tion of heat and of cold, and Herzen has reached the same 
conclusion from the observation of a case of myelitis, 
which will be referred to later on. 

The sense of pain is tested by simply irritating the 
skin, by pricking it with the point of a pin, pinching it, 
etc. It must be remembered that there are very great 
normal variations in the sense of pain of different indi- 
viduals. The results of irritation of the diseased part 
should always be compared with those of irritation of 
the corresponding normal part on the opposite side of the 
body, or, if this cannot be done, with some other healthy 
part of the integument. Bjoernstroem devised an ‘‘al- 
gesimeter,” consisting of a pair of forceps between whose 
blades the skin is compressed to the point of production 
of pain. The amount of pressure is shown upon a scale 
attached to the instrument. 

The electro-cutaneous sensibility has not hitherto seemed 
to possess any important practical bearings. The test 
may be made with regard to the minimum strength of 
current which will give rise to a perceptible sensation, 
and also the minimum strength which will be attended 
with a painful sensation. Erb employs the following 
method: One large moist electrode is placed on the ster- 
num, and the other one on the part to be tested. This 
electrode consists of a hard-rubber tube containing about 
four hundred fine, insulated metal wires, its free end 
being made as smooth as possible. The cylinder of the 
faradic battery, with which the electrodes are connected, 
is withdrawn slowly, until the first minimum electrical 
sensation occurs, and the amount of withdrawal is noted ; 
the cylinder is then withdrawn more rapidly, until a dis- 
tinct sensation of pain is felt, and the amount of this 
withdrawal is again noted. 

The rapidity of sensory conduction from the skin may 
also be interfered with. It is possible that the conduc- 
tion may be accelerated, but the recognition of such a 
condition would require very delicate instruments for 
the measurement of time. So far as we know, no inves- 
tigations have ever been made on this point. In numer- 
ous cases, however, there is an evident delay in the con- 
duction of sensation, which can be determined by the 
unaided senses, If a healthy individual is pricked on 
the sole of the foot, 7.e., on the part whence the nerve- 
current has the longest distance to travel before reach- 
ing the cerebral centre, he will immediately manifest 
his perception of the irritation. When sensory conduc- 
tion is delayed an appreciable interval—even at times 
as much as fifteen seconds—will elapse before the pa- 
tient gives evidence by some sign that he has felt the 
prick. This delay in conduction may affect only certain 
forms of sensation, while that of other forms remains 
normal, and thus gives rise to a peculiar phenomenon, 
which will be considered later on. 

Exner gives the following as the duration of the latent 
period in healthy individuals : 


Time between stimulation and per- 


Stimulus. ception, in fractions of a second. 
SR OOKMCHMMOT UREN devas tiara elon spe ejer tia heeisk. e.sleares anlar 0.12 
ss OF g oS KO) gE) OCT Yo Lea he A ei ee an eee 0.13 
ee SELOG OL Olt LOOba Acie talom teletett ere sielele'e ol e's © gisie eos 0.17 


But when all is said, it will be found that refined tests 
are not practicable in the examination of disorders of 
sensation at the bedside. In the first place, an inordi- 
nately great amount of time would be required, so that 
a thorough examination of sensibility would often. last 
many hours. But apart from this, the errors increase In 
proportion to the refinement and delicacy of the tests. 
The majority of individuals are unused to making a care- 
ful analysis of their sensations, and really remain 1gnor- 
ant of their own feelings, or are unable to convey an 
accurate idea of them in language. In many cases, fur- 


391 


Sensation. 
Sensation. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


thermore, the sensations experienced are unlike any that 
have been felt before, so that the patient is compelled to 
describe them by analogy. In those cases, on the other 
hand, in which there is a morbid habit of analyzing 
the various bodily sensations, we must be on our guard 
against unintentional exaggeration. 

In my own examinations I have entirely discarded 
the use of special instruments, having come to the con- 
clusion that even.the simple sesthesiometer furnishes un- 
trustworthy results in many cases. 

Muscular sensibility will next engage our attention. 
This is best tested with the faradic current applied, pre- 
ferably, to the motor points of the muscles. When the 
current acquires a certain strength the muscular contrac- 
tion is accompanied by a peculiar, indefinable sensation, 
which is readily distinguished from electro-cutaneous 
sensibility. When a certain increased strength of current 
is reached, the patient experiences pain in the muscle. 
The limits of both’sensations may vary from the normal. 
Some writers claim that muscular sensibility is depend- 
ent upon cutaneous irritation, but this is disproved by 
the fact that it may persist despite the most complete 
cutaneous anesthesia. Moreover, recent investigations 
have demonstrated the existence of sensory fibres in the 
muscular tissue. 

Our appreciation of the position of the limbs (with- 
out the aid of the sense of sight) depends not alone on 
the muscular sensibility, but also on that of the integu- 
ment, joints, and fasciz. This may be tested in the fol- 
lowing manner: The physician places the limb, when 
the muscles are relaxed, in various positions—it is best 
to grasp the part by means of a handkerchief, in order to 
exclude the cutaneous sense of pressure—and then directs 
the patient to place the corresponding limb on the op- 
posite side of the body, if the functions of the latter are 
normal, in a similar position. If there is paralysis or 


inco-ordination of the opposite limb, he is directed to de- 


scribe the position of the limb which has been subjected 
to passive motion. This can be done with great accuracy 
in the normal condition. 

By the muscular sense proper we are able to determine, 
with the eyes shut, the degree of contraction of the mus- 
cles during movement. We are thus able to determine 
the weight of objects by the amount of muscular force 
required to overcome it, and this sense is even more ac- 
curate than the cutaneous sense of pressure. It may be 
tested by suspending weights to the limb by means of a 
handkerchief looped over the part. For example, if the 
flexors of the forearm are to be tested, a handkerchief is 
tied into a loop, passed around the palm (the extensors 
being well supported on a firm base, so that they are 
not brought into play), and different weights are placed 
successively in the loop. We then note the smallest in- 
crement or decrement of weights which can be ‘appre- 
ciated by the patient. In the normal condition an incre- 
ment of 4'5 can be appreciated by the muscular sense, while 
only +5 can, on the average, be detected by the cutaneous 
sense of pressure. The action of the latter, however, 
can never be entirely excluded in these experiments. 
Another test consists in directing the patient, with the 
eyes closed, to perform certain movements, such as plac- 
ing the finger on the tip of the nose, describing a circle 
with the foot, etc. When the muscular sense is impaired 
these movements cannot be performed with the normal 
degree of accuracy, but are done in a bungling fashion, or 
the patient shoots wide of the mark. In some cases the 
affection may be so marked that the patient is almost en- 
tirely unable to perform any movement when the eyes 
are closed, although he may be under the impression 
that the desired movement has been accomplished. 

The real nature of the muscular sense is involved in 
great obscurity, although it has long been the subject of 
study by philosophers and physiologists, and is of far- 
reaching importance with regard to our notions of the 
mechanism of nerve action. Some writers believe that it 
is the result of centripetal impressions derived from the 
contracting muscles, others, that it results from a con- 
sciousness of the ‘‘ out-going current” from the cortical 
centres at the moment of contraction; while Weir 


392 


Mitchell suggests that it is produced by ‘‘ the messages 
sent to the sensorium from the spinal ganglia, which every 
act of motor volition excites.” 

The various forms of sensation, which we have thus 
briefly considered, may present an abnormal exaggera- 
tion, diminution, or perversion, These deviations from 
the normal may result from an affection of the terminal 
ramifications of the sensory fibres in the integument, of 
the conducting paths in the nerve-trunks, spinal cord or 
brain, or of the sensory centres. We shall deal separately 
with each form of sensory aberration. 

Cutaneous anesthesia is the diminution or abolition 
of the function of the sensory nerves of the skin. The 
function of the various nerves may be affected in different 
degrees. For example, the sense of touch may be abol- 
ished, while the sense of temperature remains intact ; or 
tactile sensibility may be abolished, while the sense of 
pain is greatly exaggerated, etc. When all forms of 
cutaneous sensibility are diminished or abolished, we 
speak of total anesthesia ; the term partial anesthesia is 
used when certain modes of sensation are alone affected. 

In many cases anesthesia is also associated with dimi- 
nution inthe rapidity of conduction of the sensory im- 
pressions, and, as we shall see later on, this may also 
affect the different modes of sensation in different de- 
grees. 

Cutaneous anesthesia, resulting from an affection of 
the terminations of the nerves, is observed in certain skin 
diseases, such as acute pityriasis rubra, certain forms 
of eczema, lichen, or psoriasis. It is also produced by 
congelation of the skin (by evaporation of ether or rhigo- 
lene, or prolonged exposure to cold), by hypodermic in- 
jections of narcotics (morphine, atropine, cocaine), or 
by the application of acids and alkalies. In these cases 
the anesthesia usually affects all forms of sensation to 
an equal degree (total anesthesia), Fournier observed 
patches of cutaneous anesthesia scattered over the entire 
body in secondary syphilis, and it is probable that this 
condition is due to the direct action of the virus on the 
terminations of the nerves. 

Anesthesia may be produced by interference with con- 
duction through the peripheral nerves. This may re- 
sult from direct injury to the nerve (by gunshot or stab 
wounds, blows, etc.), from the pressure of tumors or 
aneurisms, neuritis, rheumatic influences, the applica- 
tion of cold to the course of the nerve, various forms of 
chronic poisoning (ergot, lead, arsenic), or diminished sup- 
ply of arterial blood (embolism of an artery); and it also 
occurs in anesthetic leprosy. It is a peculiar fact that 
in compression of a mixed nerve the sensory fibres are 
usually affected to a much less marked degree than the 
motor fibres; in fact, the former may appear to be en- 
tirely intact despite complete motor paralysis. In rare 
cases, on the other hand, the opposite condition is ob- 
served. I have noticed this particularly in compres- 
sion of the ulnar nerve. ‘The comparative immunity 
from anesthesia after injury to nerves has been ascribed, 
by Arloing and Tripier, to the communication of the 
terminal sensory filaments of adjacent nerves with one 
another. This explanation does not apply to all cases. 
In view of the fact that a similar phenomenon is also ob- 
served in diseases of the spinal cord, it is probable that a 
lesion which, whey it affects a motor fibre, will interfere 
entirely with conduction, will not produce the same ef- 
fect upon a sensory fibre, either because the structure of 
the latter is more resisting, or because it reacts more read- 
ily to stimuli. 

Delayed conduction of sensibility has been observed in 
a very few cases in connection with anesthesia due to 
lesions of the peripheral nerves. Erb reported an in- 
stance of this kind in a case of injury to the brachial 
plexus, and Westphal mentionsa similar case. Stern has 
also reported delayed conduction of the sense of tempera- 
ture in a.case of multiple neuritis. 

The term analgesia is applied to loss of the sense of 
pain, This is usually coextensive with the other forms 
of cutaneous anesthesia, when the condition is due to an 
affection of the peripheral nerves, though the sense of 
pain is also retained in many cases. The term anes- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sensation, 
Sensation. 


thesia dolorosa is applied to those cases in which the 
affected part is aneesthetic, but the patient suffers from 
severe pains in the part. ‘This is the result of inter- 
ference with conduction in the affected nerve, while at 
the same time the lesion causes irritation of the central 
portion of the nerve. The irritation is reflected in con- 
sciousness to the terminal distribution of the nerve. 
This symptom is especially apt to occur in compression 
of the spinal roots of the nerves, such as is produced at. 
times in the paraplegia of Pott’s disease, but much more 
frequently in cancer of the vertebra. 

Peripheral anesthesia is also observed at times, in the 
later stages of severe neuralgias, in the distribution of the 
painful nerve. 

Asa general thing, anesthesia from lesion of the periph- 
eral nerves is complete, 2.e., it affects all forms of sen- 
sation in an approximately equal degree. It seems prob- 
able, however, that this would be found to be not so 
constant as is commonly believed, if the cases were ex- 
amined more carefully with reference to this point. 

Cutaneous aneesthesia may be unattended with any 
other symptoms, and may not be discovered until after 
examination by the physician, or until the patient finds 
that he has unwittingly injured the part by reason of the 
lack of sensibility. In the majority of cases, however, it 
is attended with pareesthesiz (perversions of sensibility), 
such as numbness, formication, a feeling of furriness, 
etc. When the anesthesia is the result of lesion of a mixed 
nerve (except in neuralgias) it is usually less marked than 
the coexisting paralysis of the muscles supplied by the 
same nerve. . 

In anesthesia of the hand the patient is unable to per- 
form delicate movements with the part unless aided by 
the sense of sight, and even then he is somewhat awk- 
ward in his movements. 

In anesthesia of the soles of the feet the so-called 
Brach-Romberg symptom may be produced. If the pa- 
tient, while standing, is directed to close the eyes when 
the feet are brought closely together, he totters from side 
to side, and may even fall to the ground. Equilibrium is 
maintained normally by centripetal impressions from the 
skin, muscles, and the semicircular canals of the ears. 
When the former ure abolished, as in anesthesia of the 
soles of the feet, the other two may be unable to main- 
tain complete equilibrium unless aided by the sense of 
sight. 

- Anesthesia is a very frequent symptom of diseases of 

the spinal cord, and inasmuch as the paths of conduc- 
tion of the individual fibres for the different modes of 
sensation here separate more widely than in the peripheral 
nerves, it is much more often partial than is anesthesia 
due to diseases of the nerves. 

In certain cases—for example, in incomplete ether or 
chloroform narcosis—the tactile sensation is preserved, 
while the sensation to pain is entirely lost. The patient, 
although conscious of the individual steps of an opera- 
tion, is insensible to pain. It is even possible that the 
sense of heat may be intact, while that of cold is abol- 
ished. Herzen reports a case of myelitis of the posterior 
columns of the cord and of the direct cerebellar tracts, 
with intact anterior columns and gray matter, in which 
there was complete and permanent tactile anzesthesia of 
the lower limbs, and abolition of the,sense of tempera- 
ture of cold substances ; while the sense of pain was nor- 
mal, and likewise the sense of heat between the tem- 
peratures of 60° to 27° C. (140° to 80.6° F.). Herzen 
concludes that the sense of heat passes through the gray 
matter, the sense of cold and tactile sensation through 
the posterior columns. Goldscheider also comes to the 
conclusion, from his experiments, that there are special 
nerves for the sense of cold, heat, and touch. 

When only certain forms of sensation are affected the 
sense of pain is lost much more often than that of touch, 
and when both are combined the affection of the former 
is usually much more marked than that of the latter. In 
much rarer cases the sense of temperature or of pressure 
is lost, while that of touch or of pain is retained. In the 
majority of cases, however, there is merely relative in- 
tactness of one or more modes of sensation. 


It is particularly in diseases of the spinal cord that we 
meet with delayed conduction of sensibility. This, like 
the anesthesia, may affect the different modes of sensa- 
tion in different degrees. Asa general thing, it is noticed 
chiefly with regard to the sense of pain or of touch, the 
former being the one which is usually delayed. If the 
patient is pricked with a pin he first makes the signal 
indicative of his perception of the touch, and then, at the 
end of a variable period (from one to four or five seconds, 
and even a much longer interval has been reported), he 
indicates the perception of pain. This condition is ob- 
served much more frequently in locomotor ataxia than 
in other diseases of the spinal cord. It is a singular fact 
that the delay in conduction is often less the more violent 
the painful impression is, and that it sometimes disap- 
pears temporarily during the course of the examination 
(Stern). In rare cases there is a similar delay in the con- 
duction of the sensation of temperature. It has been 
found, however, that the transmission of the sense of tem- 
perature is slower than that of touch, even in the normal 
condition. Anesthesia of muscular sensibility is also a 
frequent accompaniment of severe spinal diseases, and 
when it is associated, as it almost always is, with cutane- 
ous anesthesia, the patient ‘‘ loses his limbs”’ in the dark. 
Schueppel reported a case of general aneesthesia (affecting 
almost the entire surface of the body), with loss of mus- 
cular sensibility and muscle sense, in which the patient, 
when in the dark, felt as if he floated free in the air. 

Hysterical spinal anesthesia may also be associated 
with complete abolition of muscular sensibility. Du- 
chenne has also reported the abolition of ‘‘ muscular con- 
sciousness” in hysteria. The anesthetic limbs could only 
be moved when under the control of the sense of sight. 
In the dark, movement of the limbs became impossible. 

It is often an easy matter to determine the spinal 
origin of anesthesia from its distribution, but in some 
cases this is an extremely difficult problem. The anes- 
thesia may be distributed irregularly over the body in 
patches of various extent. This may occur in multiple 
lesions of the peripheral nerves (multiple neuritis), or 
the spinal cord (multiple sclerosis). A decision may gen- 
erally be reached with the aid of the attendant symptoms, 
particularly by the fact that in this form of spinal anes- 
thesia cerebral symptoms are usually present, and indi- 
cate multiple cerebral sclerosis. 

But anesthesia of spinal origin usually assumes a 
paraplegic type, and is. associated with paraplegia of 
motion. It results commonly from transverse myelitis, 
compression-myelitis, and sclerosis of the posterior col- 
umns ; it is also frequent in hysterical paraplegia. The 
existence of anesthesia with intact reflex action from the 
anesthetic part is positive proof of its central origin. 
Spinal anesthesia is usually associated with disturbance 
of the bladder, and is thus distinguished from the anes- 
thesia due to lesions of the cauda equina, which is also 
paraplegic in its distribution. Bladder disturbances are 
often absent in hysterical paraplegia, but this variety is 
usually recognized by the presence of other evidently 
hysterical phenomena, the absence of changes of electri- 
cal contractility, the occurrence of hysterical contract- 
ures, and the previous history of the case. 

Spinal anesthesia may appear in the shape of a girdle 
around the body, when the posterior roots or posterior 
gray columns over a slight area are affected by the le- 
sion. 

In unilateral lesions of the cord the sensory disturb- 
ances present a peculiar distribution. If the lesion is 
confined exactly to one lateral half of the cord, we shall 
find motor paralysis of the lower limb on the same side, 
with “abolition of muscular sense and preservation or hy- 
peresthesia of cutaneous sensibility ; the latter usually 
disappears after a while ; in the opposite limb the motor 
power and muscular sense are intact. Ferrier denies, 
however, that muscular sense is lost on the paralyzed side 
and retained on the other side, so that the question must 
be regarded as sub judice. In addition, there is usually 
a narrow zone of anesthesia above the hyperesthetic re- 
gion (on the side of the lesion), and above this there 1s 
sometimes a narrow girdle of hyperssthesia. If the le- 


393 


Sensation, 
Sensation. 


sion is situated above the cervical enlargement, corre- 
sponding disturbances are found in the upper and lower 
limbs. In the majority of cases, however, all these 
symptoms are not present. In a case under my observa- 
tion there was simply paresis of motion in one lower 
limb, and incomplete anzesthesia in the other. 

Anesthesia of almost the entire body has also been ob- 
served in spinal affections. This happens, for example, 
in a lesion of the upper part of the cervical cord, involv- 
ing the ascending roots of the trigeminus nerve. I 
have observed a case of this kind (acute cervical myelitis) 
in which the diagnosis was confirmed on autopsy. In 
Schueppel’s case, to which I have already referred, there 
was complete anesthesia of almost the entire surface of 
the body. The autopsy showed extensive syringomyelia 
following myelitis, with degeneration of the posterior col- 
umns and almost complete atrophy of the posterior roots. 

In transverse lesions of the lower part of the lumbar 
enlargement there may be aneesthesia of both limbs, with 
the exception of the parts supplied by the obturator and 
crural nerves (inner surface of the thighs), because these 
nerves are given off higher up. 

In transverse lesions of the upper part of the lumbar 
enlargement the parts supplied by the obturator and 
crural nerves may also be aneesthetic. 

In transverse lesions of the lower or upper dorsal cord 
the anzesthesia may extend over the lower limbs and the 


trunk as high up as the exit of the nerves given off from 


the site of disease. 

In transverse lesions of the cervical enlargement there 
may be complete anesthesia of the entire body below the 
head, and, as we have seen above, almost the entire body 
may be anesthetic. 

But, as in the case of anesthesia from lesions of the 
peripheral nerves, that of spinal origin is very often far 
less marked than the motor symptoms. Indeed, there 
may be complete paraplegia of motion without any ap- 
preciable loss of sensation. In certain forms of spinal 
disease this is the rule—for example, in the compression- 
myelitis of Pott’s disease. One case of this disease, how- 
ever, has been reported in which sensation was alone 
affected, while the motor power was unchanged. 

Anesthesia is a frequent symptom of cerebral diseases. 
It is observed often in the ordinary cerebral hemiplegia 
due to hemorrhage or to embolism of the middle cerebral 
artery. Itis usually distributed over the entire paralyzed 
side of the body, but it is rarely as profound as the mo- 
tor hemiplegia. As a general thing, all forms of cutane- 
ous sensibility are affected alike. It usually disappears 
much more rapidly than the paralysis of motion. In the 
beginning it is frequently—much more commonly than is 
generally believed—associated with hemianesthesia of 
the special senses (véde article on Cerebral Hemorrhage). 
In rare cases the anesthesia is much more marked than 
the disturbance of motion, and persists after the latter 
has disappeared. Hemianesthesia of the special senses 
is an almost constant accompaniment of such cases. It 
results, probably, from a lesion of the posterior third of 
the internal capsule. 

The various forms of sensation are not always affected 
in a uniform manner in cerebral diseases. In some cases 
there is abolition of the sense of pressure and temper- 
ature, while that of pain remains. <A case of hemiplégia 
has also been reported in which there was abolition of 
the sense of temperature, with intact sense of pressure 
and pain. This has been corroborated by Rosenthal. 

The relation of anesthesia to lesions of the cortical mo- 
tor centres is still the subject of dispute. There can be 
no doubt that in some cases of destruction of these cen- 
tres the cutaneous sensibility is intact. But other cases 
have been reported in which a certain degree of anzesthe- 
sia was present, while in’ others, still, the muscular sense 
was lost. 

The question of the relation of sensory to motor dis- 
turbances in diseases of the cortex is an extremely inter- 
esting and important one. Physiological experiments 
upon lower animals are almost entirely valueless in this 
respect, and pathological observations which are beyond 
criticism are extremely rare. The only thing in this 


394 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. : 


connection which seems to be tolerably clear is, that 
muscular sense may be abolished, without paralysis of 
motion, in lesions of the parietal lobe. The weight of 
evidence also seems to me to favor the view that the cen- 


- tre of cutaneous sensibility is situated in the parietal 


lobe. It is unnecessary for us to say that many writers 
deny the existence of true motor centres, and claim that 
the so-called motor centres are really sensory, and that 
in cortical paralyses cutaneous sensibility and muscular 
sense are always affected at the same time. Anesthesia 
may also appear in any organic disease of the brain (tu- 
mor, softening, abscess) which involves the sensory fibres 
in any part of their course, either directly or by pressure 
from a distance. In very rare instances hemianesthesia 
may result from cerebral syphilis. Only four cases of 
this kind have been reported, to my knowledge—one by 
Fournier, three by myself. In these cases all forms 
of cutaneous sensation were affected, and, in addition, 
there was hemianeesthesia of the special senses on the 
same side. The sensory disturbances were associated 
with hemiplegia of motion in all the cases. 

Hemianesthesia of cerebral origin is not uncommon in 
hysteria. It is often unrecognized by the patient until 
an examination is made by the physician.‘ Not alone is 
the integument of one-half of the body completely anes- 
thetic, but the sensibility of the mucous membranes and 
muscles, and often of the special senses on the same side 
of the body, is also abolished. Hysterical hemianezesthe- 
sia may or may not be associated with a corresponding 
hemiplegia of motion. In rarer cases hysteria is charac- 
terized by anesthesia of the entire body. It is also not 
uncommon to find in this disease circumscribed patches 
of cutaneous anesthesia alternating with patches of hy- 
pereesthesia. 

Hemianzesthesia has also been observed in various le- 
sions of the pons Varolii and cerebral peduncles. The 
distribution is similar to that occurring in lesions of the 
posterior part of the internal capsule, except that sight 
and smell remain intact. 

Hemianeesthesia, similar to that of hysteria, has also 
been reported in cases of chronic lead-poisoning, chronic 
alcoholism, and mercurial poisoning. 

Anesthesia is a not very infrequent symptom of vari- 
ous forms of insanity. It may involve only a small part 
of the integument, it may be unilateral in its distribu- 
tion, or it may be present over almost the entire body. 
It sometimes involves the deeper structures. Rochoux 
reports a case in which a lunatic kept his arm in the fire 
until the flesh was burned off down to the bones. The 
anesthesia generally affects all forms of sensation, but 
sometimes appears to be partial. 

Circumscribed aneesthesia, especially in the distribu- 
tion of the trigeminus nerve, is not rare in severe cases 
of melancholia. In such cases there may also be incom- 
plete anesthesia of the entire integument: 

In acute primary stuporous dementia there may be 
complete anesthesia of the entire integument, so that no 
impression from the outside appears to be able to reach 
consciousness. 

Anesthesia is also not uncommon in progressive gen- 
eral paresis. It is probably always present in those cases 
which are combined with posterior spinal sclerosis, and 
is also noticed in uncomplicated cases. 

The aneesthesias of insanity often form a basis for the 
patient’s illusions, and, according to some writers, may 
furnish a clew for treatment of the mental affection. 

Oppenheim and Thomsen have applied the term 
‘‘mixed (sensory-sensible) aneesthesia” to a peculiar con- 
dition which they observed in quite a number of cases of 
insanity and diseases of the brain. ‘‘It forms a typical 
symptom-complex, consisting of blunting or abolition of 
cutaneous sensibility in all or several qualities (bilater- 
ally, unilaterally, or in patches), and a coincident blunt- 
ing of the special senses (concentric narrowing of the 
field of vision of both eyes), with or without impairment 
of the color sense and muscular sense.” The symptoms 
were observed in cases of dementia, chronic paranoia, 
and transitory conditions of terror and confusion. Ac- 
cording to Thomsen, the symptoms are not the result of 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sensation, 
Sensation, 


the psychosis itself, but rather of the etiological factors 
of the latter. These were found, in the majority of 
cases, to consist of alcoholism, injury to the head, and 
epilepsy, either singly or in combination. The anes- 
thesia was sometimes temporary, sometimes it appeared 
to remain unchanged for years. 

According to these writers ‘‘mixed anesthesia” also 
occurs in epilepsy, hysteria, hystero-epilepsy, alcoholism, 
nervous excitability, neurasthenia, chorea, conditions of 
terror, railway spine and injuries to the head, multiple 
sclerosis, Westphal’s neurosis, and organic diseases of the 
brain. Almost all of the patients present some psychical 
anomalies. 

Schuetz has also reported a case of paranoia with total 
anesthesia of the entire body (with the exception of the 
right ear, lips, and fingers of the right hand), concentric 
narrowing of both fields of vision, anesthesia of the spe- 
cial senses on the left side, and complete loss of muscular 
sensibility. ; 

Hyperesthesia, in the strict sense of the term, is an 
exaggeration of sensibility. This condition is rare. It 
is sometimes observed under normal conditions, for ex- 
ample, in the blind, who endeavor to replace the sense of 
sight by cutaneous sensibility, and who finally become 
able to detect much more delicate impressions upon the 
skin than those who are possessed of the sense of sight. 
It is also seen in various occupations in which the cuta- 
neous sensibility is being brought constantly into play. 
True hyperesthesia is sometimes seen in hysteria, espe- 
cially in somnambulistic conditions. It has also been 
observed in the first stages of acute mania. But in the 
majority of such cases the special senses are particularly 
apt to be hypereesthetic. 

True cutaneous hyperzsthesia (hyperpselaphesia of 
Eulenburg) is also observed occasionally as the result of 
peripheral changes, and may affect any of the different 
forms of cutaneous sensibility. ‘The sense of tempera- 
ture is sometimes exaggerated after the application of 
a blister,in the painful region of herpes zoster, and in 
rare cases of locomotor ataxia. Tactile sensibility may 
also be exaggerated under similar conditions. 

‘The term hypereesthesia is applied ordinarily to condi- 
tions which are more properly called hyperalgia, ¢.e., the 
production of pain after impressions which ordinarily 
give rise to mere sensations of touch, pressure, etc., as, 
for example, when gentle stroking of the skin in the hy- 
peresthetic zone of herpes zoster gives rise to severe 
pain. Such conditions are associated, as a general thing, 
with true anzesthesia. 

Hyperalgia may be the result of affections of the pe- 
ripheral nerves, the spinal cord, and the brain. It isa fre- 
quent symptom in the first stages of various neuralgias, 
but usually gives way, after a while, to anesthesia, lim- 
ited to the distribution of the affected nerve. It is also 
a very common symptom after injuries of the nerves 
(gunshot wounds, contusions, etc.), and may then be as- 
sociated with muscular hyperesthesia. It is also an al- 
most constant symptom in neuritis, and in such cases is 
generally associated with anesthesia. In a case of neu- 
ritis of the brachial plexus, affecting mainly the radial 
nerve, and at present under my observation, there is ex- 
quisite hypereesthesia of the integument and muscles sup- 
plied by the affected nerve, although the most careful 
examination fails to reveal the slightest disturbance of 
sensation in any other respect. Even holding the news- 
paper in the hand for a little while soon causes an intol- 
erable peculiar pain in the skin and muscles. In certain 
of these cases muscular hypereesthesia is observed inde- 
pendently of cutaneous hypereesthesia. 

The latter is also a constant attendant of causalgia, 
or the burning pain in the skin, first described by Weir 
Mitchell, after injuries to nerves, and which is usually 
attended with glossy skin or other trophic changes in the 
cutaneous appendages. 

Hyperzesthesia is also observed quite often in diseases 
of the spinal cord. It is a very early symptom in spinal 
meningitis, and affects the integument and the deeper 
parts. At the same time, the cutaneous and tendon re- 
flexes in the hypereesthetic region are usually dimin- 


ished, as the result of pressure on the roots of the nerves, 
It is sometimes observed in acute myelitis, but is by no 
means as frequent as anesthesia. It generally occurs as 
hyperalgia. 

In locomotor ataxia, likewise, hypereesthesia is much 
less frequent than aneesthesia. It is often observed dur- 
ing the time when the patient is suffering from the ful- 
gurating pains, and is then usually confined to circum- 
scribed patches of skin. It generally disappears with the 
pains. Stern reports two cases in which the hyperes- 
thesia seemed to affect only the sense of touch. When 
the patches were gently touched with a pencil, a sensa- 
tion of scratching with a needle was produced, but no 
feeling of pain. Hypereesthesia to the sense of cold alone 
is also observed in tabes, and may be widely diffused 
over the body. The patients then complain of pain on 
being touched with cold objects, which cause no disagree- 
able sensation in healthy individuals. 

Leyden has also called attention to a condition in tabes 
to which he has applied the term ‘‘relative hyperes- 
thesia.” The patients are anesthetic so far as regards 
feeble stimuli, but when the stimulus reaches a certain 
degree of intensity an exaggerated painful sensation is 
produced. 

In unilateral lesions of the cord hyperesthesia is said 
to be sometimes present over the entire limb on the same 
side as the lesion. In addition, a narrow girdle of hy- 
peresthesia around the trunk is sometimes observed 
above the narrow zone of anesthesia. 

Unilateral hypereesthesia also occurs, in rare cases, in 
diseases of the pons. In some cases of pons lesions, 
hypereesthesia, confined to the trigeminus nerve on the 
side of the lesion, has also been observed. 

In cerebral hemorrhage hemihypereesthesia is observed 
rarely on the paralyzed side. It usually occurs some 
time after the disappearance of the hemianesthesia, and 
lasts a variable length of time. It is not uncommon to 
find exquisite hyperzesthesia around the joints after con- 
tracture, secondary to hemiplegia, has occurred. 

In tumors of the brain localized hypersesthesia in some 
part of the skull (sometimes corresponding very closely 
to the locality of the tumor) is a quite common symp- 
tom. Hyperesthesia of the trigeminus is observed less 
frequently under such circumstances. 

In ordinary acute meningitis there is very often ex- 
quisite hyperesthesia of the entire body, so that the pa- 
tient shrinks at the slightest touch. This is also true of 
tubercular and basilar meningitis, and the hyperzesthesia 
is often so marked that the patient reacts to a slight stim- 
ulus with evident signs of pain, even though he is in a 
semi-unconscious condition. 

Neurasthenia (nervous exhaustion) is often associated 
with localized hypereesthesia over the spine (spinal ten- 
derness), and sometimes with diffuse hyperesthesia over 
the entire body. Hypereesthesia limited to certain parts 
of the limbs is also observed in some of these cases. It 
usually consists of hyperalgia, but in rarer instances the 
sensibility to heat or cold is alone exaggerated. 

Circumscribed hyperalgia is ‘often found in migraine 
in the parietal region, or there may be diffuse hyperalgia 
of the entire side of.the head. Berger also describes, in 
migraine, exaggerated sensibility to touch (hyperpsel- 
aphesia) and to temperature over the painful side of the 
head. 

Hypereesthesia is observed rarely in syphilis as a pro- 
drome of syphilitic hemiplegia, and this may continue 
for some time after the paralysis has developed. It has 
also been noted in syphilis of the spinal cord, usually 
associated with paralysis. 

It occurs in various ways in hysteria: there may be 
exaggeration of the tactile sense, or muscular sense, but 
more frequently of the special senses. There may even 
be exaggeration of individual qualities of cutaneous sen- 
sibility. For example, the perception of pulsation in dif- 
ferent parts of the body, although the pulsation is not 
increased in violence, depends probably on a true hyper- 
cesthesia of the sense of pressure in the parts. 

The cutaneous sensibility may be so excessive that even 
the contact of a slight current of air is distressing to the 


395 


Sensation. 
Sensation, 


REFERENCE HANDBOOK OF' THE MEDICAL SCIENCES. 


patient. Hysterical hyperesthesia may affect the entire 
integument or only one side of the body. It is often 
confined to a circumscribed region, such as the back, the 
lateral or anterior surface of the chest and abdomen, the 
limbs, the vulva, the mammary glands, the region of the 
ovaries. 

The term paresthesi@, or perversions of sensation, is ap- 
plied to those conditions in which the sensation following 
a stimulus differs in kind from that normally produced 
under similar circumstances. In the large majority of 
cases these paresthesix are not preceded by external stim- 
uli, but appear to result from abnormal processes in the 
nerves or central nervous system. ‘These sensations in- 
clude itching, formication, numbness, and unusual feel- 
ing of heat (ardor), etc. When they are accompanied by 
pain, the term paralgesie@ is sometimes employed. 

Pruritus (itching) is a peculiar sensation that cannot be 
defined clearly in words. 
may also appear as an idiopathic affection. It is found 
in numerous skin diseases, In wounds during the forma- 
tion of granulations, in jaundice, scarlatina, measles, dia- 
betes, etc. In all such cases the symptom is generally 
attributed to irritation of the nerve terminations in the 
cutaneous papiille, either by morbid exudations or by the 
presence of noxious elements in the blood. In much 
rarer cases pruritus is an idiopathic affection of the skin, 
unattended by an eruption—except such as occurs sec- 
ondarily to scratching—and usually confined to circum- 
scribed parts, though in some cases, especially in old 
people, it involves almost the entire integument. 

Formication is the term applied to a sensation variously 
described as numbness, ‘‘crawling of ants,” ‘falling 
asleep,” etc. Unlike pruritus, it is not often produced 
by irritation of the terminal filaments of the nerves, but 
usually results from partial interference with conduction 
along the course of the peripheral nerves or the sensory 
tracts in the central organs. It may also result from the 
presence of poisonous elements in the blood, as, for ex- 
ample, in poisoning by ergot, opium, or veratrine. 

One of the most frequent causes of formication is com- 
pression of the nerves. This has been experienced by 
everyone, in the parts supplied by the ulnar nerve, from 
a blow on the ‘‘funny-bone.” It is often found in the 
more severe forms of nerve lesions attended with motor 
paralysis. In such cases it is usually accompanied by 
anesthesia, but it may also exist independently of the 
latter. 

Formication is also a frequent symptom in various 
forms of diseases of the spinal cord, especially in acute 
and chronic myelitis and locomotor ataxia. In myelitis 
it is generally experienced first in the legs and soles of 
-the feet. Before any demonstrable changes in sensation 
can be detected by examination, the patient complains of 
a feeling of numbness in the feet, as if he were walking 
on velvet or a cushion of air, etc. As the disease ad- 
vances this symptom generally gives place to anesthesia. 
In locomotor ataxia the feeling of formication may be 
experienced in circumscribed parts of the body, but be- 
gins commonly in the soles of the feet. Formication in 
the distribution of both ulnar nerves often precedes for a 
long time the development of the ataxic symptoms in the 
upper limbs. 

This symptom is also very frequent in hypochondriasis, 
and may appear in any part of the body. It often fur- 
nishes the basis upon which the patient erects a whole 
complex of symptoms. For example, if such an indi- 
vidual experiences formication in the back, he is apt to 
infer that he is suffering from some disease of the spinal 
cord, and ‘‘ expectant attention ” soon enables him to fur- 
nish a multitude of other symptoms. 

In hysteria, neurasthenia, and other neuroses, formica- 
tion also plays its part as a minor symptom. 

The terms ardor and algor are applied to feelings of 
unusual heat and cold of the skin, when they arise inde- 
pendently of an adequate external cause. These sensa- 
tions are usually, though not always, associated with a 
corresponding congestion or anzmia of the parts, as in 
the paroxysms of intermittent fever, the onset of acute 
infectious and febrile diseases, and in various disturb- 


396 


It is usually symptomatic, but: 


ances of the vaso-motor system. They are sometimes ob- 
served independently in hysteria and neurasthenia, and 
are very frequent in nervous women at the menopause. 
A very distressing and constant sensation of heat over 
the entire body is also a common symptom in paralysis 
agitans. 

Charcot first applied the term dysesthesia to a pecu- 
liar condition, which he described as follows: ‘It is a 
sort of hyperesthesia in which the slightest irritation, 
such as a slight pinch, or the application of a cold body, 
gives rise to a distressing sensation, which is always the 
same whatever may be the nature of the stimulus, and 
in which, according to the statements of the patients, a 
feeling of vibration predominates. These vibrations ap- 
pear to ascend and descend the limb at the same time. In 
the majority of cases the sensations persist for some min- 
utes, sometimes for a quarter of an hour or more, after 
the cessation of the cause which gave rise to them. In 
such cases the patient always experiences great difficulty 
in accurately localizing the place where the irritation 
had been produced. Finally, itis not rare that the stimu- 
lation of one limb, after having given rise to the phenom- 
ena indicated, is followed, at the end of some time, by an 
analogous sensation, which appears to be situated in a 
part of the opposite limb corresponding to the region 


primarily stimulated.” 


The phenomenon in question has been observed by 
Charcot in the compression-myelitis of Pott’s disease, and 
in acute and chronic dorsal myelitis. 

Allochiria is a peculiar perversion of sensibility, which 
was first described, in 1881, by Obersteiner. The term 
is applied to the following condition: ‘‘ When we test 
the sensibility of a patient on the leg, for example, and 
find that the two points of the esthesiometer are recog- 
nized as such at a moderate distance apart, or when a 
prick or pressure is fairly localized, and yet, as frequently 
occurs, the irritation is referred to the other side, we have 
the condition before us. The power of localization is re- 
tained as to details, while doubt or error exists as to the 
side touched, the irritation being commonly referred to 
the corresponding part of the other limb.” 

This symptom seems to have been observed in a very 
few cases of locomotor ataxia, compression-myelitis of 
Pott’s disease, and hysteria. 

Oppenheim has recently described a peculiar perver- 
sion of sensation, the significance of which is entirely un- 
known, in unilateral lesions of the brain. If the two sides 
of the body are subjected simultaneously to stimuli of 
equal intensity, the sensation is felt only on the healthy 
side, but is perceived on the paralyzed side when the lat- 
ter is irritated alone. The stimuli are perceived on both 
sides if that on the paralyzed side is applied with greater 
intensity. This symptom was observed in only four 
cases of unilateral disease of the brain, although a large 
number of such cases were examined. It never occurs 
in healthy individuals. 

Polyesthesia is a rare disturbance of sensation, first de- 
scribed by Brown-Séquard, in which the point of a pin, 
when applied to the skin, is felt as two or more points. 

Naunyn applies the term after-sensation to a peculiar 
disturbance which he noticed in locomotor ataxia. The 
pain produced by the prick of a pin rapidly disappears 
at first, but soon returns at the point of irritation, and 
then may increase in severity and persist for hours. I 
have also observed this symptom in cases of chronic mye- 
litis, but the pain was not as persistent as described by 
Naunyn. 

VISCERAL SENSATIONS.—It is very probable that the 
action of all the viscera, particularly those of the thorax 
and abdomen, is attended by a specific effect on the 
brain. In the normal state this does not rise to the 
level of consciousness, but merely affects the mood of 
the individual. In disordered action of the viscera, how- 
ever, or of the nerves which: supply them, this visceral 
stimulus often is converted into a conscious sensation, 
usually of a vague, distressing character, which may be 
referred either to the organ which is the seat of disor- 
dered action, or to remote parts of the body. Everyone 
is probably aware of the mental depression which is as- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


sociated so often with constipation, and which disappears 
at once after a free evacuation from the bowels. The dis- 
ordered action of any viscus may exercise an injurious 
effect in the same way. 

We will now enter briefly into the consideration of 
the more important disturbances of visceral sensation. 

Hunger is a peculiar sensation that need not be de- 
scribed in words; it is commonly referred to the stom- 
ach, although it is really an expression of the want of 
food by the general system. In certain cases there is 
a morbid increase of hunger, known as boulimia, which 
is observed chiefly in diabetes, hysteria, epilepsy, mania, 
general paralysis of the insane, and sometimes in cerebral 
syphilis. Romberg and Liveing state that this symptom 
sometimes occurs as a forerunner of the gouty paroxysm. 
In one case Eulenburg observed it, in connection with 
hemicrania, in a non-hysterical girl of twenty-one years 
of age. Willis and Liveing also mention a couple of 
cases in which boulimia occurred as a prodromal symp- 
_ tom of migraine. In rare instances it appears to be an 
independent neurosis. In a case under my observation 
it was transmitted from father to son. 

In these cases the patient, even within a short time 
after a hearty meal, or perhaps on awaking from a 
sound sleep, is seized with an irresistible and sudden 
feeling of hunger, and devours large quantities of food. 
At other times the ingestion of a small amount of food 
serves to relieve the distressing symptoms. In severe 
attacks the feeling of hunger may be associated with 
general tremor of the body, a profuse outbreak of per- 
spiration, and a feeling of faintness which may become 
almost insupportable. At the same time there may be 
an uneasy, gnawing sensation, with a feeling of sinking 
in the gastric region. Boulimia has been attributed to 
an anesthesia of the gastric branches of the pneumo- 
gastric nerve, but this is by no means clearly proven. It 
is quite certain that the condition is of central origin in 
many cases. Some writers believe that it is due to an 
affection of the sympathetic. It belongs, in all proba- 
bility, among the pareesthesiz. 

The term polyphagia indicates a condition in which 
satiety is not produced until an enormous amount of 
food has been ingested. In a number of cases of this 
kind, lesions of the pneumogastric have been found, 
and the affection is probably the result of anesthesia of 
this nerve. This symptom is observed in hysteria, epi- 
lepsy, various forms of insanity, diabetes, and also in 
diseases of the medulla oblongata. 

Thirst is an indication of the want of fluid felt by the 
general system, but may also arise from dryness of the 
mucous membrane of the palate and pharynx. Poly- 
dipsia is a morbid exaggeration of thirst. It is observed 
in diabetes mellitus and insipidus, and occasionally in 
hysteria. Cohnheim has expressed a doubt as to the 
occurrence of primary polydipsia, but this doubt is dis- 
pelled by the experience of Nothnagel. The latter 
writer reported a case in which polydipsia developed 
acutely half an hour after a fall on the back of the head 
which was attended with unconsciousness. This was 
followed, at the end of two to three hours, by a perma- 
nent increase in the excretion of urine. The symptom 
was probably the result of an injury to the medulla ob- 
longata. 

Fright is almost always associated with disturbed ac- 
tion of the heart, and in many cases it seems to be the 
result of hyperesthesia of the sensory fibres distributed 
to that organ. This condition is known as precordial 
fright. In uncomplicated cases the patients suffer from 
a feeling of impending dissolution, and, at the same 
time, of unspeakable anguish, attended with a distressing 
sense of oppression in the region of the heart. As a gen- 
eral thing the cardiac action is feeble, often irregular ; 
during the attack the pulse is correspondingly feeble, the 
skin pale and covered with cold perspiration. In rarer 
cases the action of the heart is strong and forcible, the 
pulse full and bounding, and the face congested. The 
symptoms on the part of the pneumogastric are some- 
times attended by phenomena which must be referred to 
the glosso-pharyngeal nerve, viz., a feeling of scratching 


Sensation, 
Sensation, 


in the throat, and a sense of dryness and constriction in 
this region. In some cases there is an intense feeling of 
‘*goneness,”’ which is referred to the epigastric region, 
This may be attended or followed by profuse watery 
diarrheea, or the discharge of so-called spastic urine. In 
severe attacks there may be confusion of ideas, and this 
may even pass into complete unconsciousness of the sur- 
roundings. 

Preecordial fright sometimes develops in healthy indi- 
viduals during dreams, especially after partaking of a 
heavy, indigestible meal. In the midst of a troubled, 
uneasy sleep there is a sudden awakening, with an agon- 
izing sense of vague fear, a feeling of great oppression 
about the heart, and severe palpitation, or perhaps a few 
labored heart-beats. The symptoms subside in a few 
moments. This condition is probably a reflex symp- 
tom of irritation of the pneumogastric in the stomach. 

But fright is not always of a precordial character. It 
is sometimes of an indetinable general character, with- 
out any special localization. This is seen not infrequently 
in cases of hypochondriasis, cerebral syphilis, and at the 
onset of various acute infectious diseases, particularly in 
miliary tuberculosis. Samt states that he himself suf- 
fers from attacks of fright which are localized in the 
frontal region. Other localizations have also been re- 
ported. a UES 

Precordial fright is a frequent symptom of nervous 
diseases. It is observed in the night terrors of childhood, 
where it is often the result of some reflex irritation, but 
is sometimes indicative of a close relationship with epi- 
lepsy. It is also seen in true epilepsy and hysteria. It 
may be a prodromal symptom of migraine, and, in rare 
cases, occurs prior to an attack of cerebral hemorrhage. 
It has also been seen in acute and chronic meningitis, in 
rupture of an abscess, or in hemorrhage into the ven- 
tricles of the brain. In a number of instances I have 
observed it in cerebral syphilis, sometimes in the absence 
of any other evidences of local brain disease. In angina 
pectoris it constitutes almost the entire malady, and may 
or may not be associated with organic disease of the heart 
or great vessels. In like manner, it is a not infrequent 
symptom of neuralgias of the abdominal organs. Ina 
case of enteralgia under my observation the condition 
was very pronounced, and, at the same time, there was 
extreme dyspnoea. 

Precordial fright also appears in various forms of in- 
sanity, but plays its most important part in melancholia. 
In the latter affection it is often the immediate cause of 
deeds of violence (melancholic frenzy). Literally beside 
himself with terror, the patient employs violence against 
himself or others, in the effort to free himself from the 
feeling of oppression. 

This condition is usually regarded as a pareesthesia 
or hyperesthesia of the various sensory nerves of the 
heart, more rarely of the abdominal sympathetic ganglia. 
But this theory is by no means proven. In the first place, 
fright is not always preecordial in character. It is some- 
times so vague as to be incapable of localization. More- 
over, it plays a part sometimes in diseases which are 
undoubtedly cerebral in character, such as epilepsy and 
migraine. It seems to me to be more plausible, there- 
fore, to regard the condition in such cases as the result 
of acerebral disturbance, probably in the cortex, which 
is conveyed to the centres of innervation of the heart, and 
sometimes to other nerves (glosso-pharyngeus, etc.). In 
other cases it seems to result from increased irritability 
of the nervous supply of the heart or abdominal viscera, 
though even then it cannot be denied that there may also 
be a primary cerebral disturbance without which the 
peripheral hypereesthesia would prove inefficient. 

Excessive voluptuous sensations may be the result of 
peripheral or central causes, the latter being much more 
frequent than the former. This condition is observed in 
various diseases of the female genitals (vagina, uterus, 
ovaries), rarely in affections of the male genitals, in dis- 
eases of the urinary apparatus and intestines (helminthi- 
asis). Romberg has observed it in neuralgia of the sper- 
matic plexus. Sexual hyperzsthesia is also observed in 
diseases of the spinal cord, such as locomotor ataxia and 


397 


Sensation. 
Septiczemia. 


multiple sclerosis, probably as the result of irritation of 
the lumbar genital centre. This condition must be dis- 
tinguished from priapism, which is generally unattended 
with increase of the sexual sensations. Among cerebral 
diseases it is observed in epilepsy (sometimes as a prodro- 
mal symptom, sometimes during epileptoid states), hys- 
teria, hypochondriasis, the initial stages of melancholia, 
and acute mania. Sexual hypereesthesia is also observed 
occasionally during convalescence from acute diseases, 
and very often during phthisis. It is a frequent symp- 
tom of hydrophobia. We have also noticed it very often 
during the menopause, sometimes even after the sexual 
desire had been abolished for a long time. 

Sexual anesthesia is observed more often in men than 
in women as an acquired condition. In women it is 
found often as a symptom of hysteria, perhaps associ- 
ated with anesthesia of the mucous membrane of the 
vulva and vagina. <A similar anesthesia of the glans 
penis is not infrequent in males, as the result of exces- 
sive onanism or prolonged sexual excesses of any kind, 
and is often associated with anesthesia of the urethra 
and prostatic sinus. These are the cases in which dis- 
gusting sexual abuses are so often found, because the 
patient must resort to some other than the natural mode 
of stimulation of the genital centres in order to consum- 
mate the sexual act, z.e., to secure the orgasm. 

Sexual anesthesia is also seen in locomotor ataxia, 
multiple sclerosis, and other cord diseases, and in numer- 
ous conditions of general exhaustion, particularly when 
associated with mental depression. It not infrequently 
forms the basis of insane delusions, especially in the fe- 
male. Leopold Putzel. 


SEPTICAEMIA AND PYAEMIA, In his admirable de- 
scription of the repair of wounds, Billroth devotes a 
section to the ‘‘ general accidental diseases which may 
accompany wounds and other local inflammations.’’ He 
states that in the great majority of cases, in wounds of any 
size, fever occurs sooner or later, and of these fevers he 
discusses at length three forms, viz., (@) traumatic and in- 
flammatory fever; (0) septic fever and septicsemia ; (c) 
suppurative fever and pyemia. The clinical history of 
these fevers may be summarized from his treatise as 
follows: 

1. TRAUMATIC AND INFLAMMATORY FEVER.—Possibly 
even on the first day of the operation the patient may 
have been restless toward evening ; he may have felt hot 
and thirsty, with no appetite, some headache, wakeful 
at night, and dull the next morning. These subjective 
symptoms increase until the evening of the next day. If 
we feel the pulse we find it more frequent than normal, 
the radial artery is tenser and fuller than before, the 
skin is hot and dry ; the bodily temperature is elevated ; 
the tongue is coated and readily becomes dry. The pa- 
tient has fever. In many cases, especially where the 
injury has affected tissues previously healthy, the fever 
does not begin till the second day, increases rapidly, and, 
with evening remissions, remains for some days at a cer- 
tain height, and then ceases gradually, rarely within 
twenty-four hours. Traumatic fever usually lasts a week. 
As long as the constitutional symptoms, especially those 
due to the fever, do not extend beyond this limit, and 
especially if the disease does not prove fatal, the terms 
traumatic, suppurative, or secondary fever are satisfac- 
tory. But, if other symptoms occur, and death results, 
these severer infections have two other names, ‘‘ septi- 
ceemia” and ‘‘ pysemia.” 

2. SEPTIC FEVER—SEPTICHMIA.—This kind of fever 
differs from the former in the greater disturbance of the 
wound, and the severer constitutional symptoms. The 
local infection is very extensive, with phlegmonous in- 
flammation and putrefaction. The patients are apathetic 
and sleepy, if not entirely comatose ; there may be great 
excitement, and occasionally maniacal delirium; the 
tongue is dry, often hard, and hence the speech is pecu- 
liar ; the thirst is great, but patients may be too stupid 
to ask for water; there may be diarrhea, but rarely 
vomiting ; sweating may be profuse at first, but later the 
skin is dry and flabby; the urine is scanty, very con- 


398 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


centrated, and occasionally albuminous; the urine and 
faeces are later passed in bed ; bed-sores over the sacrum 
early occur; the fever, as shown by the bodily temperature, 
at first rises high ; in acute pure septicaemia intercurrent 
chills never occur in the course of the disease, and initial 
chills are very rare. Later in the disease the temperature 
falls to the normal, or even below it; usually the patient dies 
in perfect collapse, with a thread-like, very frequent pulse; 
often the agony lasts over twenty-four hours. This is 
the usual course of acute pure septicemia from recent 
injuries. The post-mortem conditions in fatal septice- 
mia vary; frequently the internal organs present no 
morbid appearances ; if, however, there was continued 
profuse diarrheea, the solitary and conglobate intestinal 
glands will be found swollen; the spleen is often en- 
larged and softened, rarely it is of normal size and firm- 
ness ; the liver is usually full of blood, relaxed, and very 
friable, but without further change. In the heart the 
blood is lumpy, half-clotted, tarry, and rarely firmly co- 
agulated. In most cases the lungs are normal, but some- 
times there is diffuse single or double pleurisy of mod- 
erate extent, and also traces of pericarditis. As nothing 


- special has been found on chemical analysis of the blood 


from the bodies, what we find post mortem adds little 
that is characteristic to the picture of the disease. 

3. SUPPURATIVE FEVER—PyamiA.—The characteris- 
tic course of a case of pyemia is as follows: Supposing 
the patient to be suffering from compound fracture of 
the leg, just above the ankle, he may feel very well and 
have but little fever till about the third or fourth day, 
when the wound becomes more inflamed, secretes rela- 
tively little pus; the surrounding skin becomes cedema- 
tous and red; the patient grows very feverish, espe- . 
cially toward evening ; the swelling increases and slowly 
spreads, the whole leg becomes swollen and red, the 
ankle-joint very painful; on pressure over the leg a 
thin, badly smelling pus flows slowly from the wound ; 
the swelling remains limited to the leg; there is no 
trouble of the mind, no sign of intense, acute septice- 
mia; the patient is exceedingly sensitive to every dress- 
ing, he is restless and discouraged ; there is febris con- 
tinua remittens, with high evening temperature, and 
frequent, full, tense pulse ; the appetite is lost, and the 
tongue heavily coated. This would be about the twelfth 
day of the injury. Quantities of pus flow from differ- 
ent parts of the wound ; somewhat above it fluctuation 
is distinct ; this collection of pus may be evacuated 
through the wound by careful pressure, but the escape 
is greatly impeded, and an incision must be made at the 
above point. This being done, a moderate quantity of 
pus is evacuated ; a few hours later the patient has a 
severe chill, then dry, burning heat, and, lastly, profuse 
sweating. The appearance of the wound improves some- : 
what, but this does not last long ; we soon notice a new 
abscess near the wound, but rather behind it in the calf ; 
there is another chill; more counter-openings are re- 
quired at different spots to give exit to the pus, which 
forms in quantities. The left leg is the injured one; 
some morning the patient complains of great pain in the 
right knee-joint, which is somewhat swollen, and is pain- 
ful on every motion. The nights are sleepless, the pa- 
tient eats very little, drinks a great deal, and becomes 
much debilitated ; he emaciates, especially in the face ; 
the color of the skin changes to yellowish, the chills re- 
cur ; the patient then begins to complain of pressure on 
the chest ; he coughs some, but raises little sputum ; on 
examining the chest you find a moderate pleuritic exu- 
dation on one or both sides, from which, however, the 
patient does not suffer much, but he complains more of 
the right knee, which is now much swollen, and contains 
a great deal of fluid ; as the patient sweats a great deal, 
the urine becomes very concentrated, and is occasionally 
albuminous. Finally, bed-sores develop, but the patient 
does not complain much of this ; he lies quietly, half-in- 
sensible, muttering to himself. This would be about the 
twentieth day after the injury. The wound looks dry, 
the patient looks miserable ; the face, and especially the 
neck, is emaciated ; the skin is very jaundiced, the eyes 
are dull, the trembling tongue is perfectly dry, the skin 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sensation, 
Septiczemia, 


cool, the temperature low, and only elevated at evening, 
the pulse small and frequent, the respirations slow, the 
breath of a peculiar cadaveric odor; the patient becomes 
entirely unconscious, and may, perhaps, remain so for 
twenty-four hours before death. On autopsy you find 
nothing pathological in the skull; heart and pericardium 
normal ; in the right auricle and ventricle a firmly coag- 
ulated, white, fibrinous clot ; both pleural cavities are 
filled with a cloudy, serous fluid ; the surfaces of the 
lungs are covered with a net-like layer of jaundiced 
fibrine ; on tearing this off, under it, in the substance of 
the lung, but particularly on its surface, you find quite 
firm nodules, as large as a bean or chestnut. These are 
found chiefly in the lower lobes ; sections through them 
show that they are mostly abscesses. The parenchyma 
of the lungs, somewhat condensed, forms the capsule of 
a cavity which is filled with pus and disintegrated lung- 
tissue. Others of these nodules are blood-red, and, on 
section, the cut surface is somewhat granular, and in 
their midst there are occasional spots of pus of various 
size, making it evident that they change to abscesses. 
They are red infarctions terminating in abscesses. Some 


of these abscesses lie so near the surface that they im-' 


plicate the pleura, and the pleuritis is secondary. The 
liver is quite vascular and friable, but is otherwise ap- 
parently normal. The spleen is somewhat enlarged, and, 
on section, shows a few firm, wedge-shaped nodules, with 
their points turned inward, and their broad outer ends 
along the surface; they resemble the red infarctions of 
the lungs, and within they also have partly broken down 
into pus. The intestines and urinary and genital organs 
show nothing abnormal. An incision into the right 
knee, which was painful during life, gives exit to a quan- 
tity of flocculent pus; the synovial membrane is swollen, 
and in part hemorrhagic, injected ; the lustre of the ar- 
ticular cartilage is dulled. Examination of the wound 
shows little more than we found on the living patient, 
that is, extensive suppuration of the deep and subcuta- 
neous cellular tissue, as well as pus in the ankle-joint ; 
the walls of all these collections of pus consist mostly of 
broken-down tissue; true granulation has only occurred 
at a few points. In the veins of the legs there are old 
plugs of fibrin here and there, also yellow puriform de- 
tritus, and in some places pure pus. 


In the preceding sketch every surgeon who practised 
prior to the last decade will recognize a faithful portrai- 
ture of the general accidental diseases which formerly 
so uniformly accompanied wounds and other local in- 
flammations. Any considerable operation - wound not 
followed by inflammation and fever, was an anomaly 
that excited universal surprise. A compound fracture 
of the leg, just above the ankle, caused by the fall of a 
heavy body, which was not followed by the train of 
symptoms above detailed, was the rare exception. At 
all periods of human history the healing of wounds 
must, from time to time, have been complicated by all 
of the conditions which we now recognize as septicaemia 
and pyemia. In the works of the earliest medical au- 
thors, and even of the early historical writers, we dis- 
cover more or less accurate accounts of the appearance 
of these affections among the fatal complications of 
wounds after great battles. But the true nature of these 
complications was not suspected, and hence we find a 
great variety of crude explanations and opinions. It is not 
surprising that the etiology of these wound- and suppu- 
rating fevers has excited the interest of surgeons at all 
periods of this history. Indeed, there is no branch of sur- 
gical literature which exhibits a larger range of study and 
a more thorough analysis of clinical, pathological, and ex- 
perimental facts than that comprised in the terms septi- 
cemia and pyemia. The peculiar and mysterious train 
of symptoms which so often developed when the healing 
process pursued an unfavorable course, excited the curi- 
osity of even the most ordinary observer, and profoundly 
interested the student of pathology. And the interest of 
all surgeons in these affections was heightened by the 
great fatality which attended the severer forms of fever. 
No complications of a wound were so serious and alarm- 


ing as septicemia and pyemia. The apprehension of 
the surgeon, lest these affections be developed, was so 
great that he often felt compelled to decline operations 
unless he could choose the locality where they were to 
be performed, or the season of the year in which to op- 
erate. The fear of blood-poisoning following wounds 
has long delayed the advance of operative surgery. But, 
happily, the period of doubt and fear has passed away, 
and the art of surgery has been forever relieved of the 
greatest obstacle to its complete success. The terms sep- 
ticemia and pyemia belong to the past history of sur- 
gery, and their true significance will never again be fully 
appreciated except by surgeons who neglect preventive 
measures. 

The history of septicemia and pyemia must, there- 
fore, comprise one of the most interesting chapters in the 
science and art of surgery. The practical value of this 
history to the modern student of surgery is not limited 
to the mere knowledge of the methods by which experi- 
mental physiology has solved an intricate problem of 
pathology, but it has a far deeper significance. That 
knowledge is essential to the successful practice of the 
preventive methods in whatever form they may be un- 
dertaken. No surgeon can properly appreciate the im- 
mense revolution which has taken place in the practice 
of surgery within the last decade, and apply his knowl- 
edge successfully, who does not first understand, at least 
in some measure, the nature and details of the investiga- 
tions which led to that revolution. 

This article will be devoted, therefore, to the more sa- 
lient facts in the history of the investigations into the 
causes of septiceemia and pyzemia, with a view to illustrate 
their nature, and the reforms in practice which have grown 
out of the discovery of the conditions on which these 
affections depend. To the elaborate work of M. Jeannel 
(‘‘L’Infection Purulente ou Pyohémie,” Paris, 1880) we 
are chiefly indebted for the historical summary of the in- 
vestigations into the nature and causes of pyzmia. 

HisToricAL SUMMARY.—Many early writers described 
abscesses in parts distant from the seat of the wound. 
In 1559, Nicolas Massa reported a case of abscess of the 
lung consecutive to a wound of the head ; in 1561, Am- 
broise Paré described cases of wounds of the head with 
secondary abscesses ; in 1665, Marchetti attributed ab- 
scess of the liver, after wounds of the head, to the descent 
of the pus through the lungs and pleura ; but Boerhaave 
(1720) first formulated the doctrine that, by the admixture 
of pus with the blood, this liquid is so changed as to lead 
to the collections of pus in the organs, 

Le Dran (1731) and Heister (1739) adopted the views 
of Boerhaave. In 1761, Morgagni related several cases 
in which autopsies revealed pus in the veins, and ab- 
scesses in the viscera, after wounds of the head. He at- 
tributed their occurrence, says an author, to particles of 
pus which, having become mixed with the blood and 
disseminated, are arrested in some of the narrow pas- 
sages, and, by obstructing and irritating these, offer an 
obstacle to the circulation of the humors, and become the 
cause of the production of a much larger quantity of pus 
than that which was primarily introduced. From this 
time to the middle of the eighteenth century there were 
many publications in which cases were reported of ab- 
scesses secondary to wounds, with speculations as to the 


- origin of the pus in the abscesses. 


Bertrandi, in 1757, presented to the Academy of Sur- 
gery, Paris, a memoir on abscesses of the liver follow- 
ing wounds of the head. He regarded abscess of the 
liver as especially liable to occur when the patient vom- 
ited, or had convulsions or epistaxis, which caused a de- 
rangement of the circulation of the blood of the head. 
The result of this derangement was encephalic conges- 
tion, and an active descent of the blood in the vena cava 
superior; the hepatic branches being in a large organ 
and without action, and also connected by many open- 
ings with the ascending cava, become congested, stasis 
follows, which results in gangrene or suppuration, more 
frequently the latter. 

The opinion that multiple abscesses are due to sym- 
pathy was vaguely expressed by surgeons, and among 


399 


Septiczemia, 
Septiczmia. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


others by Pigrai, in 1612. Goursaud, in 1759, distinctly 
enunciated the doctrine that these abscesses were due to 
paralysis of the nerves of vessels, producing a stasis which 
resulted in inflammation. Desault adopted the theory 
(1794), and Larrey, in 1812, reproduced it with additional 
explanations. . Under the term fiévre jaune, which he af- 
terward abandoned, he gave very exact clinical descrip- 
tions of acute and chronic purulent infection. He re- 
garded it as contagious. In 1817, and again, in 1829, he 
reported cases and attributed them to sympathetic irrita- 
tion of the liver and lungs. Sir Charles Bell also adopt- 
ed the opinion of Desault (1817), but admitted the possi- 
bility of latent visceral lesions. Travers, in 1818, in his 
statement concerning phlebitis, explains the symptoms 
by a lesion of the nervous system. Begin (1821), Saba- 
tier (1822), and Boissat (1822), accord part of the action, 
directly or indirectly, to the nervous system. Copland 
(1844) and Brodie (1858) sustain the influence of the ner- 
vous system, the former attributing the action to the 
ganglionic system, and the latter to a lesion of the cere- 
bro-spinal system. 

In 1821, Richeraud advanced a new doctrine, in oppo- 
sition to the then prevailing doctrine of Desault. He 
attributed abscess of the liver, following wounds of the 
head, to the commotion of this organ at the time of the 
injury. He attached great importance to the large size 
of the liver, its situation, and its parenchymatous tissue. 
He ignored the frequency of multiple abscesses of other 
viscera following wounds, and considered only wounds 
of the head and abscess of the liver. 

Certain writers attributed multiple abscesses to the 
suppuration of pre-existing tubercles due to the traumatic 
fever. Though the existence of tubercles had been pre- 
viously mentioned by authors, it was not until 1817 that 
the complete theory was broached by Sir Charles Bell. 
He remarks: ‘‘If there be any tendency to disease in this 
organ, however latent before the injury, it will be de- 
veloped, and, increasing the constitutional disturbance, 
endanger the patient’s life. It also appears that as 
wounds, by their sudden and more violent inflammation, 
produce a corresponding acute attack on the lungs, so 
do they often, by more gradual influence, bring on a 
phthisis. . How often are we inclined to say that 
the patient who dies after a great operation has fallen a 
victim to abscess of the lungs, without duly considering 
how much the stimulus of the knife had to do in exciting 
this mischief?” 

Suppression of suppuration was long considered one 
cause of the occurrence of multiple abscesses. This was 
the doctrine of metastasis, pure and simple, 'viz., the 
process of suppuration, having been suppressed in the 
wound, is transferred to the viscera. In 1749, Quesnay 
entertained the opinion that the pus formed in the vessels, 
and that the suppression had no effect in producing ab- 
scesses of the viscera; the latter were not caused by the 
former, but vice versa. Boyer (1814) denied this interpre- 
tation of the phenomena. ‘‘ The accidents,” he remarked, 
“which are attributed to the suppression of suppuration 
appear rather to be the cause, especially in those cases in 
which the accidents do not precede suppression.” 

In 1774, John Hunter read his paper on the ‘‘ Inflam- 
mation of the Internal Coats of Veins,” which greatly 
intluenced the opinions of surgical pathologists. He 
demonstrated the entrance of pus from the inflamed 
vein into the circulation, and while he attributed the 
fatal termination of phlebitis to the abscesses in the vis- 
cera, he did not actually announce the dependence of the 
abscess upon the preceding inflammation of the veins. 
Hodgson, in 1816, and later his translator, Breschet (1819), 
were the first authors who suggested the connection be- 
tween phlebitis and abscesses of the viscera. The subject 
was further illustrated by the publication by Ribes, in 
1816, of a paper containing researches on the causes of 
death of puerperal women, in whom he demonstrated the 
presence of pus in the veins. In 1820, Gendrin instituted 
an experiment to prove the transformation of blood into 
pus, a view held by Quesnay and Horne. He mixed one 
part of pus with eight parts of blood, and proved, with 
the aid of the microscope, the disappearance of the blood- 


400 


globules in twenty-four hours. In 1821, James expressed 
a doubt as to the possibility of the penetration of pus into 
the vessels, but in the same year Erdmann, studying 
positive cases of purulent infection with abscess of the 
viscera, found pus in the inflamed veins, and declared 
that this was the cause of abscess and of death. 

In 1822, Gaspard first attempted to determine the ques- 
tion in dispute by the experimental method, and injected 
pus into the veins of animals. The pus was first changed 
by exposure to the air. He had not in view purulent in- 
fection, but septicemia. In 1823, Velpeau published his 
inaugural thesis, in which he employed the term énfec- 
lion purulente to designate the state of the blood altered 
by pus. Notwithstanding preceding works, the truth of 
the dogma of ‘the mixture of pus and of blood was not 
generally received. 

In 1826, Velpeau reiterated his views, in an article on 
‘* Alterations of the Blood in Diseases.” He contended 
that the vitiation of the blood by pus was the only cause 
of the lesions, and rejected all primitive inflammation of 
the solids in the genesis of visceral abscesses. He saw 
in the purulent secretion of the wound the only source 
whence the pus was obtained to infect the blood and the 
general system. In 1828, Piorry advanced the opinion 
that the blood could be inflamed, and even suppurate, 
and gave to the disease which resulted from this suppu- 
ration the name of pyohémie. The researches of Dance 
(1828-29) had a very important influence on current opin- 
ions. In aseries of twenty cases, followed by autopsies, 
he demonstrated the penetration of pus into the circula- 
tion, consecutive to phlebitis. He consequently attrib- 
uted to inflammation of the veins the origin of the com- 
plications occurring to those operated upon, characterized 
by the presence of multiple abscesses of the viscera. 

In 1834, Gunther, of Hanover, published a series of 
experiments of injection of filtered pus into jugular veins, 
for the purpose, especially, of studying the secondary 
accidents of phlebitis. He was successful, in twenty-two 
out of twenty-three operations upon the horse, in creat- 
ing in the lungs inflammatory and purulent centres 
analogous to those of pyohémie. The general symptoms 
simulated those of purulent infection, with the difference 
necessarily appertaining to the constitution of these ani- 
mals. 

The theory, embodied in the title embolic septicemia, 
consisted of two elements, viz., septic poisoning as the 
cause of the general symptoms, and vascular obstruction 
as the source of the abscess. This phase of the subject 
was largely discussed, especially by D’Arcet, Virchow, 
Bonnet, Hueter, and Verneuil, but the discussion did not 
greatly advance the general subject toward a rational 
conclusion. Virchow, and other writers who coincided 
with him, grouped these embolic affections under the 
term metastatical dyscrasie. 'Three forms were given :! 
1, Metastasis associated with the phenomena of embol- 
ism, tending to the development of multiple centres of 
inflammation and their suppuration; 2, metastasis in 
which there is something over and above embolism, and 
quite independent of its occurrence, and which may get 
well if secondary abscesses do not form in important, vis- 
cera—septiceemia, ichorrhemia (S. Ringer) ; 3, metastasis 
combining the phenomena of the two former. 

The doctrine of the spontaneous origin of pus in the 
blood was first advanced by Tessier, in 1888 (dzathése pu- 
rulente). The belief that blood might be transformed into 
pus is very ancient, and the theory had not previously 
been applied to pyemia. Tessier adopted the term puru- 
lent dvathesis, by which he understood a modification of 
the organism, characterized by a tendency to the produc- 
tion of pus in the solids and coagulable liquids of the 
economy. This diathesis is manifested under three 
forms: 1, Purulent fever; 2, purulent phlegmasia ; 3, 
the purulent state. The symptoms of rapid suppuration 
in certain parts of the body are more particularly con- 
nected with purulent fever. The formation of pus takes 
place equally in the liquids and in the solids, unless there 
is the relation of cause and effect between the two phe- 
nomena. In the course of the disease blood may be 
transformed into pus, and the transformation may be 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


_ 


Septiceemia. 
Septiczmia. 


general or partial ; it may, alone or simultaneously, take 
place in the blood-vessels or lymphatics ; often suppura- 
tion occurs only in the tissues and in the parenchyma of 
organs. From this source arise the flakes of pus found in 
the current of the circulation, the suppurative coagula of 
the heart and great vessels, the frequent phlebites, the 
purulent arthrites, and, finally, the suppurating foci scat- 
tered throughout the body, which have been described as 
metastatic abscesses. The nature of the modification of 
the organism which gives rise to the purulent diathesis 
was unknown. Moreover, traumatism is not an indis- 
pensable condition ; the diathesis and purulent fever can 
be produced spontaneously under the influence of ob- 
struction ; they may exist even before traumatism, which 
may only prove to be the exciting cause. . 

At this period, notwithstanding Tessier’s opposition, 
the prevailing opinion was that pyezmia is due to the 
mingling of pus in the blood. But the experimental 
method was again to furnish a new series of proofs, 
establishing a definite conclusion as to the effect 
of the artificial mixture of pus and blood. In 1842, 
D’Arcet reported that he had eleven or twelve times in- 
jected unaltered pus into the veins of animals; in only 
two cases were purulent collections, like those of pye- 
mia, obtained. In all of the other trials there were pro- 
duced only visceral ecchymoses ; the symptoms were 
those of purulent infection. Donné, in 1844, acknowl- 
edged that it was impossible to recognize pus-globules in 
blood, owing to their identity in form and volume to 
leucocytes. In 1846, Castelnau and Ducrest, believing 
that former experiments had not been conducted with 
sufficient exactness, undertook the injection of pus under 
conditions most favorable for obtaining visceral abscesses. 
They made seven experiments. The injection was al- 
ways made upon dogs, and in the saphena vein, at the 
external part of the leg. The pus employed was more 
or less recent, and was always filtered. Five animals 
died, and two recovered. In one instance there was pul- 
monary ecchymosis, and in four cases multiple abscesses 
were fully formed. These abscesses were more frequent 
and more numerous in muscles and cellular tissue ; twice 
‘they were found in the kidneys and spleen and in the 
articulations. The symptoms, in general, strikingly re- 
sembled those observed in wounds complicated with py- 
emia, due regard being given to the particular nature of 
the animals operated upon. The conclusions drawn from 
these experiments were confirmative of the dogma of the 
mixture of pus and blood as the origin of purulent infec- 
tion. 

Following in the same path, Sédillot, in 1849 (Brit. 
and Foreign Med.-Chir. Rev., October, 1849), undertook 
a series of experiments with a view of answering the fol- 
lowing questions: ‘‘Is pyemia the result of a diathesis, 
or is it caused by the introduction of pus into the blood? 
What is the mechanism of such introduction ? Does the 
pus act as pus, or by means of the products it gives rise 
to? If it acts as pus, to which of its elements are we to 
attribute the poisonous properties it seems endowed with? 
Is it the globules, the granules, or the serosity, separated 
or combined, altered or unaltered in properties, that give 
rise to the pyzemic changes and to death? Is the cure 
possible; and what are the true indications of treat- 
ment?” Forty-five experiments were performed on dogs. 
It appears that after a single injection of a moderate quan- 
tity (four grammes) of healthy pus into the veins, the 
animal recovered, having sustained little inconvenience. 
Recovery usually took place after the injection of larger 
quantities (fifteen to twenty grammes), even when this 
was of athickened consistency, containing many globules, 
the symptoms in these cases being much more severe. 
When the animals did die from the effects of a single 
injection, the metastatic abscesses were found to be only 
in the early stages of formation. Even after the injec- 
tion of fetid pus a recovery took place, the fatal effects 
of this fluid evidently depending upon other causes than 
its fetidity. Yet in other cases a smaller quantity of 
fetid than of healthy pus proved fatal, and a small quan- 
tity of gangrenous pus did so speedily. It appeared also 
from these experiments that ‘‘as in man the course of 


Vou. VI.—26 


the symptoms observed depends not upon the passage of 
a certain quantity of pus into the blood at one time, but 
upon the persistence of the source of pus, so, if we wish 
to imitate the effects in animals, we must produce anal- 
ogous morbid conditions by a repetition of the injection 
of pus at short intervals.” 

The theory of a purulent diathesis had been proposed 
in opposition to that of phlebitis and purulent infections 
by pus supposed to be pure. The theory of a disturbance 
or rupture of the equilibrium of the vital forces was devel- 
oped by Chauffard, in opposition to septicaemia and puru- 
ient infection by septic pus. The doctrine of Chauffard 
coincided with that of Tessier in this, that it rejected all 
mechanical causes of disease, denied to the wound and to 
its secretions all direct etiological influence, and sought 
in the individual himself the cause of pyemia. Without 
denying spontaneous pyzmia, it nevertheless made the 
presence of a focus of suppuration, or rather of trauma- 
tism, the ordinary condition of development of the dis- 
ease, and did not admit in any manner the influence of 
an anterior diathesis. Many authors had previously im- 
perfectly sketched this doctrine, but Chauffard more ac- 
curately defined it in the discussion on pyzemia before 
the Académie de Médecine in 1871. He stated that trau- 
matic fever indicates the expenditure of all of the vital 
forces of the organism in their participation in the.repa- 
ration of the wound ; it is neither a necessary nor a salu- 
tary fever ; the organism can with advantage escape it ; 
it is a pathological result of the perturbation, reparative, 
caused by traumatism ; of the effort of the entire being to 
re-establish its integrity and organize the curative pro- 
cess of suppuration. The proof of the participation of 
the organism in the process of suppuration is the pres- 
ence in the blood of leucocytes. The blood of those 
wounded is, therefore, in a temporary pathological state, 
or a state of abnormal activity which creates an unstable 
equilibrium that the least shock disturbs. This equilib- 
rium is destroyed, and the abnormal pus-creating activity 
is deviated, by one cause or another, from its normal 
evolution ; in the same manner as, under similar circum- 
stances, the cancerous activity begets all cancer, the 
syphilitic all syphilis, etc., and also in the same manner 
as the pyogenic wound separates all pus. Pyzmia is 
constituted ; centres of multiple suppuration are created 
under ordinary innocuous and common influences. 

Virchow, in 1846, undertook to prove that purulent in- 
fection, in the literal sense of the word, does not exist. 
He maintained that the venous coagula of inflamed veins 
did not become purulent, but puriform. In 1847, pass- 
ing to the examination of pyemic blood while in circula- 
tion, and relying upon the identity of leucocytes and the 
white globules of pus, he attributed to an accumulation 
of leucocytes the appearance of blood described as py- 
zmia. In 1854, he demonstrated, taking in part, at least, 
the arguments of Cruveilhier, that, the absorption of the 
pus-globules, entire and intact, was an impossibility, and 
that there is no other method of entrance of pus into the 
blood than by an open vessel. Gulliver, of the English 
army, had already stated that the puriform mass in the 
interior of clots does not originate in the walls of the 
vessel or clot, but is produced by transformation of the 
central layers of the clot. On microscopical examina- 
tion he determined that the fluid in these clots did not 
contain pus. 

With these facts as the basis of inquiry, viz., that the 
character of the contents of these clots is puriform, but 
not purulent, and is composed chiefly of granules, Vir- 
chow pursued the inquiry as to the final disposition of 
this material. It was found that these clots or thrombi 
finally soften, disintegrate, and the contents escape into 
the circulation. Virchow demonstrated the embolic char- 
acter of certain products, previously thought to be in- 
flammatory in their origin, found in the form of white, 
fibrine-like masses in the spleen and other organs. He 
was of the opinion that metastatic abscesses in the lungs 
were always embolic ; in cases of puerperal fever, with 
multiple abscesses in the lungs, he alleged that thrombi 
or clots were always found in the pelvic vessels. 

In 1850, Henry Lee performed the following experi- 


40] 


Septiczmia. 
Septiczemia. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


ment: Perfectly pure blood, recently drawn from a vein, 
was mixed with pus; the result was,.in his opinion, a 
more rapid coagulation of the blood and a firmer clot. 
Considering the fact of the frequent obstruction of in- 
flamed veins by a coagulum, he concluded that the co- 
agulation of the blood under the influence of the pus 
ought to be the first link in the chain of the morbid pro- 
cess of pyeemia. According to this theory, the presence 
of pus has the effect of thickening the blood, so that it is 
incapable of pursuing its course through the capillaries, 
and adheres to their walls, and transforms them into so 
many inflammatory centres and purulent dépdéts. This 
doctrine obtained some credence in England, but it was 
intrinsically without merit. 

In 1851-52 Henry Bennett noticed the resemblance be- 
tween pyzemia and leucocythemia. The resemblance was 
found in the identity of form and constitution existing 
between pus-globules and the white globules of the blood, 
an identity to which Donné had drawn attention in 1844. 

In 1853 Dr. W. Jenner,’ of London, attributed the 
multiple abscesses which follow acute specific diseases to 
acondition which he termed pyogenic fever. 'These ab- 
scesses were believed to be due to the diseased state of 
the blood. The opinions of Jenner were in accord with 
those previously advanced by Tessier in 1838, under the 
title purulent diathesis, which he regarded as a tendency 
to suppuration in the solids and coagulable fluids. Ben- 
nett? discussed the subject under the name tchoremia. 

The theory that infectious diseases are produced by 
micro-organisms, had long since been suggested, but in 
1831 Braconnot announced the doctrine that the virulent 
principles are the ferments. This doctrine was based 
upon the fact that agents which arrest fermentation also 
destroy the virulent properties of the infectious liquids. 
In 18386 Donné discovered microscopic organisms in the 
pus of chancres which were not found in ordinary pus, 
and to which he attributed its virulence. In the follow- 
ing year Beauperthuis and Adet de Roseville proved the 
existence of micro-organisms in the pus of chancre, and 
in 1838 the same authors advanced the opinion that these 
animalcules were the cause of fermentation. In 1841 
Raciborski noticed the resemblance between the develop- 
ment of the pustules of variola and the viscous foci and 
phenomena of fermentation. In the one as in the other, 
a minute particle of a body placed in given conditions, 
mingles ina mass of liquid which contains these elements, 
and produces a movement of decomposition, the result 
of which is the reproduction of a material of the nature 
of that which was the first cause of the movement. Com- 
paring surgical multiple abscesses with pustules of variola 
and viscous foci, he felt justified in presuming that the 
explanation was the same for visceral abscesses. The 
qualities of the liquid which they contain prove in some 
degree their origin, and render it probable that they owe 
their existence to the special action of pus on the blood. 
But in order to produce such a remarkable modification 
of the mass of the blood, it is necessary that there should 
be a state of decomposition, as laudable pus does not pro- 
duce any similar change. He, therefore, considered the 
action of putrid pus on the blood as absolutely comparable 
to fermentation, and this was, in his view, the secret of 
purulent infection. 

In 1848 Fuchs mentioned the presence of bacteria in 
certain septic diseases in animals, and, in 1850, Davaine 
reported having discovered vibriones in a quiet state in 
the blood of sheep inoculated with the blood of other 
sheep affected with splenic fever. In the same year Pol- 
lender discovered an infinite number of rods in the blood 
and sanguineous extravasations of cattle dying of char- 
bon. Many other observations were made previous to 
1861, when Pasteur began his demonstrations ; all were 
confirmatory of the existence of micro-organisms in the 
blood, after the injection of purulent fluids, and in cer- 
tain infectious diseases. 

Pasteur first demonstrated the fact that butyric fer- 
mentation has as its agent an organism, a vibrion an- 
aérobie (one living without free oxygen) He next 
(1862) proved that in the atmospheric air there exists an 
innumerable multitude of organized corpuscles, which 


402 


are the germs of fermentation. In 1863 he brought for- 
ward his researches upon putrefaction before the Aca- 
démie des Sciences of Paris. He stated that putrefac- 
tion was determined by organized ferments of the vibrio 
species ; these vibrionic ferments of putrefaction are.-all 
anaérobies ; in a closed vessel putrefaction does not begin 
to be manifested by external signs until after a certain 
lapse of time, at least twenty-four hours. During this 
first period there is a process going on which leads to the 
disappearance of the oxygen gas in the putrefiable mate- 
rial, and its replacement by carbonic acid. If, however, 
the medium is neutral or alkaline, the process is effected 
under the influence of small infusorial aérobies, which 
live by consumption of free oxygen, notably the monas 
corpusculum and the bacterium termo. When the oxygen 
has disappeared, these animalcules perish and are pre- 
cipitated to the bottom of the vase. If the liquid is free 
from the germs of putrid fermentation, the whole remains 
indefinitely in the state of rest. 

Pasteur, therefore, regarded putrefaction as a fermen- 
tation ending in the reduction of putrescible matters. 
He distinguished two phases or periods. In the first pe- 
riod, under the influence of ferments due to anaérobies of 
the vibrio kind or genera, there occurs a transformation 
of azotized matters into more simple, but still complex, 
products. In the second period these last products are, 
in their turn, reduced to binary compounds of more sim- 
ple form, by the action of infusorial agents of the aérobic 
kind (bacteria, mucosa, etc.). 

The theory of germs applied to pathology was, in ef- 
fect, the application to morbid processes of the doctrine 
of putrefaction advanced by Pasteur. At first the dis- 
cussion arose upon its application to charbon, or splenic 
fever. The bacterial origin of this disease, suspected by 
Davaine (1850), then by Pollender (1850), and Brauel 
(1856-57), was demonstrated in 1863-64 by Davaine, who 
established the fact that when we inoculate with the 
blood of an animal affected with charbon and charged 
with bacteria, the animal inoculated is infected, and bac- 
teria are reproduced and multiplied in the blood. 

The generalization of this idea of the origin of charbon 
to other infectious diseases rapidly followed. In 1863 
Signol had already announced the presence of bacteria 
in the blood of horses affected with typhus. But in re- 


gard to septicemia and pyeemia, investigations seemed, on 


the contrary, to prove at first that they were not due to 
the presence of micro-organisms. Pasteur was the first to 
advance the opinion that septicaemia had a parasitic origin. 
In 1866 Coze and Feltz published their observations on 
the presence of infusoria and the state of the blood in in- 
fectious diseases. 

The fact was-clearly established in their minds that 
bacteria constitute the septic poison. In 1872 Burdon 
Sanderson, of London, advanced the opinion that in py- 
gemia there is a special poison which does not exist in 
septicemia. As to the nature of the poison, this physiol- 
ogist discovered that the pyzemic pus contained bacteria 
of a particular character, and the number seemed to be in 
proportion to the toxic activity of the fluid. 

In the same year Klebs affirmed the identity of septi- 
cemia and pyemia, and attributed them to changes in the 
pus due to a special agent, which he designated as the 
microsporon septicum. He contended that this micro-or- 
ganism has a peculiar power of penetration and destruc- 
tion ; it penetrates with facility the tissues and excites a 
process of molecular necrosis ; it causes ulceration of the 
vessels and thus produces secondary hemorrhages, called 
septic. He believed it enters the lymphatics, and that 
after it has reached the veins the spores accumulate 
around the valves, determine inflammation of the internal 
membrane and a consecutive thrombosis which becomes 
the source of emboli. Thus the microsporon septicum 
creates metastatic abscesses, either by its own peculiar 
local influence, or by creating thromboses. ; 

In 1872 Davaine brought before the Academy of Medi- 
cine of Paris, a communication on septiceemia in which he 
contended for the progressive virulence of septiceemic 
blood ; according to his experience the millionth, or even 
the trillionth, part of a drop of septiceemic blood pos- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Septiczemia. 
Septiczemia. 


sesses a virulence which quickly destroys a rabbit inocu- 
lated with it. He explained that the progressive viru- 
lence depends upon the reproduction and multiplication 
of the septic virus, which is otherwise identical with 
the ferment of putrefaction. The deduction which he 
drew from his experiments was, that septicaemia is a pu- 
trefaction effected in the blood of a living animal by the 
same process, and by the same agents, as putrefaction is 
effected in the free air, viz., by the activity of vibrios. 
He attributed to this cause the cadaverous odor of per- 
sons dying of septiceemia and the rapid decomposition of 
their bodies. The discussion which this paper elicited 
led to a renewal of experiments by a large number of 
scientific investigators, and though many of the details 
were disputed, there was unanimity of opinion in regard 
to the essential facts. The general conclusion was that 
in septicemia the toxic and active agent is of an organic 
nature, and is a bacterium ; that the disease is closely allied 
to putrefaction, and the process which takes place is anal- 
ogous to that of putrid fermentation. The bearing of 
these facts upon the subject of pyzemia, and in particular 
upon the general accidents of an infectious and_septicee- 
mic nature occurring in this malady, is undoubfed. 

The symptoms produced in the animal were believed 
by Panum to be due to a chemical substance produced 
by these micro-organisms, and not to their multiplication 
in the blood and tissues. Bergman reports experiments 
in which he claims to have detected a crystalline Substance 
which he called ‘‘sepsin.” Subsequently (1873) Bergman 
modified his first statements, for he discovered that when 
putrid matters were deprived of bacteria by a process of 
filtration, they lost their poisonous properties, or main- 
tained them in a very limited degree. He concluded that 
if sepsin is alone efficacious, it attaches itself to bacteria, 
and it is to sepsin that the bacteria owe their toxic prop- 
erties. This confession evidently tended to confirm the 
original theory that the poison is inherent in bacteria. 

In 1873, Samuels contributed a paper to the general 
subject, in which he recognized three phases in the series 
of septic accidents, to each of which he referred a special 
variety of infusoria. The effect of these organisms was as 
follows: 1, phlogogenous, or to excite an inflammation ; 
2, septogenous, or to give rise to the putrid or infectious 
phenomena observed upon the living organism ; 3, pyro- 
genous, or to cause fever and suppuration. From his ex- 
periments he believed that the following division of 
micro-organisms might be made: 1, The bacterium termo 
was phlogogenous ; 2, spores, collected in the form of a 
rosary, and vibriones, were septogenous ; 3, bacteria (un- 
named) larger and more brilliant than bacterium termo, 
were more especially pyrogenous: 

Koch * concluded from his experiments that the patho- 
genic bacteria consist of different species. To prove that 
he did not stand alone in this view he quotes Cohn as 
stating that, in spite of the fact that many dispute the ne- 
cessity of separating bacteria into genera and species, he 
separates bacteria of different form and fermenting power 
from each other. Eidam, also, came to the conclusion 
that different forms of bacteria require different forms 
of nutriment, and that they behave differently toward 
physical and chemical influences. Koch was able so to 
isolate and cultivate two different species in mice, as to 
determine their special infective power. 

Is septicemia the result of the action of pfomaines or 
of microbes ? was the question which Jeannel and Lau- 
lanié attempted to answer. Ptomaines can pass through 
the layer of granulations lining a wound, since they are 
in a state of solution, while microbes cannot enter the cir- 
culation unless a solution of continuity exists. Now, as 
septicemia is only observed when a break in the contin- 
uity of the living membranes of a wound exists, the au- 
thors attribute to the effects of ptomaines a subsidiary 
part, while the principal function is performed by mi- 
crobes, 

Petrone® experimented on the blood and serum from 
all the tissues of patients dying from virulent septice- 
mia. One portion of the blood and serum was injected 
unaltered under the skin of rabbits. Another portion 
was boiled and thoroughly filtered before injection, and 


a certain quantity of the same fluid boiled was intro- 
duced into clean disinfected tubes containing a little 
beef-broth, and then closed, hermetically sealed, and 
placed in a warm situation. AJl of the animals presented 
the same symptoms, and all died; the necropsy showed 
the same lesions in all, and the same micro-organisms in 
the blood, serous, and intestinal fluids. The blood of 
all of these animals caused death when injected into 
other rabbits. The biood in the tubes did not become 
turbid. The conclusions are that in septicaemia the bac- 
teria are not a primary, but rather a secondary, fact, and 
that the virus of septicemia is probably represented by a 
chemical poison; in other words, the bacteria acquire 
their virulent property through a chemical ferment con- 
tained in the septic fluid. This conclusion, the author 
believes, suggests the pre-existence in the animal organ- 
ism of ordinary schizomycetes, innocuous, but which in 
the presence of septic poisons become transformed into 
pathogenic bacteria, and the fact, experimentally dem- 
onstrable, that the bacteria only are able to develop in 
the animal organism the poison in question. Of these 
two consequences he holds that the first is the most ac- 
ceptable and most logical (London Medical Record), 
RESULTS oF INVESTIGATIONS.—The preceding sketch 
briefly outlines the course of investigations into the etiol- 
ogy of the complications of wounds, but it gives a very 
meagre view of the vast amount of labor which has been 
expended upon this subject, especially during the present 
century. These studies have been undertaken and vig- 
orously prosecuted by the most eminent physiologists, 
pathologists, and scientists of every period. In the early 
history of these investigations speculation took the 
place of experimentation, and the most absurd theories 
were advocated. As pathological inquiries advanced in 
importance and accuracy more rational theories pre- 
vailed. When, finally, experimentation was adopted as 
the basis of forming an opinion, a new impulse was 
given to these investigations, and far more accurate views 
began to prevail. At length came the revelation of the 
power of micro-organisms to establish morbid processes 
in the animal system, and their presence in the pus in 
septicemia and in the abscesses of pyzmia seemed 
to determine at once the true nature of these affec- 
tions. But it is apparent, from the more recent litera- 
ture of this subject, that, while there is a consensus of 
opinion as to the potential force of micro-organisms in 
initiating the morbid processes, there is still a wide di- 
vergence of opinion as to the details of their operation. 
The tendency evidently now is toward a belief in the mul- 
tiplication of the pathogenous bacteria, and their division 
into species, each having its special morbific power. In 
regard to the nature and action of bacteria, it is held 
(Ziegler, ‘‘ Path. Anat.”) that the factors which determine 
the invasion and the course of development of bacteria 
within the human body are two. On the one hand, the 
bacteria must be endowed with certain vital properties of 
a special kind ; on the other hand, there must be a pre- 
disposition on the part of the system. Slight chemical 
changes in the constitution of a tissue often enough 
determine whether a given bacterium can develop in 
the tissue or not. In many cases, bacterial invasion de- 
pends on the formation of a local necrosis or wound, 
in which the fungus can settle and develop; in other 
cases some grave disturbance of the circulation may lead 
to a failure of resistance on the part of the tissue. 
Many bacteria can only come to development within the 
human body on rare occasions, as their usual habitat is 
without it: others only meet with fit conditions for their 
existence and growth within the body, and do not mul- 
tiply without. These micro-organisms (Cheyne) grow on 
various soils, though some are more particular than 
others ; the substances essential for their nourishment 
are water, phosphates, salts of potash, carbonaceous and 
nitrogenous organic substances ; most forms require free 
oxygen, or grow much more rapidly in it, but there are 
some which will not live unless oxygen is almost or en- 
tirely absent. As the result of their vital action these bodies 
produce extensive alterations in the materials in which 
they grow; they break up the complex organic com- 


403 


Septiczemia. 
Septiczemia. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


pounds, and reduce them to simpler forms; in this way 
the effects are slight and transient; if the wound is 
larger, as when it is left to heal by granulation, the ab- 
sorbed material gives rise to fever, which is called trau- 
matic; and again, the wound may be so large and the 
absorption of the poison so rapid as to cause fatal symp- 
toms. This is called septic intoxication. 

It is maintained (Lister, Cheyne) that while the products 
of the growth of certain bacteria give rise to general 
effects—traumatic fever and septic intoxication—they 
also act locally on the wound and cause inflammation 
and suppuration. Though inflammation and suppuration 
in a wound may be due to other causes, yet the chief 
causes are the growth of micro-organisms in the dis- 
charges from the wounds, or in the tissues. They 
grow in the walls of the wounds, and give rise to irritat- 
ing products which keep up the inflammation and sup- 
puration; they often cause extension of the inflamma- 
tory process, or burrowing of the pus, and sometimes, 
spreading into the neighboring tissues, they give rise to 
the formation of abscesses. When the pus of an acute 


Fic. 3448.—Grouped Micrococci Invading Abscess Wall. 


(Ogston. ) 


abscess is examined micrococci are always found in it, 
sometimes in large numbers. 

An illustrative example of the growth of micro-organ- 
isms in the tissues is seen in erysipelas. If portions of 
the spreading margin of the redness and of the healthy 
skin in the immediate vicinity be excised and cut into 
sections, it will be found that in the healthy skin, imme- 
diately beyond the red margin, the lymphatic vessels 
contain large numbers of a minute micrococcus fre- 
quently arranged in chains. At the red margin itself 
there are inflammatory appearances as well; the lymph- 
vessels ‘contain not only micrococci, but also numerous 
leucocytes, and there is a small-celled infiltration around 
them and in the skin; the micrococci also extend into 
the lymph-spaces. Inflammation and suppuration may 
be caused (Ziegler), not merely by growth of micro-organ- 
isms in the discharges of the wound, but also by growth 
of micro-organisms in the tissues (Fig. 3448). This 
effect is only caused by certain micro-organisms, for, on 
the one hand, many micro-organisms will not grow in 
the living blood or tissues, but yet, growing in the dis- 
charges, can produce irritating materials, and cause 
suppuration; while, on the other hand, many micro-organ- 
isms grow in the living tissues without causing suppura- 
tion. The micro-organisms which grow in the hving 
tissues and cause suppuration belong, so far as is known, 


404 


almost entirely to the group of micrococci; they cause 
fermentation and decomposition of organic substances. 
In some instances, well-known chemical substances are 
formed, and the agency of the micro-organisms is exten- 
sively employed in the manufacture of various articles of 
food and drink ; in other cases, however, the substances 
which they produce are extremely poisonous, and when 
injected into animals cause symptoms of poisoning re- 
sembling the effects of various alkaloids. 

Some micro-organisms can grow in the animal body, 
giving rise to a variety of diseases; some are fatal to 
most animals, and others are only pathogenic in certain 
species of animals. The diseases caused by the growth 
of these bodies in the blood and tissues are grouped to- 
gether under the term ‘‘ infective diseases,” of which 
there are two kinds, viz., those in which the infection oc- 
curs from a wound or open surface—the traumatic in- 
fective diseases,—and those in which no wound is neces- 
sary, and where the pathogenic organisms are supposed 
to be able to enter the body through the unbroken surface. 

Some micro-organisms produce such alterations in or- 
ganic fluids that the injection of these fluids into animals 
is followed soon after the injection by symptoms of poi- 
soning, and if in sufficient quantities, by fatal results. 
If the quantity of poison is slight there is a moderate 
elevation of temperature, which soon subsides ; if the 
quantity is greater the fever is higher and more pro- 
longed ; but if there is a fatal dose the temperature soon 
sinks below the normal, sometimes accompanied by. vom- 
iting and diarrhea. The clinical expression of these 
facts is as follows: Where a wound is small and but a 
very limited amount of infection enters the system, the 
traumatic fever is absent or light ; if a large amount is 
absorbed the fever is more or less severe, according to 
the amount; a sufficient amount may be absorbed to 
prove fatal at once. 

It may be stated as a conclusion that two theories have 
chiefly prevailed as to the introduction of bacteria into 
the animal system, and their action. 

The first theory explains their action as primarily in the 
wound, where they set up chemical changes which result 
in the formation of a poison originally called ‘‘sepsin” 
by Bergman. This poison, absorbed into the circulation, 
induces fever or septic intoxication. Under favorable 
circumstances coagulation of the blood occurs, and thus 
gives rise to thromboses. From these clots arise emboli 
which clog the small vessels of organs, and result in ab- 
scesses. 

The second theory attributes to the direct action of the 
micro-organisms, first on the wound, and second on the 
blood and tissues, the symptoms of septicemia and py- 
gemia. 

The latter theory is more generally accepted. Accord- 
ing to this doctrine,* non-pathogenous bacteria exist in 
the healthy organism in large numbers, and subsist upon 
substances accessible to them ; the result of their action 
is the occurrence of chemical changes in these sub- 
stances. If the organism is in a normal condition these 
changes are not harmful, or are quickly eliminated from 
the system. But pathogenous bacteria have the power of 
settling in living tissue; all that is necessary is that a bac- 
terium should reach a spot that affords the conditions req- 
uisite for its development ; it then multiplies and forms 
colonies or swarms; these may, according to the species 
of the fungus and the nature of its soil, remain in aggrega- 
tions forming heaps or masses, or may spread through the 
tissues. The bacteria may force their way into the sub- 
stance of the constituent elements, and especially into the 
tissue-cells, which are sometimes found to be crammed 
with bacteria. The cells attacked by the fungi often 
appear quite uninjured, or they may be altered; the 
epithelial cells swell up and liquefy or degenerate into 
flaky, homogeneous lumps, or turbid, denucleated masses ; 
often they break down into granular detritus ; the nucleus 
is broken up, or swells and disappears ; the fibrous ele- 
ments of the connective tissue degenerate like the epithe- 
lial cells; the ground-substance undergoes a change at 
the same time, becomes turbid, loses its structure, and ul- 
timately dissolves. The inflammatory process set up by 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Septiczemia. 
‘Septiczemia., 


bacterial action may be of very different intensity and ex- 
tent in different cases; it may be slight and transient, or 
it may be severe and terminate in suppuration and necro- 
sis; occasionally amore or less perfect granulation-tissue 
is formed as a result of the inflammation. Again, this in- 
flammation often results in a great aggregation of living 
celis in the affected tissue, and these may so act as to re- 
pel the continued advance of the fungi, which soon per- 
ish, and the result is healing and 
cicatrization, ‘The fixed tissue- a o 
cells of the region may also act SG : 

so as to check the development of 
the bacteria; if this happen the 


2) 


Vv. 
ree 1o) 


—————- 


Fie. 3449. — Section containing 
Colonies of Micrococci from the 
Vocal Cord of a Child. 200. 
a, Epithelium; 06, connective 
tissue of the mucous membrane ; 
c, swollen, degenerated, and 

denucleated epithelial cells; d, layer of micrococci; é, inflammatory 

small-celled infiltration of the degenerated epithelium and of the 
fibrous structures, (Ziegler.) 


bacterial invasion continues to advance; they first enter 
the surrounding tissues, passing along the natural lines 
of division, then they break into the lymphatics, and 
often into the blood-vessels also. If they can live in 
lymph or blood they go on multiplying ; if not, they per- 
ish; many bacteria, like the micrococcus of erysipelas, 
flourish best in the lymphatics; others, like the anthrax 
bacillus, are more at home in the blood. 

They reach the blood either through the lymphatics or 
directly ; in the latter case the walls of the veins in the 
invaded region are penetrated by the micro-organisms, or 
they pass into the veins from the capillaries ; once in the 
current they are carried on by it to remote parts; many 
perish in the blood, others again increase and multiply. 
Of the last some, as anthrax bacillus, thrive best in blood 
that is in motion ; others, 
as tubercle bacillus and py- 
gemic micrococcus, prefer 
blood that is at rest, and 
only grow when they come 
to a standstill in some ve- 
nule or capillary. The tis- 
sue changes are the slight- 
est in the case of bacteria 
which circulate and multi- 
ply in the blood (Fig. 3450). 
Bacteria which settle in 
the smaller vessels give rise 
to various forms of degen- 
eration (Fig. 3451), ne- 
croses, inflammations, and 
hemorrhages. 

The Nature of Septicemia and Pyemia.—The applica- 
tion of these facts to the explanation of the symptoms 
of these affections has been variously made by writers. 
This difference of opinion is due to the inherent difficulty 
of accurately determining the nature of the symptoms 
and pathological conditions which exist, their order of 
sequence, and the ultimate relation of micro-organisms 
to these obscure phenomena. The tendency now evi- 
dently is to regard both septicemia and pyzmia as dis- 
eases having many forms. Cheyne remarks: “ Septi- 
cemia is a complicated affection, and probably arises 
under several circumstances; continued absorption of 
the poisonous material from wounds will keep up a fe- 


Fic. 3450.—Micro-organisms in the 


Circulating Fluid. (Ziegler. ) 


verish state with all the symptoms of septicsemia, and if 
long continued may terminate fatally ; in other cases the 
micrococci grow in the tissues of the wound, and pour 
their products or ptomaines, as they are called, into the 
blood ; here micrococci may be found in the blood, but 
the essential seat of disease is the tissues. In a third 
form micrococci grow in the blood, and multiplying 
there, give rise to the symptoms. In a fourth form or- 

ganisms grow in the blood, but they belong to the class 

of bacilli. The last two cases correspond to what is 
found in the lower animals. In them septi- 
cemia is caused by more than one form of or- 
ganism growing in the blood, 
and giving rise to symptoms and 
post-mortem appearances which 
can only be classed together as 
septicaemia.” 

Pyemia in rabbits (Koch, 
Cheyne) has been shown to be 
y due tothe growth of micrococci 
ti os : 

in the blood. These cocci are 
very minute; they grow in col- 
onies and tend to adhere to the red blood-corpuscles. 
Masses are thus formed composed of colonies of micro- 
cocci with included red corpuscles. These masses may 
adhere to the wall of a blood-vessel, grow and block it 
completely, or being swept on in the circulation, form 
emboli in the smaller vessels, In either case inflamma- 
tion occurs in the surrounding tissue, and an abscess is 
formed in which are found numerous micrococci. The 
inoculation of another animal with the pus from these 
abscesses, or of the blood containing the micrococci, is 
followed by the reproduction of the disease. 

Koch employs the term ‘‘ traumatic infective dis- 
eases,’ 7 and states that he applies it to ‘‘a group of affec- 
tions formerly known as trau- 
matic fever, purulent infec- 
tion, putrid infection, septi- 
cemia, pyszemia, but which 
were included at a subsequent 
period (when the view became 
generally accepted that these 
diseases were essentially of 
the same nature) under the 
title ‘pyeemic or septiceemic 
processes.’” The similarity 
of the two affections is notice- 
able in the fact that, though 
pyzmia was alone thought to 
be characterized by metastat- 
ic abscess, yet a more careful study showed isolated, 
microscopic, metastatic deposits in cases which had all 
of the characteristic symptoms of septicemia. Birch- 
Hirschfeld defines septiceemia to be a disease due to al- 
terations of the blood, as the result of the absorption of 
the products of putrefaction ; while pyemia is due to a 
general infection derived from the surface of a wound or 
from a centre of primary suppurative inflammation, 
caused, probably, by micro-organisms and not by putrid 
infection. 

Billroth’s definitions are, in general, more useful for 
clinical studies. He remarks (‘‘Surgical Pathology”) : 
‘« By septicaemia we understand a constitutional, generally 
acute disease, which is due to the absorption of various 
putrid substances into the blood, and it is thought that 
these act as ferments in the blood, and spoil it so that 
it cannot fulfil its physiological functions.” ‘‘ Pyemia 
holds the same relation to simple inflammatory and sup- 
purative fever that septiczemia does to simple primary 
traumatic fever ; it is symptomatologically characterized 
by intermittent attacks of fever, and in its pathological 
anatomy by the frequency of metastatic abscesses and 
metastatic diffuse inflammation.” 

The Committee of the Pathological Society of London, 
in their report on the nature and causes of those infec- 
tious diseases known as pyzemia, septiceemia, and puru- 
lent infection, accept the conclusion that there are two 
distinct forms of septicemia. One form occurs when 
putrid blood is injected subcutaneously, no organisms ap- 


405 


Fig. 3451.—Micro- organisms in 
Stagnant Blood. (Ziegler. ) 


Septiczmia, 
Sewage. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


pear, and the disease cannot be transmitted by inocula- 
tion ; this is septic intoxication. In the other form the 
poison has been injected, and organisms appear abun- 
dantly in the blood, and are very virulent. The com- 
mittee make ten groups of pyemia, viz.: 1, Pysemia sec- 
ondary to an open wound, but without evidence of 
embolism ; 2, venous thrombosis as a secondary affec- 
tion; 3, venous thrombosis and softening of thrombus 
without embolism; 4, venous thrombosis and softening 
of thrombus with secondary abscesses in other viscera, 
but not in the lungs; 5, venous thrombosis with soften- 
ing and abscesses in the lungs and other viscera; 6, ve- 
nous thrombosis, softening of thrombus, and embolic 
abscesses in the lungs; 7, pysemia secondary to infective 
periostitis ; 8, pyemia secondary to infective endocar- 
ditis ; 9, infective myositis ; 10, spontaneous septicemia 
and pyzemia. 

SyMpTroms.—The symptoms in well-defined cases of 
septicemia and pysemia following wounds, are accu- 
rately given in the extracts from Billroth’s work. The 
chief distinction there made between these two forms of 
wound complication is based upon the pathological con- 
ditions long since established, viz., the existence (pyx- 
mia) or non-existence (septicemia) of multiple abscesses. 
This distinction is undoubtedly still the most conven- 
ient and most accurate in practice, as the symptoms vary 
in no small degree according to the presence or absence 
of this element in each case. For practical clinical pur- 
poses the relations of these wound complications have 
been clearly set forth by Billroth in the illustrative cases 
quoted at the commencement of this article. To those 
cases, therefore, we refer as embodying the order of 
symptoms of those ‘‘ general accidental diseases which 
may accompany wounds and other local inflammations.” 

Draenosis.—The diagnosis of septiceemia and pyzemia, 
when these affections develop in regular order after 
wounds or injuries, is not difficult. They may, however, 
occur under circumstances which render the diagnosis 
very difficult, and this is especially true when there has 
been no antecedent wound. The symptoms are often so 
masked as to lead the observer quite astray. The dis- 
eases which are most liable to be taken for both of these 
affections are enteric fever, typhus, inflammation of the 
kidneys and bladder, acute rheumatism, ete. 

Wagner (‘On Occult Septiceemia,” London Medical 

vecord, February 15, 1882) regards septicemia as much 

more frequent than is generally believed. He is of the 
opinion that, in consequence of ignorance of its sympto- 
matology, many cases are overlooked. He formulates its 
symptoms thus: 1. The general condition isserious ; there 
is a febrile state, suddenly apparent, rarely preceded by a 
regular rigor, but attended with much shivering, and 
very often with severe rheumatoid pains of the bones and 
joints. 2. The patient experiences so much discomfort 
that he is obliged to take to his bed at once, or, at the 
latest, after some days. 38. There is violent fever of the 
remittent or intermittent type, but always irregular ; 
the exacerbations usually assume the aspect of a severe 
rigor, 4. The pulse is very frequent, usually dicrotic. 
5. There is frequency of respiration, which cannot be 
explained by the mere elevation of the temperature, 
and which, in the majority of cases, is connected with 
serious affections of the lungs or pleura. 6. There is hy- 
pertrophy of the spleen, with scarcely any appreciable 
increase in the size of the liver. 7. There is more or less 
marked abdominal meteorism, often accompanied by in- 
testinal borborygmi, occasionally by frequent fluid stools. 
8. There is moderate albuminuria, rarely tube-casts or 
blood-corpuscles in the urine. 9. There is a pustular or 
papular cutaneous exanthem, with a hemorrhagic basis. 
10. Icterus is rarely intense. 11. Subjective and objec- 
tive symptoms are met with in the large articulations and 
the long bones, especially rheumatoid pains, occasionally 
attended with swelling or redness of the joints. 12. 
Serious cerebral symptoms occur, such as delirium, con- 
vulsions, and coma. 138. The progress of the affection is 
rapid. 14. Medicinal treatment by quinine, the salicy- 
lates, etc., is unsuccessful. 

The affections with which septico-pyemia may be 


406 


confounded are more especially typhoid fever, of which 
the progress is very much less rapid and less tumultuous, 
and which is never accompanied by icterus or by an 
exanthem similar to that described, nor by joint lesions ; 
miliary tubercle, which it is almost impossible to diag- 
nose; and epidemic cerebro-spinal meningitis, which 
presents, perhaps, still greater difficulties, since the 
rapidity of the progress and the presence of an exanthem 
can no longer be considered as means of diagnosis. The 
question is still further obscured by the fact that the 
wound does not always exist, and that in place of it 
there may be internal suppuration, necessarily overlooked 
because it does not give rise to any characteristic symp- 
toms. Ina certain number of cases it has been impossi- 
ble to find any starting-point, notwithstanding the cer- 
tainty that pyeemia existed. 

Wunderlich, in 1857, described some cases as primary 
pyemia; Schutzenberger also spoke of cases of this kind, 
and recommended careful examination of the scalp in 
cases of acute fever. Cases of pyzemia without any dis- 
coverable lesions have been reported (Cavafy, Whipham, 
Dickinson, London Lancet, June 26, 1886). In three 
cases autopsies were made and multiple abscesses were 
found, but no lesions were discovered through which the 
poison could have entered the system. 

TREATMENT.—The discovery of the etiological rela- 
tions of micro-organisms to suppuration opened a new 
and most important field of inquiry. 'The question now 
arose, can these germs be destroyed without complicating 
the wound, and, if so, what is the most useful agent.? 
In determining this question we must acknowledge the 
great services to practical and scientific surgery of Sir 
Joseph Lister. We would not detract from the merits of 
a long line of earnest students who so faithfully labored 
in this field of experimental pathology, many of whose 
works were so often apparently unproductive. Even 
their errors often led to new and more successful efforts, 
and hence added, though indirectly, to the total sum of 
knowledge necessary to the final, complete elucidation of 
this most obscure subject. But in these later times no 
one has so intelligently and so perseveringly striven to 
apply the knowledge gained as to the correct etiology of 
septiceemia and pyzmia, and as to their prevention. 

The methods of preventing these diseases are fully dis- 
cussed in the article on Antiseptics, and need not be 
noticed here. When they do occur the treatment should 
be directed, first, to the entire removal of the source of 
putrid material, and second, to sustaining the patient’s 
strength. It is now possible, by evacuating and cleansing 
abscesses, by the removal of carious bone, and by the dis- 
infection of sources of putrid emanations, to remove at 
once the cause of both septicemia and pyzmia. 


Stephen Smith. 

1 Aitken: Sci. and Prac. Med., vol. ii., p. 788. 

2 Gulstonian Lectures delivered at the Royal College of Physicians in 
London, Med. Times and Gaz., 1858. 

3 Principles and Practice of Medicine. \ 

4 Traumatic Infectious Diseases. 

5 Experimental Researches on Septiczemia, 1884. 

6 Ziegler, Path. Anat. 

7 Investigations into the Etiology of Traumatic Infective Diseases, 
The New Sydenham Society, 185U. 


SEVEN SPRINGS. Location, Washington County, Va. 

Post-office, Glade Spring, Washington County, Va. 

Access.—By the Norfolk & Western Railroad to Glade 
Spring, thence two miles to the springs; or to Saltville, 
thence five miles to the springs. 

THERAPEUTIC PROPERTIES.—Their medicinal proper- 
ties are tonic, alterative, diuretic, antiperiodic. 

These springs, seven in number, are situated in Wash- 
ington County, in the southern part of Virginia, amid the 
Blue Ridge Mountains, famed for their beautiful moun- 
tain scenery. The waters of the springs are evaporated, 
leaving’ the solid ingredients, which are bottled and sold 
throughout the country as ‘‘ the Seven Springs Iron and 
Alum Mass.” 

ANALYSIS (by J. W. Mallet, M.D., Chemist).—The mass 
appears as a stiff dough, or soft solid, of light gray color, 
and marked acid reaction to test-paper. The contents of 
several bottles having been thoroughly mixed, the follow- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


ing composition was found for the mixture in one hun- 
dred parts: 


(AIM MMES ED Nabe oka ales ete ae ea ae ere 15.215 
Ferric sulphate (persul. iron) ...........+.-.0sseeees 4.628 
Ferrous sulphate (protosul. iron) ................... Q.412 
Nickelssulplabe msec abacs fo lcreblan oes eceiweeuine dean 0.162 
Oopaltesnlpnatem rer craey. sos) s vs ernie svessvine risa ter seariae s 0.014 
MBN PRNESOMSIU NRE coe, 6 sere ciere 0 iacicssyseie Sivcialesceroree the 0.257 
@Coppersalphaverrercr cde cclace ccc ste sec causes ome 0.008 
ANT SUL ALO mee eiiee ite ott c ete ee eie sates. astac een ee 0.3801 
IMACTICRIUEN GUID UALE Mey cists fy <\clc ster els ante ocaliers spas bie 16.006 
SUVON TUNES UAC cerca aca seletelc/a la Sietgne vis) cterciel olerele trace 
@alciini salpnaten sen tes crcctiche cove. e's clei © ond wir, siete 17.538 
IPOvassil WSU pNatemrm. dees teace ac occ ets cates. 0.060 
DOCU MARS DMAues sem sete etos oe wart alatels,o sce chersre oe aigts Sole 0.226 
Mithimmpatilp nate nee neers 1s suiciees wees telose “0.019 
ATOM OU UL MAGE sare aie oN oitieoeniersicic gieie sie sels eee ore 0.022 
Soditumechlorides 265 dao. ceases cls Wat eee oes Ge tonns 0.826 
Galcium fworidees. asc. kee ve see Shp Pan eka CaP trace 
Calcium phosphater st coy skis fal one wise asic eis Win oie trace 
UE Co eerie rte eee iererer settee ciel sors. stoure accace sieve ate 1.504 
Organicinatberee ss nen: cage tees helays s cicie tats a'atie bees 0.128 
WW LOT mere le a settee aS ora ceseyere he ats s drier eislatete Ss 42.988 

99.759 

Gab: i. 


SEWAGE, DISPOSAL OF. Under this heading will 
be considered not only the disposal of the contents of 
sewers, but also the other methods of disposing of the ref- 
use products of households and communities. 

In using the term ‘‘ disposal” we may avoid confusion 
if we distinguish between immediate disposal, on the 
premises, of refuse matters as they are day by day pro- 
duced, and the ultimate disposal by which they are ren- 
dered innocuous by utilization or removal, or both. 

I shall describe, first, the methods employed for imme- 
diate disposal; secondly, those for ultimate disposal ; 
and, lastly, shall compare the merits of the various sys- 


Septiczemia. 
Sewage. 


sometimes with a layer of ashes or earth spread over the 
night-soil. In other places removal is made by means of 
some form of ‘‘ Odorless Excavator.” These machines 
act on the principle of the exhaust-pump: the contents 
of the privy or cesspool are drawn into a tank upon 
wheels ; or they may be transferred to detached barrels, 
thus obviating the necessity of keeping the pump idle 
while the night-soil is being conveyed away, and also 
affording greater facility of transportation. The appa- 
ratus for the latter is more complicated, of course, than 
that of the ‘‘tank” method ; from a description of this 
barrel-system (Fig. 3452) the principle of the other may 
readily be understood. The small hand-pump seen in the 
foreground is for alternately exhausting and compres- 
sing (as may be required) the air in the pump-receiver 
B. The little furnaces H and ZL are for deodorizing 
the air displaced from Band O, respectively. These lat- 
ter are strong oak casks. The suction hose, C, is lined 
with a spiral, flat, galvanized iron or brass coil to keep it 
from collapsing, should anything obstruct its lower end 
during the process of exhausting the air from B. The 
following extract from Ames’ description of the ‘‘ Eagle 
Odorless Excavating Apparatus,” will explain its other 
parts and mode of action : 

‘Lift the gate a, on pump-receiver B, see that the 
lower gate 6 is shut tight. Work the brakes, when 
the air will be exhausted from the receiver via the 
throat-valve opening and air-hose, fv. The contents of 
the vault will at once rise through the suction-hose, C, 
into the receiver, till the material lifts the cork float- 
valve and stops the pump, the receiver being full. In- 
stantly shut the upper gate, a. 
The foul air exhausted from B 
has passed through the pump and 
short air-hose, k, under the fire to 
the deodorizer H, and is consumed. 

‘‘ To transfer the material to the 
barrels or tank on the wagon, un- 
couple the end of air-hose, 
G, from the suction-spud 
of the pump. Remove the 
free end of air-hose, k, from 
the throat of the deodorizer, 
and couple the ends of k and 
G together. 

‘* Have goose-neck valve 
V, on the wagon-barrel, 
lifted. Lift lower gate, 0, 
on receiver, and work the 
brakes, when the com- 
pressed air, driven in at the 


a 


SS i 


Fig. 38452.—Odoriess Excavator 


tems and their relative adaptability to the needs and cir- 
cumstances of cities, villages, and isolated houses. 

I. Tae Moves or IMMepIATE Disposal at present in 
use may be classified as follows : 

1. The privy-pit and privy-vault. 

2. Dry methods. 

3. The water-carriage system, or wet method, as it is 
sometimes called. 

4, Pneumatic systems. 

1. PRivy-PIT AND PrRivy-vAuLtT.—It is hardly neces- 
sary to describe the privy-pit system, if indeed we should 
apply the term ‘‘system” to such a crude and barbaric 
device as an excavation in the earth for the reception and 
storing of filth. I shall endeavor to do a certain measure 
of justice to its demerits and their results in their appro- 
priate place, in the last division of this article. 

In the privy-vault a slight improvement is made on 
the pit by placing in the excavation a water-tight cask, 
tank, or receptacle, made of cement, masonry, or other 
material. By these means it is intended to prevent soak- 
ing of the filth into the soil, but the receptacle often be- 
comes leaky. 

In places where these pits and vaults are allowed to 
exist removal is effected in various ways, the most prim- 
itive being by carts, sometimes with a boarded cover, 


Barrel System 


top of the receiver, will 
rapidly force the contents 
through the leading hose 
into the wagon-barrel. When the wagon-barrel is full, 
its float-valve will be lifted, and the roar of the wagon- 
deodorizer, J, (which has consumed the foul air forced 
from the barrel), will cease. The goose-neck valve, V, 
and deodorizer, L, may now be coupled with the next 
wagon-barrel, and the process resumed as described. If 
a long line of leading hose is used, it will be necessary to 
reserve one wagon-barrel for its contents, or it may be 
returned on itself, and the contents discharged into the 
vault.” 

A method which is in operation in some places is to fill 
a strong metal cylinder with steam ; this condenses on 
the way to the scene of operation, creating a vacuum ; one 
end of a hose is attached to the cylinder, the other being 
lowered into the vault; a valve in the coupling of the 
cylinder and hose is now opened and the contents of the 
vault are drawn into the cylinder. 

In another method a vacuum is produced by the revolu- 
tion of the wheels of the wagon on its way to the vault 
which is to be emptied. This method is in use in Chicago. 

It is nearly always necessary to complete the emptying 
by means of the shovel, owing to the presence of sticks, 
tin-cans, or other rigid bodies. It would be desirable, 
also, to cleanse the besmeared surface of the vault with 
a solution of corrosive sublimate or other deodorant. 


407 


Sewage. 
Sewage. 


2. Dry Mrernops.—These may be divided into (a) the 
dry-earth and dry-ash systems ; (0) the various midden 
systems ; (c) the pail systems ; (d) dessication. 

(a) In dry-earth and dry-ash systems, dry earth or 
dry ashes are mingled with the feeces in sufficient quan- 


as 


Fig. 3453.—Heap’s Dry-earth Closet. Elevation. 


tity to absorb all moisture from them, to render them 
inodorous and to prevent decomposition. The earth 
should be well dried in the sun, or by artificial heat, and 
then stored in a dry place. It should contain no lumps, 
and it is better that it should be sifted or screened so 
as to form a very fine powder. 

The earth best adapted is a clay 

loam ; sand and gravel are of no 

use for the purpose. All fluids, 

pe ee eee except the urine passed during 
fC - xe defecation, must be excluded. 
oe H A small quantity of earth should 

\ We 4}i| be placed in the receptacle to be- 
41 \| cin with, and earth should be 


eH | 


i id added after each defecation. If 
i 4 | jj alarge quantity of feeces is al- 
} i lowed to accumulate before the 
lWiA : earth is thrown in, the mass is 
re kt [RJ more liable to noxious decompo- 
i ‘+ . RY] sition in its interior. Besides, 
; the odor from the uncovered 
i { ie feeces is in 
15 \ the mean- 
Qe. time very 

offensive, 
especially as 


the contents 
of the closet 
are gener- 
ally above 
ground, an 
excavation 
being’ un- 
necessary 
and indeed 
objectiona- 
ble, unless the expense of a water-tight vauit is incurred 
for the purpose of excluding surface and subsoil water 
and moisture. Hence it becomes almost a necessity to 
the success of the system in a mixed community, and 
especially where there are children, that some automatic 


P 


a0 
——— 
‘ 


Fia. 3454,—Heap’s Dry-earth Closet. Sectional view. 


408 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


method of applying the deodorizer be employed. A good 
closet of this kind is one on the principle of the Heap 
patent, such as is shown in elevation in Fig. 3453, and in 
section in Fig. 3454, by which the working of the closet 
may be understood. The lid is shown half open; just 
beneath it is seen the hopper (H), made of galvanized iron 
and hung upon the pivot X; attached to the upper poste- 
rior part of the hopper is a weight (1) which keeps it in 
the position indicated by the continuous lines when the 
closet is not in use. The seat (S) is hinged to the riser in 
front, and to its posterior edge is attached the small 
wheel or roller (W); when the seat is pressed upon, 
this wheel, acting upon the inclined plane of the hop- 
per, forces it back to the position indicated by the 
dotted lines. When the pressure is removed the hop- 
per flies forward, striking the buffer (R), and in this 
way a quantity of earth is thrown and scattered in the 
receptacle (P). The weight (I) assists in throwing the 
hopper forward. A ‘‘ urine separator” may be attached 
for the purpose of keeping the contents of the pail as dry 
as possible. This attachment is not to be recommended : 
even though a disinfectant be placed in the urinal the 
latter may become offensive, and the separate vessel is 
unnecessary if a sufficient quantity of earth is used. 

In the case of adults regularly employing a dry-earth 
closet, a simple contrivance will answer, such as that 


jie 


— E a — ———— 


Fie, 3455.—Simple Form of Dry-earth or Dry-ash Privy. 


represented in Fig. 8455, which shows the excrement 
tub, B, beneath the seat, and the other tub, A, holding 
dry earth or ashes, which are applied by means of a scoop. 
The hinged door, C, permits the removal of the pails. It 
might for some reasons be preferable to do without this 
door, and to remove the pail through a hinged seat. 
Before leaving this subject, reference must be made to 
the closets invented by the Rev. Henry Moule, M.A., of 
Fordington, Dorset, England, to whom is due the credit 
of introducing the system of dry-earth closets, and who 
has experimented largely with them. The mixture of 
earth and excrement undergoes a species of dry fermenta- 
tion, and should be kept dry till this takes place, a period 
of some six weeks being required ; otherwise the con- 
tents of the closet must be removed to some place where 
they can be utilized without offence. If kept till the pro- 
cess of fermentation has taken place, the product may be 
used again and again with the same result. The amount 
of earth required is variously estimated, the average 
being about a litre, or one and a half imperial pint per 
head per diem. Most authorities consider that finely 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sewage. 
Sewage. 


sifted coal ashes answer almost as well as earth ; some 
think that they do not prevent the occurrence of offen- 
sive fermentation. In my own somewhat limited obser- 
vation I have found them answer very well. Charcoal, 
made from burning street-sweepings and sea-weed, is said 
to be very useful, and to answer the purpose in smaller 
quantity than earth. 

In some places so-called dry-earth closets have brought 
the system into disrepute by faults in the management : 
the earth not being dry and fine, its deo- 
dorizing and anti-putrefactive properties 
have been lost ; or the hopper becomes 
clogged; or the receptacles are 
down below the ground-level 
and are not kept dry; or 
slop-water is thrown in; 
or there is neglect on the 
part of the corporation in 
providing dry earth and in 
seeing to the removal and 
storing of the product. 

The invention of im- 
proved cinder-sifters has 
done much to render more 
easy the use of the dry-ash 
closet system, and it has 
also lessened the amount 
and improved the quality 
of the resultant products 
of the next system to 
which we have to refer. 

(0) The Midden System. 
—Included under this sys- 
tem are several kinds of 
closets or vaults, which 
have taken _ different 
names, generally from the places in which they have been 
used. They differ somewhat in details, but have the fol- 
lowing features incommon: ashes, garbage, excrement, 
dust, waste-paper, and all household ‘refuse, except slop- 
water, are thrown into a water-tight receptacle, from 
which the contents are removed at short intervals by 
scavengers. Fig. 3456 rep- 
resents a section of the 
Hull ash-closet. The floor, 
back, and ends of the re- 
ceptacle are of brick or 
masonry laid in cement. 
The refuse is thrown in 
through the hole in the 


SS 


e 
7 Cm Ca ore CSP Gy 2 


Fie, 3456.—Hull Ash-closet. 


SSSSSs 


i 
eee. 
og 


d/ 


SASS 


ASSSSS 


SS 


% 
% 


Fic. 8457.—Manchester Cinder-sifter and Excrement-tub. 


seat. In front is a movable board, through which the 
contents may be removed by the scavenger’s shovel and 
broom. A useful modification would be to hinge the 


seat at the left-hand end. I have recently been in- 
formed that this is often the case in Manchester. That 
city presents some of the transitional stages from the 
Midden to the ‘pail system.” Fig. 38457 represents 
a mode by which the ashes are thrown into a movable 
por as they are sifted, the cinders being kept for 
uel. 

(c) The Pail System.—In this system pails or small tubs 
are placed beneath the 
seat ; and, as arule, noth- 
ing but excrement is 
placed in the pails. Fre- 
quent removal takes place 
—in Rochdale once a 
week. 

A wagon, made air- 
tight by rubber joints, 
takes away the full pails, 
fresh ones being left in 
their stead. The pails are 
provided with tight dou- 
ble lids. In some places 
they are strong, iron-bound wooden pails, or half-casks ; 
in others they are made of galvanized iron. 

This system is principally in use in cities far removed 
from agricultural districts, and where the contents must 
be made into poudrette or artificial manure, and must, 
therefore, present a strong fertilizing power in small 
bulk. 

In the Goux system, however, a slight departure is 
made, the pail (Fig. 3458) being lined with a slightly ab- 
sorbent material, which, according to the trade circular 
of the Goux Company, may be composed of “stable lit- 
ter, leaves, spent tan or hops, sawdust, shavings, shoddy, 
flax-dressings, or the thousand-and-one convenient sub- 
stances to be found in every place.” With the above 
a little charcoal, soot, gypsum, or other deodorant may 
be mixed. A little of this filling is placed in the bottom 
of the pail, the mould (Fig. 3459) is set upon it, and the 
interspace packed. It is stated that a 
boy can fill a hundred pails in an hour. 
When the pail is removed any filling 
projecting above the rest of the con- 
tents is broken down to cover the ex- 
crement. 

The Nottingham system differs still 
more widely, and resembles the Midden 
system, inasmuch as the ashes and 
other refuse are allowed to be thrown 
into the tubs. The reason assigned is 
that Nottingham is in an agricultural 
district, and bulky manure can be util- 
ized. When the health officer has been 
notified of the existence of infectious disease in a house, 
a red tub is sent containing a germicide. 

In all the above dry methods the closets require pro- 
vision for ventilation. 

(d) Desiccation.—I use this term to designate a method 
lately introduced, by which a continuous stream of air 
is made to pass over the fecal contents of a trough or 
long vault beneath a series of closets. The method may 
be readily understood by a reference to the accompany- 
ing cut (Fig. 3460) of part of a section of a building ven- 
tilated by the process of the Smead-Dowd Company of 
Toronto. The foul air drawn off from the building is 
made to pass through the closet vault on its way to the 
foul-air chimney. The feeces are so dried that they may 
be handled without any danger of soiling the fingers. 
The system is in operation in several places in the States 
of Pennsylvania, Ohio, Iowa, Wisconsin, New York, and 
in the Province of Ontario, and it gives great satisfac- 
tion. The small heater seen at the base of the foul air 
chimney is for use on muggy, heavy days in summer, 
the furnace not being in operation. Ventilation of the 
closets is efficiently secured, the air being drawn through 
the seats. 

It should be noted that in all the dry methods separate 
provision must be made for disposing of the bedroom, 
kitchen, and laundry slops, 


Fic. 3458.—Goux System: Pail lined 
with Absorbent. 


FiG. 


3459. — Goux 
System: Mould 


used in 
pail. 


Lining- 


409 


Sewage. 
Sewage. 


REFERENCE HANDBOOK OF 


THE MEDICAL SCIENCES. 


38. THE WATER-CARRIAGE SystTeM,—This 
has already been considered, so far as it re- 
lates to the interior of houses, under the 
headings Habitations, General Principles of 
House Plumbing, and will be further treated 
of in the article Sewerage, the ultimate dis- 
posal only of the contents of sewers being 
taken up in this article. 

4, PNEUMATIC SystEMs.—Under this head- 
ing are to be included (a) the Liernur system 
and (0) the Berlier system. The Shone sys- 
tem is sometimes called a pneumatic system, 
but it is really a mode of pumping, in con- 
nection with the water-carriage system, and 
will be referred to in the article Sewerage. 

(a) The Lternur system is the invention of 
Captain Liernur, a Belgian engineer. <A large 
steam air-pump exhausts the air in a set of 
central reservoirs, and in the air-tight iron 
mains which connect these central reservoirs 
with smaller ones under the sidewalk cross- 
ings in the streets (Fig. 3462). These latter are 
visited dailv. By means of a key a valve is 
opened in the pipe leading from the street res- 
ervoir to the central reservoir, and the air in 
the former being thus partially exhausted, the 
valve is closed, and another valve, in the pipe 
leading (by its branches) to the houses, is 
opened. This operation having been repeated 
several times, the sewage matter contained in 
the drains and in the traps at the bottoms of 
the soil-pipes is drawn into the street reser- 
voir, and thence to one of the central reser- 
voirs. From these latter it is raised, also by a 
vacuum process, into tanks ‘‘ hermetically 
sealed.” From these it may be drawn into 
air-tight barrels and taken to the country for 

direct application to the land, or 


SS w& 


SSS 


soy WENT. SHAFT 


SSSS 


3 SS - 
MA iiiieiieiaiaSRMMMKWGLMIIREA TETETRETEEEEEEESS 


Ul 
IN 
| 


(0) The Berlier system receives its name from its origi- 


nator, M. J. B. Berlier, and is employed in Paris. 


In it there are no street reservoirs, their place being 


MINI 


Ke FOWL_AIR & 


SSSA 


SS 


SS 


INSSISISS 


S 
~~ 


SSS 


ll converted into poudretie or artifi- 
cial manure. The main pipe con- 
-nects with the street reservoir by 
two branches, one at the top of 
the reservoir, by which the air is 
exhausted, the other reaching 
nearly to the 


ee DOOM Pay 
which the sew- 
“ age is drawn 
out. Some of 
the closets are 

SSMS TT Se 


supplied with a 


3 | A mechanism 
LEE CLE. by which a 
small quan- 


tity of water is supplied at each 
using ; but most of them have no 
water-supply, the hoppers being so 
constructed that no droppings are 
supposed to touch their sides in 
falling to the trap; these closet- 
traps are never emp- 

a tied, the main soil-pipe 


Gurface 


SS 


SAK 


Fig. 3461.—Liernur Pneumatic System: Closet, 
Soil-pipe, and Commencement of Drain. 


being open at its upper 
extremity. It will be evi- | 
dent that it would be im- La ES 

possible to draw the con- 

tents of the pipes out by 

suction, unless the whole bore of the pipe were filled at 
certain points. This is done at intervals by making an 
upward grade, through which the sewage is drawn, and 
then it runs down to the next rise. The effect is similar 
to that of suction on a siphon-trap, or series of siphon- 


traps. 


410 


Gin wi 
56 J all) 
3 =i, 


SCTE SY 


Fic. 3460.—Smead-Dowd System of Closets, 


taken by a tank and evacuator in each building. The 
emptying of the latteris automatic. The soil-pipe emp- 
ties its contents through the top of the tank (Fig. 3463), 
which contains a strainer for intercepting cloths and other 
large articles which might obstruct the pipes. The pres- 
ence of these may be detected by means of an axle, on 
which are fixed arms, or ‘‘ beaters,” and which can be re- 
volved from the outside. These beaters also serve to 
break up masses of feecal matter lodged on the strainer. 
Obstructions may be removed through a door in the 
tank. From the tank the sewage passes into the evacua- 
tor. The bottom of the latter is conical, and communi- 

cates with the pneumatic tube, the 

opening between the two being 
fF g.. closed by a rubber ball when the 
fg” fe evacuator isempty. This ball is at- 
tached to a large, pear-shaped float, 
which rises when the fluid in the 


Lp 


evacuator reaches a certain 
height. When the float and 
ball rise, the fluid rushes from 
the evacuator into the pneu- 
matic tube. The float works 
up and down on a vertical rod, 
and so, as the fluid rushes out,. 
the ball again falls into its 
place. There is now no fur- 
ther obstruction till the sewage 
reaches the central reservoir, or vat, in which the pneu- 


Fia. 8462.—Liernur Pneumatic 
System: Street Reservoir and 
Pipes leading to and from it. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


matic system terminates. The pneumatic pipes from the 
houses and in the contiguous streets are ten centimetres 
(four inches), and the main pipe is fifteen centimetres (six 
inches) in diameter. From the vat the sewage is forced, 
by a rotary pump, into the 
river for the present; but 
eventually it is intended to 
utilize it in some adjoining 
country district. It will 
have been seen that the 
pneumatic action in this sys- 
tem is constant, and the 
emptying of the house-re- 
ceivers automatic, the only 
dependence upon corpora- 
tion servants being at the 
central pumping-station. 

It may here be noted that 
these pneumatic methods, 
like the dry systems, do not 
provide for the disposal of 
domestic, kitchen, and bed- 
room slops, the object being 
to obtain the excrement in 
concentrated form for utili- 
zation. Further reference 
to their disadvantages and 
to any reasons which may 
be advanced for their exist- 
ence, will be made when we 
come to compare the relative 
merits of the various sys- 
tems, after considering the 
modes of ultimate disposal. 

II. Unrate DIisposat, 
—At the outset. it may be stated that, as a rule, no sys- 
tem of sewage disposal will yield a pecuniary profit, al- 
though in a few exceptional cases such a result is claimed 
—as, for example, at Pullman, Ill., and in some places 
on the continent of Europe. The plains of Gennevilliers, 
on the outskirts of Paris, 
have, by the employment of 
“sewage, been transformed 
from sandy wastes into 
beautiful gardens, and the 
value of property has been 
greatly enhanced. But, as 
a rule, the highest result 
that is looked for is to gain 
as much as will reduce toa 
minimum the cost of rid- 
ding a community of its 
waste products, which, if 
not properly disposed of, 
would produce an increase 
of sickness and mortality. 

In the case of manu- 
factories it sometimes 
happens that neglect- 
ed waste products 
may be converted from of- 
fensive nuisances into sub- 
stances of commercial 
value. 

In order to simplify and 
condense our consideration 
of ultimate disposal, we 
may classify refuse prod- 
ucts as follows : 


hes 
— 
. 
N 
N 
N 
N 
N 
\ 
N 
Ne 


Fia. 8463.—Berlier Pneumatic Sys- 
tem: ‘*Receiver.’? A, Entrance 
of soil-pipe; B, stand; C, strain- 
er; F, arms revolving on axle (E) ; 
the arrow shows pipe for passage 
of sewage to the ‘* evacuator.” 


WLZZ LLL LLL LLL LLL LLL 
Fiqg. 3464.—Berlier System: ‘‘Evac- 
uator.” K is a pear-shaped float, 
which on rising carries the ball 


Sewage. 
Sewage. 


I, and allows the sewage to rush 
through the discharge-pipe J,into 
the pneumatic tube below ; the ar- 
row indicates the other end of the 
pipe shown by an arrow in Fig. 
3463. 


1. Concentrated excreta, 
or night-soil, which has not 
undergone any artificial 
change, and which has re- 
sulted from the adoption of 


the privy-pit, privy-vault, pail, or pneumatic systems. 


2. Garbage. 


3. Dry-earth and dry-ash products. 


4. Liquid sewage. 


1. THE MODES OF DISPOSING OF NIGHT-SOIL are (@) di- 


rect application to land ; (2) manufacturing into artificial 
manure ; (¢) cremation ; (d) carbonization. 

(a) Night-sotl is sometimes applied directly to the land. 
This cannot be done without producing an offensive nui- 
sance to persons residing in the neighborhood, and it is 
difficult to find an uninhabited place near enough to the 
community from which the night-soil is removed. ‘‘ San- 
itary agents”—this is one of the recent euphemisms— 
will frequently annoy a rural neighborhood till the nui- 
sance and the deterioration of health are no longer toler- 
able, and the arm of the law is invoked with sufficient 
pertinacity to put a stop to their proceedings. 

On the outskirts of large cities where there are exten- 
sive market-gardens, cesspools are sometimes built, the 
night-soil is mixed with fluid and applied to the soil in 
which are growing plants. Sufficient care is not always 
exercised in the mode of-application, and, in case the 
plants are ready for market, this may give rise to un- 
pleasant and baneful results. 

(0) The manufacture of dry artificial manure. This 
may be effected by drying the excreta and resolving them 
into a powder, as, for example, in Amsterdam, where 
the Liernur system is employed, and poudrette is manu- 
factured by the aid of superheated steam and special ma- 
chinery. Or the excrement may be mixed with other 
substances before drying, as in Rochdale, where the pails 
are emptied into trenches containing ashes, the drying 
being hastened by the addition of sulphuric acid ; or in 
Birmingham, where one of General H. Y. D. Scott’s 
processes is employed, namely, adding to the contents of 
the pails magnesia, distilling off ammonia, collecting it 
in sulphuric acid—forming a sulphate of ammonia—and 
then adding phosphoric acid. The solid residue is dried 
for manure. Heat from the burning of other refuse is 
employed in this process. 

In Glasgow admixture of ashes and street sweepings 


_takes place; the process will be described presently. 


Poudrette made from excreta alone cannot be stored 
with full confidence that it will remain innocuous. Fe- 
vers have been known to result from its storage and 
transportation, and these have sometimes presented ty- 
phoid characteristics. 

(c) Cremation is another mode of disposing of night- 
soil. It is in operation in many places on this continent 
as well as in Europe, and among those where I have been 
informed by health authorities that it has given satisfac- 
tion, I may mention Montreal, Ont., and Des Moines, Ia. 
A description of these cremators or destructors will be 
more appropriately given presently, when we speak of 
the associated destruction of garbage. 

The dried excreta resulting from the use of the Smead- 
Dowd system may be readily burned on the spot. Jron 
caps are provided for the closet-seats, with a shallow rim 
coming down past the wooden seat. The whole thus be- 
comes an iron vault, and a small fire being kindled at 
one end, the contents of the vault are quickly burned out. 
Or they may be raked out and thrown into the heating 
furnace. They may, of course, be carted away without 
offence and used on land. 

(d) Carbonization is the term employed to designate a 
process with which the names of Mr. Hickey, of Bengal, 
Mr. Stanford, and, later, Mr. Fryer, of Manchester and 
Nottingham, have been connected. Fryer’s patent method 
has been used in Manchester. The dry refuse being taken 
to the works along with the pails, the contents of the 
dust- and garbage-carts are sorted in a manner similar 
to that employed in the more recent works at Glasgow 
presently to be described. The coarser portions are 
burned in the destructors, while all suitable material is, 
by the heat from the destructors, reduced to charcoal in 
revolving cylinders, called carbonizers ; and in a third 
set of chambers, called concretors, the excreta, mixed 
with a little sulphuric acid, are resolved into artificial 
manure, a small quantity of carbon from the carbonizers 
being sometimes added. 

2. GARBAGE.—As a typical example, conveying much 
useful information regarding some of the recent modes 
of disposal of refuse, I propose to describe the system 
adopted at the works lately set in operation at Crawford 


411 


Sewage. 
Sewage, 


Street, Glasgow. I may premise by saying that in Glas- 
gow they are by degrees abolishing the pit and vault of 
former days, that the number of water-closets is increas- 
ing, and that in addition the pail system isin use. The 
works at Crawford Street present some improvements on 
similar works established a few years ago in the same 
city. 

I quote from the remarks of Lord Provost McOnie at 
the opening of the works: ‘' All the carts on entering 
are weighed. Any material, 
such as stable manure, which 
requires no manipulation, is > 
carted straight into the middle 
floor, where closed latches are 
provided for simply shooting it 
into the railway wagons. All 
the general city refuse, which is 
composed of (1) contents of ash- 
pits and bins, (2) excreta, and 
(3) street Sweepings, is taken to 
the top floor, where special pro- 
vision is made for each variety. 
The contents of ash-pits and 
bins are shot into revolving 
screens of new design. Each 


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Fia@. 3465.—Beehive Destructor: Plan through Line S 7 of Fig. 3466. 


screen (making fourteen revolutions per minute) has a 
double action, and, although in one piece, is practically a 
screen within ascreen. By the first action upon the inner 
mesh, sloping from west to east, all the rougher rubbish 
which will not pass through a one and one-third inch 
opening is separated and delivered on a travelling carrier 
at the east end of the screen; and by the second action 
upon the outer mesh, sloping in the opposite direction, 
the material which has passed through the inner mesh 
travels back over the one-half inch outer mesh. The 
material—chiefly cinder—which passes over this one-half 
inch mesh is delivered at the opposite end of the screen 
from the rubbish, and is thereafter passed down a shoot to 


412 


\\ WE . [N 
SS 


- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the front of the boilers, where it is used as fuel and serves 
to raise steam for the works. The fine ash and smaller 
manurial particles fall through both meshes of the screen, 
and thence down a shoot into the mixing machines, which 
stand upon an elevated platform on the floor immedi- 
ately below. Into these mixers there passes at the same 
time a mechanically regulated quantity of excreta. The 
carts and vans in which this material is collected also 
ascend to the top floor, where the contents are passed 
through gratings into closed cast-iron tanks, 
which rest on the second floor, and from which, 
by a simple mechanical arrangement, the desired 
supply is allowed to escape into the mixers along 
with the fine ash, which absorbs and deodorizes it. 
In order to fix the ammonia and further deodorize 
the compound, provision is made for adding sul- 
phuric acid, or other disinfectant or deodorant, to 
the excreta in the tanks.” The other material 
which is shot into the mixer is the more concen- 
trated detritus from the paved streets of the city 
(the sweepings and scrapings of the macadamized 
streets being sent off to a heather swamp which 
is being reclaimed). It is also taken to. the top 
floor, passed, if wet, through drainage tanks, and 
then added, in certain proportion, to the com- 

pound already de- 


scribed sin yt be 
WRN mixing machines, 
whose _ revolving 


blades thoroughly 
mix the whole into 
a deodorized com- 
pound, which is 
delivered into the 
railway wagons di- 
“rect, and the farm- 
ers are supplied 
with a prepared ma- 
nure in good con- 
dition for spreading 
on the land. The 
rough rubbish, it 
has been observed, 
is delivered by the 
inner screen on a 
travelling carrier. 
This is an endless 
web of iron plates 
on pitched chains, 
which is made to 
travel thirty feet 
“per minute. Wom- 
en are stationed in 
front of it to pick 
off anything which 
can be sold or util- 
ized. One picks 
off, first of all, what 
is manurial, such as 
dirty straw, pulsy 
; matter, vegetable 

refuse, etc., and this 

garbage she drops 

down a shoot by 

her side to the wag- 

on direct, where it 
gets mixed with the compound as it comes from the 
mixer. The other materials picked off for use are old 
iron, old boots, meat tins, rags, paper, etc. The remain- 
der is shot from the carrier into a specially constructed 
cremating furnace, where it is reduced to cinders, which 
are, of course, innocuous, and, like common furnace ashes, 
go to make roads or fill up ground. [In some places they 
are ground up for mortar and sold.] The various articles 
of garbage above referred to are mostly sold to persons 
who can make use of them. Old iron goes for precipi- 
tating copper; ammonia is extracted from old boots; 
solder is taken from meat tins, and so on.” There are 
four sets of rails running inside the building, with a trav- 


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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


erser for shifting wagons from one ps 


to the other; all traversing and haul- 
ing are done by steam-power. A large 
exhaust-fan carries off foul air and 
sends it through the furnace-tires, 
Lavatories, baths, and eating-rooms 
are provided for the work-people. 
One great feature of this establish- 
ment is that nothing capable of de- 
composition is left on the premises 
for twenty-four hours. 
Of refuse crematories, or destructors 
(as they are mostly called to distin- 
guish them from ¢ncineraria), there 
are already many varieties. In the 
most successful it is claimed that 
little or no fuel is used, except to 
start the fires, but that, on the other 
hand, the heat from the burning ref- 
use is used in destroying night-soil, 
furnishing motor power, ventilating 
sewers, etc. One that has been long 
and extensively used is the Bee-hive 
Destructor of Mr. J. E. Stafford, 
A.M.1.C.E., of Burnley, Lancashire, 
England; for which there are agents 
in America, There may be used either 
a single cell-destructor, or one of many 
cells, the latter being the most effec- 
tive, the heated gases from one cell 
being carried over to the next—con- 
tributing heat and giving up to de- 
struction the noxious vapors. A de- 
structor with six cells is shown in 
Fig. 8465, the plan being taken just 
below the grates, on the line S 7 of 
Fig. 3466. Fig. 3466 shows a vertical 
section through two opposite cells on 
the line 7 P of Fig. 3465, Fig. 3467 
is a vertical section through the zig- 
zag line Y Z of Fig. 3465, and shows 
the flues leading from the upper sur- 
face of one fire to the lower surface 
of the next, and from the last fire to 
the chimney. 

~ Fires being lighted on the grate-bars 
K, carts are driven to the shoot J 
(Fig. 3466), down which the garbage 
is dumped ; sliding down the refuse 
chamber B, where it becomes some- 
what dried, it reaches the combustion- 
chamber A. When the fires are first 
started, or when from any other cause 
there is a poor draught through the 
flues C, C (Figs. 3465 and 3467), the 
dampers D, D, D (Figs. 3467 and 3465) 
may be shut, and #, #H, H opened 
(Fig. 8465), and the smoke will pass 
through the flues 5, 0, 5, directly to 
the main flue G, and so to the chim- 
ney. When the fires are good and 
the flues (, C clear, the position of 
the dampers is reversed, and the va- 
pors pass through the flues (0, C and 
through the successive fires on their 
way to the main flue G. As in all 
crematories, the parts exposed to fire 
are lined with fire-brick. 

The Engle Cremator ‘‘ has been re- 
cently invented at Des Moines, I[a.; 
it contains two fireplaces, one at each 
end, and is so arranged that the gases 
of either can be passed through the 
other fire by a shifting of dampers. 
The bottom of the furnace is made of 
heavy iron plates, so set that they 
form a chamber beneath, through 
which the fire may pass on its way 
to the flue. Just above these plates 


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Fia. 3466.—Bee-hive Destructor: 


Sewage. 
Sewage. 


there is a grating upon which the 
material lodges after it is dumped or 
thrown in at the top. The fires are 
so arranged that one will pass over 
the top of the material to be consumed, 
driving the gas forward and down- 
ward through the other fire, there 
inflaming all of the gases from the 
material, and using the heat to main- 
tain the fires of the furnace, and at 
the same time rendering the escaping 
material [gas] from the flues inodor- 
ous and nearly transparent.”’ 

At Montreal, Q., garbage and night- 
soil are cremated in a furnace (Fig. 
3468) of very simple construction, and 
the result is said to be very satisfac- 
tory. The furnace was planned by 
the City Contractor, Mr. William 
Mann. The grate isa little over six- 
teen feet long and nine wide, extend- 
ing by a gentle upward incline from 
the fireplace at one end, where the 
fire is started, to the flue at the other 
end. The combustion-chamber is 
quadrilateral, a little over sixteen feet 
long, nine broad, and ten high. On 
each side of it are nine doors; three 
at its upper portion open out upon a 
stage on to which carts are driven, 
the refuse being put into the furnace 
through these doors ; the next lower 
doors open just above the line of the 
grate, and are used for stirring the 
fire; the three lowest are at the bot- 
tom of the furnace, and are used for 
removing the ashes. Under the grate 
is a receptacle for water (not shown 
in the sectional cut, Fig. 3468). This 
may be varied in, different furnaces, 
the object being to prevent over-heat- 
ing and destruction of the grate. 
This latter consists of iron bars, their 
ends being laid on the brick, the in- 
ter-spaces between them being two 
inches. The flue is about twenty-two 
inches long and eighteen wide—in- 
side measurement. The chimney is 
ninety feet high. Among other fur- 
naces may be mentioned the Rider 
Furnace, of Pittsburg, Pa., which has 
been but a very short time in opera- 
tion, and of which, therefore, nothing 
very satisfactory can be said. 

While there is no doubt as to the 
success of garbage-cremation, the va- 
rious forms of furnace may be said 
to be still on trial, as the reader may 
have inferred from the above descrip- 
tions. It seems as though the best 
results would be obtained by cremat- 
ing on a large scale, and maintain- 
ing a constant high temperature ; by 
so arranging the furnaces that surface- 
heat may be utilized in drying mate- 
rial on its way to the fire; and by 
consuming the heated gases on their 
way to the chimney. 

Individual householders can mate- 
rially aid in the disposal of garbage. 
Vegetable matters, if carefully kept 
from grease and animal contamina- 
tion, may be given toa horse or cow, 
if one is kept. In some cities and 
towns garbage is, to a great extent, 
burned by the householders. It may 
be prepared for burning in a recepta- 
cle fashioned something like a steam- 
er used for cooking. 


413 


Sewage. 
Sewage. 


8. OF DRY-EARTH AND DRY-ASH METHODS nothing need 
be added to what was said in the section treating of imme- 
diate disposal. 

4, Liguip SrwaGE.—The modes of ultimate disposal 
are: (a) Emptying into tanks or cesspools ; (0) discharg- 
ing into some body of water ; (c) irrigation ; (d) filtration ; 
(e) precipitation and deodorization. 

(a) Cesspools are excavations in the earth into which 
sewage is allowed to flow. They are sometimes water- 


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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


dation takes place far less readily than in fresh water 
(see Sewerage). 

(c) rrigation.—This consists in discharging the sewage 
upon or into the soil in such a way that it shall be acted 
on by growing vegetation. The soil acts as a filter, 
straining out particles ; then, by the separating action of 
the earth-particles, a large surface of the fluid is ex- 
posed to the action of the air, and the organic is reduced 
to inorganic matter. The experiments of Mintz, Pas- 


ey 
A 


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Fic. 3467.—Bee-hive Destructor: Section through the Zig-zag Line Y Z of Fig. 3465. 


tight, and sometimes the sewage is allowed to percolate 
through the bottom. Their walls and roofs may be of 
wood, brick, masonry, or cement. Sometimes the walls 
are allowed to be pervious as well as the bottom. They are 
generally provided with an overflow, unless the soaking 
away of the sewage is fully insured. Old wells are oc- 
casionally turned into receptacles for sewage. In those 
rare cases where cesspools are allowable, they should be 
ventilated by a tall outlet, and shorter inlet, shaft. 

(0) Discharge into some body of water.—This is the 
mode which has been generally adopted and continued 
in each individual case, until it has caused a nuisance 
such that means have been taken to prevent it. So gen- 
eral had the nuisance become in England, owing to the 
density of population, that in 1876 the Rivers Pollution 
Prevention Act was passed, providing that no rivers or 
streams should be polluted through the admission of crude 
sewage. For years, both before and since that time, the 
question of sewage-disposal has engaged the attention 
of numerous parliamentary committees and commissions, 
and of many of the foremost scientific men. Some 
places, as, for example, 
cities situated on rivers 
like the Lower Missis- = 


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Lawrence, tage INA Daoars, far 
are so favor- fer Carty, NZ 

ably situated INZ 


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teur, and others, go to prove that this process is aided by 
micro-organisms in the soil. Vegetation also assists by 
utilizing the inorganic substances. 

Hence, it will be apparent that there must be alterna- 
tions of sewage and air in the soil, and that the soil must 
be in such a condition as to allow the sewage to run 
through and out of it, and that the vegetation must not 
be overdosed. ‘There are great differences, moreover, in 
the capacity of various kinds of plants for utilizing sew- 
age: In England osiers, Hungarian grass, Italian rye- 
grass, cabbages, mangolds, and other coarse-grained and 
succulent vegetables are especially recommended. But 
the market must also be considered. During a recent 
visit to Pullman the writer was informed by the cour- 
teous farm-superintendent, Mr. E. T. Martin, that he 
grew Italian rye-grass, 
but could not get cat- 
tle-feeders to take it 
away, although he of- 
fered finally to give it 
to them. The stalks 


the Pnlrance of Refuse 


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difficulty; butin very Lab =! heal pars: aes 

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water-supplies ; and 
it has given rise to 
commissions of inquiry, the reports of some of which 
form valuable contributions to the literature of the sub- 
ject. Among them may be mentioned the reports of Dr. 
Charles F, Folsom, Mr, J. P. Kirkwood, C.E.,; and others, 
in the Annual Report for 1876 of the Massachusetts State 
Board of Health, and the later report (1884) of Mr, Sam- 
uel Gray, City Engineer of Providence, R. I. 

In discharging into the ocean much difficulty has arisen 
from the action of tides, coupled with the fact that oxi- 


414 


Fic, 3468.—Cut showing principle of Montreal Garbage Destructor. 


grew very thick, rank, and watery. The principal crops 
at Pullman are cabbages, celery, and onions; turnips do 
well, but the market is unreliable. Potatoes fail utterly. 
Other vegetables can be raised, but those mentioned are 
found to suit best. It is a common mistake to suppose 
that rain is not needed on sewage-farms ; it is necessary 
for the destruction of insect-pests. The Pullman farm 
has yielded a fair profit on the investment, apart alto- 
gether from sanitary advantages, except in those years 


Q 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sewage. 
Sewage. 


when frost or other unfortunate accidents have had a de 
structive influence. 

Sandy loams, and loams with a substratum of gravel 
or chalk, are well adapted for irrigation. In the case 
of stiffer soils, subsoil drainage is necessary. Experi- 
ence has Shown that it is not well to use pipes of a smal- 
ler diameter than four 
inches for this purpose. ; 
They should be laid ata 
depth of from four to 
six feet, but the distance 
between the lines of 
drain varies very much 
in practice; in some 
places we read of their 
being forty inches apart, 
in others as much as 
eighteen feet. These subsoil pipes should, of course, be 
porous and open-jointed. 

Solid substances are screened out before the sewage 
is applied to the land. In some places the sewage is con- 
ducted or pumped to the highest part of the farm, and 
thence distributed by sluices and ‘‘ carriers” in the sev- 
eral methods presently to be described ; in others it is 
carried in underground pipes and pumped from hydrants 
placed at intervals—one hydrant to every two and one- 


Fie. 3469.—Tile-carrier, with separate 
Side-pieces. 


form of broad irrigation is what is termed the ‘ con- 
tour” or ‘‘catch- water” method, which consists of 
a series of shallow channels, or carriers, terraced one 
above the other, with gently sloping land between; the 
water flows into and overflows the highest carrier, then 
down the slope into the next, and soon. The carriers fol- 
low as far as possible the contour of the ground, and the 
distance is regulated by the slope and nature of the soil— 
an average of two hundred feet is recommended. 

The ‘‘carriers” may be formed in the earth itself, 
which is generally firm enough, or they may be edged 


‘with turf, or tiles may be used, as shown in Fig. 3469. 


The capping of these tiles may be used as a footpath—a 
great advantage. It may be noticed, too, that the side R 
is higher than L, which allows the sewage to overflow. 
In carriers valves are sometimes placed, similar to the 
flap-valve in the Palmer trap (see Sewerage), but regulated 
as to the amount of opening byahandle. These must, of 
course, be contained in a closed-pipe carrier. The side- 
pieces (L, R, Fig. 3469) are made separate from the bot- 
tom tile B, and additional side-pieces may be let in, thus 
making the carrier deeper, if required as a conducting 
main. ‘These main carriers or sluices are sometimes con- 
structed in the earth and edged as above described, or 
they may be of tile or cement. 

Fig. 3470 represents a farm on the ‘ flat-bed” system. 


ie 


il 


Fia. 8470.—A Sewage-Farm, Irrigated on the Flat-bed System. 


third acres is the apportionment at Pullman. It is ap- 
plied to the land in various ways: it may be poured out 
upon it in a stream, the direction of which may be 
changed by hose, boxes, or half-pipes, which latter may 
be turned with the foot ; to this the term ‘‘ broad irriga- 
tion” is applied. Grass land often receives a ‘‘ surface 
treatment” of this kind, a section thus treated being 


oe, 
Fia. 3471.—Section of Land Irrigated on the Flat-bed * System, the sew- 


age in this case being confined by a strip of turf on the lower edge of 
each bed, and supplied by a carrier at the upper edge. 


fenced off for a few days before cattle are allowed on it. 
A rain following the application of the sewage improves 
the land very much for pasture purposes. A modified 


*T am aware that the term “ flat-bed” system has received a different 
application at the hands of some: but it is used as given in the text by 
Mr. Wm. Eassie, O.E., F.L.S., F.G.S., as also are the terms ‘‘ pane and 
gutter” and ‘“ sewage-cropping,” respectively applied to the next two 
modes. See Our Homes, Cassell & Co., London, 1883. 


(From Dr. Foisom’s Report.) 


The surface must be graded so as to have a slight incli- 
nation—say one foot in fifty, to one in one hundred and 
fifty, according to the nature of the soil, the crop, and 
the amount of irrigation required. The sewage 1s con- 
ducted along the main sluice A, E, and can be stopped 
at any desired point by the main dam F;; it is led into 
the laterals by the gates G, G, G, and it may be stopped at 


Frq. 3472.—* Pane-and-gutter”’ or ‘‘ Ridge-and-furrow” System of Sew- 
age [rrigation. 


any required distance by the lesser dams D, D. The 
sewage is thus made to flow over a portion of the land 
for a few hours at a time, at intervals of as many days 
as may be found necessary. A method is in operation 
(and is being gradually extended) at Pullman by which a 
more uniform result is obtained. The beds are arranged 
in sets of six, three on each side of a broad, low, turf 


415 


Sewage. 
Sewage. 


wall, which runs lengthwise down the slope; the re- 
maining sides of each bed are also surrounded by a little 
turf wall, and in this rink-like form the sewage can be 
more evenly spread ; a hydrant stands at the head of the 
broad dividing wall, and, by means of a sluice-box, sup- 
plies sewage to the beds on either side ; at the lower end 
of each of the first and second beds, close by this median 


H) 
if) 


ra ff 
Ue. 


y /} My Hf My 


Wy) Wy] 
f Yi if ik Hf / , I, fi | 
WAT i} YL i / 


Fic. 3473.—‘‘ Sewage-cropping,” by allowing the sewage (C) to flow in 
the gutter (D) and percolate into the beds on either side. 


i I) if Hf} ‘ 

YY yh WIN Fa 

Hy Wi 
Hy, f 


wall, is a small sluice-gate, so that the sewage can be let 
into the lower beds only, or into any of them at will. 

In Fig. 3471 is shown a section of a series of beds on a 
somewhat similar principle. 

The ‘‘ pane and gutter ” or “‘ ridge and furrow” method 
is represented in Fig. 3472. 

The land should be deeply cultivated and well pul- 
verized, and arranged in ridges and furrows so as to form 
long beds, as shown in Fig. 8472. These should be from 
forty to ninety feet wide, according as the land is light 
and loamy, or of a less porous nature. The slope should 


be from one in twenty to one in forty, according to the nat- | 


ure of the soil. The sewage is then conducted in a carrier 
or shallow trench along the ridge, and allowed to overflow 


uA and soak 

Pay 
oF, through 
oon Be the slop- 
HE. C4 ; : 
vg er ing bed; 
Bee o if grad- 
Siooper ing and 
distanc- 


ing be carefully done, 
there will be little over- 
flow left to be carried off 
in the gutters by the 
time they are reached. 
In some places porous 
or perforated and open- 
jointed tiles are placed 
on the ridges instead of 
the carriers. 
Another mode of ap- 
plying the sewage is to 
allow it to flow into 
gutters or channels in 
the earth, and soak 
through the sides of 
these channels into beds 
on either side, from 


BA, 
Oa EGR 


Fic. 3474.—A Diagram showing the mode of disposing of the Sewage 
of the Double Cottage A, by Subsoil Irrigation. 


which it is taken up by the roots of vegetation. It will 
be evident that the sides of these channels will require to 
be scraped or loosened more frequently than in the other 
methods, so as to allow more ready percolation. Fig. 
3473 gives an example of this method of irrigation, to 
which the term ‘‘sewage-cropping” is applied by Mr. 
Eassie. In this case the distance A B from centre to cen- 
tre of the beds is about two feet, but they are often much 
wider ; the depth of sewage-space in the gutter, C to D, is 


416 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


about nine inches ; the length of the distance to be trav- 
ersed in the gutter by an outflow of sewage will, as be- 
fore, depend upon the character of the land, and may be 
about one hundred feet in light soils, and more in less 
porous soils. 

Subsow Irrigation.—There are at times circumstances, 
such as close proximity to dwellings, which render it 
undesirable to have sewage exposed on the surface, and 
in these cases it may be applied about a foot below the 
surface. This must not be confounded with subsoil 
drainage referred to above. Unless the subsoil is very 
porous, we still have to employ subsoil effluent drains 
below the subsoil irrigation-drains. This is shown in 
connection with the disposal of the sewage of two cot- 
tages in Fig. 3474. It is not prudent to have the sewage 
discharge into the soil near the dwellings, and the black 
lines nearest the tanks D D represent water-tight glazed 
tiles which conduct the sewage into porous tiles with 
open joints, represented by the branch lines CC CC; 
the effluent drains are represented by the light lines B B, 
converging into O, the main effluent. Subirrigation- 
drains have to be raised, as they are liable to become 
clogged. It is well to do this every season, or bends 
only may be raised, as they are most liable to clog. In 
taking up the drains another advantage may be gained, as 
their lines may then be laid in fresh portions of the soil. 

In places where the flow is small, as in private houses, 


tank is employed, the sewage be- 
ing discharged periodically. The 

tank may be made to discharge 
by some automatic ar- 
rangement, as seen in 
Field’s Flush-tank (Fig. 
3475). This is a cylin- 
drical iron tank, A. In 
the case of its receiving 
sewage from a discon- 
nected pipe (see Sew- 
erage) it should 
have a trapped in- 
let, B, which also 
serves aS a mova- 
ble cover. Cis a 
ventilating opening; D is the siphon; /’, termed the 
‘* discharging trough,” consists of asmall chamber, which 
may be turned around so that it may connect properly 
with the pipes G, through which the sewage discharges. 
It has a movable cover for getting at the mouth of the 
siphon. This trough forms a temporary check to the 
flow, so that the siphon can be brought into action. An- 
other advantage of this periodic discharge is the period 
of rest which is given to the soil, the necessity for which 
has been alluded to. 

In irrigation on the large scale this intermittent action 
must be regulated by the attendants according to the 
crop. Sometimes it is desirable to allow three or four 
days to elapse between ‘the successive irrigations. It 
is always desirable to have a fallow or idle field on to 
which sewage may be turned, when the crops would be 
injured by it, or when they are being taken off. 

In irrigating on the large scale the distance traversed 
is generally sufficient to break up fecal matter, and the 
action of pumps has a similar effect, so that all may be 
turned on to the land. ‘There are many other matters in 
sewers, however, which must be screened out. Where 
their value as manure is not a consideration, the excreta 
are sometimes intercepted, and treated by some of the 
methods recommended for night-soil. In household ir- 
rigation—by gravity—they are generally intercepted. 
The solids are sometimes precipitated by some of the 
methods presently to be described, and the supernatant 
fluid alone is used in irrigation. This is not to be rec- 
ommended from an economic point of view. 

I have before stated that in the dry and pneumatic 
methods the disposal of the slop-water has to be pro- 
vided for. This may be done.by means of irrigation. 


Si 
i 


eg) a Ps Me ~ 


Fie, 3475.—Field’s Automatic Flush-tank. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Town sewage can be far more profitably treated if the 
separate system of sewerage (see Sewerage) has been 
adopted, thereby rendering the sewage less in quantity 
and more concentrated. 

The amount of land required for irrigation will, of 
course, vary with the nature of the soil and character of 
the sewage, but one acre to one hundred people is given 
as a fair proportion. 

It was at one time considered doubtful whether sewage 
could be disposed of by irrigation in winter in very cold 
climates. This difficulty has been solved by the expe- 
rience of Dantzig, of the City of Pullman, before al- 
luded to, and of the State Asylum for the Insane at Au- 
gusta, Me., where the sewage flows out in winter. Its 
warmth keeps it from freezing, and it flows over the 
ground ; if this is covered with snow it works its way 
underneath. It is found that the soil purifies it even 
without the action of growing plants. 

(d) Filtration. —Intermittent downward filtration resem- 
bles very much the mode of irrigation with subsoil drain- 
age. The drains are placed at a greater depth if the 
nature of the soil and outfall permit, and larger quanti- 
ties of sewage are poured upon the land, and with greater 
frequency ; as less regard is had to the paying result in 
cropping, a less quantity of land is required. The land 
is divided into several filter-beds—four at Merthyr Tydvil 
—the sewage being successively poured for a certain 


UaivMm 1G 


Sewage, 
Sewage. 


‘“‘ The phosphate sewage process patented by Mr. David 
Forbes and Dr. Astley P. Price. Phosphate of alumina 
and lime.” 

‘‘ Bird’s process. Sulphuric acid and clay.” 

‘“‘Stothert’s process. Lime, sulphate of alumina, sul- 
phate of zinc, and charcoal.” 

‘2, Processes which employ lime as the chief precipi- 
tating agent : 

‘‘ Hille’s process. Lime, tar, salts of magnesium, etc.” 

“‘ Marsden and Collins’ process. Lime, carbon (a waste 
product of prussiate of potash manufacture), house ashes, 
soda, and perchloride of iron.” 

‘‘ Holden’s process. Sulphate of iron, lime, coal-dust, 
and clay.” A 

‘*Fulda’s process. Lime and sulphate of soda.” 

‘‘ Blythe’s process. Superphosphate of lime, with mag- 
nesia and lime.” 

‘“Whitthread’s process. Dicalcic and monocalcic phos- 
phate and milk of lime.” 

‘“Campbell’s process. Soluble phosphate of lime.” 

‘“Hanson’s process. Lime, black ash, and red hematite 
treated with sulphuric acid.” 

‘‘Goodall’s process. Lime, animal carbon, ashes, and 
sesqui-persulphate of iron.” ; 

‘The Lime process. Milk of lime.” 

‘“General Scott’s process. Milk of lime; the sludge 
being burnt, forming Portland cement.” 


cCARBOY 
SULPHURIC 


. Fie. 347%6.—Process of the Widnes Alkali Co., for Deodorizing the Contents of Sewers, by forming and mixing with them (as made) Permanganate of 


Soda. 


A is an iron tank about six feet by six feet by four feet, with cold-water supply-pipe and overflow-pipe. 


Manganate of soda is introduced 


into this tank, the cold-water inlet-tap opened, and the solution flows out of the overflow-pipe into the mixing vessel C, a small, lead-lined cistern | 


about two feet by two feet by two feet. 


Here it meets with sulphuric acid from the lead-lined cistern B (about four feet by four feet by two feet in 


dimensions), the flow of which acid is regulated in such quantity as to turn to a bright pink color the manganate of soda solution from tank A. 
The manganate of soda solution is thus turned intoa permanganate of soda solution in the tank C, and runs through the overflow-pipe at the top of 


C into the drain or sewer where it is required, 
~ regulates the rate of overflow to the required quantity. 


number of hours upon each ; in this way time for aéra- 
tion isgiven. At Merthyr Tydvil irrigation upon another 
tract has been added. 

Upward filtration has been tried, as at Ealing, but has 
not proved satisfactory. Of carbon-filtration the same 
may be said, the carbon being at present too expensive. 

(e) Precipitation and Deodorization.—After the agitation 
against sewage-pollution began, a vast number of pro- 
cesses were proposed, ranging from simple subsidence in 
tanks to the use of chemicals, appalling in their number 
and variety. It most cases these chemicals are mixed 
with the sewage in settling tanks, the clarified liquid be- 
ing decanted off and the precipitated sludge being dried, 
or put on land at once. Some of the processes contem- 
plate the addition of the chemicals in the sewers. 
the most recent of these is the permanganate of soda pro- 
cess of the Widnes Alkali Co., of Widnes, Lancashire, 
which may be understood by the accompanying cut (Fig. 
3476), and description. 

The following well-arranged, brief list of some of the 
more important chemical methods that have been tried 
I extract from Gray’s Report, before alluded to : 

‘1. Processes that employ salts of alumina as the chief 
precipitating agent : 

‘“The Coventry process. 
salts of iron, and lime.” 

‘The Native Guano, or A, B, C, process. Alum, blood, 
clay, and animal charcoal.’’ [In addition to these the 
original specification stated that magnesia, magnesia lime- 
stone, manganate of potash, chloride of sodium, and burnt 
clay might be added, and that vegetable might be substi- 
tuted for animal charcoal. | 


Vou. VI.—27 


Crude sulphate of alumina, 


Among | 


The process is a continuous one, the manganate being fed slowly into A, while the inlet water-pipe 


‘¢3. Processes in which salts of iron are used as pre-. 
cipitants : 

‘* Chloride of iron and lime.” 

‘* Sulphate of iron and lime.” 

‘‘4. Miscellaneous processes.” 

These processes are very numerous, but have led to 
no practical results. In England, from 1856 to 1876, 
there were four hundred and seventeen patents issued, 
all more or less connected with sewage and manures. 

Of the many methods that have been tried for the 
chemical treatment of sewage, there are but three that 
stand prominent at the present time. These processes 
are those of ‘‘ The Rivers’ Purification Association, Limi- 
ted [which controls and employs principally that which 
is], better known as the Coventry process. 

‘“The Native Guano Company, Limited—better known 
as the A, B, C, process ; and 

‘« The lime process.” 

The precipitated ‘‘sludge” itself becomes a nuisance 
during the drying process ; in order to get rid of the wa- 
ter (which generally amounts to about ninety per cent.), 
heated floors, blasts of air, and other artificial methods 
are resorted to. But one which seems more likely to 
prove satisfactory is the filter-press of Messrs. 8. H. Joln- 
son & Co., of Stratford, England (Fig. 3477). 

‘‘Tt consists of a number of narrow cells held in a suit- 
able frame, the interior faces being provided with appro- 
priate drainage surfaces communicating with an outlet, 
and covered by a filtering medium, generally cloth or 
paper. The interiors of the cells so built up are 1n com- 
munication directly with each other, or with a common 
channel for the introduction of the matter operated upon, 


417 


Sewage. 
Sewage. 


7 


} hs 


t 
| 
| 


5) TT 


NNN 
ine 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Fia. 3477%.—Johnson’s Filter-presses for drying Sludge, 


and as nothing introduced into the cells can find an exit 
without passing through the cloth the solid matter fills 
up their interior, the liquid leaving by the drainage sur- 
faces.” The sludge is forced into them by the action of 
compressed air. The sludge-cakes are removed upon 
opening the press; they contain about fifty per cent. of 
solids and fifty per cent. of water, eight hundred parts 
per thousand of water having been forced out, leaving 
still one hundred of water and one hundred of solids. 

The cost of the treatment of sewage by precipitation 
varies in English towns from seventeen cents to sixty 
cents per head of population per annum. But, as labor, 
chemicals, and apparatus are more costly in this country, 
we might have to double these amounts in order to obtain 
practical results here. 

III. A CoMPARISON OF THE ABOVE METHODS, AND 
THEIR ADAPTABILITY TO CITIES, VILLAGES, ETC.—We 
will now compare the merits of the various methods de- 
scribed, and their relative adaptability to the needs and 
circumstances of cities, villages, and isolated houses. 

The Privy-pit and Privy-vault Systems.—It is hardly 
necessary in a work of this kind to describe at length the 
evils of the privy-pit : the poisoning of wells, the pollu- 
tion of soil and air, the effects of the exposure of the 
nude person over a large pit full of cold and mephitic 
gases, the conveyance of germs of disease into the air and . 
water, the general deterioration of health from taking 
into the body such air and water even when specific 
germs are not present—all these evils the medical reader 
should be able to comprehend and amplify for himself. 
I may, however, state a few facts illustrative of the extent 
of pollution from this cause. .I was asked to examine, a 
few days ago, a site on which is to be erected an addition 
to one of our largest public schools. On one edge of the 
site a row of privies had existed ; on the contiguous edge, 
about fifty feet distant, is an old well; the cellar excava- 
tion, about forty-three by twenty-eight feet, had been dug 
to the required depth of about seven feet. The structure 
of the soil is sand overlying a stratum of blue clay, with 
pockets of sand dipping into the latter. It was found that 


418 


‘this entire area was a mass of stinking filth. How far be- 


yond and around this filth extends I cannot say. The 
school has been supplied for some time with city water 
from Lake Ontario. A method of treating such a sewage- 
polluted site would be to remove all the soil down to the 
clay, to scrape the latter and flood it with a solution of bi- 
chloride of mercury, 1 in 500, and to lay a good concrete 
floor, the space between the clay and the concrete being 
previously filled with a mixture of clean clay loam and 
chloride of lime, or quick-lime; as an additional precaution 
air-spaces of porous tile, or brick arches, might be formed 
under the concrete floor, connecting with a hollow wall 
air-space outside the foundation at two sides of the build- 
ing, one of these latter being connected with a furnace flue, 
the other communicating with the outside air. A con- 
temporary issue of a newspaper in one of our country 
towns relates the following incident: ‘‘ A short time 
since in making an excavation for a building, the work- 
men struck a vein of polluted earth, the stench from 
which was almost unbearable. Being curious to see and 
know the cause, I had the men follow the vein and found 
that it had its origin in a pit, and its outlet in a well, the 
distance to which was about one hundred and forty feet. 
In its passage the liquid matter from the pit had defiled 
the earth for several feet in all directions.” Similar soil 
pollution exists around and amid dwellings in city, town, 
and country, everywhere, and we are occasionally aroused 
by unmaskings of what is continually, but secretly, going 
on around us. <A calculation from actual facts will help 
to show the intensity of this evil: In some of the thickly 
inhabited portions of cities, even on this continent, we will 
find as many as five hundred people on a space of seventy 
by two hundred yards, Taking the basis, as given by phys- 
iologists, of two and a half to three ounces of feeces and 
forty ounces of urine per diem, for each individual, there 
is deposited in, and spread through, the subsoil of this area 
every year from fourteen to eighteen tons of feeces, and 
more than forty-five thousand gallons of urine, besides 
slop water, all which is left to slowly decompose for 
years without removal. It seems strange that such con- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sewage, 
Sewage. 


ditions should have been so long tolerated, but the people 
at large are slow to act on the dicta of a few sanitarians 
until the facts and consequences have been made plain to 
them ; they are slow to move out of old grooves, espe- 
cially when private rights and convenience stand in the 
way. Moreover, proper disposal of sewage in communities 
requires combined action, and it is often difficult to get 
municipal corporations to act on scientific principles, 
especially when it is thought that a little false economy 
will better serve political interests. Medical men must 
persevere in their efforts to awaken the public to a real- 
ization of the extent and nature of the evil. Boards of 
health generally must follow the example of those boards 
which are bringing about a rectification of this evil. 

In many places the work was begun by ordering the 
cleansing, filling, and replacing, by some proper substi- 
tute, of every pit or vault reported to the board of health 
and found to be a nuisance. In others the board has in- 
troduced and carried out, throughout an entire district, 
some proper system under its own oversight. 

The privy-vault is somewhat less objectionable than 


the mere pit, inasmuch as it is at first water-tight; but 
there is great danger of soakage or of pollution of soil 
and water eventually occurring, and in the meantime 
the vaults pollute the air. 

The Midden system is not to be commended. It is a 
very doubtful improvement over the old want of system. 

Deposits of garbage in cities, towns, and villages are re- 
sponsible for much sickness. Garbage—decomposable 
animal and vegetable matter, generally mixed with ashes 
and other rubbish—is dumped into hollow places, and 
after a time excavations are made in these. Sometimes 
the cellars and foundations of houses are constructed in 
this ‘‘ made soil,” and the ascensional current draws up 
the gases of decomposition from the soil. Occasionally 
the owner and.builder are not aware of the nature of the 
site. 

The diminution of mortality by the introduction of im- 
proved means of sewage disposal is shown in the follow- 
ing tables, and from it may be inferred a great decrease 
in the amount of sickness, and a consequent gain in mate- 
rial wealth : 


Death-rate Death-rate 
City. Period. | Sanitary condition. | Pont ee | Period. | Changes in sanitary condition, | oe Pia 
fever. | fever. 
Frankfort-on-the-Main. ............... 1854-59 | No sewerage. 87 1875-80 | Sewerage completed. 24 
DAN LZAG Ree tere ce ote on done ace ee hes 1865-69 | No sewerage; no 108 | 1871-75 | Water-supply introduced. 90 
proper water-sup- 1878-80 | Sewerage added. 18 
ply. ; 
MimiCh eared aces tne cet ee eee teens 1854-59 | rie sess no reg- 242 1860-65 | Reforms begun by cementing 168 
| ulations for keep- the sides and bottoms of cess- 
ing the soil clean. pits. 
1866-73 | Partial sewerage. 183 
1876-80 | Sewerage improved. 87 
1881-84 | Sewerage still further improved. 17 
Average mortality | Average mortality Reduction oti Geemackomiy 
Place. ae 1,000 before er 1,000 rae Saving oflife.| typhoid fe-| rate of phthi- 
construction of | completion of ware : 
works, works, ' pe 
¢ Per cent. Per cent, Per cent. 
ES Bri DIE Vewerrnee tee IOS Melaie sits rae scans arses bie wintersic ss Fis Gress s 23.4 20.5 124 48 41 
Gardifin ere stem, Wee socom oe ce ine aie ce ole va hietee a Siets a Se nbc Salalectsrs 33,2 22.6 32 40 17 
AULOY LONE ree meee sel aee ie afte via hats salad Sacks’ sare gclaaton are aiaaute 23.7 18.6 22 63 17 
TOV. GEM tate wee Emerita s ora e ve tae a one ahs lee Sis Satine able sic wilde eine 22.6 20.9 7 36 20 
WON yn nigieo. Sci SH. Se USC BRIE DOOR DIELS CERIO 6 ORES rego te are Nine carer ea tr 23.9 20.5 14 56 4% 
elcesheremmm teen tats states cas or OLne ooo ae eee omet cere. 26.4 25.2 4g 48 32 
Macclestiold aera cme cess oom a cite e Sek oniiwna ae delsielahcie blot elsletatare 29.8 23.7 20 48 31 
Ment liyiie eras eiaearas cee ceteris ak oe Sache dotnet sida nae ces 33.2 26.2 18 60 11 
ING WOT Me etree a ctteals is} ores cteets seh atm Ain sro-are) tls eile aida Wma gio wre soo" 3 31.8 21.6 32 - 36 32 
FoR Ok awa aes Gad OTos CAO SSG nae OST SEE okt cn arc eee ae 19.1 18.6 21g 10 43 
MALEDUnY Memeo atte ce ealtie cee cies viet cee oles epihis see ceed os 26.9 21.9 20 75 49 
WEI RQELOS  Gcks Soin. c CE ODED DEERE OTe Ie SAORI FORE ioe Easy eects Poll 21.0 Tg 52 19 


A large number of statistics illustrating this subject 
may also be found in a paper by Mr: Erwin F. Smith, 
published in the ‘‘ Annual Report of the State Board of 
Health of Michigan” for 1885. 

Water-carriage is undoubtedly the most preferable 
method in places where the sewage can be properly got 
rid of without further outlay, or where it can be utilized 
with little or no loss. It is quite possible that the time 
may not be very far distant when there may be some 
better and more intelligent understanding between the 
agriculturist and the sanitary authority, when there may 
be some such combination as will put an end to some of 
the difficulties and loss at present attendant upon sewage 
disposal and utilization. But accepting the fact that 
there is generally at the present day a small loss, this is 
counterbalanced over and over again by the gain to the 
community in the saving of life, time, and the expenses 
resulting from sickness and death. But as this saving is 
brought about in varying degrees by all sanitary im- 
provements, we may briefiy consider what are the special 
reasons for preferring the water-carriage system : 

First, in all systems there. must be some means of 
disposing of chamber, house, and kitchen slops; and, 
strange as it may at first sight appear, it has been found 
in large communities that the exclusion of excreta makes 
but a slight difference in the character of the sewage. 


From De Chaumont’s edition of Parkes’ ‘‘ Hygiene” 
(‘‘ Wood’s Library” for November, 1883, pp. 32, 52), 
the following remarks are quoted: ‘‘ This difficulty is 
felt in the case of the foul water flowing from houses 
and factories without admixture of excreta almost as 
much as in sewer-water with excreta. The exclusion of 
excreta would indeed hardly lessen the diffi- 
culty—” . ‘‘the solid excreta of only six per cent. 
of the inhabitants [of Birmingham] pass into the sewers, 
while the solid excreta of the remainder pass into mid- 
dens. The problem of disposal is as serious for Bir- 
mingham as if all the excreta passed in.”” The conclusion 
of the Second Rivers Pollution Commission accords with 
this. 

Secondly, after a proper building of the entire system, 
there is more perfect automatic action and less depend- 
ence upon individuals. 

Thirdly, the conveniences are much greater, and the 
encouragement given to the liberal use of water conduces 
to health. 

Fourthly, in a well-constructed system of sewerage all 
refuse, except garbage, leaves the community within a 
few hours of the time it becomes refuse; and garbage 
may, by individual household management, be destroyed 
in the same time. ; 

Many persons have objected that the water-carriage 


~ 419 


Sewage. 
Sewerage. 


system makes avenues for the entrance of sewer-gases 
into houses. This objection holds not against the sys- 
tem as it should be, but against the faulty and defective 
contrivances that are too often allowed. How these de- 
fects may be obviated is shown in the articles on Habi- 
tations: General Principles of House Plumbing, and on 
Sewerage. To enforce correct principles in spite of the 
wilful neglect of avaricious and unscrupulous builders 
and tradesmen, we must come to a strict system of in- 
spection of plans and buildings. 

The groundlessness of the above objection to the intro- 
duction of systems of sewerage will be evident from the 
statistics already given and referred to. 

Then, again, fears have been expressed regarding the sa- 
lubrity of localities in the neighborhood of sewage farms, 
and regarding the wholesomeness of the products of the 
latter. On these subjects M. A. Durand-Claye quotes 
from a letter addressed by Dr. Frankland to M. Mille, 
inspecteur général des Ponts et Chaussées, ‘‘ In reply to 
your letter of the 12th inst. [May, 1881], I will say that I 
have followed with the most lively interest the recent 
researches of your illustrious compatriot, M. Pasteur, 
and I consider them of the highest importance. . . . 

‘* These considerations, however, have not modified my 
opinion as to the harmlessness of sewage irrigation ; for 
its harmlessness has been proved by ample experience. 

It has been recently proved by experiments in 
my laboratory, that although bacteria live and multiply 
in sulphuric acid, in cyanogen, and other deadly poisons, 
they are at once destroyed by that inoffensive material, 
metallic iron. 

‘“That there may be in nature powerful agents for the 
destruction of the germs of disease cannot be doubted. 
; Experience seems to show that some of them are 
active in the process of sewage irrigation ; for it has been 
demonstrated many times in this country that sewage, 
even when infected by cholera and typhoid fever, has never, 
when used in irrigation, transmitted disease, either to 
those living on the irrigation fields, or to those who con- 
sume the crops raised upon them.” 

Microscopic examination of Paris sewage, and of the 
effluent from the irrigation fields, shows the number of 
microbes per cubic centimetre to be twenty thousand, and 
twelve, respectively ; and chemical analysis also shows a 
remarkable purification to have taken place. 

Dry Systems.—The difficulties connected with the con- 
stant oversight required by the dry-earth, and dry-ash, 
and pail systems in a mixed community, will have been 
apparent, and the offensiveness caused by several days’ 
storage, without deodorant, in the latter system, is an ad- 
ditional objection. In both, too, there is a continuous 
outlay. 

There are, however, circumstances in which these 
systems may be advisable; as, for example, to serve a 
temporary purpose till the more permanent system of 
water-carriage and its suitable disposal can be introduced. 
In the case of railroad carriages, too, either the dry-earth or 
dry-ash method, or pail with disinfectant solution, should 
be employed ; the present disgusting and unpleasant mode 
is well adapted for spreading typhoid fever and cholera, 
should the latter pass the maritime barriers. A resolution 
which aims at bringing about the substitution just indi- 
cated has been adopted by the American Public Health 
Association, at its recent meeting at Memphis, Tenn. 
(November, 1887), and should receive general support. In 
places where neither a suitable outfall nor land suitable 
for irrigation is obtainable, one of the dry systems for 
excreta, and precipitation for’ slop-water, may be em- 
ployed. 

Pneumatic System.—It was to meet the needs of places 
of this character that the Liernur system was introduced, 
but it is apparently an uncleanly and somewhat offensive 
method (see Sewerage), and has not met with much 
favor. 

Disposal of Surface Water.—A question of a general nat- 
ure presents itself for consideration : Shall we allow the 
surface water to enter the sewers? If we do so, instead 
of adopting the separate system of sewerage (see Sewer- 
age), we so dilute the sewage and increase its quantity 


420 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


that we render its utilization (except under circumstances 
rarely met with) much more difficult and costly, besides 
increasing the cost of the sewers, and rendering them, as 
arule, more likely to become foul in dry weather. If we 
do not allow the surface water to enter, what are we 
going to do with the horse-droppings and other surface 
filth? The question must be differently answered accord- 
ing to varying circumstances. 

We are now in a position to apply the foregoing facts 
and principles to the various conditions of cities, villages, 
and isolated houses. In so doing individual opinion may 
differ somewhat, according to the objects which may seem 
to different persons to be of greatest importance, and ac- 
cording to the point of view from which they look at 
them. 

In cities the water-carriage system is likely to prevail 
for the reasons already stated. Where an outfall into a 
body of water may be permitted without any of the evils 
of water pollution, and if the surface slopes toward the 
water-front, then the surface and rain water may be al- 
lowed to flow along surface channels in gutters (un- 
less the volume is too great), and the separate system 
may be employed for sewage. If there is no suitable 
outfall, then the first washings (being more concentrated) 
may be intercepted by the sewers (see Sewerage), and 
the larger volume be excluded. If there be a sufficient 
quantity of suitable land near the city, irrigation or 
filtration may be resorted to. If distance or other rea- 
sons forbid this, then precipitation may be employed. In 
either case, while it is not well to stint people in the 
amount of water they use, it is well to prevent waste 
and leakage. In cities with large sewers, built for both 
storm water and sewage, especially when there is little 
fall, it is well to encourage the use of plenty of water, 
in dry seasons more particularly. If surface water is ex- 
cluded from the sewers, road pavements should be built 
and frequently swept, and other roadways should be 
scraped clean. In employing irrigation, if there be a 
large quantity of light, suitable land near the city, and a 
good fall, we need be less sparing of the quantity of 
water entering the sewers than if the reverse conditions 
prevailed. While it is true that very light, sandy soil is 
well adapted for irrigation and filtration purposes, sand 
a few inches above the water, as on a lake shore, is of 
no use, however dry it may look. A few inches down 
the sewage stagnates in the water, and runs laterally in- 
stead of running off. Cesspools should never be allowed 
in cities, nor should vaults or pits. Where these two 
latter do exist the choice of ultimate disposal is between 
cremation along with the garbage, and the deodorizing 
and making of artificial manure. They should never be 
allowed to connect with the sewers, unless with vaults 
we include latrines with water-supply (see Sewerage). 
In cities which are very flat, and with broken surface, the 
use of Shone’s ejectors should be borne in mind. 

In villages with scattered houses, and in the isolated 
parts of cities, the dry-earth or dry-ash system may be 
used. But in compact villages the water-carriage system 
may well be employed. A central tank may be built and 
some form of pump used if there is not sufficient fall. 
Whatever mode is employed, it should at once be system- 
atized, and corporation sanitary officials should have the 
oversight of it. The surface water may be left to look 
after itself—the filth per capita being smaller and the 
quantity of surface and subsoil water greater than in 
cities. 

In isolated houses the householder can readily decide 
between the water-carriage and dry-earth or dry-ash sys- 
tems, as to the mode best adopted to his surroundings, 
and the occupation of himself and his servants. If he 
has plenty of water and a suitable water-service, water- 
carriage with a small glazed sewer will be the best meth- 
od. If he has not an outfall which will not be a nui- 
sance to himself or his neighbors, he may employ irrigation 
or subirrigation on the cottage plan, described before. 
The tank must be protected from frost, and separated 
from the soil-pipe by a disconnecting trap (see Sewerage), 
or by a trap and vent-pipe. Cesspools should not be em- 
ployed unless they are so situated that they cannot possi- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sewage, 
Sewerage, 


bly contaminate wells or the soil in the vicinity of houses. 
During the course of an investigation into the causes of 
typhoid fever in a large public building, I caused to be 
unearthed a cesspool, the existence of which was not 
known to the officers of the institution, who supposed 
the drain for the soil-pipe opened into the main drain. 
Sewage had been for a long time filtering into the base- 
ment. 

For isolated buildings it appears as though the Smead- 
Dowd apparatus would serve the double purpose of 
carrying off foul air and disposing of the excreta. 

In all cases the householder can greatly aid the sani- 
tary authorities in the disposal of garbage, but in country 
places he ought to find no difficulty in utilizing it. It 
should be borne in mind that ashes make, with the wet 
earth, excellent hard walks. 

In conclusion, I wish to express my indebtedness to 
the gentlemen to whom reference has been made in this 
article, for the assistance obtained from their writings. 

Wm. Oldright. 


Appended are some suggestions and a form of tender and specification 
which may be of some service in small communities where the dry-earth 
system has to be introduced. They are taken from a pamphlet issued by 
the Provincial Board of Health of Ontario for use in the Municipalities, 


The following suggestions are made to Municipalities contemplating 
the establishment of the dry-earth system: 

In the outlying portions of a town or village where garden space is am- 
ple, the househulder may safely be allowed to procure the earth necessary 
and to dispose of the used earth as manure in the garden and fields. The 
sole duty of the Municipality will be to see that the old privy-pits are 
done away with, and proper dry-earth closets substituted, and to occa- 
sionally inspect the premises, 

In the central and more thickly populated portions it will be necessary 
to make special provision for the supply and removal of earth. This may 
be done by contract or day labor—if by contract the contractor may be 
allowed to sell the resulting manure for his own benefit. 

Perhaps the simplest and fairest method of meeting the expenses con- 
nected with this system would be for each householder to pay the Muni- 
cipality for the earth delivered at so much per cart load, and for the earth 
removed in the same way ; all the carts used in the work to be of exactly 
the same size, and to have their contents in cubic feet branded on the 
sides. 

It might happen that, even in the crowded districts, many householders 
might find it preferable to use ashes instead of earth; in such Cases, if 
payment were made in the manner above suggested the householder 
would pay simply for the removal of the product, 7.e., for the work re- 
quired to be done, and for nothing more. 

The Municipality may also make each person bear the expenses of the 
preliminary work done on his own premises, such as the cleaning and 
refilling of privy-pits, the building or repairing of privy-houses, providing 

—earth-closets, etc, 

As it would be difficult to include the repairs of existing privy-houses 
in a contract, such work had better be done by day labor, either by the 
Municipality or by the householder or owner. 

In order to supply the earth, the Municipality might set aside, or pur- 
chase, a certain quantity of land, or else the contractor might be allowed 
to obtain earth at his own expense. 

The earth removed should be deposited in such places as may be ap- 
proved of by the local health officer, until such time as it is sold for 
manure. 

A good shed should be built at the place where the earth is procured, 
under which a sufficient store should be kept in reserve, so as to tide over 
periods of stormy and wet weather, when the earth would otherwise be 
unfit for use. 

It would not be necessary that the earth should be supplied and re- 
moved at stated periods. It will be found sufficient in geueral for cach 
householder to notify the contractor or the local health officer of his needs 
as they occur, in order that they may be immediately attended to, This 
should be subject, however, to the discretionary power of the local health 
officers, for the whole system of earth-closets in the Municipality will, of 
course, be under the jurisdiction of the local health board. 

With careful management the supply necessary may be reckoned at the 
rate of one cubic foot of earth per individual, per month, if used only 
once; but as the earth nay be used several times without becoming offen- 
sive, the quantity required may be reduced considerably. However, 
where earth is plentiful this plan is not recommended. 

It may be of assistance to individuals, and to municipal authorities, to 
have approximate information of the prices of automatic closets complete, 
and of closet fixtures. The prices asked are somewhat as follows: 


Closet, for house use, neatly finished, all complete, and 

which can be placed in a vacant room or shed, ready 

for use, according to material and finish, about .... $14 00 to $16 00 
Commode closet, neatly finished, which can be easily 

moved from one room to another in case of sickness, 


MOU bis ele ol eT on ote, Foret ices aginst eines ofsie t's 12 00 to 14 00 
Closet to be placed over a vault, plainly finished, with 

HOD Pele tise hina nen Actors iets aetna ea ier svabe ils, clear seas 10 00 
Fixtures for vault closets, with seat, about............ 5 50 to 8 00 
£xtra pail for the commode closet, for greater conven- bs 

LOT CE mene CUE We tie Gere ta Gh aa, was by otro ataretetcne ao 0% 


For quantities, for schools and public buildings, some reduction could 
be obtained from the above prices, 


The following are proposed forms of specification and 


tender for the works connected with the system of dry- 
earth removal: 


FORM OF SPECIFICATION 
MUNICIPALITY OF ——. 


Dry-earth System of Removai. 


The work to be done consists of the following items: 

1, All privy-pits within the Municipality to be thoroughly cleansed and 

filled with clean earth, the number of the same being approximately 

2. The contents of the privy-pits to be removed to ——, where they are 

to be thoroughly mixed with a sufficient proportion of fresh earth (or 
ashes) to render the mass an inoffensive manure. 

3. Earth-closets of some approved pattern, either patented designs or 
consisting simply of excrement- and dry-earth tubs placed under 
hinged seats, to be substituted for the former privy-pits, 

(Clauses 4 to 12, inclusive, apply to thickly settled districts. ) 

. Earth to be supplied for use in the closets, and the used earth or ashes, 
as the case may be, to be removed to a suitable place. 

. The earth supplied to beloamy initsnature, Earth difficult to screen 
or bring to a powdery condition will not be allowed to be used. 

. The earth to be obtained at ——. 

. The earth or ashes after use in the closets to be deposited at ——., 

. The quantity of earth to be supplied may be reckoned at one cubic 
foot per individual, per month, but this quantity may be lessened by 
the earth being used more than once, and also by the use of ashes, 

9, The earth to be delivered and removed in carts containing —— cubic 
feet, having their capacity branded on the sides, 

10, Sheds to be built on the premises of each householder, for the proper 
storing and screening of the earth, where none suitable for the pur- 
pose exist, 

11. A suitable shed to be built at the place where the earth is procured, 
wherein a sufficient quantity is to be maintained to prevent scarcity 
in the supply, arising from the long continuance of weather during 
which excavation cannot be carried on. 

12. The district to be supplied with earth contains about —— inhabi- 
tants, and is bounded as follows: 

18. The prices for cleaning and filling privy-pits, providing earth-closets, 
building privy-houses and sheds, supplying and removing earth, ashes, 
etc., must include all the labor, tools, sheds, materials, land,* horses 
and carts, and all other appliances and expenses necessary for the 
proper carrying out the work. 

14. The contractor will not be permitted to take advantage of any error 
or omission in the foregoing specification, as full instructions will al- 
ways be given should any error or omission be discovered. 

15. The work will be carried on under the inspection of, and subject to 
the approval of, the local health officer. 

16. Payments will be made monthly, on the certificate of the local health 
officer, for all work included in this specification. In the case of the 
delivery of earth and remoyal of soil, the bills of the contractor, cer- 
tified by the householder, may be accepted by the local health officer. 


Deli Or 


FORM OF TENDER. 
MUNICIPALITY OF ——-. 
System of Dry-earth Removal. % 


Cleansing and refilling privy-pits, including proper disposal of con- 
tenta Mer’ Pit. Fy. Bavtetie ees eis eae, ace ne eae Perera ers == 
Earth-closets, patented designs, per closet ..............--...0005- oa 
$3 as dry-earth tub, excrement-tub, and scoop, per set .... —— 
Privy=HOUSES eMC eral ctr. te crenry Mote otc eratare le ibiereersicke ie cs. cece eae eke Ss 
Sheds for storing and screening earth, etc., each .................. ——— 
Supplying earth for use in closets, per cubic yard.............. OR! Smt 
os Tie a Uh POL LOMA svat erin cine tus isle — 
Removing earth or ashes from closets, per cubic yard.............. Bas 
Me Ss Per oad ered ns cs ere BA ME: — 


The undersigned hereby propose and undertake to perform all the work, 
and furnish all the material, plant, etc., required for the proper perform- 
ance of the same, in accordance with the specifications and advyertise- 
ments dated —-—, copies of which are hereunto attached, and are pre- 
pared to enter into a contract with the Municipality of , for the due 
performance of the same, at and for the rates and prices set forth in the 
foregoing schedule. 


SEWERAGE. Under the heading Habitations: Gen- 
eral Principles of Plumbing, the commencement of the 
water-carriage system, within the house, has already been 
considered ; and in the article Sewage, Disposal of, the 
ultimate treatment of the contents of sewers has been 
dealt with, as well as the modes of disposing of refuse 
matter by other systems. In this article it is proposed 
to give such a consideration of the ‘“ water-carriage sys- 
tem” from the house to the outfall as may be of profit 
and interest to the medical reader, thus filling up the gap 
between the two articles above referred to. And while 
we are obliged, in order to attain this object, to glance 
over the field of the sanitary engineer, ménutiw of en- 
gineering will not be attempted. , 

PRELIMINARY CONSIDERATIONS.—In connection with 
the sewerage of any particular place, there are Certain 
preliminary considerations which must be taken up. 


* Where the Municipality has not set aside or purchased land for the 
purpose. 


421 


Sewerage, 
Sewerage. 


One of these has been partially discussed in the article 
on the Disposal of Sewage ; I refer to the question of de- 
ciding between the combined and the separate methods 
of sewerage ; nothing but excreta, laundry, and kitchen 
slops, and certain kinds of waste from manufactories and 
stables, being allowed to enter the sewers in the separate 
system, and in some cases enough of the rain-water from 
the roofs for flushing purposes; while in the combined 
system all the storm and surface water is also admitted. 

The position and character of the outfall will have an 
important bearing upon the whole character of a sewer- 
age system. If the outfall be such that we have to treat 
the sewage by irrigation or precipitation, this will be 
one element in determining some method by which only 
the concentrated portions will pass to the outfall, the 
superfluous storm-water being diverted into other chan- 
nels. 

The amount and character of the rainfall—whether 
equable or varying—will have to be considered, with a 
similar object in view. Heavy rains tax the capacity of 
the sewers far more than frequent gentle showers, even 
though the total annual rainfall may be more in the latter 
than in the former case. 

The geological and physical nature of the sotl will have 
a manifold influence; a sandy or loamy soil, especially 
if the slope be not great, will leave much less water to 
go into the sewers or down the gutters than a more im- 
penetrable and steeply sloping one. The configuration 
of the soi] may cause engineering difficulties, which again 
may enter into the determination of the system to be 
adopted ; and the existence of rock or sand may present 
difficulties in construction or in permanence. 

The area and population—preseut and prospective— 
will also have to be considered. With scattered popula- 
tion the difficulties are increased, especially those of the 
combined system. On the other hand, sufficient care is 
not always exercised in regulating the size of sewers to 
meet the probable growth of the sewerage system of a 
town or city. 

The bearings of water-supply, of the habiis of the people, 
and of the sanitary appliances already in existence, will 
be apparent. An abundant supply of water, with care- 
less waste, may unduly tax the sewers, and unduly dilute 
the sewage ; or a scanty supply may promote the liability 
to deposit. 

THE FOLLOWING PRINCIPLES must be kept in view in 
connection with systems of sewerage : 

All matters entering the sewers should be removed, 
and removed completely, to a suitable outfall (no lodge- 
ments, no leakage). 

They should pass entirely from the sewerage system 
before there is time for decomposition to take place. The 
limit is often placed at twenty-four hours ; but when we 
come to speak of velocity it will be seen that in the 
largest ordinary system not half that time will be con- 
sumed if the sewers are so constructed as to be self- 
cleansing. 

There should be free ventilation through the entire sys- 
tem. ; 

Means should be provided to direct the necessary es- 
cape of the gaseous contents to points where they cannot 
come in contact with human beings, and to prevent es- 
cape at points where they may come so in contact. 

These principles, and violations of them, will be ex- 
plained more fully as we now 


proceed to take up the various 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


valve; or they may be laid horizontally with a block un- 
der each end and the weight applied in the centre. The 
best test, however, would seem to be by hydraulic press- 
ure from the inside ; sometimes pipes having fire-cracks 
and looking to be poor will stand this most 
natural test better than others whose ap- 
pearance is not so bad. They should be 
true-fitting, for any defects in contour, such 
as shown in Fig. 3478, will affect the for- 
- _ imation of joints and give rise to leakage. 
oe 3478.—Pipe Fie, 3479 represents the form of tile 
efective in * 

the Contour of Most commonly used, having a socket at 

its Socket End one end into which the other (spigot) end 

and making @ of the next pipe above is placed to make 
eaky Joint. ah 
the joint. 

Fig. 3480 shows a different form of pipe, without any 
socket—the joint being made by placing the ends of two 
pipes in contiguity inside the ring, Fig. 3481. 

Fig. 3482 is a representation of Doulton’s opercular 
pipe, which is of service in ena- 
bling a person to search for and re- 
move any obstruction, as in faulty 
places where there is little fall, or 
where for some other reason stop- 
page may be feared. Jenning’sac- 
cess pipes (Fig. 8483) are plain at both ends, and are laid 
in chairs (C) similar to the metals of a railway, the pipes 
being kept six, nine, or twelve inches apart, according to 
the diameter. They provide for the same object as the 
last-named pipe, and they have the advantage that, on 
lifting the upper part of the saddle, 
a pipe may be lifted out and a junc- 
tion inserted to allow of the con- 
nection of another line of sewer at 
any subsequent time. The saddles 
may also be so placed as to allow 
of the passage of subsoil water beneath the pipes. They 
present one serious defect, however; the invert, or bot- 
tom, does not present an even, smooth surface, and can- 
not be made to do so, although an attempt be made to fill 
in with cement; it might be improved by a raised piece 
in the centres of the chairs or saddles. Other 
forms of tiles are used, but those above describ- 
ed are the best suited for practical purposes. 

Iron pipes must be used when a larger size 
of pipe is required, or when any unusual strain 
or pressure has to be borne, as where there is a 
long or heavy lift in pumping, or where some 
stream or chasm has to be crossed. They should be test- 
ed and examined, in the manner above described, for brit- 
tleness and defects in their walls and contour. They are 
sometimes enamelled inside when used for house connec- 


Fig. 3479.—Socket Pipe. 


Fra. 3480.—Ring Pipe. 


Fie. 3481. 
—Ring. 


WATER LINE WHEN OPEN 


tions; but for such purpose, where there is no heavy 
pressure or strain, the glazed tiles are preferable. 

Brick must be the chief material for large sewers. 
The bricks should be very hard and impenetrable, espe- 
cially for the invert, to withstand the grinding friction 


5 
ez s->=): 


= = SS 


Fie, 8482,—Doulton’s Opercular Pipe. 


points in the construction of 


sewers. 


CONSTRUCTION OF SEWERS. 
—The materials of which sew- 
ers are constructed. 

Tiles answer well up to a 
diameter of eighteen inches or 
two feet. They should be of salt-glazed, vitrified earth- 
enware ; lead-glazed pipes chip, and allow soakage and 
leakage. Their strength may be tested by placing heavy 
weights upon them, or dropping weights on to them in a 
trench ; they may be placed under a weighted lever, ar- 
ranged like the arm which carries the weight of a safety- 


422 


Fig. 3483.—Jenning’s Access Pipe. 


of the passing contents. Their strength may be tested 
by a weighted lever, as above described in the case of 
tiles. Their porosity is a very important point, and may 
be tested by weighing them when kiln-dried, and again 
after soaking in water. Great care should be exercised 
in seeing that they are built with good (water-proof) ce- 


_ REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sewerage. 
Sewerage. 


ment, that the joints between the bricks are smooth and 
even, and that the sewer is not covered in too soon, be- 
fore the joints have had time to set and harden. 

; Concrete and artificial stone have 
been used, but not very extensively, 
nor with much success. 

Wood. The too common prac- 
tice of using wooden box-draing 
must be condemned, unless as a 
temporary makeshift. Sometimes 
a form of: barrel-drain, bound with 
metallic hoops, is used. This pro- 
test against box-drains might seem 
Fie, aN Ae ne Aa to be superfluous; but it is not 

pepe ke more than five years since it was 
found that, in a city afflicted with an epidemic of ty- 
phoid fever, one of the main sewers was a box-drain, 
with no bottom (except the earth), the sides being held 
together by pieces of scantling laid on 
the earth. With this were connected 
the drains of cesspools and houses, some 
of the latter of wood and untrapped. 

The shape of sewers is a very important 
consideration, and must vary according 
as the flow is expected to be equable or 
variable ; if equable, the circular form 
(Fig. 3484) is to be preferred, because it 
gives the greatest capacity with the least 
expense of wall. Hence it is almost ex- 
clusively used in the separate system of 
sewerage. If the flow is variable, the 
ovate shape gives the advantage of the deep narrow 
stream ; and when the quantity of sewage is small, de- 
posit is less apt to take place. Hence the use of this 
shape in the combined system. In old 
times sewers had to be cleaned out by scav- 
engers, with the same regularity as chim- 
neys were swept. The bottoms were broad, 
flat, and uneven ; the slow, sluggish streams 
=! allowed deposits to be formed, which 
Fra. 3486.—Box- quickly increased by their own impeding 

drain laid flat, action. The same plan is commonly fol- 

xocumilatne, lowed with box-drains (Fig. 3486). In ‘cases 

‘ where they are employed (and it should 

only be temporarily), they should be set angle down, so 

-as to give the fluid its greatest possible depth and force, 
and prevent deposit. 

Joints have been incidentally de- 
scribed above as regards their modes of 
formation, when a description was given 
of sewer-pipes. They should be true 
fitting, so as to prevent gaps out of z 
which the cement or clay may fall or = 
be forced. Care should also be taken pye. 3487. — Box- 
to prevent the apposed ends from los- drain placed angle 
ing their concentricity when laid: if aR Se ae ie 
the joints be fitted with puddling-clay Wa 
or other soft material, this will give way under the down- 
ward pressure of the small end of the pipe, until this lat- 

ter rests directly on the receiving collar 

of the next pipe, leaving no space be- 

tween them on the under wall, but a 

large gap on the upper (Fig. 38488). 

This will be especially the case if no 

spaces have been cut to receive the 

tN BAN shoulders. To prevent it the joints 
pavine rotates 3 should be stuffed with oakum, and then 
the spigot end has with puddling-clay or cement, or, if the 
displaced the ce- pines be of iron, with 

Peete *“ lead, and should be | 

"thoroughly calked. El/= 
This method of aww S 
naking joints wil a 
also prevent the fill. & 
ing of cement or &= 
lead from running 
into the inside and 
forming a nucleus for deposit. It will also help to pre- 
vent the intrusion of rootlets of trees, which are apt to in- 


Fria. 3485.—Ovate- 
shaped Sewer. 


Fre. 3489.—Improper Junction, 


sinuate themselves and cause accumulation and choking. 
Some persons try to kill rootlets by mixing bichloride of 
mercury in the filling. This is a 
poor expedient at best. 

Juncttons of sewers, whether they 
are in a vertical or horizontal plane, 
should not be 
at right an- 
gles (Fig. 
3489), as the Sz 
interruption ~~ 
of the stream 
and the eddies thus formed will cause deposit which, 
when once commenced, will rapidly increase. The tribu- 
tary stream should be made to enter in a course some- 
what parallel to that in the main 
sewer (Fig. 3490). 

For junctions, Y-pipes (Figs. 
3490 and 3493) and V-pipes (Fig. 
3492) are manufactured. Theuse . 

of the T-pipe (Fig. 3491) should 
Fie, 3491.—T-pipe, for Use be for inspection holes and ven- 

in Pouuabenon for In- tilating openings. The V-pipe is 

ase ter ak ste Yt used where the main drain is 
made of two branches uniting, and flows in a direction 
between the lines of the branches; two branches should 
never run into a third drain with their mouths opposite 
to each other ; one should enter 
a little lower than the other. 

Where a small sewer-pipeshas 
to be received into the socket of 
a larger one, an ‘‘increasing- 
pipe” (Fig. 3494) is used to pre- 
vent a bad joint, which would 
be made if the gap were filled 
with cement and pieces of brick 
or stone. Fig, 8495 shows the 
reverse, or ‘‘ diminishing-pipe.”’ 

The direction of a sewer should 
be as straight as possible, so as 
to retain the velocity. If it requires to be changed, grad- 
ual curves should be made. It sometimes happens that 
an impediment or junction may require a slight deflec- 
tion. An ‘‘offset” (Fig. 3496), or 
‘* bends,” ‘‘ quarter-bends,” or “‘ el- 
bows” (Fig. 3497), may then be 
of service. 

The foundation or bed of a sew- 
er should be firm and solid, so as 
not to permit of any breaking or 
disjointing. If pipes are used, 
small excavations should be made to receive the shoul- 
ders, so that these shall not have to bear the whole weight 
of pipe, contents, and superincumbent earth, with no 
support to the rest of the pipe, which 
. is then liable to break 

or crack. Provision 
7 should be made for 
SSS carrying away sub- 

iat. soil water, which is a 
Fie. 8494,—Increas- Jighle to make for the F!@ 495.—Diminish- 
ee ERS new earth formed in ree 
digging the bed of the drain. If the drain lie ¢n a po- 
rous stratum and over an impenetrable one, the chances 
of the water running along its course will be especially 
great. Some tiles are made with a subsoil space, porous or 
perforated, so as to 
carry off this water. 
Fig. 3498  repre- 
sents a sewer made 
of artificial stone in 
iene this way, in which | 

[-— the sewer, A, and pre 3497.—Bend, 

Fia. 3496.—An Offset. Subsoil space, J, or Elbow, 

are allin one piece ; 
C, CO, C, are small orifices through which the subsoil 
water makes its way into the subsoil space. Invert 
blocks with subsoil space are also made separately for the 
bottoms of brick sewers, which are then built upon them. 


423 


Fiac. 3492.—V-pipe, for Junc- 
tion where the Main Drain 
runs in a Direction different 
from that of either Branch. 


Fie. 3493.—Y-pipe. 


Sewerage. 
Sewerage, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Want of attention to the foundation of sewers, espe- 
cially where tiles are used, is one of the most common 
causes of deposit and of sewage pollution of the soil ; 
; then decompositon occurs, 
and foul gases are evolved. 
The writer has seen rows 
of houses rendered unten- 
antable from the occurrence 
of diphtheria and other zy- 
motic diseases from this 
cause. In one _ instance, 
where a sewer had been laid 
in sand, it had to be taken 
up in less than a year; the 
sewer had assumed a zigzag 
outline, and the tiles were 
choked with sand and sew- 
age. 

The velocity of the stream 

in sewers is dependent, not 
only upon the slope or fall, 
but also upon the shape, 
size, smoothness, and even- 
ness of surface and the 
volume and equableness of 
flow. The ordinary velocity 
required will also depend 
upon the nature of the mat- 
ters to be carried and the facilities for flushing. Some 
of these interdependent points have already been consid- 
ered. ; 
The size of the sewer requires careful consideration on 
the part of the engineer. If the sewers are too small 
there will be flooding of the connections with the lower 
portion of the insufficient sewer or system of sewers ; if 
too large there is needless expense, and, what is of greater 
importance, there may be deposit from sluggish flow, and 
there will be a larger space for sewage exhalations to form 
in. I know of an institution with about five hundred in- 
mates, situated about one hundred yards from the edge 
of one of our great lakes, which has two five-foot brick 
sewers to carry off its sewage! They were built in the 
good old times, and by convict labor. Fortunately, they 
had a short and rapid fall. The invert of one of them 
subsequently made a good foundation for a one-foot 
tile sewer which was recommended to be put in. 

It has been found by experience that it is not well to 
have sewers fora mixed population smaller than nine 
inches, as they are very liable to obstruction. In Mem- 
phis, I am informed by Colonel Merriwether, City Engi- 
neer, that it isa common thing to find them obstructed 
by the carpenter’s rule with its six-inch joints. 

Mr. Baldwin Latham, in his work on “Sanitary En- 
gineering,” gives formule and tables for computing the 
velocity in sewers of various slope, size, and volume. 
He also states the results of a number of experiments 
for determining the carrying power of sewer-streams. 
From these it would appear that, for efficient house-drains, 
a velocity of three feet per second is necessary ; and that 
this would require, in a nine-inch drain, a fall of 1 in 
206 ; in a six-inch, 1 in 137; and in a four-inch, 1 in 92; 
and it is presupposed that the drains would run half full. 
The quantities of sewage discharged under these circum- 
stances will be 39.76, 17.66, and 7.85 cubic feet, respec- 
tively. When running full they are capable of discharging 
double these amounts, but the velocity and scouring force 
will not receive any further increase. The point to be borne 
in mind is, that if the sewers cannot obtain sufficient fluid 
to half fill them, the slope must be greater. In the case 
of street-sewers it will be evident, on consideration, that it 
is in the upper ends that the least volume of sewage will 
be found, and hence the most natural position for flush- 
ing apparatus—the head of the sewer—is that where it is 
most needed ; the size, too, may here be less, and this will 
add to the facility for flushing. 

For flushing, various devices are in use. One very 
extensively employed is Field’s automatic flush-tank, 
represented and described in the article on Sewage, Dis- 
posal of (see Fig. 3475). Somewhat similar is Van Vran- 


Fie. 3498.—Sewer-pipe of Artificial 
Stone, with Subsoil Space. 


424 


ken’s flush-tank (Fig. 3499). The lower end of the longer 
or descending limb of the siphon is constantly immersed 
in water contained in a small tilting-tank, hung in a 
chamber below the bottom of the main tank. The drain 
is connected with this chamber. When the water rises 
in the main tank as high as the arch of the siphon and 
trickles over into the tilting-tank, the centre of gravity in 
the latter is changed, and it tilts over to the position 
shown by the dotted lines; the level of the water in it 
is suddenly lowered about an inch, and this starts the 
siphon action by which the main-tank is rapidly emptied. 
With both these tanks the intention is to allow them 
to fill slowly by a small trickle of water; by experience 
this can be so adjusted as to fill them once or twice in 
the twenty-four hours. In some places suspended mat- 
ter in the water interferes with this intention. The tanks 
hold from one to two hundred gallons each. It is found 
that only about two per cent. of the total water-supply 
is required for flushing. 

In valve-tanks (such as Pierson’s tank) the valve is dis- 
placed from the outlet by a float attachment. In col- 
lapsing-tanks the sides collapse by the sudden filling and 
sinking of a floating vessel. 

Large tilting-tanks and flushing-gates are also em- 
ployed. They may be operated by automatic mech- 
anism. 

Flushing-gates are sometimes placed in the courses of 
sewers at long distances from their heads, the sewage 
itself being the flushing medium. It should be borne in 
mind that such an arrangement is liable to cause deposit 
above the gate, and that the scouring action is exerted 
below, and not to any appreciable extent above, the point 
where it is situated. Hence this method is not to be 
recommended. 

In some sewers, where only a very slight fall can be 
obtained, flushing all along the line of the sewer has to be 
resorted to. In Chicago, for example, a “‘ pill” (to be ex- 
plained presently) is placed just above the man-hole open- 
ing, and the contents of a flushing-cart are poured down 
the latter into the sewer. . 

Cleansing of sewers by other methods has sometimes to 
be resorted to, notwithstanding the fact that the aim of 
sanitary engineers is to so construct them that they shall 
be self-cleansing. To facilitate the task of keeping 


TH 


ULL 


= 


sewers clean, man-holes, inspection openings, lamp-holes, 
and cleansing openings are constructed. 

Fig. 3500, copied from Dr. Ford’s article in Buck’s 
‘‘ Hygiene,” shows a form of man-hole with ventilating 
grating and dirt-box adopted by Mr. Denton. It is pro- 
vided with steps for descending to the sewer-pipe with 
which it is connected. 

Another form of man-hole and ventilator (Fig. 3501) 
will be described when we come to speak of the ventila- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sewerage, 
Sewerage. 


tion of sewers. The object of these man-holes is for 
workmen to descend, inspect the sewers, and cleanse 
them. This is done by means of various kinds of scrap- 
ers, rakes, hoes, drills, screws, balls, brushes, hooks, etc., 
which may be mounted on jointed rods such as those used 
by chimney-sweeps. Even with the sewers of the separ- 
ate system, specially designed to avoid deposit, and flushed 
daily, it is found necessary, in Memphis and elsewhere, to 
use periodically the ‘‘ pill” and brush. The ‘‘ pill” isa 
hollow water-tight globe of thin metal, made three inches 
smaller in diameter than the sewer. The end of a rope 
is attached to a staple on one side of the pill, which is 
lowered down a man-hole or inspection-opening into the 
sewer and allowed to float (still held by the rope) down 
to the next opening. The pill may be held, or drawn 
back a little, at any point, and the volume of fluid, being 
obliged to pass through the three-inch crescent beneath 
it, will scour away any movable deposit. As soon as the 
pill reaches the next opening, a brush may be attached 
to the other end of the rope at the opening above, and 
drawn through the portion of sewer which has just been 
traversed by the pill. 

Observation- or inspection-openings have been suffi- 


EEA: 


Fie. 3500.—Man-hole Connected with Pipe-sewer. 


ciently explained in the above description. They are, of 
course, smaller than man-holes. — 

Lamp-holes are still smaller; they are generally con- 
structed at no great distance from the man-holes, and are 
for the purpose of literally throwing light upon the inter- 
vening portion of sewer. The absence of light will in- 
dicate complete obstruction. 

Sometimes cleansing- and flushing-openings are made 
to enter the sewer af obtuse angles with the portions be- 
low them. In this way a flushing-hose or cleansing-tool 
may be introduced through a comparatively small and 
inexpensive opening. — 

In some of the older sewers of the combined system, 
pits have been left in the invert at the bottom of the 
man-holes, for the purpose of collecting, and ‘periodically 
removing, deposit. This is not to be recommended, as it 
favors deposit, which, if neglected, forms a nucleus, and 
which by its decomposition gives off offensive and inju- 
rious gases rising into the street. Similar pits are also 
made, in the course of the small sewers of the separate 
system, below stables and other points where obstructions 
have, in the experience of the officers, been found to re- 
sult from the habits of careless people. The writer has 


atmosphere. 


seen plans of these, with their contents graphically de- 
picted, and labelled as ‘‘ Sardines,” etc. (the ‘‘ Sardines” 
were empty boxes, of course). Care must be taken to 
have these pits frequently inspected and cleansed. 

In some of the large Paris sewers trucks were made to 
run, with the wheels on platforms, on each side of, and 
above, the sewage-channel, while a sort of gate the shape 
of the sewer-channel dips into it; this is carried along 
by the sewage and shoves deposit in front of it, while 
it also carries along the truck to which it is attached. 
When the deposit in front obstructs the action of the 
gate, the dirt is scooped up into the truck. 

Ventilation of Sewers.—I have endeavored to point out 
the methods in the construction of sewers by which we 
are to avoid the retention of decomposable material, 
and to so cleanse the sewers that foul gases will be re- 
duced toa minimum. But it has at the same time been 
made manifest that we are still liable to their formation. 

Among the gases more commonly evolved from sewers 
may be mentioned sulphuretted hydrogen, carbonic acid, 
carburetted hydrogen, nitrogen, and ammonia. Many 
cases of asphyxiation in sewers and cess-pits are on rec- 
ord; no less than eight deaths from this cause occurred 
in the sewers of Chicago in one year. 

The rise and fall of sewage, with the alternate wetting 
and drying of the walls of the sewers, cause a continual 
evolution of vapor. It is no conclusive proof of the ab- 
sence of sewer-gases that they cannot be perceived by 
the sense of smell. Some injurious gases reveal them- 
selves unpleasantly to the nose, while others do not. 
These last are so insidious in their nature as to be doubly 
dangerous. As examples, the baneful results which en- 
sue from living in houses under which water lodges and 
becomes stagnant may be referred to. There are few 
medical practitioners who have not witnessed these re- 
sults. The miasmatic poison of ague is inodorous, or 
has no necessarily unpleasant odor. In like manner sew- 
ers have sometimes very little unpleasant smell. Some- 
times there is a smell somewhat similar to that produced 
by those burning fluids into the composition of which 
fusel-oil enters. We must be very careful, therefore, 
how we accept negative evidence as to the presence of 
noxious gases. In the experience of most practitioners, 
living in sewered districts, instances are common of the 
occurrence of zymotic diseases, clearly traceable to the 
presence of sewer-gases, where there has been little 
or no unpleasant smell. I am not aware of any ap- 
preciable odor from the contagia of scarlatina and 
measles, and yet they act through the medium of the 
One or two specific instances, in proof of 
what has now been stated, may be mentioned when we 
come to speak of some particular defects in sewerage. 
It is evident, then, that every care must be used to estab- 
lish a thorough ventilation of sewers, and to secure it in 
such a way that the gaseous contents shall not, in making 
their exit, come in contact with human beings. ‘Too 
often, and by too many avenues, they find their way into 
dwelling-rooms. How this should be avoided has been 
pointed out in the article on Habitations. It falls within 
the scope of the present article to point out the means 
commonly employed for the ventilation of sewers, the 
pneumatic forces which are at work in them, and the 
means which, in the opinion of the writer, should be 
adopted; to change the air in them as frequently as 
possible. 

It will be found that most of the agencies at work in 
sewers are variable and alternating in their action, some- 
times drawing air into the sewer, and sometimes ex- 
pelling gas through the same opening. ‘The principal 
of these agencies are, besides the natural diffusion of 
gases, the following: 

Difference of temperature between sewer and external 
air, causing an-interchange in accordance with the laws 
which regulate the movements of unequal weights of air. 

Upward draught in houses, acting as a ventilating 
shaft, in the wake of which the sewer-air will follow if 
allowed ; sometimes a full flow of water down into the 
sewer will cause a current of air to accompany it. ) 

The expansion force created by the sudden accession 


425 


Sewerage. 
Sewerage. 


of heat in the drain, viz., by pouring down hot arenas 
of boiling water. This’ expansion is equal to 1 volume 
in 491 for each degree of Fahrenheit. As air expands 
the pressure is increased, If the temperature of the air 
in the drain be raised from 50° to 150°, the result will be 


COVER ct 


MN 


ri Anan AO SA Ma TAN TAT 


Cy 
‘| WM Ws 


Fig, 8501.—Rawlinson’s Manhole Charcoal tans and Tumbling- 
bay. 


pressure equal to that of 6;% feet head of water. And 
this rise of temperature is not at all an improbable one. 

The flow of water into the drain causes an expulsive 

force. When water is poured into a drain it must, of 
course, displace its own bulk of air (less the small 
amount gained by compression), for two bod- 
ies cannot occupy the same space at the same 
time. Out of which end of the drain (suppos- 
ing that it has no ventilator) this air shall pass 
will be determined by circumstances ; it passes 
most readily where it meets with least resist- 
ance, always giving preference to an upward 
direction, owing to the greater gravity of the 
water, Storm-water suddenly filling the sew- 
ers acts powerfully in this way. This ebb 
and tlow operate like a double-acting piston or 
syringe. Partial choking of the drain gives 
rise to confined air constantly increasing, ex- 
panding, and being displaced. Tides have a 
similar action. Wind blowing up the mouth 
of a sewer will drive gases before it ; wind 
blowing across its mouth will often produce a 
down current. 

From the rising of sewer-gases to the upper 
ends of sewers the higher, ae at one time more 
healthy, portions of towns and cities have 
sometimes compared badly with the lower por- 
tions which have been improved part passu. 

Until lately the principal dependence for the 
ventilation of sewers has been on the ventilating “ 
gratings in the road-bed, both as inlets and outlets. 
Sanitary engineers, having experienced the necessity of 
deodorizing the air exhaled from the sewers, have in- 
vented and patented ventilators containing charcoal. 
One of these, Mr. Rawlinson’s, is shown in Fig. 8501, 
which i is copied from Dr. Ford’s paper in Buck’s ‘“ Hy- 
giene.” An inspection of the diagram shows the course 
taken by the sewer-gas. The man-hole has a tight cover 


426 


uy a 
me 


so 0 


| trough S, by means of the handle h. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


to keep the charcoal dry. Below the ventilating cham 
ber is a space for collecting the dirt which falls in, and’ 
which may be removed by unscrewing the plate at the 
bottom of the space. The flap-valve and bay are for the 
purpose of directing the gas up the ventilator, and the 
tumbling-bay is for the purpose of getting rid automati- 
cally of any deposit which may be caused behind the flap- 
valve. 

Mr. Baldwin Latham gives a figure and description of 
a spiral charcoal ventilator (Fig. 3502), invented and thus 
described by him: 

‘‘The larger sizes combine in themselves man-hole 
cover, lamp-hole, and ventilator, while the smaller sizes 
fulfil the two last offices. Each of the large ventilators 
consists of four parts : 

‘‘ist. The frame a, for receiving the cover, and on the 
bottom of which hangs the dirt-box and charcoal venti- 
lator. 

“©2d. The cover C, the centre part of which is solid, so 
as to form an efficient cover for the charcoal and protect 
it from rain, or the water used in street watering; g is 
the open grating in the cover by which air escapes or is 
drawn into the sewers. The openings of this grating are 
arranged concentrically, and are formed with the aper- 
ture wider below than at the street level, so that mud is 
not likely to adhere, or, if it does, is soon removed and 
falls directly into the dirt-box immediately below the 
grating. The cover in the illustration is shown filled in 
with wooden blocks (placed endways of the grain), for 
deadening the sound and giving an efficient foothold for 
horses. The covers, however, may be filled with any 
other suitable material, such as stone, concrete, or asphalt. 

‘*3d. The dirt-box d hangs in a groove, 2, made in the 
lower part of the frame a. The dirt-box is circular on 
plan, and the groove @ is intended to be filled with fine 
sand. The weight of the dirt-box and ventilator press- 
ing into the sand forms a gas-tight joint ; , /', are han- 


| dles attached to the dirt-box for raising or lowering it ; 


S represents an open spiral trough which forms part of 
the dirt-box, and which is used for conveying away the 
overflow-water from the dirt-box to the sewer ; 0 is a slot 
in the side of the dirt-box, communicating with the upper 
portion of the spiral trough, through which the water 
enters the trough. 

“4th. The spiral trays ¢, for containing the charcoal, 
which are screwed into the ventilator over the spiral 


TUT CEA 
Hee ll a 


=== 


a | 
u a Ui 


¢ 


| Ee 


a 


— —— Qh IMGE S 


Mi 


Fig. 8502.—Latham’s Charcoal Ventilator. 


_ Each tray consists 
of a central shaft P, which is square, and out of every 
face project arms of T-iron. These arms are attached at 
the extremities by a strip of iron coiled spirally, and the 
bottom of the trays is filled in with network. 

“To recapitulate the advantages of this ventilator: 1. 
That, should the charcoal concrete in the tray, or if its 
pores are stopped with dust, no impediment is offered to 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sewerage, 
Sewerage, 


ventilation, as there exists a free communication between 
the sewer and the external atmosphere. 2. That the char- 
coal is completely protected from rain or water entering 
the ventilator or leaking through the joints of the cover, 
consequently it will retain its efficiency for a long period. 
3. That the passage provided for the overflow-water 
from the dirt-box is not dependent upon traps, or any 
other uncertain device needing assistance to maintain it 
in perfect working order. 4. The escaping vapors are 
all brought in contact with the charcoal, it being impos- 
sible for any to escape by the sides of the tray or in any 
other way.” 

These charcoal ventilators are now mostly discarded 
as impeding the passage of air, and the contention of 
engineers often is that they are generally inlets; but the 
frequent stench, and the steaming exhalations from them 
in heavy winter days—exhalations through which our 
boys delight to run—do not support this contention, but 
rather go to show that the surface of the road-bed, amid 
the traffic of street passengers, is not asafe place in which 
to discharge these gases.* 

As regards charcoal trays, even were the charcoal con- 
stantly dry, sewer-gas at times makes its exit too rapidly 
for the charcoal to exert any action upon it; so that, 
however useful an adjunct charcoal may be, it cannot be 
considered a preventive to the injurious effects of sewer- 
gas, and we cannot rely upon it as a germicide. 

At one time it was a common practice to have the 
openings from the gutters untrapped; but as these open- 
ings were noticed to be very offensive, and were nearer to 
the foot-walks, they have been provided with traps. (See 
below.) 

Laying aside the propriety of having such a point of 
escape for sewer-gases, it will be evident on considera- 
tion that the size of the street-gratings is insufficient, 
even when they are open ; in our northern climate many 
of them are at times closed for weeks together, and they 
are often partially clogged with mud. But even when 
open, their interstices, if combined, would yield about 
forty-nine square inches, and if allowance be made for 
friction in the little openings, their carrying capacity 
would be about equal to that of a five- or six-inch pipe, 
and this to ventilate a length of six hundred feet (the 
distance given by Mr. Latham) of average street sewer. 

Hence, it seems evident to me that the principle which 
is now being advised and adopted by leading sanitarians 
and architects, for the safety of the individual house- 
holder in regard to his house-drain, ought to be advised 
and adopted by sanitarians and engineers for the safety 
of the whole community in regard to the street sewers. 
A four- or five-inch pipe should be carried from every 
house-drain to the roof of the house which the drain is 
intended to serve, and should discharge the sewer-gas at 
a sufficient distance from all chimneys, windows, doors, 
or other openings into the house. Between this pipe 
and the sewer no trap should intervene. And this is the 
plan now generally adopted in Memphis and some other 
places, sewered on the separate system, there being no 
trap, save in exceptional instances, between the sewer 
and the soil-pipe extended above the roof. In the state 
of plumbing practice still in existence in many places, 
it would, in my opinion, be better to have a trap between 
the pipe and the house, provided that, in addition to 
the extension upward from the soil-pipe there is another 
four-inch pipe, forming a counter-opening and allowing 
a current of air to circulate freely through the house- 
drain and its connections and vents ; but wherever good 
plumbing and rigid inspection are insisted upon, this mul- 
tiplicity of pipes and traps could, and should, be done 
away with. There would then be a direct passage from 
the sewer to a point above the roof, carefully removed 


* On the day after the above was written the writer was called to visit 
a patient living near the head of a street in one of the finest districts of 
the city. Persons residing in the neighborhood have made loud com- 
plaints regarding the stench arising from several man-holes in this street 
and a street which crosses the head of it. At times, when a south wind 
is blowing, windows are kept shut and children cannot be allowed out to 
play in the immediate locality. Complaints have been made to the Med- 
ical Health Office regarding the matter. Numerous other instances of 
this kind might be reported did space permit. 


from chimneys, doors, windows, and all other openings 
into the house. Colonel Waring is a strong advocate 
for the abolition of traps on house-drains, contending 
that they impede ventilation and are themselves sources 
of danger. 

It must be borne in mind that by the plan advocated 
the air allowed to escape through the soil-pipe (or outside 
vent-pipe) is not the same concentrated foul gas that 
often arises through street-gratings, for the number of 
openings, each of them almost of the same capacity as a 
(subdivided) manhole-grating, is so great that the gas is 
very much diluted ; in a closely built street, with houses 
on each side of from twenty-five to fifty feet front, there 
will be one such opening for every twelve to twenty-five 
feet—instead of every six hundred feet, the limit for 
street-gratings given by Mr. Latham. Of course, this 
system, when adopted, should be made general. In places 
already sewered it could be introduced by the corpora- 
tion authorities putting in ventilating pipes at such dis- 
tances as would give some relief, and passing a law re- 
quiring that every new house-drain, and every drain 
that shall need to be reopened, be ventilated in this way, 
and that within a reasonable time the same shall be the 
case with all house-drains. 

It has been objected that, inasmuch as house-drains do 
not usually enter the sewer at the highest point of the 
latter, there is a space in the crown of the street sewer 
that cannot be ventilated through the house-drain when 
the water in the sewer is higher than the mouth of the 
drain. To this I would answer that the air being con- 
fined to the crown of the sewer, its temporary stagnation 
during the time of flood-water will do no harm to any- 
body ; if the pressure becomes very great the gases will 
be dislodged and will be carried off at a point higher up 
the line of sewer, where the drains are not water-locked ; 
it is only at times that the house-drains will be so full 
as not to allow of counter-currents and through-drafts ; 
and there is nothing to prevent the house-drains from 
entering sewers close to the crown, if so designed. 

It has also been objected that air will not enter the sew- 
ers down the long stand-pipes; so long as the gas, when 
it does move, moves off overhead, we need not so very 
much mind its remaining in the sewer for a short time. 
But, asa matter of fact, a careful consideration of pneu- 
matic laws and of the forces acting in sewers will show 
that the objection does not hold. The columns of gas or 
air on opposite sides of the street, if they are of the same 
temperature and density, will counterbalance each other ; 
but let the sun shine on one side, and immediately an 
ascensional action begins; or let a cold wind blow on 
the other, and a dense column begins to descend. Be- 
sides, the rising and falling of the liquid in the sewer 
will cause the gas to be expelled, or the air to be drawn 
in. Again, the air will blow up the sewers from their 
mouths ; and, for this reason, flaps should never be placed 
on the mouths—free vents being made all along the 
course of the sewer—although the contrary practice is 
recommended by some engineers. 

Various contrivances for propelling air into sewers and 
extracting gases from them, such as fans, pumps, steam- 
jets, and furnace chimneys, have been employed. They 
are costly, and, alone, are insufficient and unsatisfactory. 
When plenty of free vents and good traps exist they are 
unnecessary, and when these do not exist they are dan- 
gerous, inasmuch as such propulsion will force traps, and 
such extraction will empty them by suction where free 
vents do not exist. 

The true plan seems to be to make plenty of breathing- 
holes, plenty of channels through which currents will 
continually pass, and which will discharge gases at a 
safe distance overhead. 

In many of our larger cities sewer ventilation is quite 
insufficient and faulty, and much apathy—or rather a want 
of appreciation of correct principles—is found in regard 
thereto. It has therefore been thought a subject which 
should receive here a full consideration. 

YARD- AND GULLY-TRAPS.—In discussing the means to 
be adopted inside of houses to secure the exclusion of 
sewer-gases from dwelling-rooms, various forms of traps 


427 


Sewerage. 
Sewerage. 


have been described, and the methods and principles by 
which their efficiency is to be maintained have been dealt 


Fie. 3504.—Trap with Hand- 
hole on the Upper Side of the 
Seal. 


F1a. 3503.--Trap with ‘‘ Hand-hole” 
in Centre; not suitable for drain 
with floating filth. 


with. (See Habitations: General Principles of Plumb- 
ing. 

in dealing with the means of excluding sewer-gases from 

_ __. __ frequented places out of doors, it only re- 
| YAA, Ynains, therefore, to describe some forms 
of traps applicable to these places. Fig. 
3508 shows a form of glazed-tile trap 
very suitable for a drain conveying rain 
or other water free from floating filth. 
Pipes may be brought from the hand-hole 
in the centre up above the ground-level, 

with Hand-hole for the purpose of observing and remov- 
below the Seal. ing deposit. 

Filth in such a trap might remain floating for a long 
time in the hand-hole above the current, and hence it is 
not suitable for a house-drain. 

Figs. 3504 and 3505 show traps more suitable for con- 


veying floating filth. If the hand-holes are to be used 
merely for removing obstructions (should they occur), 
their sockets should be plugged and cemented ; by means 
of pipes the openings may be brought up within a foot 
or two of the surface. But these hand- 
holes may also be used for purposes of ven- 
tilation, and for protecting the seals of the & 
traps from accidents explained in connection 
with house-traps, due care being exercised 
as regards securing a sufficient supply of 
water. 

Fig. 3506 represents a ‘“bell-trap ;” to the 
left it is seen with the seal perfect, and in 
the centre the seal is broken, the ‘‘ bell” (to 
the right) having been lifted out. This 


ental | 
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4 UJ ? 
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LE 

Y “2 

Fie. 3507.—Intercepting Grease-chamber, with Disconnecting Gully- 
trap. 


constitutes a great objection to the bell-trap ; the grating 
becomes clogged, or the space below becomes filled with 


428 


LOOR LINE. Hat 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


dirt, and the bell is taken out, and by careless persons 
not replaced. If it is so fastened down that it cannot be 
removed, the dirt in the box around the mouth of the 
descending pipe collects and decomposes. It is better to 
use the forms of traps 
already described, 
protecting them with 
a grating. Masonry 
or wooden traps may 
be constructed on the 
‘mid - feather” principle, 
with partitions extending 
vertically across the drain 
and dipping down from the 
crown into the trap-cham- 
ber, between the points of 
entrance and discharge. 

Traps and drains are liable to 
become choked with congealed 
fat; to prevent this, grease-traps 
are sometimesemployed. A form 
of grease-trap is shown in Fig.. 
3507, copied from a paper in 
‘Our Homes,” by Mr. William Eassie, an English engi- 
neer. To the left may be seen the grease-chamber, closed 
by a cover, which may be removed in order to skim off 
the floating fat. This chamber should be ventilated by 

k a pipe or pipes, 
carried to a safe 
position away 
from openings into 
the house. In the 
centre is seen a 
gully -trap for 
taking surface- 
water from the yard, and also for discon- 
necting the sink-waste outside the house. 
This ‘‘ disconnection ” is, of course, unsuit- 
ed to the climate of the northern portions of 
our continent, but in England it is com- 
mon to disconnect the house-drainage just 
outside the house. 

Fig. 3508, from the same work, shows 
Dean’s yard- or gully-trap, which contains 
a box, 8, for catching any dirt that may 
drop through the grating G. To the box is attached a 
rod, R, by which it may be lifted out when it is neces- 
sary to empty it. H is the discharge-pipe. 

Fig. 3509 represents a street-gully, from which sewer- 
gas is excluded by Bt ise wh esate ed As 


Fria. 3508.—Dean’s Yard- or 
Gully-trap. 


Re me meee e eS 
. 


means of’a trap in- 0 


3 


bee 


vented and patent- 

ed by the late Mr. ; 

Thomas Gueérin, } 

C. E., of Ottawa. rl 
i 


ert 


a 


The water from | 
the gutter runs} 
through Ointothe |" pe====== Spee! het hogs 
guily-chamber' Oy. fo.) [Swe lvire ihe 
as it rises it lifts . ~~. 
the floating V, 
which rises in the 
trap-chamber A, and permits the fluid to escape. As the 
fluid evaporates, or if it leaks away, the plug falls back 
into its seat. The plug being conical in its lower por- 
tion, R (Fig. 3510, which is an enlarged view of the trap 
only), any backward pressure of gas drives it more firmly 
into its seat. It is made of wood tipped with brass, and 
is furnished with a small hook for lifting it out. The 


Fia. 3509.—A Street Gully, protected by Gué- 
rin’s Gully-trap. 


- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


trap-chamber is of iron, and fitted with a tight movable 
cover, X. A trap of this kind will obviate the dangerous, 
and sometimes disgusting, va- 
por which we frequently notice § 
from unsealed gullies. salt 

Dry Traps.—The principle of “YJ 
dry traps is illustrated in Fig, 
3011. Fig. 3512 represents the | 
same style of trap, with a coup- 
lingclamp attachment. In these 
traps the flap is hung without 
bolt or pin, by being hooked 
on to two little projecting pieces 
above the circular opening 
which it is intended to close. 
The trap thus formed is inserted 
into the socket end of any pipe 
and kept in place by the spigot 
end of the next pipe above. Its place in asystem of sew- 
erage may be tersely described by a certificate given by 
the writer in 1878, and which he hardly expected would 
be deemed sufficiently meritorious for publication. Per- 

haps the pa- 

AM tentee valued 

i iy 24 it as bearing a 

stamp of du- 

SS SCbious honesty 

on the face of 
1G. 

‘The best 
method of 
preventing 
reflux of sew- 
er-gas is, in 
my opinion, a good water-trap, with sufficient seal, suffi- 
cient vent and ventilation, and frequent change of its 
fluid contents. Where these conditions cannot be ob- 
tained, then resort must be had to a dry trap, and the 
very best of these I have ever seen is Palmer’s trap.” 

Iam glad to be able to refer now to what escaped me 
at that time, viz., its power of preventing reflux of back 
water from sewers into cellars in low-lying districts. 
One great reason for the preference of water-traps over 
dry traps is the tendency of the latter to become foul and 
clogged with deposit, and the liability of their mechanism 
to become ineffective by reason of rust, dirt, and the in- 
terference of solid bodies. 

WEEPING DRAINS, for draining the subsoil of houses, 
should not be laid inside the foundation, if it can possibly 
be avoided. The subsoil of houses, or blocks of houses, 
can generally be drained by porous tiles laid outside, so 
as to surround the foundation-walls at a sufficient depth 
below the level of the cellar floors. When the builder or 
owner of any particular house cannot accomplish this, he 
should be careful to provide the trap interposed below 
the weeping drains with some slight automatic water- 
supply, so that its contents shall be frequently changed. 
Sickness arising from want of attention to this particular 
is common ; the supply of subsoil water ceases, 
the traps become dry, and sewer-gas passes up 
into the house. Two examples may be cited. 
Becoming convinced that there was something 
wrong with the drainage of a house in which § 


Fig. 3511.—Palmer's Trap. 


Sewerage. 
Sewerage. 


careful individuals a hopper-closet, washed while in use 
by an automatic swirl of water from a valve set below 
the frost line, may be used; but when numbers of per- 
sons of various classes have to use closets, they cannot 
be relied upon for care and cleanliness. Latrines should 
therefore be used to supersede the privy-pit in the densely 
populated districts in which the water-carriage system is 
established, unlessit is resolved to use the dry system un- 
der corporation management. In many places the change 
from the old system to the new is being gradually made. 
No new pits are allowed to be dug ; and when any exist- 
ing one becomes a cause of complaint, it is ordered to 
be cleaned and disinfected, and filled with fresh earth. 
These latrines can be controlled by some servant of the 
corporation, or other person, who shall, from time to 
time, change their contents and supply them with water. 
Of the various forms of latrines, the following may be 
mentioned : 

So-called tron stinks are manufactured in various cities 
on this continent, and are being largely introduced. One 
of them, Mott’s Latrine, is shown in 
Fig. 8518. The hopper, or receptacle, 
and: its corresponding section of 
drain, are made in one piece, and the 
several portions of the drain are then © 
connected. The con- 
tents are run off peri- 
odically by raising a 
plug at one end of the 
drain, and the drain 
and latrines are refilled. 
When these are situat- 
ed out-doors, slight ar- 
tificial heat must be 
used in winter. These 
latrines are very mod- 
erate in price. 

The Liverpool trough- 
closet ‘‘may be described as consisting of a series of clos- 
ets communicating with a long trough (W), situated be- 
neath and behind the seat, which receives the excreta 
from each closet in the series. The lower end of the 
trough communicates with a drain (D, Fig. 3514), leading 
to the sewer by an opening which is closed by a plug (P). 
Behind the back wall of the closet there is a small space 
to which no one has access but the scavenger, and from 
which alone the plug can be raised by means of a handle. 
The scavenger visits the closet daily, empties the trough, 
washes it out with a hose (A) connected with a hydrant, 


Fie. 8512.—Palmer’s Trap, 
with Coupling Attach- 
ment. 


I was attending several members of a family 


showing symptoms of low fever, I requested a 


thorough examination to be made. There was 
no smell of sewer-gas, but on raising the board 
cover of a trap in the furnace-cellar over 
which the weeping drains emptied, a blast of 
air shot upward. Five members of this fam- 


ily were prostrated by typhoid fever, The 
other instance was in a house where diphtheria 
persisted in remaining, and recurring ; the 
weeping drains were found to connect with the sewer (a 
very foul one), without any traps. 

OuT-DooR CLOSETS AND LATRINES. — That out-door 
closets and latrines, in connection with the water-carriage 
system, can be used even in the northern part of this con- 
tinent, is now established by experience. In the case of 


Fig. 3513.—Mott’s Latrine, or School Sink. 


and again charges it with water. As much water is let 
in as will cover the excreta received during twenty-four 
hours, and so prevent any smell. The closets are kept 
clean by the users.” 7'represents a trapped overflow from 
the closet-trough to the drain, to prevent any accident 
from leakage of the hose-pipe. 


429 


Sewerage. 
Sewerage. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


The Bristol Hject.—This consists of a strongly con- 
structed dip-trap, interposed between the privy-trunk, as 
It thus admits 


the receptacle is termed, and the drain. 
of the ready extraction of foreign 
matters which may be thrown 
in; it is not easily broken; and, 
as it is flushed and kept clean 
by the servants of the corpora- 
tion, it is found to answer much 
better than ordinary water-closets 
among the poorer classes of large 
towns. 

Other forms of latrines, on the 
same principle, are thus spoken 
of in Wilson’s ‘‘ Handbook of 
Hygiene:” ‘For barracks, 
prisons, etc., water-latrines of a 
much simpler construction than 
either of the above answer ex- 
ceedingly well. An open metal 
trough, roofed in, and with the 


necessary partitions , i. 

: ME jE 
and doors, receives fi Pee 
the excreta, while its = eA f; 


anterior upper margin 4 A WA Mie Pp, 
constitutes the seat. ON Ot ie 
In order that the ex- 2 a 

creta may be constant- mee 
ly covered, the trough - 
should be kept one- 
third full of water. 
It should also be well 
flushed at least twice 
daily, and the contents allowed to run off into a drain con- 
nected with a sewer. A plug, or flap-door, at the lower 
end of the trough, will be required to prevent the water 
from draining off at intervals. 

‘“There is a further advantage, common to all closets 
of the trough system, which may here be pointed out. 
In the event of an epidemic of cholera or enteric fever 
raging in the crowded courts where these closets are in 
use, it will be an easy matter to throw disinfectants into 
the troughs and thus destroy the infectious power of the 
alvine discharges.” 

In some latrines water does not stand in the receptacle, 
but is admitted daily to sweep out the contents with a 
sudden flush. Those in which feces are received into 
the water, the whole being suddenly let off and flushed, 
are to be preferred. 

If a moderate artificial heat were introduced with the 
use of such latrines a double gain would be secured. The 
exposure to severe cold is sometimes very injurious. Not 
to enter deeply into the subject, let us take the case of a 
school-child just recovered from scarlet fever, the peel- 
ing of the skin having been accomplished ; exposure of 
the skin to severe cold may produce fatal disease of the 
kidneys. If, however, these conveniences cannot be 
heated, we must place the water appliances deeply, as is 
done now with our water-pipes, hydrant-services, and 
drains, always remembering that the open troughs are 
more exposed to atmospheric changes of temperature. 
In this regard great care needs to be exercised. 

URINALS become offensive through want of proper pro- 
vision for preventing the incrustation of them with de- 
posits from the urine, and of proper means of frequently 
cleansing or removing surfaces which collect the drop- 
pings. A tray of ashes or sawdust in front of and be- 
neath the urinal will meet this latter requirement, the 
contents of the tray being frequently changed. The 
urinal should have in front a narrow projecting lip. For 
the first mentioned cause of offensiveness it seems neces- 
sary to have a flow of water washing the urinal while in 
use. For this purpose various automatic contrivances 
have been arranged, such as the opening of a valve-tap, 
ay person stands upon a platform in front of the 
urinal. 

INTERCEPTING SEWERS may be divided into those 
which intercept or receive the whole of the contents of 
other sewers, and those which intercept only a portion 


Fia. 3514, Liverpool Trough-closet. 


430 


of the contents, allowing the rest to flow on. There is 
nothing peculiar in the construction of the former. They 
may be used under various circumstances. For example, 
a city may be so situated that the sewage of the upper 
district would flow by gravity to the intended outfall, 
while that of the lower districts would not; in such case 
the sewage of the upper district would be collected and 
carried off to the outfall by an intercepting sewer, the 
sewage of the lower district being pumped either to the 
intercepting sewer on the higher level, or directly to 
the outfall. Or the configuration of the place may be 
such that the natural drainage of the streets has a very 
long fall, while there may be a water-course lying at a 
comparatively short distance to one side; in this case 
a great saving in the size of the sewers may be effected 
by intercepting and beginning anew below the inter- 
cepting sewer. Or the city may be built on knolls, so 
that an intercepting sewer becomes a necessity, unless 
Shone’s system (see below) is employed. 

Sometimes it is desirable to collect only the more con- 
centrated portion of the sewage, and allow the less im- 
pure to flow on, either because the former has to be 
utilized or pumped, or in order to save expense in the 
size of the intercepting sewer. How this object may be 
accomplished is shown in Fig. 8515. The intercepting 
sewer is seen below the divided invert, C, #, of the 
sewer, the concentrated sewage of which is to be intercept- 
ed. The ordinary fair-weather flow, and the first impure 
flush of a rainfall, will drop through the opening B, 


Fic. 38515.—Intercepting Sewer, with Overflow. 


while a heavy flow or flood of water will shoot over, as 
represented by the dotted line A in the diagram. 

Another example of intercepting sewer is shown in 
Fig. 3516. The description is taken from an ‘‘ Account 
of the Trunk-sewer of Buffalo,” by Col. George L. War- 
ing, Jr.: ‘‘The connection of the trunk-sewer with the 
city sewers is shown in Fig. [3516], representing the Por- 
ter Avenue interception. The dry-weather flow of the 
sewer is delivered at an-angle of forty-five degrees with 
the course of the trunk sewer, through a cast-iron pipe 
two feet in diameter. The bottom of this pipe is one foot 
above the bottom of the sewer, and its top is one foot be- 
low the middle of the sewer. 

“For dry weather and light rains this would suffice. 
In order to secure the introduction of as much as pos- 
sible of the discharge of the city sewers during heavy 
storms, it was arranged that its flow should be somewhat 
stilled in a well over the mouth of the inlet-pipe, to allow 
the escape of the rarge volume of air sometimes involved 
in the rapid current of steep sewers during storms. This 
is so done as to bring the full head of the intercepted 
sewer to bear on the inlet. 

‘‘So much of the flow as cannot gain access to the 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


trunk-sewer through the lower inlet, passes on over the 
vertical well and runs into it through a three-foot open- 
ing in its crown. Should the sewer be so full that the 
entire flow of the intercepted sewer cannot gain admis- 
sion, the surplus passes on to the canal.” 

Tidal variations cause much difficulty in connection 
with outfall sewers ; by the ebb and flow of the sewage- 
laden tide a serious and 
wide-spread nuisance 
is often created. And 
in this connection it 
should be borne in 
mind that sewage oxi- 
dizes more slowly in 


N 


Fic. 3516.—Intercepting Sewer, Porter Avenue, Buffalo, with Overflow. 


sea-water than in fresh water. If the sewer discharges 
continuously on the shore at or near high-water mark, the 
nuisance is intensified ; if it discharges below low-water 
mark, the rising tide causes a backing up of the sewage 
and deposit of its solid portions, with all the evils inci- 
dent to such a condition. It will also, by rising in the 
sewer, force backward the gases therein contained. To 
prevent this, flap-valves are often placed on the mouths 
of such sewers. It is more desirable to make ample 
vents for discharging the sewer-gases, as before described 
when speaking of the ventilation of sewers. 

Fig. 3517, copied from ‘‘ Suggestions as to Plans for 
Main Sewerage,” by Robert Rawlinson, C.B., C.E., of 
the Local Government Board of Great Britain, is a ‘‘ sug- 
gestion” for an outfall adapted to tidal variations. Its 


High .water? of Spring ‘lides. 


<water of Neap tides 


Sewerage. 
Sewerage, 


pumping-station, where it is raised to a sufficient height 
to enable it to flow through a tunnel, over a mile long, be- 
neath Dorchester Bay, to Squantum, and thence through 
a flume, for another mile, to Moon Island ; here it is held 
in reservoirs and periodically discharged into the outgo- 
ing tide. At the pumping-station such straining and sub- 
sidence are effected as may be necessary to obviate deposit 
in the tunnel. 

Pumpine SEwaGe.—The ordinary methods of pump- 
ing sewage have been dealt with, as far as needs be, in 
the article Sewage, Disposal of ; there now remains to be 
described a mode of pumping, called Shone’s Pneumatic 
Sewerage System, which is a combination of the separate 
system with a method of pumping sewage by the direct 

action of compressed air, 

the reverse of that em- 
ployed in the Liernur and 

Berlier systems. It is the 

invention of Mr. Isaac 

Shone, a mining and civil 

engineer of Wrexham, 

Wales. It is well described 

in the report of Mr. Samuel 

Gray, Civil Engineer, of Provi- 

dence, R. I. (already referred to in 

the article on Sewage Disposal), as fol- 

lows : 

‘In applying this system to a city or town, 

the house-drainage, comprising excreta and 

all liquid wastes, is conducted by gravity to a 

low point in each drainage district, through ordinary 
sewers, in which nothing else is permitted to flow. 

‘At each of these points is situated a ‘ pneumatic eject. 
or,’ into which the sewage flows, and by which it is 
raised, by the direct pressure of compressed air, to any 
required height, into a system of cast-iron pipes jointed 
like water-pipes, in which the sewage is forced to the 
point of discharge. ‘This may be at the sea-shore, far 
below the high- or low-water level, or may be at a sewage 
farm, where the sewage can be applied to the land. An- 
other arrangement is to deliver the sewage from the 
ejectors into an upper tier of gravity-sewers leading to 
the outfall. The choice between these two methods de- 
pends upon the topography of the locality. 

‘““The air, which forms the motive power of all the 
ejectors, is compressed at some convenient place by a com- 
pressor operated by steam or water power. Thence the 
compressed air is supplied to the ejectors through small 
iron pipes laid through the streets. 

‘‘The system is confined to the removal of house- 


Fie. 3517, 


construction is explained by descriptions on the cut it- 
self. It will be noticed that the pipe leading ‘‘ to and 
under low-water” is of smaller size and steeper gradient 
than either the ‘‘ Outlet Sewer” or ‘‘ Flood-water Over- 
flow ;” the tendency of this would be to prevent deposit. 

In Boston the difficulty has been met by building a 
main sewer (with elaborate overflow and other apph- 
ances) which conducts the sewage over three miles to a 


sewage, both to prevent its dilution and to render more 
uniform the volume of liquid to be raised by the ejectors ; 
it being evident that, should storm-water and subsoil 
drainage be admitted, the ejectors would either be un- 
able at times to perform the work required of them, or 
would need to be so large that they would not work 
economically under ordinary conditions. Storm-water 
and subsoil drainage are therefore expected to be con- 


431 


Sewerage. 
Sewer-Air. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


veyed in a distinct system of sewers.” ‘* The 
sewage is discharged from the gravity-sewers into a 
receiving chamber, 
from which it passes 


into a separating 
chamber, where all 
floating substances 


are arrested, and 
thence into the eject- 
or. Sometimes the 
sewage passes direct- 
ly from the gravity- 
sewers into the eject- 
ORF see ae The 
action of the ejector 


Fia. 8518.—Shone’s Ejector, Filling. 


is seen in Figs. [38518] and [8519]. Fig. [8518] shows the 
ejector while it is fillmg. At the top of the ejector is an 
automatic-valve apparatus, controlied by a weighted le- 
ver. A rod connected with one end of this lever passes 
through a stuffing-box, and into the interior of the eject- 
or. On this rod is a reversed cup or ‘ bell,’ and connect- 
ed with its lower end 
is a weight or ‘cup.’ 
While the ejector is 
filling, the valve marked 2 is 
held to its seat by the pressure 
from the rising main, and the 
valve marked 1 is lifted by 
the pressure of the inflowing 
sewage. The air within the 
ejector passes out through an 
exhaust-port and pipe to the 
man-hole or sewer. When the 
ejector is full, the ‘ bell’ is af- 
fected by the buoyancy of the 
water, and the weighted lever falls, closing the exhaust- 
port ; and immediately afterward opening the inlet-port, 
admitting compressed air to the interior of the ejector. 
This action upon the surface of the sewage causes the 
valve 1, Fig. [8519], to close, and the valve 2 to open and 
permit the passage of the sewage to the pressure-main in 
the street at a higher level, to which it is raised by the 
. force of the compressed air. When the sewage has fall- 
en to the bottom of the ‘cup’ suspended from the valve 
mechanism, its buoyancy has been withdrawn and the 
‘cup’ falls and reverses the valves, closing the inlet-port 
and immediately afterward opening the exhaust-port 
through which the compressed air within the ejector es- 
capes by a pipe leading to the man-hole or to the sewer. 
The atmospheric pressure being restored within the 
ejector, the valve 2 closes, and it begins to refill with 
sewage. 

-** From this description it will be seen that the Shone 
system is essentially a method of pumping sewage in de- 
tail by means of small pneumatic pumping engines, situ- 
ated in different parts of the city, all of which are oper- 
ated by power generated at a single station. The system 
may be applied to the entire sewerage of a city, or may 
be confined to special districts, according to .circum- 
stances, 

‘The Shone system is particularly valuable in the sew- 
erage of towns where fall sufficient to produce a proper 
velocity of flow cannot be obtained, and where it is im- 
practicable to convey the sewage to one general pumping 
Station, since in this system it is not necessary to follow 
the general topography ; but the sewers may be given 
such grades as may best promote the rapid discharge of 
the sewage. An ejector may be placed wherever these 
grades cause the depth of the sewer to be excessive, and 
the sewage may be raised to a height from which it may 
flow to the outfall, either under pressure or by gravity. 
The cost of an equal number of small steam-pumps, with 
their appurtenances, to do the work done by the ejectors, 
would be very great.” 

RELATIVE VALUE OF THE SEPARATE AND COMBINED 
SystEeMs.—Of the separate and combined systems of sew- 
erage, the distinctive features and some of the relative 
merits have, of necessity, been described and discussed 
under the various details of Sewerage and Sewage Dis- 


EEC? eeom= 
GRAVITAT nN. SEGA 


Fie, 3519.—Shone’s Hjector, Dis- 
charging. 


432 


posal. A brief comparison will therefore be all that is 
necessary here. . 

In behalf of the separate system it may be urged : 

From a sanitary standpoint, the smooth glazed pipes 
are less liable to deposit and to acquire a slimy lining. 

They can be more fully and readily flushed at will and 
periodically. 

Their smaller size leaves less surface for the exhalation 
of vapor, less space for its collection, and greater facility 
for its change by removal. 

From an economical standpoint, its cost is very much 
less, say from $0.75 to $2.00 per foot, as compared with 
that of the combined system, say from $5.00 to $10.00 
per foot, which figures are given by Messrs. Staley and 
Pierson. 

The advocates of the separate system state that street 
and surface filth should be swept up and removed by 
some dry method. 

That even when the combined system is used for the 
safe conduct of surface water the sewers are insufficient 
in time of unusual flood, and flooding of cellars takes 
lace. 

By those who hold that the combined system may, 
under certain circumstances, be the most advisable, it is 
represented : 

That inasmuch as it is well known that excreta only 
form a small percentage of the filth of sewage, and that 
street and surface filth form a large percentage, it is nec- 
essary to provide for the removal of the latter, and wa- 


ter-carriage is the cheapest and best method of removal. 


That in places where the natural drainage fall is 
lengthy, the volume of water will become so great that 
subsurface conduits become necessary ; and it is only 
once in years that these volumes become so excessive that 
flooding of cellars takes place, the fall in the sewer and 
over the surface generally provided being sufficient to 
prevent flooding. That flooding is more likely to take 
place by overflow from the surface, and hence is more 
liable to occur with the separate system. 

That some cities are so flat that surface water would 
stand in ponds, 

That the cost is increased by providing two systems, 
one for rain- and storm-water, and another for household 
sewage. 

That obstructions in the small pipes of the separate 
system necessitate frequent excavation down to the 
sewer. 

That in deep cuttings the pipes are liable to be crushed 
(unless made of iron) and obstruction thus take place. 

That two systems of sewer-pipes in the same street are 
liable to give rise to confusion in making connections 
and repairs. 

There is much force in the arguments for both sys- 
tems, and perhaps we should not look upon them as op- 
posed arguments on behalf of rival systems, so much as 
points to be considered in connection with the sewerage 
of any particular place. 

There can be no hesitation in saying that in a place 
where the surface water can be left to flow off over the 
surface without flooding houses or impeding traffic, and 
where it will not cause pollution, the separate system is 
the best. 

Nor can there be much hesitation in saying that in 
other cases, if we can compass the cost of sewage and 
storm-water conduits separately, it had better be done. 

But it is evident that in each community it is necessary 
to make a study of all attending circumstances, and we 
cannot lay down a dogmatic decision to apply to all ; we 
must be guided by principles as applied to the partic- 
ular circumstances. . 

There may, too, be ahappy medium, as there is in most 
things; the mode of intercepting only the more con- 
centrated portion of the surface water, that which first 
flows in, has already been referred to. Another plan, 
that might with advantage be adopted in places where 
the surface water is liable to form streams too large to 
flow over ground all the way to the outfall, would be 
to admit it in the higher districts into the (combined) 
sewers, and to exclude from them that in the lower 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


districts. The advantages of this would be that the up- 
per parts would receive the flushing which they more 
especially need, the size of the sewer would not increase 
below, to the great extent that it now does, and the 
volume of surface water from the lower districts only 
would not be so great. 

THE PRESERVATION OF DRAINAGE AND SEWERAGE 
PLANS is a matter to which I would refer as one of very 
greatimportance. Often they are lost or do not pass into 
the possession of those most interested, the owners of the 
properties concerned ; and a vast amount of time is lost, 
property destroyed, and mistakes committed, in delving 
and searching for hidden drains. When our health or- 
ganizations are firmly established in the relations they 
should occupy in regard to the sanitary construction of 
houses, copies of all such plans and specifications should 
be obtainable from them. When they are not so, and 
perhaps in any case, these plans should be preserved in 
the registry offices along with the title-deeds. 

In conclusion, I desire to express my thanks to the 
gentlemen whose names and work have been mentioned 
in this article, and to any others whose names have been 
overlooked, but from whom, as contributors to the gen- 
eral fund of information on this subject, I have derived 
assistance. Wm. Oldright. 


SEWER-AIR (Sewer-gas). DrErrnrrion. — Sewer-air, 
as the name implies, is the air usually found in sewers. 
It is composed of atmospheric air containing certain 
gases, vapors, and micro-organisms resulting from the 
decomposition of sewage and excrementitious matters 
found therein. 

In this article the definition will be extended to in- 
clude the air of house drain-pipes, privy-vaults, cess- 
pools, and other imperfectly ventilated places containing 
decomposing animal and vegetable matters. 

The term ‘‘sewer-gas” is frequently used as synony- 
mous with sewer-air, but it is objectionable, from the 
fact that it seems to imply that sewers contain a specific 
gas having a definite chemical composition. Such is not 
the fact ; on the contrary, sewer-air is a mixture of air 
with other gases and vapors in ever-varying proportions. 

Composition.—In order to understand the composi- 
tion of sewer-air we must call to mind the composition 
of sewage, and how the air is contaminated by it. Sew- 
age of cities and large towns consists of water flowing 
slowly through an underground conduit, and holding, 
partly in solution and partly in suspension, the excreta 
of men and animals, refuse from kitchens, grease, soap, 
the drainage from slaughter-houses, stables, factories, 
laundries, streets, etc. It is therefore a complex mixture 
of organic and mineral matters, very prone to putrefac- 
tive decomposition. This decomposition is brought about 
by the agency of the usual putrefactive bacteria, and 
with the development of carbonic dioxide (CO.), marsh- 
gas (CH,), nitrogen, ammonia, and sulphuretted hydro- 
gen (HS). 

Letheby found that sewage-water containing 128.8 
grains of organic matter per gallon, and excluded from 
air, evolved, for nine weeks, 1.2 cubic inch of gas per 
hour, or 28.8 cubic inches per day. The analysis of this 
gas gave, in 100 parts, by volume: 


DAREA ORR Sie eee ee ee Moe et Sate cece cee 78.83 parts, 
Carbonidioxideweet eases fete. Soe de hee ss 150m 
IN EOR ON ee Rare vr. ister oe 2 ce cea ee ee 10.19 * 


UUs. 


Similar experiments with sewer-mud in the Seine, by 
Durand-Claye, gave a gas of the following composition : 


Sulpniuretted bydrogen 7.5. i054 wits scree se 


MAYEN -CARS amete ts citric serok Mvcexte re me eee 72.88 per cent. 
Warboirdioxidensi et. dh ae cetees aes ates Gye 
INITROPON BEE ot. 7 Pec eh ei clote Sek aa tae LU pg en Mle 
Ogrhou MOnoxiGe 4.0 aoe: tae cna eoate PE UP 
Sulphurerted hydrogen,........«2sese ne nee ental) ae ee 


Such mixtures are never found in an ordinary sewer, 
as the gases are always mixed to a greater or less extent 
with air. The quantity of these gases to be found in the 
air of a sewer will depend upon the composition and the 
velocity of the movement of the sewage, as well as upon 
the ventilation of the sewer. 


Vou. VI.—28 


Sewerage, 
Sewer-Air. 


Dr. Letheby gives the following as the average per- 
centage composition of the air of London sewers : 


OXY CCN teva ae ese cet eee einen cece nthe ee ene 19.51 
NIGFORETIME renee tore nee sore cele mise Here ete cae 79.96 
Carbonaioxiders. cairns fe ve sss oll Homes. es aclae cee 0.58 
MAGS AP AS oun MCu sc reiis. 6: caudletelansteiaiet ots oie ate iue desc 

PA TIIMONIL Gates clear sate ke eee ee ee traces 


Professor W. R. Nichols, of Boston, analyzed the air 
of a badly ventilated sewer in that city, with the follow- 
ing maximum and minimum percentages : 


Maximum. Minimum. 
ONG CMe Ser Panett CeV ahd setae ORI s aie ae es 20.90 20.48 
MN TOMO SOT ra tveccrslitee: aehrepoe obs ene chet shetty « 79.26 78.89 
Carbon[ dioxide... naeaaeo ee ci ee 0.50 0.40 
Sulphuretted hydrogen................. trace trace 


In extreme cases the oxygen has been found as low 
as 13.79 per cent., the carbon dioxide as high as 3.4, and 
sulphuretted hydrogen as high as 2.99 per cent. Besides 
the gases here mentioned, sewer-air always contains bac- 
teria and volatile organic matters, sometimes in large 
amount. The exact nature of these organic matters is 
not well understood. Some of them seem to belong to 
the class of bodies known as compound ammonias, or 
amines. When sewer-air is shaken up with a dilute so- 
lution of potassium permanganate, the organic matter 
undergoes oxidation at the expense of the oxygen in this 
salt. 

We may form an idea of the amount of organic mat- 
ter present by the amount of a standard permanganate 
solution decolorized by a measured volume of the air. 
Dr. Angus Smith found that the air of a cesspool de- 
stroyed two thousand eight hundred and forty times as 
much permanganate as the same volume of pure air. 
The air of a house into which sewer-air had penetrated 
destroyed twenty times as much permanganate solution 
as the same volume of pure air. ‘These organic matters 
are probably much more deleterious constituents than 
those shown by the chemical analyses above quoted. 
These gases seem to possess considerable diffusive power, 
and will pass easily through walls and porous earthen- 
ware, or brick sewers. In this way these gases frequently 
find their way into the cellars of houses, especially in the 
vicinity of a broken sewer or improperly constructed cess- 
pool. Fungi readily grow in such air, and articles of 
food, such as meat or milk, soon become tainted and de- 
compose when exposed to it. Experience has shown that 
stagnant sewage gives off more gas, and is more danger- 
ous, than that which is kept in motion. Sewer-drains 
which have a steep grade are, therefore, to be preferred 
to those having a slight grade. Where sewers are fre- 
quently flushed with water, and where there is no chance 
for stagnation, with a reasonably good ventilation, the 
danger from sewer-air is reduced to a minimum, 

There are very strong reasons for believing that the 
specific poisons, or germs, of a number of the contagious 
diseases may be transmitted by sewer-air. That dysen- 
tery, diarrhoea, and periodic fevers are frequently pro- 
duced by sewer-emanations cannot be doubted. It is 
also believed that the poisons of typhoid fever, of chol- 
era, and of yellow fever, have been transmitted from 
house to house by the medium of the sewers. Indeed, 
the evidence of such transmission amounts almost to a 
positive proof. ; 

PuystoLoeicaL Errects oF SEwER-Air.—The ef- 
fects of breathing sewer-air depend upon its composition 
and upon the degree of dilution. Poisoning by this gas, 
or mixture of gases, may be acute and rapidly fatal, or 
chronic, only manifesting itself after weeks or months 
of exposure. Acute poisoning from breathing sewer- 
air, or the air of cesspools, privy-vaults, etc., occasional- 
ly leads to fatal results. These effects may usually be 
traced to one of two causes: 1. The air may be deoxi- 
dized, or deficient in oxygen, and contain excess of carbon 
dioxide. 2. It may contain a poisonous quantity of sul- 
phuretted hydrogen (H.8). : 

According to Thénard, asphyxia of persons by breath- 
ing sewer-air is often due to breathing an air containing 
a deficient supply of oxygen, rather than an excess of 


433 


Sewer-Air. 
Sewer-Air. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


carbon dioxide. Experiment has repeatedly shown that 
an animal can endure for hours a greater proportion of 
carbon dioxide than is ever found in ordinary sewer- 
air, provided that the proportion of oxygen is kept up to 
the normal amount, or is in excess of the normal. The 
poisonous properties of carbon dioxide are very slight 
when the oxygen of the air is increased above the nor- 
mal proportion. Thus, an animal may live for hours in 
an atmosphere composed of forty per cent. of oxygen, 
twenty per cent. of carbon dioxide, and forty per cent. of 
nitrogen. An addition of five per cent. of carbon diox- 
ide to normal air may be endured for some time with- 
out fatal poisoning. As sewer-air seldom contains more 
than four per cent., it is evident that unless the oxy- 
gen be reduced below the normal, the mixture could not 
prove rapidly fatal from carbon-dioxide poisoning. A 
case of asphyxia from breathing sewer-air, then, is oftener 
due to a deficiency of oxygen than to an accumulation 
of carbon dioxide ; or, perhaps, to the combined effect of 
this with an excess of carbon dioxide. In such cases 
resuscitation is likely to prove successful, if pure air can 
be supplied in time. 

In certain cases sewer-air may contain enough sul- 
phuretted hydrogen (H.S) to become poisonous. <A 
number of cases of fatal poisoning by sewer-air contain- 
ing sulphuretted hydrogen are on record. Woodman 
and Tidy! mention twelve cases of sewer-gas poisoning. 
They seem to attribute the poisoning to H.S in most, if 
not all, of these cases. It must be admitted that it is 
only in exceptional cases that this gas accumulates in 
sewers in sufficient quantity to give rise to acute poison- 
ing. 

A discharge of a considerable quantity of mineral acid 
into a collection of sewage-matter containing an abun- 
dance of sulphides may cause an evolution of H.S, which, 
in a poorly ventilated and flushed sewer, may accumulate 
in fatal quantity. A liquid charged with sulphuretted 
hydrogen or ammonium sulphydrate, like gas-liquor, 
may be discharged into a sewer so as to temporarily 
poison the air. By far the largest number of these cases 
of acute poisoning occur to workmen engaged in hand- 
ling night-soil, the contents of privy-vaults and cess- 
pools, or the mud of sewers. In such cases the pent-up 
gases May escape in poisonous quantities, and overcome 
the workmen before it has had time to diffuse itself. 
Sulphuretted hydrogen is a deadly poison, even when 
mixed with large quantities of air. 

The results of experiments upon animals show that :? 


1 part of H.S in 1,500 of air killed small birds ) Parent 

a eg ee COU ee: aoe es O11 bS u 

i! Sal) co eo ee me LOnSeS Chatelet. 

1 ee B00 sae birds a 

5 ae ase D1) ** 6 ry. dogs Dr. Barker. 
1 SUPA NENG Oe birds 

1 fatiivon, fe aoe { Dr. Letheby. 


Dr. Letheby considers that one per cent. of the gas 
in air would destroy human life. As +49 per cent. (1 
part in 10,000 of air) can be detected by the odor of 
rotten eggs which it imparts, there can be little danger 
of being acutely poisoned by it unawares. 

It is more than probable that the fatal effects, above 
referred to, are as largely due to deoxygenated air as to 
the poisonous action of the sulphuretted hydrogen, or of 
the ammonium sulphide. 

TREATMENT OF ACUTE POISONING BY SEWER-AIR.— 
The treatment of this form of poisoning may conven- 
iently be divided into preventive and remedial. 

The prevention of acute poisoning by the air of sew- 
ers, cesspools, etc., is very simple. In sewers thorough 
flushing and ventilation is all that is needed. In cess- 
pools and vaults it is important to stir their contents 
before emptying, in order to allow the greater part 
of the gas to escape. If the generation of hydrogen 
sulphide is rapid, it may be necessary to throw down 
a little chloride of lime, a day or two before going 
into the vault, or to generate chlorine in the vault b 
means of chloride of lime and dilute acid. The test 
of lowering a candle into such places is not always a 
safe test to depend upon. The remedial treatment of 


434 


asphyxia from sewer- or cesspool -air consists in the 
admission of fresh air, and the use of cold affusions. 
Warm brandy or whiskey and water may be given freely, 
to sustain the heart. 

Dr. Eskbridge has used, with success, intravenous in- 
jections of aqua ammoniez fortior in a case of acute 
poisoning. He proposes to use this solution, diluted with 
two parts of water, at a temperature of 110° F. 

Commonly, the simple removal of the person into pure 
air, if done without delay, is sufficient to restore him. 
Woodman and Tidy recommend the breathing of air con- 
taining a trace of chlorine, formed by putting chloride 
of lime in a bottle. The object of this treatment is to 
decompose the hydrogen sulphide that may be in the 
residual air of the lungs, or, possibly, in the blood. 

SymMpTomMs AND Post-MorTEM APPEARANCES.—The 
symptoms of acute poisoning by sewer-air, the air of 
cesspools, or the gases evolved by night-soil, are usually 
those of asphyxia, or of poisoning by hydrogen sulphide. 
The surroundings of the person at the time of the acci- 
dent can usually be determined, and thus the cause of 
the symptoms, or death, inferred. The first effect will 
probably be nausea, faintness, or dizziness ; cold, clammy 
skin ; frequent pulse, and irregular or jerky respiration. 

Later, or if the sulphuretted hydrogen be more abun- 
dant, the person loses the power of motion, and becomes 
insensible. His lips become livid, and a bloody, frothy 
mucus may exude from the mouth or nose. The pulse 
becomes weak, rapid, and irregular. The respirations 
now become rapid, laborious, and irregular. The volun- 
tary muscles are relaxed, with occasional twitchings, or 
even tetanic convulsions. Death may occur suddenly, or 
the patient may slowly regain consciousness on exposure 
to pure air. 

The post-mortem appearances are usually those observed 
after poisoning by hydrogen sulphide. The blood will 
everywhere be found to be of a very dark color, some- 
times almost black, and fluid. The right. side of the 
heart is usually found filled with blood. The body emits 
an offensive fecal odor, and rapidly undergoes putrefac- 
tion. When the cause of death is sulphuretted hydro- 
gen, the mucous membrane of the bronchial tubes is 
smeared with a dirty-brown mucus, easily rubbed off. 
This appearance is very characteristic, and may serve to 
distinguish between suffocation by deoxygenated air and 
sulphuretted-hydrogen poisoning. 

CHRONIC POISONING BY SEWER-AIR, AND THE DISEASES 
PRODUCED By IT.—This is a subject upon which a great 
deal of attention has been spent, without entirely satisfac- 
tory results. Opinions differ as to the effects of sewer-air 
upon the human economy, when breathed for a consider- 
able time in a highly diluted condition. While some phy- 
sicians believe that it is not deleterious to health under 
these conditions, others claim that it is a cause of many 
cases of serious illness, and a frequent carrier of such dis- 
eases as typhoid fever, dysentery, cholera, yellow fever, 
diphtheria, scarlet fever, measles, etc. While it is not 


“easy to obtain reliable data upon this point, the weight 


of evidence, as well as reason, seems to declare that there 
is some connection between sewer-emanations and some 
of the diseases mentioned. It would carry us too far for 
the limits of this article to discuss at length the evidence 
that must lead us to this conclusion. 

It is certain that there are well-established observa- 
tions, which seem to prove that sewer-air, even when 
largely diluted, produces a very deleterious effect upon 
the health of persons who breathe it for a considerable 
time. The teachings of writers on toxicology, the clini- 
cal experience of hundreds of physicians in our large 
cities, the experience of sanitarians and of sanitary en- 
gineers, all lend weight to this opinion. It is equally cer- 
tain that these effects cannot be due alone to the gases 
which have been described as entering into its chemical 
composition. 

Mixtures of air with carbon dioxide, marsh-gas, sul- 
phuretted hydrogen, and ammonium sulphydrate, when 
prepared in the laboratory, in the arts, or in metallurgical 
operations, have never been known to produce typhoid 
fever, dysentery, malaria, or any other of these specific 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sewer-Air. 
Sewer-Air. 


diseases. Indeed these gases, with the exception of H.S, 
are known to be harmless when highly diluted. Sulphu- 
retted hydrogen has lately been recommended and used 
by inhalation in the treatment of phthisis. The author 
has so used it, with no apparent ill effect. 

Some other cause for the well-known effects of sewer- 
air must be found than is revealed by the analyses above 
quoted. This must be in the organic matters or micro- 
organisms that have been described as present in sewer-air. 
The air of sewers has been. found to contain large quanti- 
ties of bacteria. This may be easily shown by exposing 
in a sewer a glass slide moistened with glycerine, and 
then submitting the slide to microscopical examination. 

Professor Frankland * has shown that few solid or liquid 
particles are evolved from sewage unless it be agitated. 
He found that the ordinary flow of the sewer-water did 
not scatter any particles into the air; but when it began 
to ferment and evolve gases, the bursting of these bub- 
bles sent small portions of the liquid into the air. From 
this fact he argues that sewage pollutes the air with dan- 
gerous germs only when it is giving off bubbles of gas. 
If we take proper measures to carry off the sewage be- 
fore fermentation takes place, the danger will be reduced 
to a minimum, or entirely obliterated. If, as above stated, 
the putrefactive bacteria are thus disseminated through 
sewer-air, there is no known reason why pathogenic mi- 
crobes, when present, should not be scattered in the same 
way. 


A case in which sewers probably played a part in the - 


spread of cholera, is given by Dr. Parkes, in his report to 
the officer of the Privy Council on the cholera in South- 
ampton, in 1866. There is good evidence that the-con- 
tagious principles of yellow fever and typhoid fever have 
been disseminated by sewer-air, 

In the city of Brooklyn, N. Y., in 1885, there were a 
large number of cases of typhoid fever in two pretty well- 
defined localities, both situated on high ground. After 
a thorough investigation of the cause of the localization 
of the cases, the conclusion was reached that the sewers 
were infected by the discharges of a few imported cases ; 
that the poison was disseminated by the sewer-air tend- 
ing always toward high levels, and gained an entrance 
into houses in the immediate vicinity through defects in 
the plumbing. In a very large number of the houses 
where cases occurred, such defects were actually found 
on inspection. 

Upon this subject Dr. John Simon, Chief Medical Offi- 
cer to the Privy Council of Great Britain, in his essay on 
‘‘ Filth Diseases,” while speaking of morbific ferments, 
or contagia, says: ‘‘The ferments, so far as we know 
them, show no power of active diffusion in dry air; but, 
as moisture is their normal medium, currents of humid 
air (as from sewers and drains) can doubtless lift them in 
their full effectiveness, and if into houses or confined 
exterior spaces, then with their chief chances of remain- 
ing effective.” 

Dr. Parkes‘ says: ‘‘ The air of sewers passing into 
houses aggravates most. decidedly the severity of all ex- 
anthemata—erysipelas, hospital gangrene, and puerperal 
fever (Rigby) ; and it has probably an injurious effect 
upon all diseases.” ‘‘Two special diseases have been 
supposed to arise from the air of sewers and fecal emana- 
tions, viz., diarrhea and typhoid (enteric) fever.” ‘That 
typhoid fever may, and frequently does, arise from sewer- 
emanations is a doctrine certainly well supported by 
facts. The writer’s experience has furnished examples 
of this fever that were apparently contracted from 
sewer-air. There are several cases on record where ty- 
phoid fever has constantly recurred in houses exposed to 
sewer-emanations, and in which proper attention to sewer- 
defects has completely prevented further outbreaks. 

Water has been known to become contaminated by 
sewer-gases, and afterward to produce typhoid fever in 
those who drank it. Dr. F. de Chaumont?® cites a case 
where a cistern was thus poisoned by sewer-air passing 
into it from the sewer through the overflow-pipe. An 
analysis of this water showed it to contain a considerable 
excess of ‘‘albuminoid ammonia,” derived from the ab- 
sorbed gases. A similar case is recorded by Dr. Robert 


King, in the Medical Times and Gazette for August 2, 
1879. These, and other similar cases, add an interest to 
the question of overflow-pipes to wells and cisterns, and 
of the efficacy of water-traps, not usually appreciated. 

Mr. William Budd cites instances in which those mem- 
bers of a particular household, who used one closet into 
which the dejecta of a typhoid patient were thrown, con- 
tracted the disease, while other members of the same 
household, who were in close personal contact with the 
sick person, escaped. 

From what is here said, it will be understood that the 
results of breathing sewer-air are not always the same. 
The effects will depend upon the quality much more than 
upon the quantity of the air breathed. A small amount, 
at one time, may cause a fatal contagious malady, and at 
another time a much larger amount may produce only a 
slight malaise. A small quantity laden with the germs 
of a specific disease is more dangerous than a large quan- 
tity of gas from an uninfected sewer. 

SYMPTOMS OF CHRONIC SEWER-AIR PoIsoNING.—As 
already remarked, the symptoms of sewer-air poisoning 
are usually insidious in their development, and by no 
means always constant. I am disposed to believe that 
the effects may even remain unnoticed for months, as 
long as the sewer is not infected with harmful germs, 
and may develop with certainty whenever such infection 
does occur. 

In adults the symptoms, when no specific disease- 


‘germs are at work, are malaise, headache, loss of appe- 


tite, with even dyspeptic symptoms, drowsiness, and 
slight feverishness. There is a marked tendency to 
anzemia and general debility. ‘These symptoms are fre- 
quently grouped under the name of ‘‘ malaria.” In 
children, to these symptoms may be added a smooth or 
glazed, broad, flabby tongue, with a marked tendency to 
digestive trouble, as vomiting, diarrhoea, dysentery, and 
attacks of gastric catarrh and catarrhal tonsillitis, 

The tendency of sewer-air poisoning, then, is to derange 
the organs of primary assimilation, rather than the lungs ; 
as, for example, gastric catarrh, duodenitis, hepatitis, 
splenitis, diarrhea, enteritis, and colitis, Besides these 
effects, the debilitating influences of the polluted air ren- 
der the persons so effected an easy prey to any intercur- 
rent malady. 

In times of epidemic diseases these are apt to assume 
a severe or malignant type. There is less tendency to 
periodicity, and more variability in sewer-air poisoning 
than in marsh-miasm. The effects seem to depend 
largely upon the bodily vigor and activity, at the time of 
exposure, and are therefore greater in night exposure 
than during active working hours. Hence workmen 
engaged in ventilated sewers and vaults seldom suffer 
any particular harm. Numerous inquiries upon this 
subject have been made, and, although there has been 
some difference of opinion, the weight of evidence would 
seem to indicate that sewer-workmen suffer no more 
from disease than do other men, aside from a few acci- 
dental cases of asphyxia. Those*who suffer most from 
sewer-gas poisoning, or sewer-malaria, are women and 
children who spend most of their time in the house, 
especially in poorly ventilated apartments. As might be 
expected, an exposure to sewer-air during sleep is more 
dangerous than during waking hours, and during a pe- 
riod of active exercise. 

While we admit the injurious nature of air contami- 
nated with sewer-air, we must admit that we occasionally 
meet with cases where persons have lived in houses for 
years, where traps were unknown, and have suffered 
from no apparent bad effects. These facts have led some 
sanitarians to deny the relation of sewer-air to any form 
of disease. It will not be claimed that the specific germs 
of disease are always present in any given sewer, espe- 
cially if it is well ventilated, and if the sewage is con- 
stantly in motion. The air of a badly ventilated and 
stagnant sewer is always to be regarded as more dangerous 
than that of one where these conditions do not prevail. 
It has repeatedly been shown that the conditions under 
which the various microzymes grow, have a great influ- 
ence upon their virulence in producing disease. It is 


435 


Sewer-Air. 
Sex. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


quite possible that the ordinary putrefactive bacteria, 
when germinating in pent-up sewage, may be the cause 
of the catarrhal sore throats and diarrhceas produced by 
sewer-air. The virulence of many of the microzymes of 
the specific diseases, when present in sewers, is increased 
by germination in closely confined and stagnant sewage. 
It will be admitted that these disease-germs are not al- 
ways present in sewers, and under favorable conditions, 
such as rapid flow and free ventilation, would do no dam- 
age when they were present. The importance of secur- 
ing these favorable conditions in sewers is therefore very 
apparent. 

TREATMENT.—The treatment of chronic sewer-gas 
poisoning is partially remedial and partially preventive. 
In the former, fresh air is of first importance. Pure out- 
door air acts as a tonic, and, at the same time, a diluent 
and disinfectant of the sewer-air. As the tendency of 
sewer-air, aside from the specific disease-germs, is to 
produce a lowered vitality and anzemia, quinine, arsenic, 
salicin, iron, and the mineral acids are indicated. A 
change of location is often of the greatest benefit. It 
should be remembered that the effects of sewer-air are 
frequently seen only in their aggravation of other 
maladies. Thus, a simple sore throat may, under its in- 
fluence, assume a very serious and aggravated form. A 
simple gastro-intestinal catarrh, in children exposed to 
sewer-air, is often found to be most intractable, until a 
change of location is secured. The author has seen cases 
of summer diarrhoea very greatly benefited, and even 
cured, by a removal for the distance of a few blocks in 
the city. The effects of a removal to the country are too 
well known to demand discussion. Many of the cases of 
infantile cholera are undoubtedly due to the combined 
effect of a polluted air and high temperature. Fresh air 
is curative in a large number of these cases. 

The effect is the same whether the fermenting sewage 
is contained in sewers or has soaked into the ground 
about the house. Both may pollute the air with the 
same gases, and may produce like effects. When furnace- 
fires are used in the house, the gases from a sewage- 
soaked soil may be drawn into the cellar and thence into 
the rooms above, giving rise to all the injurious effects 
of sewer-air. 

The prevention of sewer-air poisoning is of more im- 
portance than is its treatment. The principal requisites 
for a system of sewers are, free ventilation of all drain- 
or waste-pipes, and sufficient grade or inclination in out- 
let-pipes to secure a somewhat rapid current of the sew- 
age. To secure thorough ventilation of the pipes in the 
house, it is now customary and proper to carry a ventilat- 
ing pipe, from the sewer side of all traps, toa larger pipe 
leading to and above the roof of the house ; also, to carry 
a pipe from the house side of the trap, between the house- 
and street-main, to the open air. This last pipe allows 
the air to enter the house-system, whence it finds its way, 
in a constant current, through the pipes and out of the 
ventilating pipe above the roof. By this arrangement 
there can be no stagnant air in the pipes of the house, and 
they are constantly purified by a current of out-door air. 
When this is secured, and there is no leakage in the pipes, 
we need fear no trouble from sewer-air. _ 

DETECTION OF SEWER-AiIn.—The detection of sewer- 
air is not always an easy matter. The chemical tests de- 
pend upon the detection of sulphuretted hydrogen (H.8) 
or ammonium sulphydrate. If a piece of filter-paper be 
dipped in a solution of lead acetate, and be exposed to an 
atmosphere containing either of these substances, it turns 
dark-brown, and finally black. A paper dipped in a so- 
lution of nitro-prusside of sodium assumes acrimson, and 
turmeric paper a brown color with ammonium sulphy- 
drate. White-lead paint is darkened by both the above 
compounds, while zinc white is not changed in color. 

The peculiar odor of H.S may be easily detected, when 
the proportion reaches 1 part in 10,000 of air. On closing 
a room tightly for some hours, and then going into it 
from the open air, a musty or oppressive odor is detected 
when sewer-air or emanations from decomposing animal 
matters have found their way into it. If any circum- 
stance should lead to the suspicion that sewer-gas is en- 


436 


tering a room or heuse, it would be best to test the drain- 
pipes by the ‘“‘smoke test” or the ‘‘ oil-of-peppermint 
test.” 

A. suspected joint in a sewer- or drain-pipe may be 
tested by wrapping it with a single layer of white muslin 
moistened with a solution of acetate of lead. As the gas 
escapes through the meshes of the cloth, it will be black- 
ened by the sulphur-compounds. 

As above stated, all these tests may fail in certain cases, 
when the amount of sewer-air is small in comparison with 
the air with which it is mixed. It is therefore to be rec- 
ommended that the plumbing of houses be examined by 
an expert at least once a year. E. H. Bariley. 

1 Forensic Medicine and Toxicology, 1877, p. 494. 

2 Woodman and Tidy, 1877, p. 492. 

3 Proc. Royal Soc., 1877. 


4 Practical Hygiene, sixth edition, vol. i., p. 148. Wm. Wood & Co. 
5 ‘« Lectures on State Medicine,” p. 77. 


SEX is a term employed with two significances, which 
are often confused, but which it is indispensable to dis- 
tinguish accurately. Originally sex was applied to the 
organism as a whole, in recognition of the differentiation 
of the reproductive function. Secondarily, sex, together 
with the adjectives male and female, has been applied 
to the essential reproductive elements, ovum and sper- 
matozoon, which it is the function of the sexual organ- 
isms (or organs) to produce. According to a strict bio- 
logical definition sexuality is the characteristic of the 
male and female reproductive elements (genoblasts), and 
sex of the individuals in which the reproductive elements 
arise. A man has sex, a spermatozoon sexuality. 

Sexuality, then, is primitive and essential, and sex is 
dependent upon it. We consider, therefore, 1, the nature 
of sexuality ; 2, the nature of sex. Ina third section a 
few words will be added on the origin of sexuality. 

1. NatTuRE oF SEexuaLity.—The essential facts of sex- 
ual reproduction are: that two bodies, partaking more 
or less plainly of the character of cells, fuse together into 
a single body, which seems in every respect homologous 
with a cell, and which undergoes a series of divisions 
from which result a number of new cells. In all the 


‘higher plants and animals the two bodies are obviously 


different. In all metazoa one body is large, contains a 
store of nutritive material, and has a special envelope of 
its own (see Ovum) ; the other is small, and provided with 
means of active locomotion (see Spermatozoa) ; the de- 
tails of the process of their union are described under 
Impregnation, g.v. 

The only hypothesis, as to the nature of the sexual ele- 
ments, which rests on much basis of fact, is that of 
Minot.!. This hypothesis is based upon the consideration 
of three categories of facts : 1. Sexual reproduction is ef- 
fected by the union of a male and a female element, 
which produces a cell; this cell is, therefore, hermaph- 
roditic, or, perhaps, one should say asexual, since it 
is neither male nor female. It.produces other cells by 
division, and it is probable that the new cells are likewise 
hermaphroditic or asexual.* 2. When the cell which 
gives rise to the female element matures into an ovum, 
it undergoes a remarkable process of unequal division, 
known as the extrusion of the polar globules. In other 
words, the cell separates into two kinds of bodies, a, 
several polar globules; 0, a single female element. 3. 
Although our knowledge of the development of sperma- 
tozoa is extremely unsatisfactory, and although no suc- 
cessful attempt has been made to elucidate what is essen- 
tial, yet there are reasons for thinking that the parent- 
cell, which generates the male elements, divides during 
the process into two kinds of bodies, first, a number of 
smaller corpuscles (spermatoblasts), and second, a single 
larger structure (mother-cell), The deduction from these 
premises is evident. In the cells proper both sexes are 
potentially present ; to produce sexual elements the cell 
divides into its parts ; in the case of the egg-cell the male 
polar globules are cast off, leaving the female ovum ; in 
the case of the sperm-cell the male spermatoblasts, which 


* Van Beneden has attempted to give an elaborate proof of this in his 
paper on Ascaris, but unsuccessfully, as his observations were defective. 


- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


by this hypothesis are homologous with the polar glob- 
ules, are further specialized and employed while the 
mother-cell atrophies ; the mother-cell is homologous with 
the ovum after the extension of the polar globules. 

The hypothesis just outlined is purely morphological, 
and offers at present no insight whatever into the phys- 
iological aspects of sex. It has, however, been adopted 
provisionally by many writers, Sabatier has carried it 
somewhat further, having attempted to demonstrate that 
the central portion of the cell is female, the peripheral 
portion male. For a more exact statement of these views 
the reader is referred to Sabatier’s original memoirs. In 
opposition to Minot’s view, it has been suggested that the 
formation of polar globules is merely an atavistic rem- 
nant of the process of cell division (Whitman), but this 
suggestion offers no explanation of the universal fact 
that the polar globules are always present,* and always 
entirely different from the ovum proper. Similarly, it 
has been suggested that the multiplication of the sper- 
matoblasts was an atavistic cell-divisional process (Bit- 
schli), but the evidence in favor of this view is inconclu- 
sive. A fanciful comparison between the multiplication 
of spermatoblasts and the segmentation of the ovum has 
found favor with some writers, notably with Geddes, but 
I am unable to recognize any evidence in favor of the 
comparison. 

In regard to the physiological relations of the sexual 
elements, all sorts of credible and incredible hypotheses— 
especially the latter—have been advanced. None of them 
appears to me to deserve mention, unless it be Geddes’ 
speculation that the spermatozoon is the outcome of Kat- 
abolic changes, and the ovum of anabolic changes ; but 
does not such speculation pass far beyond the present 
possibilities of science ? 

According to Minot’s hypothesis, then, sexual reproduc- 
tion consists in the splitting up of cells into sexual ele- 
ments, and the reunion of a male and a female element 
to make a new asexual cell. We know from empirical 
observation that such a new cell has an increased power 
of growth. It is inevitable, therefore, to suppose that 
the object of sexual reproduction is just this renovation, 
or the formation of a new young organism. Why there 
should be such renovation ?7—By what physiological 
change it is accomplished ?—are questions to which no 
answer can be given yet. Weismann has brought for- 
ward the important thought that the union of the sexual 
elements mingles two hereditary tendencies, and so pro- 
duces variability, and thus helps natural selection. Weis- 
mann thinks that this is the only object of sexual repro- 
duction, but I cannot follow him in that. 

Parthenogenetic ova develop without impregnation, 
that is, without the addition of a male element. In ac- 
cordance with Minot’s hypothesis of sexuality, it might 
be assumed that in parthenogenetic ova the male element 
was retained, and that the cell remained a true asexual 
cell and did not become a sexual element. Blochman 
and Weismann have shown that this is the case by their 
discovery that in parthenogenetic ova only one polar 
globule is formed, while there are always two in ova 
which are impregnated ; hence it is probable that one 
polar globule (by hypothesis male) is retained. + 

There are reasons for thinking that the physiological 
cause of the formation of the sexual elements is defec- 
tive nutrition. There are numerous observations on 
plants which indicate this conclusion. Among animals 
the coincidence between the diminution of growth and 
sexual maturity may be brought forward as a similar 
argument. The fact, too, that puberty arrives earlier 
among the poorer classes, points in the same direction. 
There is certainly enough evidence in favor of the con- 
clusion that there is a causal relation between impeded 
nutrition and the development of the sexual elements to 
more than justify a thorough investigation of the sub- 
ject. 

We may describe the life-cycle as beginning with the 


* See discussion in article Ovum. 

+ Weismann seems to have overlooked this interpretation, which ap- 
pears obvious and natural, and has endeavored to strain his important 
observations into an argument against Minot. 


Sewer-Air. 
Sex. 


union of the sexual elements, resulting in a cell with a 
great power of growth and multiplication ; as multipli- 
cation continues the cycle of cells is continued, but the 
power is gradually exhausted. After a time the exhaus- 
tion (impeded nutrition) causes, according to the hypoth- 
esis just advanced, the formation of sexual elements, 
and so creates the possibility of a new cycle. The prob- 
lem of life-cycles has already been discussed in the ar- 
ticle on Growth. 

2. NATURE OF SEx.—As a matter of speculation, we 
must assume that originally the cells could produce both 
sexual elements in an efficient form at once, but, as a 
matter of fact, we see that in all (?) known cases only 
one kind of sexual element is brought to development 
from one cell. Very early in the evolution of plants and 
animals, certain cells or groups of cells assumed the spe- 
cial function of producing the sexual elements (geno- 
blasts). Sexual organs were differentiated very early. 
In the metazoa, originally, the same individual produced 
both male and female genoblasts, and was therefore her- 
maphroditic. As evolution continued hermaphroditism 
was replaced by a new differentiation, in consequence of 
which the individuals of a species were, some, capable 
of producing ova only ; others of producing spermatozoa 
only. Individuals of the former kind we call females, 
of the latter males, and they are said to have sex. In 
connection with this differentiation there have been 
evolved manifold secondary modifications, so-called sex- 
ual characters, the origin and importance of which were 
first brought out clearly by Darwin. 

The reason why some individuals become male and 
others female is unknown. Van Beneden advanced the 
theory that there was a sexual difference between the 
germ-layers, all male elements arising from one, all fe- 
male elements from the other. Weismann has shown 
that this theory was a speculation based upon insufficient 
observations. In vertebrates the sexual organs (ovaries 
and testes) arise from the middle germ-layer and out of 
the genital fold (see Foetus). At first it is impossible to 
tell whether the fold is to give rise to an ovary or a tes- 
tis ; on the contrary, the beginnings of the two organs 
appear identical. This observation leads naturally to the 
supposition that the sex of the individual embryo is at 
first non-existent and is determined during the course of 
development. It is, therefore, noteworthy that nearly 
all attempts to discover the causation of the sex of an in- 
dividual seek the cause at the moment of impregnation, 
Thus we find many hypotheses assuming that the rela- 
tive condition of the ovum and spermatozoon at the time 
of their union decides the sex resulting. For example, 
Hofacker (1828) and Sadler (1830) maintained that when 
the father was older than the mother there were most 
sons, but when the mother was the older, then most 
daughters. Thury thinks that the time of fertilization 
is important, and that females result if ova are impreg- 
nated when freshly matured ; males when impregnation 
is retarded. This view has many advocates, notably 
Stieda, Berner, Diising, Girou, and others. Another fa- 
vorite doctrine is that of relative potency or comparative 
vigor, according to which the most vigorous of the ele- 
ments determines the production of its own sex, or, ac- 
cording to some, of the opposite sex. This doctrine has 
been further elaborated by the assumption that the poten- 
cy of the sexual element depends upon that of the organ- 
ism at the time of producing it (Starkweather). Another 
set of explanations is offered by those who see the vera 
causa of sex in the nourishment of the developing young. 
Good nourishment is supposed to promote the produc. 
tion of females, poor nourishment that of males. For 
plants this has been advocated by Girou, Haberlandt, 
Meehan, and others; for insects, by Gentry and Mrs. 
Treat ; for amphibia, by Yung; for mammals, by Gi- 
rou, Diising, etc. a my 

The whole subject urgently calls for a thorough critical 
revision, based upon proper experiments. At present all 
we can say is, we do not know why or how sexual indi- 
viduals are produced. ~ 

The proportion of the sexes in man has been very care- 
fully studied. The statistics compiled by Oesterlen of 


437 


Sex. 
Shock. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. : 


59,350,000 births in Europe show that for every 1,000 
girls there are 1,063 boys. The result may be confidently 
accepted, asthe proportion of boys in the single countries 
varies only from 1,052 to 1,072. In animals the propor- 
tion varies greatly according to the species; in many 
mammals females are in excess—thus for 1,000 mares 
there are only 994 stallions (Darwin); in plant lice the 
excess of females isenormous, and of some copepods there 
are plenty of females, but the males are unknown. I do 
not recall any instance of a great excess of males. The 
best authority on the determination and proportion of the 
sexes is Hensen (Hermann’s ‘‘ Ilandb. der Physiol.,” Bd. 
vi., 2 Th., pp. 203-211). Dising’s memoir® is an elaborate 
and useful compilation. 

3. ORIGIN OF SEXUALITY.—It is still uncertain whether 
sex is co-extensive with life ; Weismann maintains that it 
is not, but was evolved on account of its value in increasing 
variability ; but Weismann disregards some considera- 
tions which, I think, have an essential bearing upon the 
problem. It is, however, certain that the conjugation of 
unicellular plants and animals is identical with the con- 
jugation of the spermatozoon and ovum (see article on 
Reproduction, in the Appendix). Indeed, we must as- 


sume that sexuality arose before the evolution of life had 
progressed to the differentiation of animals and plants ; 
since sex occurs in both kingdoms, it is probable that it 
existed before they were separated and is a common in- 
heritance. This carries sex very far back indeed, and 
makes it more prudent to recognize the crudity of our 
knowledge concerning the lowest forms of life, than to 
attempt premature conclusions about the origin of sex. 
The evolution of sex in plants has been much studied, 
and is treated in many text-books of botany—those of 
Sachs and Goodale may be specified as excellent in this 
respect. Zoologists have neglected the subject unduly. 
There is, so far as I know, no good comprehensive trea- 
tise on the evolution of sex in the animal series. 
Charles Sedgwick Minot. 
1 Theorie der Genoblasten, Biolog. Centralbl., Bd. II., p. 865. 


SHARON SPRINGS. Location and Post-office, Sha- 
ron Springs, Schoharie County, N. Y. 

Access.—By the Delaware & Hudson Canal Co. Rail- 
road (Susquehanna Division) to the Springs ; or by the 
New York Central & Hudson River Railroad to Palatine 
Bridge, thence by carriage nine miles. . 


ANALYSIS. 
White Sulphur. Magnesia, Red Sulphur. | Gardner Magnesia. Eye-Water. 
One Gallon Contains. 48° F. 48° F. 48° F, : 48° F, 48° F. 
Prof. Lawrence Reid. | Prof. Lawrence Reid. | J. G. Pohle. J. G. Pohle. Prof. Lawrence Reid. 
Solids. Grains. Grains. Grains. Grains, Grains. 
Sulphate of Magnesia......... steele’: 34.000 22.700 18.960 19.680 7.500 
Sulphiatetot limes... see er iene 85.400 %6.000 96.643 93.500 77.500 
Bicarbonate of Magnesia............... 24.000 30.500 0.691 1.360 82.000 
Bicarbonate of: Soda.\.ija05 s20-ceet eee | A ee eee ee ee eee 0.492 (0.544 Sis ea aie Sore 
Bicarbonate; of “Limes, oer strc cies eit De mae cic ere oto 12.925 pee Sas oe 
Chloride of Sodium 0.883 1.232 
Chloride of Magnesium ‘ eo a 200 BO { 0.730 0.438 t vin 
Chloride:of: Caleinm > tei. ou. ct) ae ee ee ee ee es ee 0.070 0, 162°) #2 ae 1, eee 
Sulphurets of Calcium and Magnesium. 3.000 0.500 0.893 0.62539 Sa) UE ee hia eek: 
SILICIC ACIG Miele Rite scien e cco We eee he ee ne en eee ne oe 0.450 400, ees oie eatin ee See ae 
DOUALA ACER hws Scuttle caeee 149.100 132.700 132.187 127.689 119.500 
Gases. cubic inches, cubic inches. cubic inches. cubic inches. a citmete 
Sulphuretted Hydrogen................ 20.50 10.50 G00 i glee due ae 
Carbonic Acid.......... ene chetstodc ne Oy MM MIMGs vc ee nena tenn DPE. oe tace 4.58 Dee ge Wee eer oe Sete tes 
Atmospheric Auris cs eciad sider esis ool Ae ee eeee nS ee ee 4,00 3:00.10 Pala Se ee ee 
19.08 i ie YE tg May SRE Te 


THERAPEUTIC PROPERTIES. — These are celebrated 
sulphur waters. They are used internally and externally 
in chronic skin affections, gout, rheumatism, and catar- 
rhal states associated with lymphatic conditions. There 
are no better waters of this class. 

Sharon Springs is situated in a valley, about eleven 
hundred feet above sea-level, and sixty miles west of 
Albany. The scenery of the surrounding country is 
charmingly diversified with hills and vales, while in the 
distance the peaks of the Adirondacks are visible. The 
accommodations for guests are ample and of the best, 
consisting of the main building, ‘‘The Pavilion,” and 
twelve cottages situated on a shaded lawn of fifty acres. 
The bath-house is new and contains all the modern ap- 
pliances for comfort and convenience. Billiards, bow]l- 
ing, and other forms of amusement are provided for. 

There are various points of interest within driving dis- 
tances. G, Bi IG 


SHELDON SPRINGS. Location and Post-office, Shel- 
don Springs, Franklin County, Vt. 
AccrEss.—By the New York Central & Hudson River 


and Central Vermont Railroads; or from the east to. 


Lowell, thence by the Central Vermont to St. Albans. 
From St. Albans the Missisquoi Railroad runs direct to 
the Springs. 

THERAPEUTIC PROPERTIES.—This is a delightful al- 
kaline-saline water. It is employed in gastric, uterine, 
and cystic catarrhs. 


* Diising’s article appeared in the Jenaische Zeitschrift, 1884, and has 
been republished separately. 


438 


Anatysis (S. Dana Hayes, M.D.).—One gallon con- 
tains: 


Grains. 

Potash 1.23 2.5 Aa toro daa te ee ee Eee 0.096 
SOGWM M4 ks ein ae ta wovb re iaelde oer acetone oe: 0.148 
SOd acres oaMny rane eteeeee tee mee cnc che aeemee ace ee 4,012 
Ammonia s.¢5.\lccb ae ee oe anon te he eEee trace 
TAME 82% god oy i ee ee ee 1.077 
Magnesia | ..::.,4..°-< Ae nee terc ere ee Peron 0.166 
‘Protoxide’ OL Iron seer eae ernie eee 0.010 
Builphuric acid Vesa sen eee Lee Shee. ee eee 0.508 
Silici¢:acid Mc2h ee eee Skee ee oe eee 4.587 
Carboniciacid combined ascot eee eee 2.115 
Crenic acid and organic matter.................%... 2.867 
Chlorine ‘205. Yeah 6 omens ieee toe ne etree 0.166 

Dotal.i.4 ossaie bo arene beaks teats oSieten aare 15.752 


These springs are situated in the northwestern corner 
of Vermont, ten miles from St. Albans, on the banks of 
the Missisquoi River, in a beautiful pastora] country of 
hill and dale, with Mt. Mansfield and other peaks of the 
Green Mountains within sight. From a hill near the 
hotel Lake Champlain can be seen. The hotel, ‘‘ Con- 
gress Hall,” stands on the banks of the river, and is fitted 
with all conveniences for the comfort of its guests. The 
bath-house is supplied with water from the Sheldon 
Spring, which flows fourteen thousand gallons per twenty- 
four hours. In addition to the above spring there are 
the Central, the Missisquoi, and the Vermont, within a 
distance of two miles along the Missisquoi River. 

Ga Bol. 


SHENANDOAH ALUM SPRINGS. Location and Post- 
office, Shenandoah Alum Springs, Shenandoah County, 
Va. 

AccrEss.—By the Baltimore & Ohio (Harper’s Ferry & 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Valley Branch) Railroad to Mount Jackson, thence by 
stage twelve miles to the Springs. 

ANALYsIs.—-A qualitative analysis shows the Alum 
Spring to contain this ingredient in very marked propor- 
tion, together with the usual salts and a trace of iron. 

THERAPEUTIC PROPERTIES.—As an astringent and al- 
terative this spring is resorted to with success by those 
suffering from catarrhal diseases of the alimentary tract 
and urinary apparatus. 

This group of springs, eight in number—three alum, 
a chalybeate, a healing, a sulphur-iron, an arsenic, and 
a lithia well—are situated in the Shenandoah Valley near 
the North Mountain, amid the grand and picturesque 
scenery of that region, at an elevation of over 2,000 feet ; 
there are numerous drives to various points of interest in 
the surrounding country, over good roads. Hotel ac- 
commodations are good. Gi Buf. 


SHOCK. Shock, or collapse, is a sudden, and more or 
less profound, depression of the vital powers, character- 
ized by general prostration, a feeble pulse, clammy skin, 
cold extremities ; pale, wrinkled, pinched, and shrunken 
features ; faint and sighing respiration, and often more 
or less impaired consciousness. 

The terms ‘‘ shock,” and ‘‘ collapse,” are very properly 
used synonymously, and yet. while the symptoms are 
similar or identical, there is often a difference in their ap- 
plication. That condition which is the result of an in- 
jury or of an operation, is called shock ; while the same 
group of symptoms arising in the course of some other 
affection, as peritonitis, strangulated hernia, or hemor- 
rhage is called collapse. The moribund state is an ex- 
treme collapse. It is not practicable to make a distinc- 
tion in the application of the terms, and no effort will be 
made to do so in this article. 

Syncope resembles collapse in that it comes on sud- 
denly, is attended by weak pulse and respiration, and 
complete prostration. But in syncope the cause is often 
mental rather than physical, and the cerebral symptoms 
are by far the most prominent. Consciousness is lost, 
as it is not usually in collapse from injury, except in the 
most serious cases. Furthermore, the symptoms in syn- 
cope are generally of a much shorter duration and of a 
much less dangerous character. On the other hand, the 
symptoms of collapse are more severe, the danger is great- 

~er, and they may be followed by more or less permanent 
after-effects. 

CausEs.—Among the causes of shocks which call for 
consideration are the following: injuries, operations, 
burns and scalds, lightning and electricity, haemorrhage, 
poisons, pain, and mental emotions. It goes without 
saying that the more extensive the injury, the greater will 
be the shock, and also that the greater the power pro- 
ducing the injury, the more serious will be the result. 
These facts are noticeable in railroad accidents, and in 
falls from great heights. A man who has been struck 
by a locomotive, for instance, will experience a far great- 
er degree of shock than had he been run over by a wag- 
on. The immediate disturbance resulting from a high 
fall, by which the whole system is jarred and shaken, will 
be much more severe than that which ordinarily fol- 
lows a blow from some falling body. Hence the man- 
ner of receiving an injury is an important element in the 
prognosis and treatment. 

Injuries to different parts of the body are followed by 
varying results. A crush of the upper extremity is less 
dangerous than one of the lower, and is usually attended 
by less shock. Injuries to the head are proverbially dan- 
gerous, and the symptoms of shock are often masked by 
those resulting from cerebral lesions. Contusions and 
perforating wounds of the abdomen and its contents, 
liver, kidneys, intestines, etc., are especially prone to be 
followed by serious collapse. So are cases of peritonitis 
from whatever cause, intestinal obstruction, and strangu- 
lated hernia. The painful effects resulting from a blow 
upon the pit of the stomach are familiar to most people. 
A crushing or laceration of the testicle generally gives 
rise to profound shock, and a smart blow upon the breast 
of a woman is apt to be followed by a similar condition. 


Sex. 
Shock. 


Severe or prolonged surgical operations are very gen- 
erally followed by more or less collapse, especially if the 
operation be attended by much hemorrhage. This con- 
dition is more marked after primary operations for in- 
jury, as the shock of the injury is augmented by that 
of the operation. Secondary operations, performed upon 
persons of a fairly sound constitution, are much less likely 
to be followed by severe collapse or shock, from the fact 
that the system seems to have become habituated to the 
altered condition, Itis a matter of common observation, 
that a febrile attack, or an acute inflammation, will in 
many instances protect the system for a certain time, so 
that an operation of severity may be performed with a 
fair prospect that the immediate inflammatory disturb- 
ance will be comparatively mild. In critical cases it 
would seem to be wiser to do two operations of moderate 
severity, than to risk the greater danger attending a single 
more severe one. The writer has performed amputation 
at the hip-joint in several instances, by first removing the 
limb at the middle third of the thigh, and in a few weeks 
completing the work by disarticulating and removing 
the remainder of the femur. The shock is thereby dis- 
tributed, or divided, and while there may be more in the 
aggregate, yet it does not all come upon the system at 
once, and hence there is less danger of its overwhelming 
the vital powers. The extent of shock following an opera- 
tion depends not alone upon its severity, or upon the 
idiosyncrasy and condition of the patient, but also upon the 
time consumed in its performance, upon the amount of 
hemorrhage, the length and degree of anesthesia, the ex- 
posure to cold, etc. These matters will receive further 
attention under the head of prophylaxis, 

Burns and scalds involving a great extent of surface, 
even if superficial, are more prone to produce collapse, 
than are those of limited area which extend deeply into 
the tissues. The immediate effects of injuries of this kind 
to the chest and abdomen are particularly severe. The 
prostration and pain resulting from inhaling steam or 
flame are very great, and very frequently the victims die 
from shock. Similar results are often produced by swal- 
lowing caustic or other irritating poisons, as arsenic, cor- 
rosive sublimate, oxalic acid, caustic potash, etc. 

As might be inferred from the nature of the agent, in- 
juries from electricity are especially severe and dangerous. 
Lightning often kills instantly, as does the current from 
the wires used in the modern electric lights. The col- 
lapse which results from these injuries, when immediate 
death does not follow, is often more severe and more 
prolonged than that following the more common acci- 
dents. 

Hemorrhage not only aggravates collapse, but when 
sudden, severe, or prolonged, it may produce the condi- 
tion in any degree, from the mildest to the most grave. 
The more sudden the loss of blood, the greater will be 
the immediate prostration, and the less are the chances 
of recovery. A small quantity of blood abstracted 
from the circulation suddenly will produce more serious 
effects than a larger quantity taken slowly. 

Severe and long-continued pain will aggravate, or may 
even produce, collapse, as is occasionally seen in some of 
the neuralgias, like intestinal colic. There can be no 
reasonable doubt that pain conduced to a fatal result in 
a case Of peritonitis which recently came to the knowl- 
edge of the writer. A young lady suffering from this 
affection was attended by a physician who did not ap- 
prove of opiates. The result was that the patient tossed 
upon her bed, and evenrolled upon the floor, in her agony, 
until she finally sank into a comatose state, and died at 
the end of five days. 

Death from shock produced by mental emotion alone 
must be a rare event. A remarkable case is related by 
Lauder Brunton, in which some medical students, becom- 
ing displeased with a janitor, seized him, and made him 
believe that they were about to execute him. He was 
blindfolded, made to kneel before a block, and was then 
struck a smart blow upon the back of the neck with a 
wet towel. To their amazement and horror, on remov- 
ing the bandage the man was dead, literally frightened to 
death. 


439 


Shock. 
Shock, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


The minor effects of strong mental excitement upon 
the whole system, as well as upon various organs, are 
matters of every-day observation. Miscarriages attended 
by severe or even alarming prostration, are occasionally 
due to mental causes, such as fright, grief, anger, etc. 
Hysteria, catalepsy, and other affections of the nervous 
system are familiar examples of psychical disturbances. 
The unfavorable and even dangerous effects of bad news 
and other depressing influences upon very sick or very 
sensitive people are well known to all physicians. Such 
a shock is as real, and at times as profound, as is that 
which depends upon some physical lesion, and, more- 
over, it may be followed by permanent impairment of 
some function or organ. Deafness has been caused by 
fright. The normal balance of the nervous system has 
been permanently impaired in many instances by various 
powerful emotions, and the patient has been thereby 
rendered an invalid during the remainder of life. 

The degree of shock or collapse resulting from injury, 
disease, or any cause whatsoever, is influenced more or 
less by age, and by the physical or mental condition. 
Some persons are prostrated by comparatively slight in- 
juries, while others sustain very severe ones without 
having any symptoms of shock. This depends, among 
other things, upon the natural powers of resistance, upon 
the frame of mind the patient was in at the time of re- 
ceiving the injury, and upon the surroundings. Wounds 
received in battle are often ignored until the excitement 
of the conflict is over. It is doubtful if sex has much to 
do with the susceptibility to shock, except in those cases 
which have some mental disturbance for an exciting 
cause. It is a common opinion that women bear pain 
with more patience and fortitude than men, yet it is not 
certain that they can endure pain of a greater degree, or 
for a longer time, than men. For example, it is seldom 
that a man dies from the shock and exhaustion of a fract- 
ured hip, but old women not infrequently succumb to 
this injury. 

Weak and debilitated people, and those having a ‘“‘ lax 
fibre,” both mentally and physically, suffer from shock 
to a greater extent than the strong and robust. The vic- 
tims of alcoholism withstand shock, as well as most affec- 
tions of the nervous system, poorly. They frequently, 
in such cases, suffer from delirium tremens, mania, or 
other complications ; while the rallying power is dimin- 
ished, the convalescence is prolonged, the prognosis is 
more unfavorable, and the effects of all kinds of treat- 
ment are often anything but satisfactory. The very 
young and the very old are peculiarly susceptible to 
shock and collapse. The symptoms are more pro- 
nounced in the former, but more lasting and more dan- 
gerous in the latter. A temporary collapse is very com- 
mon in children after many operations and injuries of 
no great severity. While it is not a very dangerous con- 
dition under most circumstances, yet it is to be looked 
for, and is to be carefully watched until it disappears. 
Quiet and artificial heat are all that will usually be re- 
quired in the way of treatment. On the contrary, in the 
aged the symptoms of shock are frequently.mild in char- 
acter, but they do not pass away, as might be expected. 
They are apt to persist, and finally to merge into some 
more serious and perhaps fatal condition. 

Symproms.—The symptoms of shock or collapse are 
strikingly characteristic, and once seen they are not easily 
forgotten. 
The patient lies perfectly still upon his back, too weak 
to move, and almost too weak to breathe. The pulse is 
feeble, quick, irregular, or absent; the sounds of the 
heart are indistinct, or perhaps inaudible ; the inspira- 
tion is faint, sighing, and slow ; the features are pinched 
and shrunken; the lips pale and livid; the eyes dull, 
sunken, and often turned upward; the pupils dilated 
and sluggish ; the skin is pale, cold, and clammy ; the 
sweating is at times profuse ; the extremities are cold, 
and the nails purplish. The temperature falls in pro- 
portion to the severity of the shock, the depression some- 
times exceeding two degrees. Except in the most un- 
favorable cases, or in those complicated with injuries to 
the head, the intellect is usually clear and unimpaired. 


440 


The vital powers are profoundly prostrated. . 


The patient may be perfectly conscious, and yet be too 
weak to speak, or to notice his surroundings, or his own 
sensations, unless he be in severe pain. ‘There may be 
vomiting, which is a sign of reaction, or hiccough, and 
the sphincters may be relaxed. 

In other instances the patient is extremely restless, 
throwing himself about first in one position and then in 
another, but is easy in none. Tossing of the arms, gasp- 
ing for breath, and calling for water are common and 
unfavorable symptoms attending a severe hemorrhage. 
The mind under these circumstances is usually clear, 
the voice is strong, but vision may be lost. At times the 
patient suffers the most intense agony from fear of im- 
pending death. Travers, in his valuable work on ‘‘ Con- 
stitutional Irritation,” has called this restless stage 
‘‘prostration with excitement,” and the term exactly ex- 
presses the condition. It is to be borne in mind that, 
while in this state, the patient is on the brink of dissolu- 
tion, and that great care is required in performing opera- 
tions to prevent collapse. The power of resistance seems 
to be reduced to the lowest point, and a little additional 
shock suffices to turn the scale the wrong way. 

A peculiar, as well as deceptive, form of collapse is 
occasionally seen in cases of strangulated hernia. The 
pain and vomiting, after persisting for a period varying 
from two to five or six days, finally subside, leaving the 
patient quiet and comfortable ; he talks rationally, and 
with some strength. To a casual observer he seems to 
be convalescent. But he has no pulse at the wrist, or at 
best an extremely weak one. Patients in this condition 
generally die inside of twenty-four hours, and any opera- 
tion performed to relieve the strangulation will only 
hasten the end. 

The term ‘‘ shock” has of late years been applied to a 
peculiar condition of the nervous system, which is usu- 
ally the result of a railroad accident. A person is in a 
collision, for example, and receives a severe shaking up, 
perhaps in the form of a violent to-and-fro motion. He 
crawls out of the wreck apparently unhurt, with the ex- 
ception of a few unimportant bruises. Perhaps he as- 
sists some of his fellow-travellers, or goes on his way to 
his destination. In the course of some hours or days 
after the accident he begins to feel nervous and festless ; 
is easily frightened or excited ; cannot sleep; has head- 
ache, pains in his back and in various parts of the body. 
He is depressed, hypochondriacal, loses his interest in 
everything and in everybody except himself and his own 
sensations ; his appetite fails, and he grows thin; be- 
comes weak both mentally and physically, and presents 
the appearance of premature old age. He is said to be 
suffering from ‘‘shock to the nervous system.” The 
normal poise or equilibrium is for the time destroyed. 

These symptoms, as will readily be seen, are entirely 
unlike—both in character and in the time of their ap- 
pearance—those met with in the ordinary cases of shock 
following an injury. Their course, duration, and treat- 
ment are also very different. It isa singular fact that 
cases attended by symptoms of shock immediately after 
an accident, seldom develop the symptoms peculiar to 
‘“‘shock to the nervous system.” This peculiar affection 
is so frequent after railroad accidents, although not 
wholly confined to them, and so often involves a ques- 
tion of suit at law for personal damages, that the various 
complaints have received the name of ‘‘ litigation symp- 
toms.” Experience proves, however, that they have a 
real existence, and that they may persist for a long time, 
or may even result in some permanent affection. Yet 
the tendency, in the great majority of cases, is toward re- 
covery. 

Experimental physiology has demonstrated that in 
shock there is a reflex paralysis of the heart and abdom- 
inal vessels through the medium of the vaso-motor system. 
“The slow, feeble, or almost annihilated pulse, the pallor 
of the lips and coldness of the extremities, the mental 
hebetude, the aneesthesia of the surface, the relaxation of 
the sphincters, the lessened secretion of the urine, the im- 
paired muscular action,” ! all indicate the effect of a more 
or less severe paresis of the heart and vessels, and its ac- 
companying impression upon the whole nervous system. 

' 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Shock. 
Shock, 


‘Shock is an example of reflex paralysis in the strict- 
est and narrowest sense of the term—a reflex inhibition, 
probably in the majority of cases general, affecting all 
the functions of the nervous system, and not limited to 
the heart and vessels only.” ” 

Proenosis.—To arrive at a reasonable prognosis in a 
case of shock or collapse, the nattire of the injury, the 
character of the symptoms, their course and duration, 
and the age and previous condition of the patient, must 
receive careful consideration. The longer the symptoms 
have persisted, the more unfavorable will be the prognosis. 
Should reaction be delayed more than eight or ten hours, 
in cases not complicated with head injuries, the outlook 
is very serious, although by no means hopeless, as many 
patients have recovered after a much longer time. The 
greater the force producing the injury, and the more pro- 
found the collapse, the greater the danger of a fatal re- 
sult. Deepening of the stupor, or increased restlessness 
with diminished force of the pulse, persistence of the pal- 
lor and of the coldness of the surface, profuse sweats, in- 
ability to swallow, insensibility of the pupils, persistent 
vomiting, and relaxation of the sphincters, all betoken the 
greatest danger, and are seldom followed by recovery. 

On the contrary, returning consciousness, ‘‘ coming to 
himself,” as it is commonly called, increasing interest in 
the surroundings, a stronger and. steadier pulse, deeper 
and more regular breathing, warmer and drier surface 
and extremities, more natural color and expression, a 
brighter eye, an increasing muscular power enabling the 
patient to change his position at will, are all favorable 
symptoms. They indicate a healthy reaction, and prom- 
ise a favorable termination so far as the immediate results 
are concerned. 

In some instances reaction sets in well, progresses to a 
certain stage, and then stops, leaving the patient in a 
weak and unsatisfactory condition, which may persist 
for an indefinite period. ~ Again, the symptoms of col- 
lapse may recur after having entirely disappeared, and the 
patient may be brought to even a worse condition than 
he was in during the primary shock. These secondary 
attacks of prostration should lead to the suspicion of 
some internal lesion, or of some organic change, which 
had not hitherto been discovered. Hemorrhage, extrav- 
asation of urine, perforation of the intestine, embolism, 
or other internal injuries and affections must be thought 
of, and the proper means taken to determine their exist- 
ence. 

Temperament is an important factor in the prognosis 
of shock, especially in that form which follows surgical 
operations. The hysterical or neurotic temperament is 
a particularly troublesome one. Slight operations upon 
these persons are often followed by great nervous excite- 
ment and pain, which are out of all proportion to the 
severity of the treatment. The symptoms are persistent, 
and, as arule, they are not very responsive to the action 
of drugs. The convalescence is not only longer, but the 
final result is more doubtful. The writer is cognizant of 
an instance in which a tenotomy of the tibialis anticus in 
a young lady was followed by the most alarming collapse, 
as well as by many months of severe prostration. In 
short, the patient has never been as well as she was be- 
fore. Operations of expediency should be performed 
upon this class of people only after the most careful con- 
sideration, and with the expectation that the subsequent 
effects may be much more serious than they would be 
under ordinary circumstances. As a rule, patients who 
are courageous, cheerful, and hopeful do better than the 
irritable and despondent. Those individuals who ask for 
an operation for the cure of some surgical affection, have 
their minds prepared to a certain extent for the ordeal, 
and therefore they undergo the trial better than those 
who are suddenly struck down in robust health by an ac- 
cident, and are compelled to submit to an operation. In 
the former case the system is somewhat prepared for the 
state of invalidism which the patient is obliged to lead 
for a time, and the change in habits is much less in de- 
gree, and hence is productive of much less disturbance 
both mental and physical. 

TREATMENT.—In slight cases of shock little is required 


in the way of treatment beyond keeping the patient warm 
and quiet, and thus allowing the vital forces to regain 
their normal condition. Too much dosing with drugs 
and stimulants under these circumstances does more 
harm than good. 

In the severe cases, however, much can be done, and 
much can be left undone, to aid the patient’s recovery. 
The main indications for treatment are to preserve and 
supply heat to the body ; to keep the heart going ; to con- 
trol restlessness ; and to treat the complications, as ham- 
orrhage, etc., according to the indications and oppor- 
tunities. A person suffering from shock should be placed 
in an easy position upon his back, with his head low. 
He should be surrounded by bottles of hot water, or hot 
bricks, or whatever is most convenient, care being taken 
that the skin is well protected from being burned, a not 
uncommon accident in these cases. He is to be warmly, 
but not too heavily, covered with blankets, and if such 
an article is at hand, by a rubber sheet. The patient is 
to be moved about as little as possible. The clothing 
should not be changed unless it is wet or unless there 
is some absolute necessity calling for the change. He 
should not be bathed nor “‘ tidied up” for the sake of ap- 
pearances. The physician’s examination should be con- 
ducted as quietly and as gently as possible, and need be 
carried only far enough at the time to determine the 
danger, and to indicate the treatment immediately re- 
quired. Unnecessary handling and moving, changing 
the clothes, etc., only tend to increase the exhaustion. 
Hemorrhage should be checked in the speediest and 
most efficacious manner, and the wounds should receive 
as little treatment at the time as is compatible with the 
future well-being of the patient. 

As the processes of digestion and absorption are more 
or less in abeyance during collapse, it is useless, and 
worse than useless, to give the patient a large quantity of 
food or stimulants by the mouth. The stomach in many 
instances will retain everything for a time, but no symp- 
toms of reaction manifest themselves. Finally, vomiting 
sets in, and the ejected matters show that the stomach 
has been inactive, and incapable of performing its func- 
tions. Time has thus been lost, and the depression has 
been steadily increasing. It is better to delay the admin- 
istration of food until partial reaction has taken place, 
but stimulants are indicated from the first in proportion 
to the degree of collapse. To get the speediest and 
surest effect from them they should be given hypoder- 
mically. A syringeful (3j.-ij.) of sulphuric ether, 
brandy, or other liquor may be injected into the arm, or 
other convenient part of the body, at intervals of five or 
ten minutes, or less frequently, until signs of reaction 
manifest themselves, when the intervals are to be length- 
ened, and small quantities may then be given by the 
mouth and rectum. Whena fair amount of reaction has 
become established, food, in the form of milk and lime- 
water, beef-tea, etc., should largely supplant the stimu- 
lants. 

Restlessness and pain are best controlled by morphine 
given subcutaneously. The drug acts asa strong, steady, 
and continuous stimulant, and it is a most valuable agent 
to maintain the vital powers in shock, as well as to 
prevent this condition. The dose may vary from one- 
twelfth to one-fourth of a grain, according to the indica- 
tions, always taking care not to repeat the dose often 
enough to get the narcotic effects of the drug. The stim- 
ulant action, and not the soporific, is desired under these 
circumstances. 

Digitalis has been recommended for its stimulant ef- 
fect upon the heart and circulation. It may be given 
under the skin or by the mouth, preferably by the former 
method to get the effects speedily. The dose is half a 
drachm of the tincture, which is to be repeated every 
hour until signs of improvement are apparent. 

Transfusion, or what is more practicable, and proba- 
bly fully as efficacious, an intravenous injection of salt- 
water, is indicated in collapse resulting from hemorrhage, 
but not under other circumstances. The great advan- 
tage of the saline injection is that it is always at hand, 
and can be used with a fountain, or any other good syr- 


441 


Shock, 
Shoulder-Joint. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


inge which carries a steady stream, and which can be 
filled while in position. The solution should be warm, 
and the proportion of salt should be about a drachm and 
a half to the quart. The following formula, suggested 
by Mikulicz, may be used, if time is not pressing : 


SG, Me LOT IC Ete che ota cttacca res eens 3 jss 
OU SOICADL Nc, oc stutelcie tre cue eee tiers or xy, 
AG: Geptnlatei ee. one scene Keser O ij 


M. 


The solution should be raised to a temperature of 100° 
F., and it is to be injected very slowly, and in quantities 
varying from one to four pints. The pulse and respiration 
are to be carefully watched during the operation. The 
simplicity of this mode of treatment, as well as the fa- 
vorable results which follow it, are strong arguments in 
its favor. 

It is more than doubtful if venesection is required in 
those cases of collapse attended by congestion of the sur- 
face and distended jugulars. ‘‘ The heart is distended 
because it is paralyzed, and not paralyzed because it is 
distended.” # 

Authorities are pretty well agreed that surgical opera- 
tions should not be performed while a person is in a 
profound collapse. The shock of the operation added to 
that of the injury augments the danger, and thereby 
diminishes the patient’s chances for recovery. The 
claim put forward by some writers, that the stimulant 
effects of sulphuric ether counterbalance the depression 
of the operation, is not sustained by experience. It is 
true that the primary effect of ether is stimulating, but 
it is of short duration, and is not to be relied upon. If 
the anzsthesia be profound, or if it be kept up for any 
length of time, the subsequent prostration is frequently 
alarming. 

The operation should always be delayed, if possible, 
until a fair reaction has become established. The ex- 
act stage of reaction which justifies a resort to opera- 
tive procedures is to be decided by the condition of each 
individual case. A weak, irregular pulse, sighing and 
irregular respiration, cold extremities and cold sweats, 
contra-indicate an operation. On the other hand, an 
operation may be undertaken when the patient is fully 
aware of what is going on around him, when the pulse 
is regular and of fair strength, the surface is warm, and 
the breathing natural. No regrets need be entertained 
by the surgeon because a patient dies from shock without 
an operation. If he could not rally from the collapse 
alone, he certainly could not do so after an additional 
burden had been put upon him. 

Unconsciousness from shock, not complicated with 
head injury, is an exceedingly grave symptom, and, as 
a rule, precludes an operation. Should it be necessary 
to perform one under these circumstances, no ansesthetic 
is required. It is not necessary to control pain, as the 
patient, being unconscious, feels no pain. Neither is the 
ether called for as a stimulant, because there are other 
and better methods of stimulation. Should the patient 
be sensible to suffering, a very little of the anesthetic, 
administered at the commencement of the operation, is 
of great value. It quiets the nervous system, deadens 
or prevents pain, and if used rightly, it does not add 
to the shock and subsequent prostration. 

PRopHyLAXxis.—This subject is of so much importance, 
that a few concluding sentences may be devoted to its 
consideration. Very much can be done to prevent col- 
lapse after surgical operations by paying special atten- 
tion to the following points: Temperature, time, ham- 
orrhage, degree of anesthesia, and personal disturbance. 
It isa great mistake to suppose that the time consumed in 
performing an operation is of little importance so long 
as the patient is under the influence of an anesthetic, and 
hence not conscious of suffering. There can be no doubt 
that the longer a person is subjected to an operation or 
to an examination, the greater will be the shock to the 
nervous system, and the greater will be the subsequent 
prostration. Deep or long-continued anesthesia aug- 
ments the unfavorable symptoms. The patient may 
seem to be going on well under an operation with full 


442 


anesthesia, when suddenly the pulse fails, the strength 
vanishes, profuse sweats break out, and the patient is in 
collapse. The operation is either hastily concluded or 
abandoned, and hours are consumed in efforts to keep 
the person alive. This state of affairs may often be 
avoided by giving just enough ether to deaden the pain 
of the primary incisions, and perhaps the dividing of the 
bones, and by being as expeditious as possible in all the 
manipulations. It is advisable to give a moderate dose 


of morphine (gr. 34s to +) under the skin, previous to 


_ etherizing any patient who is about to undergo a critical 


operation. The strength is sustained thereby, less ether 
is required, and the suffering is mitigated. In many in- 
stances so little of the aneesthetic is required, under these 
circumstances, that the operation may be said to have 
been done under the primary effects of the agent. 

It is, of course, important that all possible precautions 
shall be taken to prevent hzemorrhage, and, in case of its 
occurrence, that it should be controlled in the speediest 
and most effectual manner. It is not necessary, in most 
instances of peril, to apply ligatures to all the bleeding 
points, as the hemorrhage from the smaller vessels may 
be stopped by compress and bandage. Neither is it wise 
to consume too much time in the toilet of the wound 
under these circumstances. The object should be to get ° 
the patient into a warm bed as soon as is compatible 
with safety, and many minutie of the final dressing may 
therefore be omitted for the time being. For example, 
in an excision of the scapula, which was necessarily a 
long and bloody operation, the principal vessels were 
tied, the wound was hastily closed, the dressing quickly 
applied, and the patient, being wrapped in warm blankets, 
was carried up-stairs feet foremost, and put to bed, where 
he was allowed to remain undisturbed for three days. At 
the end of that time he had rallied sufficiently to allow 
of his being cleaned up, and having his dressings and 
clothing changed. As it is the little things which tell 
in these critical cases, they are worthy of notice. 

The preservation of animal heat is of the greatest im- 
portance, and especial attention should be paid to the 
matter. Heaters in the shape of hot bricks, or jugs or bot- 
tles of hot water, are to be placed about the patient, care 
being taken that they shall not touch the flesh, and thus 
possibly be the means of producing an eschar, a not in- 
frequent occurrence. He should be warmly, but not too 
heavily, covered with blankets, and he should be moved 
about or disturbed in any way as little as possible, be- 
cause all these things increase exhaustion, disturb the 
circulation, and prevent rest. In a desperate case of py- 
mic suppuration of the knee-joint, at the Boston City 
Hospital, an amputation of the thigh was successfully 
done without removing the patient from his bed. He 
was not under ether over three minutes, and the shock 
was only moderate. 

A man entered the hospital suffering from a large sar- 
coma of the knee, of rapid growth. He was in a state of 
extreme exhaustion. Pulse, 150; temperature, 103°F. ; 
pale, weak, and emaciated. Preparations having been 
made, he was brought from the ward in his own bed, 
given a hypodermic injection of morphine (gr. 4), and 
after inhaling a little ether, he was transferred to the ta- 
ble, still being surrounded by heaters, and covered with 
blankets and a rubber sheet. The thigh was quickly 
amputated by the circular method, and as soon as the 
bone was sawn the ether was removed. Not over three 
ounces had been consumed, and the patient had not 
been unconscious more than five minutes. Hardly any 
shock followed the operation, and in twenty-four hours 
the temperature was normal. He speedily recoyered 
from the operation. 

Another patient, suffering from extensive and long- 
standing necrosis of the femur, was brought to the lowest 
state of exhaustion before allowing surgical interference. 
He finally consented, and under all the precautions men- 
tioned above, the limb was amputated at the hip-joint by 
making a long external incision, disarticulating the head 
of the femur, and dividing the soft parts at a single 
sweep of the knife. The subsequent shock was not seri- 
ous, and he made a good recovery. Upon the same day 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Shock. 
Shoulder-Joint, 


another amputation at the hip was performed upon a 
boy, the victim of hip disease. The head of the bone 
had been removed by excision a few weeks previously. 
The patient was in a most wretched condition, emacia- 
ted to the last degree, with high temperature and rapid 
pulse, suppuration extending in all directions, into the 
pelvis, through the acetabulum above the pubes, and 
down the thigh. The operation was performed quickly, 
and all possible precautions were taken to guard against 
shock and prostration. For several days he had a high 
temperature, with sweats, delirium, restlessness, and even 
vomiting. He finally rallied, gained strength and flesh, 
and was out-of-doors upon crutches, when symptoms of 
tubercular meningitis suddenly made their appearance, 
and he died three months after the amputation. 

These cases serve to illustrate the importance of the 
principles advocated in this paper, and by following 
them carefully it is firmly believed by the writer that 
many patients, who are in an apparently hopeless condi- 
tion, can be carried through a critical operation with 
safety. . 

Briefly stated, these principles are as follows: Keep 
the patient warm. Avoid exposure to cold. Save time, 
and prevent hemorrhage to the fullest extent possible. 
Stimulate and feed by the skin and rectum. Put little 
or nothing into the stomach until reaction sets in. Give 
the smallest possible quantity of aneesthetic that will con- 
trol the major portion of the pain. Disturb the patient 
as little as possible, and get him into his warm bed as 
soon as is compatible with a proper performance of the 
operation. George W. Gay. 


1H. W. Page: Injuries of Spine and Spinal Cord, p. 145. 

2Mr. C. W. Mansell-Moullin: International Encyclopedia of Surgery, 
vol. i., p. 369. 

3 Dr. F. B. Harrington : Boston Medical and Surgical Journal, vol. 
exiy., Nos. 9 and 21. 4 Mansell-Moullin, loc. cit. 


SHOULDER-JOINT. The articulation between the 
shoulder-girdle and the humerus. The cavity for the re- 
ception of the head of the humerus is called the glenoid 
fossa, and in animals possessing a separate coracoid bone 
it is formed by the union of the coracoid and the scapula. 
In man the coracoid unites with the scapula at an early 
age, but a trace of the primitive condition is found in 
foetal life, for the embryonic coracoid forms a portion of 
the fossa. 

Like the corresponding articulation of the lower ex- 
tremity, it is a ball-and-socket joint, and in low mammals 
the two are very similar in other anatomical characters. 
But as the hip-joint becomes more solid and firm by rea- 
son of the necessities of the erect position, so the shoul- 
der-joint becomes freer and more movable when the 
limb is no longer required to support the body, and less 
strain is put upon the investing capsule. It is, therefore, 
one of the loosest joints in the body, depending for its 
strength less upon the ligaments which unite it and the 
shapes of the articular surfaces, than upon the muscles 
which surround it and form a series of active ligaments, 
so to speak, as their tension may, under ordinary circum- 
stances, be adjusted to the needs of the occasion. Ow- 
ing to these peculiarities, dislocations occur at the shoul- 
der-joint more frequently than at all other articulations 
in the body put together, and usually when the muscles 
are taken off their guard. In reducing the dislocation 
here it is advisable to remember this peculiarity of the 
muscles, and to attempt the operation when the patient’s 
attention is attracted elsewhere, or when relaxation has 
been produced by an anzesthetic. 

Outside of the joint proper, with its investing cap- 
sule and the muscles immediately in relation with it, 
there is asecondary investment, consisting of what may be 
called the acromio-coracoid arch (viz., the acromion pro- 
cess, the coracoid process, and the ligament that stretches 
between), and the deltoid muscle, which folds down over 
the shoulder as a dense triangular mass. The deeper 
structures play against the superficial ones, and large 
bursal spaces are thus formed, so that there is a second- 
ary imperfect articulation outside of the true one. When 
we add to these peculiarities the fact that the joint is 
rendered adaptable for still freer movement by the pos- 


sibility of shifting the scapula either laterally, or by tilt- 
ing it upward and downward, it will be seen that we 
have a mechanism more easily adapted to a great variety 
of positions, and with a far wider range of motion, than 
any other joint in the body. 

The articular surfaces involved are the large semi- 

lobular 
head of the 
humerus 


Gleno- 
humeral >. 
ligament.) *. 


3520), 
the com- 
parative- 
ly small 
glenoid 
fossa of 
the scapula, 
deepened 
slightly by 
the rim of 
fibro -carti- 
lage called 
the glenoid ligament SX 
(see Fig. 8521). The SS 
area of the cup is 
about one-third that of the 

head of the humerus. Ex- 
amining the latter with great 
care before the articular carti- 
lage has been removed, it will 
be seen that the surface in- 
volved in the articulation com- 
prises about two-thirds of a 
sphere, but that the lateral half 
differs slightly in curvature 
from the median half, the di- 
viding line being defined 
above between the coracoid process and the greater tu- 
berosity, below by the scapular head of the triceps. For 
motions toward the anterior plane of the body there is, 
therefore, a different set of articular surfaces used from 
those which relate to the posterior plane. The greatest 
measurement is in a horizontal direction, indicating the 
wide extent of the forward and back movement of the 


Sesamoid. 


Fic. 3520.—Head of Humerus, 
with Part of Capsule Attached. 
(Morris. ) 


mAh Coraco-acromial ligament. 
+7: Coraco-humeral ligament. 


Tendon of biceps. 


A. .Gleno-humeral ligament. 


ee eT eee 


Fra. 8521.—Glenoid Fossa of Scapula, with Part of Capsule Attached. 


arm, and this greatest diameter lies about midway be- 
tween the upper and lower edges. The greatest vertical 
diameter lies about in a line with the bicipital groove, 
and indicates the plane in which the greatest excursion 
takes place upward and downward. This plane, if pro- 
duced, cuts the articular surface of the lower end of the 
humerus obliquely, and usually falls behind the inner 
condyle. Considerable variation in this occurs 1n differ- 


443 


Shoulder-Joint,. 
Shoulder-Joint. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


ent individuals, and it is found that, as we descend to 
lower races, the angle between the axes of the articular 
surfaces of the upper and the lower ends of the humerus 
becomes constantly greater. In the apes this increase 
becomes still more marked. As movements directly to- 
ward the median line are soon checked by contact with 
the body, there is much more of the articular surface 
above the horizontal axis of the humeral head than be- 
low it. 

The head is joined to the shaft by means of a slight 
constriction marking the attachment of the capsular liga- 
ment, called the anatomical neck. <A line perpendicular 
to the central portion of the head represents the axis of 
this neck. It cuts the axis of the shaft at an angle of 
about 140°, which may be compared with the angle which 
the neck of the femur makes with the shaft, viz., 181° 
in adults. From observations made upon young bones 
Krause concludes, however, that the anatomical neck is 
not strictly comparable with the neck of the femur. If 
we take a humerus of a subject about fifteen years of age, 
in which the proximal epiphysis has not yet united, and 
make a horizontal section of it through the greater tuber- 
osity, it will be seen that a strong spur-like projection 
extends upward and inward from the diaphysis, resem- 
bling the similar structure which forms the neck of the 
femur. This becomes completely encapped by the epi- 
physial ossification. He regards this as the real neck of 
the humerus, concealed within the centre of the bone. 
This may, perhaps, be a vestige of the time when the 
humerus really possessed a markedly constricted neck. 

The cartilage on the head is thickest about the middle, 
that is to say, at the place where the bone strikes most 
forcibly when the arms are extended, as in pushing. 

The glenoid fossa (Fig. 3521) contrasts markedly with 
the acetabulum of the hip-joint, being very shallow and 
much more limited in extent. Instead of having a 
spherical form it is of an irregularly oval shape, somewhat 
like a pear, with the large end downward, resting on the 
strong axillary costa of the scapula, while the upper nar- 
rower portion is at the root of the coracoid process. The 
slight notch on the inner side between these two is a ves- 
tige of the original division of the cavity into two parts, 
one belonging to the coracoid bone, the other to the 
scapula proper, thus resembling the constitution of the 
acetabulum. The bony fossa is deepened, as in the hip, 
by a rim of fibro-cartilage called the glenoid ligament. 
This is triangular in section, its fibres are concentrically 
arranged, and it bridges over the slight notch as the 
transverse ligament does the acetabular notch. Its out- 
line does not exactly fit the head in all’positions, but its 
elasticity allows it to adapt itself to the surface when- 
ever the arm is moved. At the upper part of the glenoid 
rim the tendon of the biceps muscle of the arm is at- 
tached, its fibres passing around and blending with the 
fibro-cartilage. The tension of the tendon assists in hold- 
ing the rim firmly against the head, and takes some press- 
ure off the cavity. It has been suggested that the glenoid 
ligament is merely the remains of a former, somewhat 
more extensive, insertion of the biceps ; that its coracoid 
head and glenoid head were formerly united in a single 
muscular sheet which had insertion around the glenoid 
fossa. No comparative evidence has been adduced for 
this view, as far as I] am aware. The tendon is not so 
strongly blended but that it can be torn away from its 
glenoid attachment without detaching the cartilage. 

The osteo-cartilaginous cavity thus formed for the 
humeral head measures only about oneinch and a half 
in its vertical diameter, and an inch horizontally at its 
widest part. When the scapula is at rest it looks out- 
ward, forward and a little downward. It is a little more 
prominent on the inner side, to counteract the pull of the 
muscles and the result of blows on the shoulder, which 
tend to displace it in that direction. The cartilage is 
thickest at the edges and lower part of the cavity, as it 
is here that the greatest pressure is received in carrying 
weights and also in lifting, for the muscles above the 
joint (biceps, supraspinatus, and infraspinatus) hold 
the head firmly against this portion. Notwithstanding 
the sharpness of the edge of the glenoid ligament, imper- 


A444 


fect luxations have been noted in which the humerus 
rested upon it. It is difficult to see how this apparently 


_ unstable position could be maintained without there be- 


ing at the same time a rent in the capsule through which 
the head extruded, and which thus fixed it. } 
The capsule of the joint (Fig. 3522) forms a complete 


Fig, 3522.—Capsule of Shoulder-joint. 


(Altered from Heitzmann.) 


conical investment attached by its truncated summit to 
the scapula at the edge of the glenoid fossa. For the 
greater portion of its extent it is blended with the outer 
margin of the glenoid ligament. This blending is most 
complete at the bottom, where it springs immediately 
from the edge of the liga- 

ment; on the sides it is less aC ah 
so, leaving the edge free in 
the joint-cavity;  . ; 
while above it leaves 5s< 
the ligament and is 
attached to the 
base of the cora- #32 
coid process, af- 
fording a free 
margin for the 
insertion of the 
biceps tendon. 
Upon the humerus it 
is attached just be- 
yond the articular 
surface at the base of : 
the tuberosities, except at the 
bicipital groove, which it bridges 
over in order to allow the ten- 
don of the biceps to enter the 
joint-cavity, and below, 
it. extends for a short distance 
downward upon the surgical 
neck. Resection within the cap- 
sule is therefore possible, and a 
pure fracture of the anatomical 
neck must always be intra-cap- 
sular. Some instances of this 
surgical curiosity are on record, 
and they almost invariably end unfavorably, as the head 
appears to be cut off from all nourishment and no union 
is possible. 'The capsule is very lax, and would admit a 
humeral head of twice the size of the actual one. Thus 


w 


~'24 
4 ay. 
» 


Al 


T mj 


where Fia. 3523.—Frontal Sections of 
the Shoulder-joint while the 
arm is hanging. (Henle.) t, 
clavicle ; ac,acromio-coracoid 
ligament; D, deltoid muscle ; 
B, tendon of long head of 


biceps; Ss, subscapularis ; 
Ss}, supraspinatus; Al, tri- 
ceps; 7mj, teres major; *, 
posterior circumflex artery ; 
** trace of epiphysial union. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the arm is never checked in its motions, except at the 
limits of its course. In the ordinary position, when the 
arm hangs loose (Fig. 3523), the capsule forms a pocket 
reaching down- 

ward as far as the D 
teres major, and is 
united there to the 
periosteum of the 
upper end of the 
humerus by loose 
connective tissue. 
This pocket may 
receive any prod- 
ucts of effusion or 
inflammation, and 
be felt as a fluctu- 
ating body in the 
axilla. When the 
arm is lifted away 
from the side (Fig. 


3524), it becomes 
obliterated, and Fi¢. 3524.—Frontal Section of the Shoulder- 
the motion is joint while the Arm is lifted Horizontally. 
(Henle.) D, deltoid muscle; Ss, subscapu- 
checked by the  laris; AZ, triceps; Tm, teres major. 
tension of the cap- 


sule as soon as it has reached a right angle. This is as 
far as the arm can be lifted without calling in the aid of 
the scapula. The laxity of the capsule is so great that 
when effusion occurs into it the bones may be pushed 
apart to the extent of half an inch, 
which explains the lengthening of 
the arm often seen in cases of this 
kind. When the extension reaches 
the maximum the elbow is pushed a 
little backward and the arm rotated 
\ inward. If the muscles are all dis- 
\ sected off, the head of the humerus 
# still remains applied to the glenoid 
fossa, but if the capsule is penetrat- 


Ssi 


Gv Sa 


: SI “2 ent. cae ie 


This shows that the articular sur- 
faces are kept in contact by atmos- 
pheric pressure, as is the case in the 
hip-joint. By no other means 
could the arm have been sus- 
pended against a shallow 
socketrwith such freedom of 
motion. 
The capsule is composed of 
bundles of tissue mostly of 
the white fibrous variety, but 
with yellow elastic fibres 
sparingly inter- 


Gleno- mingled. Some of 

Coraco- ieee these run longitu- 
Beer ment, dinally, some ob- 
ee Biceps Jiquely, while a 
tendon. deeper set run cir- 

‘Capsule, Cularly, parallel to 

the capsular inser- 

tions. A great number of 


vessels and nerves ramify 
between these bundles, and 
there is constantly a consid- 
erable quantity of fatty 
matter, even in lean per- 
sons (Sappey). 
As there are no great strains put 
upon it habitually, the capsule does 
not show the marked differences in 
thickness which characterize that of 
the hip-joint. Differences do, how- 
ever, exist, and*are of two kinds, 
viz., those caused by accessory 
ed off from the Cap- hands thickening the bundles of the 
meg a Neem capsule proper, and those caused by 
the union therewith of the tendons of the muscles which 
have their insertion near by. Several distinct thickening 
bands have been described. Among these the coraco- 


Fie. 3525.—The Special 
Thickenings of the 
Shoulder-joint Dissect- 


Shoulder-Joint. 
Shoulder-Joint. 


/} ed, it at once drops considerably. . 


humeral ligament is the most important (see Figs. 3522 
and 3525). It arises from the base of the coracoid pro- 
cess immediately below the acromio-coracoid ligament, 
and passes over the capsule to the greater tuberosity. 
From its situation it is sometimes called the suspensory 
ligament of the humerus, and it is indeed likely that the 
conditions of strain caused by the weight of the arm have 
occasioned the formation of this band. Sutton, how- 
ever, considers it a vestige of a former insertion of the 
pectoralis minor. He finds that in some apes that muscle 
has an insertion upon the greater tuberosity of the hu- 
merus, and concludes that it has been displaced from 
that to the coracoid process, leaving the coraco-humeral 
ligament as the atrophied remains of its tendon. 

Connected with the coraco-humeral ligament is another 
deeper structure which appears as a fold of synovial 
membrane, arising from the margin of the glenoid fossa 
and passing down with that ligament to the humerus. 
This fold has received various names. It appears first to 
have been noticed by Schlemm, who called it the dégamen- 
tum glenotdeo-brachiale internum or innere Schulterband. 
Flood called it the gleno-humeral ligament, which is the 
name generally used by English anatomists. Sappey 
calls it the coraco-glenoid ligament, tracing it from the 
coracoid process. Welcker, who has made a careful 
comparative study of it, describes it as a posterior col- 
umn of the coraco-humeral ligament, and in this he is fol- 
lowed by most recent German authorities. He considers 
the two structures as analogous to the ligamentum teres 
of the hip-joint. His view of their connections when 
dissected away from the capsule is shown in Fig. 3525. 
Sutton, who believes that most cord-like ligamentous 
structures represent the atrophied vestiges of muscles 
that have formerly been active around the joint, suggests 
that the gleno-humeral ligament is the relic of’a former 
insertion of the subscapularis muscle. By an examina- 
tion of many shoulder-joints of lower animals, he finds 
the ligament constantly present whenever the ligamentum 
teres is developed in the hip-joint, and traces the whole 
series back to a muscle which in Menobranchus corre- 
sponds to the subscapularis of man, and traverses the 
shoulder-joint very much as the human biceps tendon 
does. Itis generally thought, however, that the struct: 
ure in question is merely a thickening of the capsule, 
caused by the play of the biceps tendon against the sy- 
novial membrane. 

Other accessory bands are described by some authors, 
viz., an inner ligament passing from the inner edge of 
the glenoid fossa along the lower margin of the subscap- 
ularis tendon to the lesser tuberosity, and the inferior lig- 
ament, which passes from the under edge of the glenoid 
cavity to the under part of the anatomical neck. These 
bands appear to be nothing more than the thickenings 
which naturally take place in the capsule where it is not 
strengthened by the tendons of muscles. The inner 
band is usually stretched or torn in subcoracoid disloca- 
tions, and the inferior one when the arm is wrenched so as 
to drive the head through into the axilla, producing the 
subglenoid dislocation. When this occurs, it may per- 
manently injure the capsule so that whenever the arm is 
uplifted a dislocation takes place, by the action of the 
muscles which pull upon the tuberosities. 

The tendons of the muscles associated with the joint 
strengthen it far more efficiently than do any bands of 
the capsule. They form around the articulation an in- 
complete hollow cone, with its base at the shoulder- 
blade and its apex at their humeral insertion, so that the 
capsule and the muscular investment appear like two in- 
terpenetrating cones with their bases in opposite direc- 
tions. The tendons embrace about three-fourths of the 
upper surface, the wide tendon of the subscapularis being 
on the medial side, the teres minor and infraspinatus 
laterally, and the supraspinatus above. The union of 
the tendons with the ligaments is not as intimate as at 
the knee-joint ; with care they can usually be dissected 
off. Beneath the tendons the capsule becomes extremely 
thin, and under the subscapularis it is deficient, so that 
the synovial membrane is in immediate contact with the 
tendon. Thesubscapularis has usually a small sesamoid 


445 


Shoulder-Joint,. 
Sialagogues. 


developed in it (Fig. 3520), where it rubs against the 
lesser tuberosity. Some of the fibres of the long head 
of the triceps become blended with the lower part of 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


tuberosity of the radius (Humphry). 


the outer, thus tending to counteract the outward twist 
of the arm given by the insertion of the muscle upon the 
Sudden muscular 
contraction has been known to pull it asunder, and 
this accident may at once be recognized by a promi- 
nent swelling on the front of the arm, caused by the 
tonic contraction of the muscular belly. In rare 
cases it has been torn from its seat in the groove, 
usually by direct violence. The groove can then 
usually be felt as empty ; the humeral head is slightly 
elevated and rotated inward (White). In cases of 
dislocation of the humerus the tendon usually re- 
mains uninjured, but may be torn from its attach- 
ment or dragged from its normal situation. The 

head of the bone may pass between the two 

heads of the biceps, which may hold it and of- 

fer an obstacle to the reduction of the disloca- 
tion. In resection of the head the tendon is con- 
siderably in the way, and it is usual to detach it 
from its groove and hold it to one side. Tillaux 


Fra. 3526.—A, Section Showing the Relation of the Long Tendon of the Biceps to holds that in these cases it is quite proper to cut it, 


the Shoulder-joint. 

Membrane. (Allen Thomson in Quain’s Anatomy.) 
the capsule, and no doubt tend to draw it downward and 
prevent it from being nipped when the arm is brought 
toward the side. 

But the most interesting feature of the muscles about 


the shoulder- 
joint is the pecul- 
lar behavior of 
the long tendon 
of the _ biceps. 
This at first lies 
in the bicipital 
groove between 
the two tuberosi- 
ties, penetrates the capsule, and passes 
through it, lined with a special process 
of synovial membrane, to its insertion 
already described upon the glenoid 
ligament, above the fossa. The pecul- 
iar nature of its course will be clear 
on examining Fig. 3526. Some of the 
fibres pass beyond the glenoid ligament 
and are attached directly to the bone. 
By this peculiar course the tendon 
becomes one of the most efficient 
strengtheners of the articulation, act- 
ing precisely where force is needed, 
and holding down the bone against 
the glenoid fossa like a strap, prevent- 
ing its displacement upward by the 
action of the deltoid and the muscles inserted into the 
tuberosities. It grooves the inner tuberosity more than 


Fie. 3527,—Abnormal 
Arrangement of the 


Biceps. a, Coracoid 
head; b, glenoid 
head; c, humeral 
head; d, capsular 
head. 


446 


B, is an outline showing the Arrangement of the Synovial jf jt at all embarrasses the operation, as it is almost 


certain to slough during the ensuing suppuration. 

The varieties which occur in the biceps muscle have 
given rise to a careful investigation of its mode of origin. 
One of the most rare of these is shown in Fig. 3527. 
The biceps here has four heads, one of the supplementary 
ones arising from the capsule of the joint. Welcker has 
examined the behavior of the long head of the biceps in 
many animals, and finds that in some cases it is entirely 
superficial, separated from the capsule by a bursa. Be- 
tween this and the usual condition all stages of pene- 
tration of the capsule are found. These are shown in 
Fig. 3529. The tendon first grooves it, then penetrates 
it, and lies between the ligament proper and the synovial 
membrane, then buries itself sideways in this, gradually 
acquiring a fold connecting it with the 
wall known as the mesotenon; then 
this is finally lost, the muscle passing 
freely through the joint invested by its 
own special sheath of synovial mem- 
brane, which becomes continuous with 
that lining the joint at either end. On 
investigating the stages of development 
in the human fcetus, we find a similar 
series of changes. The mesotenon of 
the foetal joint is shown in Fig. 3528. 
It appears therefore probable that the 
capsular head shown in Fig. 3527 is 
merely a detached fascicle, left behind 
by the long tendon in its gradual penetration of the cap- 
sule. 

Some cases of absence of the long head of the biceps 
have been reported. While most of these are doubtless 
due to pathological causes, the tendon having been ab- 
sorbed by inflammatory processes, there are yet some in- 
stances of congenital absence, the bicipital groove being 
empty and nearly obliterated, and there being no trace of 
a process of the synovial membrane corresponding to an 
atrophied tendon. 

The synovial membrane of the joint is large, but it 
rarely becomes diseased. Indeed, it is freer from dis- 
orders than that of any other of the large joints of the 
body, owing probably to the general absence of any ex- 
citing causes. Two diverticula of the synovial sac are 
found, as already mentioned, one under the subscapu- 
laris, the second running down along the tendon into the 
bicipital groove. These are respectively called the bursa 
scapularis and bursa intertubercularis (see Fig. 3530). 
The opening of the subscapular bursa varies in size. 
Humphry states that the head of the humerus has been 
dislocated into it with but little apparent rupture of the 
capsule. ‘The place where any effusion into the joint first 
becomes manifest is anteriorly, in the interspace between 
the deltoid and pectoralis major. 

Immediately outside the capsule are situated a num- 
ber of bursal sacs which do not usually communicate 
with the joint, but which alleviate the friction between 
the muscles immediately surrounding the capsule and 


Fie, 8528.—Shoulder- 
joint of a Fetus 
Showing the Meso- 
tenon of the Biceps. 
(Welcker. ) 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


i) 


Fig. 3529.—Stages passed through by the Biceps Tendon, as shown by Specimens from Different 
(Welcker.) 8, Biceps tendon; C, capsule; S$, synovial membrane. 


Individuals. 


those which lie more superficially. The most important 
of these is the bursa subdeltoidea (Fig. 3580), a large sac, 
usually double, that lies between the 
capsule and the structures arising 


eeCOrAaCO- Clave Mela semcat eos sae ccicee es 


: “B. fosse infraclav. 
SHUDSCADWIALI Seoul ners ae olste ctecie 


B 

B 

B : 
B. subcoracoidea ............4- B. v. pect. min. 
B 

B 

B 

B 


. supracromialis.........--. 
. subdeltoidea .......--- 


! ML YZ 


. intertubercularis. 


. subt. teret. 
fmaj. 


B. subt. latiss, 
dorsi, 


Fria. 3530.—The Principal Bursze about the Shoulder. 


from the acromion process, viz., the coraco-acromial | 
ligament and the deltoid muscle. This may become in- 


Sy R 
Fig. 3531.—Horizontal Section through the Right Shoulder, 
mann. ) 
flamed or enlarged, and simulate an affection of the 
joint. 


(Heitz- 


Shoulder-Joint. 
Sialagogues, 


The extent to which the deltoid caps over the joint 

laterally will be seen on looking at a horizontal section 

G6 (Fig. 3531). Its thick and strong fibres con- 

ceal most of the features of the joint, but yet 

the humeral head does make a con- 

siderable prominence externally, and 

whenever it leaves its socket a de- 

pression, easily recognized if taken 

before swelling sets in, can be noted 
just below the acromion process, 

The deltoid is supplied by the cir- 
cumflex nerve from the brachial 
plexus, and this also gives the main 
supply tothe joint. The suprascap- 
ular and subscapular nerves also 
send twigs. One of the most frequent complications 
of a fracture of the surgical neck of the humerus is a 
paralysis of the deltoid, occasioned by an injury to this 
nerve where it winds around between the bone and the 
long head of the triceps. This is a serious difficulty, for 
the deltoid is the only muscle that can abduct the arm. 
The nerve must be carefully avoided in all resections of 
the head. 

The arteries supplying the joint are all insignificant 
branches from the axillary and the subclavian, offering 
no real obstacle to the surgeon. 

The movements possible to the joint consist of angular 
motion in all directions, the combining of these to form 
circumduction and rotation. Movement toward the an- 
terior plane of the body is more free than that behind. 
The coracoid arch limits abduction beyond a right angle, 
to lift it higher the scapula must be tilted. Rotation is 
used to assist the pronation and supination of the fore- 
arm. Frank Baker. 


SIALAGOGUES (also written Scalogoques), agents which 
excite the flow of saliva. Agents producing this effect are 
naturally divided into two classes, viz., (1) those which 
act locally and directly, and (2) those which exert their 
influence upon the salivary glands secondarily, through 
the medium of the general circulation. 

In the first class, termed masticatories, may be ranked 
all agents capable of directly exciting a flow of saliva 
when placed in the mouth or chewed, excluding, of 
course, mere alimentary substances. For practical pur- 
poses, however, the term is restricted to a limited num- 
ber of articles, some of which have been employed for 
medicinal purposes, but most of them are used by the 
laity for stimulant or narcotic effect. Thus, among 
people of our own country, tobacco is largely employed 
as a masticatory, while in South America coca, and in 
India betel, are used in the same manner. These drugs 
placed in the mouth and slowly chewed excite a more or 
less abundant flow of saliva, in which is dissolved the 
active principles of the plant employed ; and the saliva 
so impregnated being swallowed, or taken up by the ab- 
sorbents of the mucous membrane of the buccal cavity, 
produces the effect desired, generally in a slow and con- 
tinuous manner. But in the case of habitual tobacco- 
chewers the flow of saliva is, as a rule, excessive, and is 
commonly ejected from the mouth, the entire narcotic 
effect being produced through the medium of the ab- 
sorbents of the buccal cavity. 

Now, when we consider the important part played by 
the saliva in digestion, it appears evident that this exces- 
sive flow, nearly all of which is ejected, must be injuri- 
ous. Still, this is but an incident compared with the 
narcotic effect of the drug which enters the circulation. 
And though in some instances the excessive flow of sa- 
liva becomes almost a systemic depletion, the more seri- 
ous results of tobacco-chewing, as compared with tobacco- 
smoking, are due to the fact that a far greater amount of 
the drug enters the circulation in the former than in the 
latter way. This is partly due to the greater concentra- 
tion of the active principles of the drug in the saliva of 
the chewer, and partly, also, to the fact that the chewer 
uses tobacco almost continuously during his waking 
hours, while the smoker indulges, as a rule, only at in- 
tervals. 


447 


Sialagogues. 
Silver. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Among the other masticatories handed down by the 
text-books from generation to generation are pyrethrum, 
armoarcia, and mezereon, but their medicinal use in this 
manner is long since obsolete. 

The gum-resins of certain forest-trees, as the sweet- 
gum (Liguidambar Styraciflua), tamarack (Laria Amert- 
cana), and black spruce (Adzes nigra), are used as mastica- 
tories, particularly by women and children, but this habit 
is an offence against conventionality rather than hygiene. 
Indeed, gum-chewing, in some instances of feeble diges- 
tion, appears to be beneficial, whether by reason of the 
simple ingestion of saliva—for the gum is practically in- 
soluble in this secretion—or because the individual’s mind 
is diverted from his laboring stomach, it is not important 
to inquire. 

This statement, however, is only applicable to the di- 
gestive period, for the pouring of an excessive amount 
of saliva into an empty stomach is not innocuous. 

Turning from masticatories to sialagogues proper—those 
agents which excite a flow of saliva through the medium 
of the general circulation—we are struck by the contrast 
of their diminished number, for the drugs known to 
possess this property are very few. At the head of the 
list, until recently, has long stood mercury. Generations 
of medical men have employed mercury for the express 
purpose of increasing the salivary secretion, with the 
idea that in this manner the system of the patient was 
purified of morbific matter. This practice, begun as a 
cure for syphilis, rapidly extended until it ultimately be- 
came the standard routine treatment for nearly all dis- 
eases. Its history is, indeed, one of the curiosities of 
medical literature, as upon this property of mercury was 
based a pathological theory which long fettered the 
medical mind and effectually retarded scientific progress. 

As the action of this drug is minutely discussed in an- 
other part of this work (see Mercury), it is only necessary 
here to observe that its use as a sialagogue is practically 
obsolete. That is to say, profuse salivation by mercury 
is, at the present day, considered a poisonous rather than 
a strictly medicinal effect, and it is therefore carefully 
guarded against. The interest, then, attached to mercury 
as a Sialagogue is little more than historical. 

Not so, however, with the next drug to claim our atten- 
tion, namely, jaborandi. In jaborandi we have an agent 
which, in addition to a powerfulinfluence upon the sweat- 
glands, also greatly stimulates those of the salivary appa- 
ratus, And this effect is not produced slowly, as is the 
case with mercury, nor for a great length of time. It 
follows quickly upon the administration of the drug, 
and is of short duration. Moreover, the flow of saliva 
produced by an efficient dose of jaborandi is so abundant 
as to amount to a positive depletion, often found of es- 
sential service, especially in cases of uremic poisoning. 
Though the salivary glands are excited to a remarkable 
degree, this excitement is but transitory ; and the inflam- 
mation and ulceration so commonly attendant upon mer- 
curial salivation never result from the use of jaborandi. 
Unfortunately, however, jaborandi is a cardiac depressant, 
and on this account requires to be used with caution. It is, 
in fact, the only sialagogue properly entitled to the name, 
since it is the only agent which can be employed to excite 
the flow of saliva for remedial purposes. And even as a 
sialagogue it is much less valuable than as a diaphoretic. 
(See Jaborandi.) 

A few other medicinal agents occasionally produce 
salivation as one of their effects, but as they are never 
used for this purpose their consideration may well be 
omitted. Laurence Johnson. 


SILICATES. The only use at present for the silicates 
is in surgery, in the preparation of immovable dressings 
for fractures, etc. For this purpose solutions of both the 
potassium and the sodium salts (called soluble glass) have 
been employed, but the latter is far preferable to the 
former, and should always be selected when possible. 

The solution of Silicate of Sodium (Liquor Sodii Stlica- 
tis) is the only officinal preparation of the silicates. It is 
‘‘a semitransparent, almost colorless, or yellowish, or 
pale greenish-yellow, viscid liquid, odorless, having a 


448 


sharp saline and alkaline taste, and an alkaline reaction. 
The sp. gr. of the commercial solution is between 1.300 
and 1.400. A drop of the solution, when held in a non- 
luminous flame, imparts to it an intense yellow color. 
If a portion of the solution, considerably diluted with 
water, be supersaturated with nitric acid, a gelatinous 
or pulverulent, white precipitate of silicic hydrate will 
be produced. A small quantity should not produce any 
caustic effect when applied to the skin (absence of an ex- 
cessive amount of alKali).” For an account of the surgi- 
cal uses of sodium silicate the reader is referred to the 
article Splints. 

Silicate of sodium is said to possess anti-fermentative 
properties, and has occasionally been employed as an an- 
tiseptic by some French surgeons. Marc Sée has reported 
good results from its external use in chancre, and from 
urethral injections in gonorrhea. Dubreuil injected it 
into the bladder, in a case of vesical paralysis occurring 
with hypertrophy of the prostate gland in an old man, 
and found that it prevented ammoniacal decomposition 
of the urine. The sodium and potassium salts have also 
been given internally in rheumatism. The medical uses 
of the salts are, however, obsolete, and as they have been 
shown to possess toxic properties in experiments upon 
dogs, it is probably just as well that their therapeutic em- 
ployment should not be revived. 

Hydrated magnesium silicate, the meerschaum from 
which pipes are made, has been suggested by Garraud 
as a substitute for bismuth subnitrate, which salt it re- 
sembles, in diarrhcea. Good results were reported from 
its use, but it did not appear to possess any advantages 
over the bismuth. Tee 


SILURIAN SPRING. Location and Post-office.—Wau- 
kesha, Waukesha County, Wis. 

Accrss.—From Chicago by the Chicago, Milwaukee 
& St. Paul, or the Chicago & Northwestern Railroads. 

ANALysis.—Professor W. 8. Haines. One gallon con- 


tatns : 
Grains. 
Chioridé-of sodium™....5.. tee ee eee SOREN ee Cicer ee 0.1926 
Sulphatesotrscdinm lope. eee met reer eae 0.2917 
Bicarbonate of tsoditimia. see eee cee eee 0.0801 


Carbonatelofecalciumenn jean eon en ae eee 9, 9277 


Carbonate of maconesitiiisc eee ee cee eee 6.8324 
Carbonate ofdron tow enaceeseen eer ene ieee 0.1285 
‘Phosphaterofl-ironyes ae ases aac or eee eee ‘cso. traces 
Phosphate of manganese jane. cies teeing eectenioe ae traces 
Alumina. nee. oe Ghcckeacs ta Oot eee eee 0.5827 
Sili@a Ee yah, Pe ne cee cares Laon eae 0.7004 
Orpanicimatter tact te adage cistern. ster very faint trace 

TL Otal-SOHGS Hy pecteiec crannies eer 18,6861 

Cub. in 

Carboniciacid!pastacince ec ree ore eee eee eee 44.7 


THERAPEUTIC PROPERTIES.—This water is very simi- 
lar in composition and effect to the Bethesda. It is 
mildly alkaline and saline, and, being perfectly free from 
organic matter, it acts freely as a diureticand antacid. It 
is used with success in dyspepsias and kidney and mucous 
membrane diseases generally. This spring is situated in 
the southern part of Wisconsin, about twenty miles west 
of Milwaukee, on the Fox River, in the town of Wau- 
kesha. There areanumber of good hotels in the village, 
which has a population of about thirty-five hundred. 
Within a distance of ten miles are several beautiful lakes, 
affording good fishing. Gis are 


SILVER. I. GENERAL MEDICINAL PROPERTIES OF 
COMPOUNDS OF SiLVER.—In medicinal dosage the most 
important effect that follows persistent internal medica- 
tion with silver is the tendency to a bluish-black discol- 
oration of the skin and mucous membranes. This stain- 
ing shows first on the mucous membranes, so that by 
inspection of the inner surfaces of the lips and of the 
fauces, during a course of medication by silver, and by 
stoppage of the medicine upon the first beginning of a 
bluish discoloration of those parts, no serious risk of stain- 
ing of the skin need be incurred. Asa rule, efficient dos- 
age with silver can be maintained for from one to three 
months before coloration begins. In overdosage silver is 
a constitutional poison, impairing nutrition generally, and 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sialagogues. 
Silver. 


deranging the nervous system particularly. Therapeu- 
tically, impregnation of the system with silver tends to 
oppose, albeit feebly, the onward march of certain dis- 
eases of the nervous system, such as epilepsy and tabes 
dorsalis. But in the more intractable of these diseases, 
such as tabes, the influence is so slight as to be of no 
value—if, indeed, it exist at all—and in epilepsy other 
remedies are far more potent. The use of silver for con- 
stitutional effect is, therefore, in modern practice, seldom 
resorted to. 

Locally, the effects of silver compounds differ with the 
individual preparations according to their solubility, and 
will be described in connection with the several com- 
pounds themselves. 

Il. Tue MEDICINALLY USED COMPOUNDS OF SILVER. 
—These comprise the several salts, argentic oxide, todide, 
and nitrate. The cyanide is also officinal in the U. S. 
Pharmacopeeia, but for pharmaceutical purpose only. 

Argentic Oxide: Ag,O. Argentic oxide is officinal in 
the U. S. Pharmacopeeia as Argent? Oxidum, Oxide of 
Silver. It is ‘‘a heavy, dark brownish-black powder, 
liable to reduction by exposure to light, odorless, having 
a metallic taste, and imparting an alkaline reaction to 
water, in which it is very slightly soluble. It is insolu- 
ble in alcohol” (U.S. Ph.). This oxide readily yields its 
oxygen in presence of oxidizable matter, and hence 
should not be triturated with any such material. It dis- 
solves in water of ammonia. From its comparative in- 
solubility this compound has little local effect, but when 
swallowed, probably through chemical conversion, it is 
capable of absorption, and exerts the constitutional ef- 
fects of silver, such as they are. In such operation the 
oxide is thought to be less prone to discolor the skin than 
the nitrate, but it is certainly not wholly innocent of this 
tendency. Upon the stomach and bowels silver oxide 
has quite a marked potency to allay irritability, tending 
to quell vomiting, even in such complaints as ulcer and 
cancer of the stomach, and to control diarrhcea when 
arising as a reflex of nervous irritation. The principal 
employment of the medicine is in such disorders of the 
digestive apparatus. The average dose is about 0.06 Gm. 
(one grain), best given in powder or capsule. The pill 
form is bad, because of the deoxidation of the compound 
by the organic matter of the excipient, which reaction may 
even be attended by explosion. Gum arabic is recom- 
mended as the least objectionable excipient. 

Argentie Iodide: Agl. The salt is officinalin the U.S. 
Pharmacopeeia as Argentt Iodidum, Iodide of Silver. It 
is ‘‘a heavy, amorphous, light-yellowish powder, unal- 
tered by light if pure, but generally becoming somewhat 
greenish-yellow, without odor and taste, and insoluble in 
water, alcohol, diluted acids, or in solution of carbonate 
of ammonium. Soluble in about 2,500 parts of stronger 
water of ammonia” (U. 8. Ph.). Argentic iodide is, 
medicinally, substantially a duplicate of the oxide, and 
may be used for the same purposes and in the same dose. 

Argentic Nitrate: AgNO;. This, by far the most im- 
portant compound of silver, is officinal in the U.S. Phar- 
macopeeia in three conditions, namely, in crystals, in cy- 
lindrical sticks moulded by fusion, and in similar sticks 
in admixture with equal parts of potassic nitrate. 

Argenti Nitras, Nitrate of Silver. This title signifies 
the salt in crystals, which the Pharmacopeceia describes 
thus: ‘‘ Colorless, transparent, tabular rhombic crystals, 
becoming gray or grayish-black on exposure to light in 
presence of organic matter, odorless, having a bitter, 
caustic and strongly metallic taste and a neutral reaction. 
Soluble in 0.8 part of water and in 26 parts of alcohol at 
15° C. (59° F.), in 0.1 part of boiling water, and in 5 parts 
of boiling alcohol. When heated to about 200° C. (892° 
F.), the salt fuses to a faintly yellow liquid, which, on 
cooling, congeals to a purely white, crystalline mass. At 
a higher temperature the salt is gradually decomposed, 
with evolution of nitrous vapors. It should be kept in 
dark amber-colored vials protected from the light.” These 
crystals constitute the purest form of the nitrate, and are 
used for internal giving or for the making of solutions. 

Argentt Nitras Fusus, Moulded Nitrate of Silver, 
«<Fused Nitrate of Silver,” ‘‘ Lunar Caustic.” The crys- 


Von. VI.—29 


tals are melted by heat, and the fused salt poured into 
moulds where it sets on cooling. But inasmuch as the 
pure nitrate is, when fused, inconveniently brittle, the 
Pharmacopeeia provides for a trifling admixture of ar- 
gentic chloride, which is a tough compound. To this 
end about four per cent. of hydrochloric acid is added to 
the melted crystals, whereby a small portion of the nitrate 
is converted into chloride. Reaction having ceased, the 
mixed mass is ready for moulding. Lunar caustic is 
cast in narrow cylindrical sticks, which are hard, brittle, 
and,. when freshly made, white in color. As commonly 
found, however, they are gray, or even blackish, through 
chemical reaction with matters present in the atmosphere. 
‘*Soluble, with the exception of about five per cent. of 
chloride of silver, in 0.6 part of water and 25 parts of al- 
cohol at 15° C. (59° F.), in 0.5 part of boiling water, and 
in 5 parts of boiling alcohol. It is insoluble in ether. 
Whatever is left undissolved by water is completely sol- 
uble in water of ammonia” (U. 8. Ph.). Fused nitrate 
of silver should only be used for its legitimate purpose, 
that of external application. 

Argentt Nitras Dilutus, Diluted Nitrate of Silver. 
Argentic and potassic nitrates, in equal proportion, are 
melted together by heat and the fused mass poured into 
moulds. The product is ‘‘a white, hard solid, generally 
in form of pencils or cones of a finely granular fracture, 
becoming gray or grayish-black on exposure to light in 
presence of organic matter, odorless, having a caustic, 
metallic taste, and a neutral reaction” (U. 8. Ph.). The 
sticks dissolve freely in water and possess the same prop- 
erties as the undiluted lunar caustic, only in milder de- 
gree. They are used only for local application. 

Nitrate of silver differs from the oxide and iodide in 
the essential particular of free solubility, on which prop- 
erty depend the most valuable medicinal virtues of the salt. 
The most important reactions of the nitrate are that its 
solutions are precipitated by soluble chlorides to form 
the very insoluble salt, argentic chloride. ‘This reaction 
is one of the most delicate in chemistry, and since traces 
of chlorides are present in almost all natural waters, the 
use of distilled water is necessary for solutions of nitrate 
of silver, if a clear, bright solution be desired. Nitrate of 
silver also reacts on organic matter generally, suffering 
decomposition, and forming, with the organic substance, 
compounds insoluble and acquiring a rusty brownish- 
black color under the action of light. Hence sticks of 
lunar caustic grow gray and black on the surface by keep- 
ing, by reaction with the organic dust of the atmosphere, 
and solutions of silver nitrate deposit a fine black sedi- 
ment, and stain textile fabrics and skin. The stain on 
the skin, if recent, can be fairly well removed by rubbing 
with a moistened lump of potassic cyanide, and washing— 
always remembering the very irritant and poisonous char- 
acter of such cyanide. But if the stain be old, and fixed 
by exposure to sunlight, the cyanide fails, and the fol- 
lowing means may be resorted to: Moisten the stains, 
drop on them a little tincture of iodine, and then wash in 
a six per cent. solution of sodic hyposulphite. Or, very 
efficient, mix ina saucer a few bits of iodine with a little 
water of ammonia; rub the stains quickly with the re- 
sulting preparation, and immediately wash both skin and 
saucer while they are still wet. This latter precau- 
tion is necessary, since the compound of iodine and nitro- 
gen produced by the mixture of chemicals spontaneously 
explodes upon slight agitation when dry. Other reac- 
tions of silver nitrate are its precipitation by sulphuric, 
hydrosulphuric, phosphoric, hydrochloric, and tartaric 
acids and their salts; by the alkalies and their carbonates, 
lime-water and the vegetable astringents, and arsenical 
and albuminous solutions. 

Nitrate of silver is an irritant astringent, with also the 
peculiar specific effects of silver compounds already de- 
tailed, viz., the allaying of gastric irritability, and the 
induction of certain constitutional control over nervous 
disease. The local effects are the more important, and 
are as follows: The salt readily combines with albumin 
to make an insoluble compound, the albuminate of silver ; 
hence, when in strong solution or in solid stick, its appli- 
cation to the surface of a mucous membrane or of granu- 


449 


Silver. 
Skeletons. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


lation-tissue produces a white streak of cauterization, 
which, by the insolubility of the compound formed, 
limits the action of the caustic to the production of such 
shallow slough. Concentrated applications: to the skin 
speedily blacken the epidermis, and, more slowly, raise a 
blister. In solutions less than ten per cent. in strength 
the salt is hardly caustic, but acts only as an irritant 
astringent. When swallowed, quite small doses act 
locally like the oxide, while large produce irritant poi- 
soning. Therapeutically, local applications of silver ni- 
trate judiciously made have a marked tendency to pro- 
mote absorption in such tissues as are capable of under- 
going this process ; to induce healing ; to limit and abate 
the catarrhal process ; to destroy skin-parasites, though 
not very searchingly ; and to neutralize the virulence of 
specifically noxious pus. 

The medicinal uses of silver nitrate are such as may be 
deduced from the foregoing. Internally the medicine 
may be given, for constitutional or local effect, in doses of 
from 0.015 to 0.03 Gm. (from about one-fourth to one- 
half grain) in pill or solution. In neither way of giving 
does the salt probably reach the stomach as nitrate ; for, 
if in solution, a medicinal dose must almost certainly be 
decomposed in the swallowing, and, if in pill, be acted 
on similarly by the necessary organic matter of the ex- 
cipient. To obviate this effect as far as possible in the 
case of pills, it is advised that bread-crumb be particu- 
larly avoided as an excipient, because of its containing a 
soluble chloride (common salt) as well as organic matter, 
and that some vegetable extract, or a dry powder made 
sticky by a minimum of gum, be selected. In any case 
the crystallized silver salt should alone be prescribed. 
Externally, silver nitrate may be used as a caustic, but 
only where a superficial effect is wanted, as for the de- 
struction of the lining membrane of acyst. The fused 
stick is in such cases used, its moistened surface being 
swept over the surface to be destroyed. More common 
is the application to promote absorption, as in case of 
exuberant granulation-tissue or trachoma-bodies ; to de- 
termine healing, as in unhealthy ulcers; or to shorten 
and abate the course of a catarrh. For such purposes 
various strengths of the nitrate are used, from applica- 
tion of the pure or diluted sticks of lunar caustic to that 
of solutions of not more than the one-fifth of one per 
cent. strength. To determine absorption the stronger 
applications are necessary, to control catarrhs the weaker; 
but in all cases care should be taken not to overdo the 
matter, and, by too strong or too frequent application, to 
actually interfere through excess of irritation with heal- 
ing or with resolution. Inthe case of catarrhs, moreover, 
the remedy should not be used at all until the second 
Stage of the process is reached, as betokened by the es- 
tablishment of the catarrhal secretion and abatement of 
the initial pain or sensitiveness. Then, too, the strength 
of the application should be adjusted to the different de- 
grees of sensibility of the different mucous membranes ; 
for while the comparatively insensitive membranes, such 
as those of the fauces or vagina, may take a five per cent. 
solution, or even stronger, hardly more than the one- 
tenth of this strength can be applied without undue irri- 
tation to the nasal passages or to the male urethra. When 
a very brief action is wanted, the application of silver 
may be immediately followed by one of a solution of 
common salt, which salt immediately precipitates all ex- 
cess of nitrate as the insoluble, and therefore inert, com- 
pound, silver chloride. 

Argentic Cyanide: AgCN. This salt is officinal in the 
U.S. Pharmacopeeia as Argenti Cyanidum, Cyanide of 
Silver. It is a ‘‘ white powder, permanent in dry air, 
but gradually turning brown by exposure to light, odor- 
less and tasteless, and insoluble in water and in alcohol. 
Insoluble in cold, but soluble in boiling, nitric acid, with 
evolution of hydrocyanic acid; also soluble in water of 
ammonia and in solution of hyposulphite of sodium. 
When strongly heated, the salt fuses, gives off cyanogen 
gas, and, on ignition, metallic silver is left” (U. S. Ph.). 
Argentic cyanide is not used in medicine, but only in 
pharmacy, for the making of diluted hydrocyanic acid. 

Edward Curtis. 


450 


SILVER, POISONING BY. The most important salt 
of silver, medico-legally, is the nitrate, which is prepared 
by dissolving silver in dilute nitric acid. It crystallizes 
in transparent rhombic plates, and has an exceedingly 
acrid metallic taste. It is soluble in less than its weight of 
water at 59° F. (15° C.). Melting-point, 198° C. The melt- 
ed salt run into moulds forms the oflicinal Argentz Nitras 
Fusus (lunar caustic). To overcome its brittleness, or to 
modify its action, the salt is sometimes fused with a cer- 
tain proportion of silver chloride or potassium nitrate. 
Nitrate of silver, when pure, is not blackened by expos- 
ure to light; but, when in contact with organic matter, 
it is decomposed, with formation of a black, insoluble 
compound. Hence its use in indelible inks. For the 
same reason living tissues to which the nitrate has been 
applied soon turn black. Hydrochloric acid or soluble 
chlorides produce in solutions of this salt a white, curdy 
precipitate (silver chloride), soon turning violet upon ex- 
posure to light, soluble in ammonium hydrate, insoluble 
in nitric acid. The nitrate is used in indelible inks, in 
hair-dyes, largely in chemical analysis and in photog- 
raphy, and in medicine, both externally and internally. 
Poisoning by nitrate of silver may be either acute or 
chronic. 

ACUTE Porsontine.—This is rare, and is usually acci- 
dental, resulting from swallowing pieces of nitrate of 
silver pencils which have been broken off in the act of 
cauterizing the throat. Very rarely a solution has been 
taken accidentally or for suicidal purpose. The disagree- 
able taste of the salt is likely to frustrate any attempts to 
make use of it for criminal poisoning. 

Symptoms.—Nitrate of silver is a violent irritant and 
corrosive. Large doses are followed, therefore, by symp- 
toms of gastro-enteritis, namely, severe burning pains in 
the region of the stomach and intestines, violent vomit- 
ing, and diarrhea. If the ordinary chemical antidote 
(common salt) has been administered, the vomitus and 
feeces may be white and curdy, becoming violet or neariy 
black upon exposure to light. This appearance, as well 
as the black stains upon those parts of the body with 
which the salt has come in contact, such as the lips, aid 
materially in making a diagnosis. The nitrate also acts 
upon the nervous system, producing loss of conscious- 
ness, convulsions, paralysis, and disturbances of respira- 
tion. 

Hatal Dose—Fatal Period.—These are not determined. 
Death has followed the ingestion of 1.94 gram (30 
grains). ‘Taylor mentions the case of a woman who took 
3.24 grams (50 grains) in divided doses, and died in three 
days. Recovery has taken place in two cases after the 
ingestion of 31.1 grams (%j.). Death has ensued as early 
as six and nine hours—children in both cases, 

Post-mortem Appearances.—These, so far as observed, 
are similar to those characteristic of the irritant poisons 
in general, namely, redness and injection of the mucous 
membranes of the cesophagus, stomach, and intestines. 
White or grayish patches have been noticed in the stom- 
ach and duodenum. 

Treatment.—Common salt and milk should be admin- 
istered freely. Vomiting should then be induced; for 
the chloride of silver is soluble in an excess of sodium 
chloride, and the albuminate is soluble in the digestive 
fluids. In other respects the treatment should be symp- 
tomatic. 

Mode of Action.—It is reasonably certain that the ni- 
trate undergoes decomposition as soon as it reaches the 
stomach. It forms, with hydrochloric acid and soluble 
chlorides—as sodium chloride—the chloride of. silver. 
This is insoluble in water, but soluble in solution of so- 
dium chloride. Withalbuminous matters it forms an al- 
buminate, soluble in solution of sodium chloride and in 
the digestive fluids. Itis probable that silver is absorbed 
in one of these forms, or in some similar form. 

Rouget has shown, by experiments on animals, that 
the soluble salts of silver produce, first, vomiting and di- 
arrhoea, soon followed by muscular weakness, paralysis, 
disturbances of respiration, and weak clonic convulsions. 
In cold-blooded animals their administration is quickly 
followed by severe tetanic convulsions, similar to those 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


produced by strychnine, then by disturbances of respira- 
tion and paralysis. Death is due to asphyxia. Two 
theories have been proposed in explanation of the as- 
phyxia. One assumes that it is due to congestion of the 
lungs and to the excessive secretion of mucus in the 
lungs—such as has been observed in experiments on dogs 
and cats ; the other that it is due to a direct action of the 
poison on the central nervous system (Charcot and Ball, 
Rouget, Curci). The results of Rouget’s experiments on 
animals point to the latter as the more probable explana- 
tion. For, although finding respiratory symptoms prom- 
inent in all cases, only occasionally were any pulmonary 
lesions found after death. Curci considers the general 
paralysis a reflex paralysis. According to Falck the 
temperature sinks 44° to 63.7° F. (6.7° to 17.6° C.) after 
subcutaneous injection of the nitrate in rabbits. 

CHRONIC PoIsoNING—ARGYRIA.—The name argyria 
has been given to a condition which follows the long- 
continued use of nitrate of silver, and which is charac- 
terized by a gray discoloration of the skin, of greater or 
less intensity, the color being ordinarily deeper on those 
parts of the body which are exposed to the light. It is 
most frequently the result of the long-continued use of 
medicinal doses of the nitrate taken internally. Two 
cases are reported which were the result of its applica- 
tion to the throat, extending over some years, as a caus- 
tic, small quantities being swallowed and absorbed (Du- 
guet); and a case is reported, the result of the use, for a 
number of years, of a solution of the nitrate for coloring 
the beard (Bresgen). Recent observations made on silver- 
plate workers in Berlin have shown that absorption of sil- 
ver may follow constant handling, for a long time, of the 
metal, and that among such workers characteristic-col- 
ored patches, round or oval in shape, and varying in size 
from a millet-seed to a broad bean, are very frequent, oc- 
curring principally upon the dorsum of the left hand. 
The men affected were invariably those who had some 
ulceration or abrasion of the skin, through which the 
metal was probably absorbed. 

_ The first symptom of argyria is usually an inflamma- 

tory swelling of the gums, with a blue or violet line at the 
junction of the gums with the teeth. If the administra- 
tion of the silver compound is continued, there appear 
later, on various parts of the skin, grayish patches, which 
gradually increase in size ; the whole skin, as well as the 
visible mucous membranes, finally presenting a grayish 
or grayish-black discoloration. This discoloration is not, 
however, limited to the skin and superficial mucous mem- 
branes, but may involve the internal organs and mucous 
membranes. It is more intense on those parts of the skin 
which have a thin epithelial covering. A local argyria 
may be produced by the frequent application, over a long 
period, of nitrate of silver to wounds of the surface of the 
body or mucous membranes. 

The length of time and the amount of silver preparation 
requisite to produce the discoloration of the skin cannot be 
definitely stated. A general discoloration of the body is 
not likely to appear, so far as can be judged from recorded 
cases, till the lapse of a year or thereabout, or till as much 
as fifteen to thirty grams (3% to 7} drachms) of the nitrate 
has been administered. Larger amounts have been taken, 
however, without producing any discoloration. It would 
seem that the suspension of the nitrate for a while has no 
certain effect in postponing the appearance of the discol- 
oration when the administration is again resumed ; for a 
case is reported in which the administration was resumed, 
after an interruption of six years, and was followed by 
discoloration in six months. The explanation is prob- 
ably to be found in the failure of the system to eliminate 
to any great extent the silver which has once been ab- 
sorbed. The line on the gums has been observed in two 
months, during which time 3.9 grams (60 grains) of nitrate 
of silver had been taken (Guipon). 

The general health does not appear to suffer in argyria 
in man. Bogoslowsky, however, produced argyria in ani- 
mals, and observed in them loss of appetite, diarrhea, 
emaciation, albuminuria, followed by death. 

Microscopic examination shows that the discoloration 
in argyria is due to the presence of minute black gran- 


Silver. 
Skeletons, 


ules, probably metallic silver or some compound of silver 
(according to Krissinsky an organic compound of silver). 
In the skin they are found under the rete Malpighii in the 
superficial layers of the corium, in the deep connective 
tissue, in the sweat and sebaceous glands, in the smooth 
muscular fibre, and in the media and adventitia of the 
arteries. The epithelium is free. In the intestines the 
epithelium is also free from color, while the remaining 
parts are pigmented. In the internal organs the deposit 
is most noticeable in the smaller vessels and connective 
tissue. In the kidneys the glomeruli especially are pig- 
mented. The substance of the brain and spinal cord is 
free, but in the choroid plexus the deposit is abundant. 
It is also especially abundant in the cells of the medulla 
of the bones (Krissinsky), the intima of the aorta and 
other large vessels, and in the mesenteric glands. Bo- 
goslowsky in his experiments on animals found advanced 
fatty degeneration of the parenchymatous organs of the 
body, especially the liver and kidneys; and of the mus- 
cles, especially the muscular fibres of the heart. 

The discoloration in argyria is permanent. No method 
of treatment is known by which it can be removed. 

Absorption and Elimination of Silver.—Silver is ab- 
sorbed and may be detected after death in the various 
organs of the body. The quantity taken into the circu- 
lation is probably very minute ; the greater part of that 
taken into the stomach being removed with the feces. 
Silver has been detected in the urine, and is probably 
eliminated chiefly through the kidneys. It is to be in- 
ferred from the permanency of the discoloration in argy- 
ria that elimination is very slow ; that, in fact, in most 
cases, it is never completed. The pigmentation of the 
liver has been observed as late as five years after the ces- 
sation of a course of treatment with nitrate of silver. 

Other Preparations of Silver.—Cyanide of silver and 
‘* silver solution,” which consists of cyanide of silver dis- 
solved in cyanide of potassium (the proportion of the 
latter very variable) are the only remaining preparations 
possessing medico-legal importance. The effects pro- 
duced by these, so far as observed, do not differ materi- 
ally from those produced by hydrocyanic acid, and it is 
probable that their poisonous action is due almost entirely 
to the acid. Reference is therefore made to the article 
on Poisoning by Hydrocyanic Acid. Nothing definite is 
known regarding the poisonous dose of either prepara- 
tion. Death has occurred in ten minutes after swallow- 
ing fifteen cubic centimetres (3 iv.) of silver solution. 

William B. Hills. 


SKELETONS, PREPARATION OF. General Direc- 
tions.—a. ‘‘If one can choose the specimen, a young 
adult should be selected. In too young animals the epiph- 
yses are apt to separate easily from the diaphyses, and 
the symphyses open too easily. On the other hand, old 
animals sometimes have exostoses, or abnormal growths 
on their bones, and the sutures and symphyses are liable 
to be entirely obliterated.” 

b. If possible, a perfect skeleton of the part or parts 
under preparation should be before the operator, so that 
the exact position of delicate bones and processes may 
be seen, and hence not be lost or broken through inad- 
vertence. : 

c. Careful notes should be made of the natural curves 
of the vertebral column, and of the position of the scap- 
ula, os hyoides, and in the lower animals of bones un- 
connected or but loosely connected with the rest of the 
skeleton. Measurements should be made of the length 
of the vertebral column and the thickness of the fibro- 
cartilage between two vertebral centra of each region at 
least. The thickness of the fibro-cartilage in the pelvic 
and other symphyses should also be determined, as also 
the thickness of the muscles separating the scapula from 
the ribs. 

d. Whatever method is employed for the preparation 
of the bones, it is better to divide the animal, if it is large, 
into several parts by disarticulating some of the principal 
joints, as the humero-scapular, the femoro-innominate, 
the occipito-atlantal, and the other principal joints. The 
parts will then be more manageable. 


451 


Skeletons. 
Skeletons, 


e. The whole animal should bear a label, giving the 
name, date, sex, and, if possible, the age. Each sepa- 
rated part should have a label, giving the above general 
data, and also the name of the part. This is imperatively 
necessary with the vertebree, the ribs, and the phalanges ; 
hence, each must be labelled as it is separated from the 
rest of the body. 

jf. Parts like the pelvis and scapule, and the limb 
bones, exclusive of the manus and pes, which cannot be 
mistaken, may be put together and labelled as for the 
whole animal. Parts that might be difficult to distin- 
gcuish should be kept in separate dishes and each prop- 
erly labelled. The vertebrae might be divided into sets— 
cervical, thoracic, lumbar, etc.—and then connected by 
attaching a manilla string to a wire and passing it through 
the neural canal and tying the ends. The order of the 
bones cannot then be changed as they separate on the 
removal of the soft parts. 

The ribs of one side, at least, should be removed one by 
one, and tied in order on a string or put into separate 
dishes. The phalanges of each hand and foot, commenc- 
ing with the thumb and great toe, should be tied in order 
on a manilla string, then they and the other bones of 
each hand or foot may be very conveniently kept in a 
small sack made of cheese-cloth. Sesamoid bones would 
be best preserved in separate sacks or vials, each one hav- 
ing its own label. 

In some of the lower animals the so-called splanchnic 
bones, 7.e., bony parts of organs, like the heart in the ox, 
diaphragmatic bone of the hedgehog, bone of the penis in 
the cat, raccoon, etc., must be removed from the animal 
before the cleaning commences, or the organs are removed 
and thrown away. If these are to form part of the pre- 
pared skeleton, it is essential to determine accurately 
their relative position on the fresh animal as they are re- 
moved. 

g. Bones of different animals should not be put into 
the same dish, unless they differ so greatly in size or con- 
formation that confusion would be impossible. 

Finally, it is unnecessary to bore holes in the bones in 
order to allow the interior soft parts to escape or be re- 
moved, as is often recommended, for the natural canals 
in a bone render it somewhat like a sieve or sponge, and 
give sufficient communication between the interior and 
exterior. 

ARTIFICIAL AND NATURAL SKELETONS, AND METHODS 
oF PREPARATION.—When all of the soft parts of the 
body are removed in any way, most of the bones fall 
apart, and if they are to be arranged and held in their 
natural relations, they must be connected artificially by 
wires, strings, bolts, etc.; hence the name artificial skele- 
ton, in contradistinction to a natural skeleton, in which 
the natural ligaments or fibro-cartilages are left to hold the 
bones in position. 

Whether the skeletons are to be natural, artificial, or 
simply kept as separate bones (so-called .disarticulated 
skeletons), there are four principal methods of removing 
the soft parts : 

1. Putrefactive Maceration in Water.—For this, stone- 
ware, porcelain, or glass dishes, or zinc-lined tanks are 
employed, to avoid discoloration of the bones. The 
various parts of the animal, prepared as described in the 
general directions, are placed in separate dishes, and 
covered completely with clean, preferably soft, water. 
The dishes should then be placed in a room where the tem- 
perature does not fall below 18° to 20° C. (64.4° to 68° F.). 
If the room is still warmer the maceration will proceed all 
the more rapidly. The water should be changed frequent- 
ly at first, z.e., every day or every other day, if possible, 
for the first ten days or two weeks, then occasionally until 
the maceration is as complete as desired. By macerating 
in a warm room, and changing the water as directed 
above, discoloration of the bones and the formation of 
adtipocire are almost always avoided. According to 
Morel and Duval, experience has shown that the placing 
of bodies in running water is not so good a method of 
maceration as that described above; there is, also, far 
greater danger of losing some of the bones. 

During maceration the bones should be examined oc- 


452 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


casionally, and, if a natural skeleton is desired, the bones 
must be removed as soon as the muscles have decayed. 
If the bones are to be entirely freed from soft parts the 
maceration should be allowed to continue till these have 
completely decayed, or until they may be readily re- 
moved by a brush or adull but smooth-edged knife. 
When sufficiently freed from their adherent soft parts 
the bones are rinsed with water and placed on clean paper 
or wood, to dry, each bone or set of bones being always 
accompanied by the proper label. The vertebre, ribs, 
etc., may remain tied on a string, or they may be num- 
bered. The bones of the hand and foot, and other small 
bones, are very conveniently kept in small cloth sacks. 

It requires from two weeks to several months for com- 
plete maceration of a skeleton. The bones of small ani- 
mals, and the young of the larger ones, macerafe much 
more rapidly than those of large adult animals. Dissect- 
ing-room bodies that have been preserved by antiseptic 
injections macerate with great slowness. Frequent 
changes in the water, especially at the beginning, are 
necessary in order to wash away the preservative, which 
prevents the action of the putrefactive bacteria. It may 
be necessary to boil the bones of such subjects to remove 
most of the soft parts, using the macerating method only 
to finish the cleaning process. 

2. Bowling in Water alone, or in Water to which has been 
added some Chemical Substance.—The animal is prepared 
and all the precautions taken as described under the gen- 
eral directions, then the bones are soaked a day or more 
in cold water, to dissolve out the coloring matter of the 
blood. They are then boiled in water, changing the 
water once or twice, until the soft parts are so far soft- 
ened that they may be completely removed if an artifi- 
cial skeleton is desired, or all removed but the ligaments 
and the fibro-cartilage, if a natural skeleton is to be pre- 
pared. Bones boiled in plain water are liable to be 
‘‘ greased,” as it is called, that is, the melted fat pene- 
trates the bones and makes them appear as if they had 
been soaked in oil. To avoid this, and also to hasten the 
disintegration of the soft parts, some saponifying substance 
is often added during the last half of the boiling. The 
following has proved quite satisfactory : After soaking 
the bones in cold water, and then boiling in plain water, 
about half as long as described above, they are boiled in 
the following mixture, diluted with an equal volume of 
water: Best soap, 75 grams ; nitrate of potash, 12 grams; 
strong water of ammonia, 150 c.c; water, 2,000 c.c. 

After the bones are cleaned by the boiling process they 
are rinsed and spread out to dry, as described for the 
macerated bones. 

Boiling and the use of the saponifying substance have 
the advantage of being far less disagreeable than the mac- 
erating process. It is also much more rapid. For small 
animals, in which the bones are very dense, this method is 
entirely unobjectionable ; but for man and the larger ani- 
mals, generally, the ligaments, periosteum, etc., are so 
tough and thick that the boiling must be continued so 
long to soften them that the organic base of the bones is 
partly gelatinized and dissolved out, thus leaving the bones 
too brittle. . 

Preparation of Skulls. —The skull should be separated 
from the body, and if only the skull is to be preserved it | 
is well to keep with it the atlas and axis. The eyes, skin, 
and most of the muscles are removed; the brain is broken 
up with a stick or metal instrument, and washed out 
with a syringe or strong stream from thé tap ; the larynx 
and os hyoides are removed together from the rest of the 
skull, and a natural skeleton made, leaving thelarynx in 
its natural relations with the os hyoides. It is unsafe to 
macerate or boil the os hyoides and larynx, and a natural 
skeleton should be made by scraping (see below) the fresh 
specimen, or after preservation in twenty-five to thirty 
per cent. alcohol. 

The skull may be boiled or macerated. Maceration is 
preferable for all but the smaller skulls. It is well to 
macerate the smaller skulls, even after they are cleaned 
so far as possible by boiling, in order to remove the soft 
parts covering the turbinated bones. To prevent the 
teeth from falling out it is well to disarticulate the man- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Skeletons. 
Skeletons, 


dible (inferior maxilla) and place the skull and the man- 
dible, with the teeth uppermost, in the macerating dish ; 
then they are held in place by gravity. The cleaning 
must be done with great care, to avoid breaking delicate 
processes and injuring delicate bones. Pieces of wood 
of various sizes and shapes are excellent for removing 
the softened muscles, ete. ' 

Cements for Bones and Teeth.—The pelvis and mandible 
often separate at their symphyses, and the teeth may be- 
come loose and be in danger of falling out. This is espe- 
cially liable to occur with macerated skulls. To unite 
separated or broken bones one may use glue, proceeding 
as for gluing wood; or the white-zinc cement used by 
histologists for sealing microscopical preparations may be 
used. If weight or traction is to be brought to bear on 
the connected parts they must be wired also. For fas- 
tening teeth in their sockets either of the above cements 
may be used, or plaster-of-Paris for large animals, or sili- 
cate of soda or potassa (liquid glass) mixed to a paste 
with powdered chalk. This hardens quickly, therefore 
it, as well as the plaster-of-Paris, must be used soon after 
preparation. The silicate cement and the glue are soft- 
ened by water, and the white zinc is softened by the ben- 
zine used in degreasing. (See below.) 

As soon as a macerated skull is rinsed, the teeth that 
are loose should be taken out one by one, the socket part- 
ly filled with one of the cements and then the tooth re- 
planted. In this way the teeth may be kept in their 
proper places, and as the skull dries the teeth will be 
firmly fixed. Although the teeth of a boiled skull may 
be loose while it is moist, the gelatinized dental perios- 
teum will usually fasten them very firmly as the skull 
dries. The teeth may, if necessary, be cemented as di- 
rected for macerated skulls.* 

3. Cutting and Scraping the Soft Parts from the Bones 
of Fresh, Dried, or Preserved Specimens.—Fresh, dried, or 
preserved specimens may have the skeleton cleaned by 
simply cutting and scraping away the soft parts. It is 
necessary to work with great care, otherwise delicate pro- 
cesses and thin bones will be injured in removing the 
tough connective tissue. When the bones are cleaned as 
well as possible they are allowed to dry, when they may 
be degreased and bleached as described below. 

The safest way to prepare the sternum, with its costal 
cartilages, the os hyoides, in connection with the larynx, 
is to prepare them fresh as just described, or, after pres- 
ervation, in thirty to forty per cent. alcohol, if they can- 
not be freshly prepared. Cutting and scraping the flesh 
from the bones of minute animals, either in the fresh con- 
dition or after preservation in alcohol, is probably the 
only safe method. It is an especially valuable method 
for the preparation of natural skeletons of small and me- 
dium-sized animals, and of parts, as the sternum, of larger 
animals. 

4. Allowing Insects (Ants, Dermestes, Wasps), Tadpoles, 
or Sea-animals, to Hat away the Soft Parts of Fresh Speci- 
mens.—It is desirable to remove the skin and most of the 
soft parts as for maceration or boiling ; then, if dermestes 
are to be utilized, the partly cleaned skeleton is left in a 
damp room. The dermestes will find them, and the larvee 
of these beetles will eat away the soft parts. If the aid 
of ants is to be sought, the partially cleaned bones are 
put in a box, with several holes in it, and placed near 
an ant-hill, and sugar sprinkled along the ground and on 
the bones. The ants will clean the bones more satisfac- 
torily than the dermestes. . It usually takes about a week 
‘for them to clean a cat’s arm. Part of a fresh animal 
may be hung by a wasps’ nest ; they are said to clean it 
quickly and well. If tadpoles or sea-animals are to be 
utilized, the fresh specimen should be sunk in water in 
which the proper animals are known to be present. These 


* ** So far as concerns the general aspect of the skull, the incisors may 
be interchanged, and missing teeth may be replaced by teeth from other 
skulls. It is to be feared that such substitutions are sometimes made 
with skulls prepared for sale. Unless the changes are carefully specified 
such skulls have no real scientific value as regards the teeth.” The same 
may be said of skeletons in general, in which several are put into the same 
macerating or boiling tank, and then the completely separated bones se- 
lected out and put together, or incomplete skeletons are completed by 
borrowing bones from another animal of the same or an allied species. 


methods are unsatisfactory. Only small animals or small 
parts of large animals will be cleaned by wasps or ants, 
and the dermestes only aid decomposition in the air, and 
the bones are very dirty and offensive after their action. 
In utilizing water-animals there is great risk of losing 
small bones. As a general remark it may be stated that 
a really good skeleton, perfect in all its parts, can be 
obtained only by a great amount of care, knowledge, and 
skill, 

Preparation of the Bones of Young Animals.—Great care 
is necessary in this, on account of the readiness with 
which the epiphyses separate and the bonesof the skull 
fall apart. The maceration or boiling should proceed 
only about as far as in preparing natural skeletons, the 
rest of the cleaning being done by careful scraping and 
cutting. As the boiling process is so rapid, it is per- 
haps safest, as the specimen is then constantly under the 
eye of the preparator. 

Disarticulating Skulls—A young or barely mature 
animal should be chosen, since the cranial sutures are 
liable to be partly or wholly obliterated in adults and the 
old. The skull may be cleaned by maceration or boiling. 
If the boiling process is used, boil the skull half an 
hour longer than for one not to be disarticulated. ‘While 
still moist, the bones may be separated by steady traction 
and careful prying and wedging. This may be done with 
great readiness if half-grown animals are used. Skulls 
that have dried are usually more easily disarticulated after 
being soaked in cold or warm water until the remnant 
of connective tissue between the sutures has become 
softened. Fora human skull to be disarticulated, that 
of a person from fifteen to eighteen years is best. It can 
be best cleaned by very complete maceration ; then, while 
it is still moist, or after it has been remoistened, the 
bones are separated by traction, by wedging and prying, 
as described above. It is best to commence with the 
bones of the face, so that the larger and firmer bones may 
serve as a kind of handle, and also as asupport. The 
disarticulation of skulls, except those of young animals, 
is very tedious, and requires a great deal of time and 
skill. 

Degreasing Bones.—Except in rare cases neither does 
all the fat decompose in maceration, nor is it all sa- 
ponified in the boiling process, hence it is necessary to 
use some solvent of fat to remove what remains. This 
solvent should not injure the bones, and it should be 
cheap. Benzine answers these requirements. After the 
bones have been cleaned in any of the ways described 
above, and thoroughly dried, they are placed in large 
glass jars or other vessels that can be tightly closed, and 
covered with benzine. If the bones are very greasy, it 
may be necessary to change the benzine once or twice. 
The time required for the degreasing depends on the size 
of the bones and the amount of grease in them. Two 
weeks is usually sufficiently long for a human skeleton. 

Natural skeletons may be degreased by the benzine, 
but they must not be left too long in it, for it makes the 
ligaments, especially of boiled skeletons, too fragile. 

Bleaching Bones.—If care be taken in changing the 
water during the first few days of maceration so as to 
remove all the blood, also if the blood be soaked out be- 
fore boiling, the bones usually require no bieaching.* 

If for any reason the bones are not sufficiently white 
they may be bleached after being well degreased : (a) By 
exposure to the sun, rain, and dew. This requires con- 
siderable time and a protected place. (b) The bones 
may be soaked in a weak solution of chloride of lime— 
chloride of lime, 25 grams ; water, 100 cc.—Labarraque’s 
solution or eau de Javelle, 1 part to 4 or 5 of water. 
Chlorine is the bleaching agent in all of these, and the 
hydrochloric acid formed in the chemical reactions re- 
mains in the liquid and injures the bones, hence the ne- 
cessity of a weak solution and a short exposure (4 to 12 
hours). After the bones have become sufficiently bleached, 


*Tf one has the specimen to be skeletonized in a fresh condition, it 
usually repays the trouble to wash out the blood by injecting a large 
amount of water into the blood-vessels. The arch of the aorta might be 
injected until the water runs uncolored from the veins. A constant- 
pressure apparatus is very convenient for this. 


453 


Skeletons, 
Skin Diseases, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


they are washed and dried. It is often advantageous to 
give the bones several short immersions, allowing them 
to dry in each interim, rather than one long immersion. 
Great care is necessary in bleaching natural skeletons 
with any of the chlorine compounds. (¢c) Degreased bones 
are quickly bleached by peroxide of hydrogen (Hz O2».). 
A so-called twelve to fifteen volume per cent. solution, 
diluted with an equal volume of water, and rendered neu- 
tral or slightly alkaline by the addition of ammonia or car- 
bonate of soda, etc., will bleach a human skeleton in a 
few days. The bones must be put into a jar, and then 
covered with the peroxide solution, and tightly closed to 
prevent the escape of the oxygen. It is well to remove 
the bones and allow them to partly dry once or twice, to 
hasten the bleaching. The stock solution of peroxide 
should be kept in acool place, and tightly corked, to pre- 
vent deterioration. Peroxide is the best bleaching agent 
for bones, as no injurious product is formed during the 
bleaching process. It is, however, expensive. 

Final Arrangement of Skeletons.—If the skeleton is to 
be a disarticulated one, that is, if the bones are to remain 
separate, it is desirable to have each skeleton in one box, 
having the smaller bones in sacks or small boxes. The 
articulation or joining of the bones to make an artificial 
skeleton is a purely mechanical process, although it re- 
quires skill and experience. It can best be learned by 
working with an experienced workman. Rule of thumb 
should, however, be checked by careful observation of 
the natural attitude of the body and its curves, also the 
actual position of such movable parts as the scapula in 
the various positions in which it is desirable to mount 
skeletons. ‘This can be done only on the living model. 

A good general rule to follow in articulating a skeleton 
is to bore all necessary holes before attempting to put 
the bones of a part together. In this way strain on the 
partly mounted skeleton, and the necessity of boring 
holes in inconvenient positions, will be avoided. It is 
desirable to have diagrams of the various parts, showing 
the exact number and position of all wires and bolts. 
For study, and also for guidance in mounting, a hand 
and foot, with the bones held in apposition with spiral 
springs, instead of the wires ordinarily used, are very con- 
venient, as the bones can be sutticiently separated to 
bring the articulating surfaces into view. 

For natural skeletons the various parts should be ar- 
ranged as desired while the skeleton is moist. If the 
parts are held in position by strings, pins, etc., they will 
dry and remain in the desired position. It is a great ad- 
vantage to have a natural skeleton somewhat flexible. 
This may be attained by soaking the skeleton before it 
has been dried, or after remoistening it, in Wickerscheim- 
ers preservative,* for three to ten days before it is ar- 
ranged and dried. It is an excellent plan for small and 
young animals to have the hyoid, sternum, and tail pre- 
pared as flexible natural skeletons ; it is also desirable in 
many cases to have the hand and foot (manus and _ pes) 
of one side prepared as a flexible natural skeleton, al- 
though the rest of the skeleton is artificial. 

The statements and directions in the present article are 
based upon personal experience in the Anatomical De- 
partment of Cornell University, upon the manuscript 
notes of Dr. Theobald Smith, and upon the works and 
papers named below. 


REFERENCES. 


Batty, J. H.: Practical Taxidermy, pp. 86-90. New York, 1880. 

Ateey Capt. Thomas: The Taxidermist’s Manual, pp. 94-99, London, 

Capus, G.: Guide du Naturaliste Préparateur, pp. 150-167. Paris, 1883. 

Kingsley, J. S.: The Naturalist’s Assistant, pp. 16-18. Boston, 1882. 

Morrel, C., et Duval, M.: Manuel de l’Anatomiste, pp. 60-66, 134-135. 
Paris, 1888. 

Mojsisoyics, E. von Mojsv4ér: Leitfaden bei Zodlogische-zootomischen 
Praparirtibungen, pp. 38-44. Leipzig, 1879. 

Patterson, A. M.: A Method of Maceration, being a Description of the 


* This solution is prepared as follows: Arsenious acid, 16 grams; so- 
dium chloride, 80 grams ; potassium sulphate, 200 grams; potassium ni- 
trate, 25 grams; potassium carbonate, 20 grams, are dissolved in 10 
litres of boiling water. After cooling, the solution is filtered, and to it is 
added 4 litres of glycerin and 750 c.c. of ninety-five per cent. alcohol. 
For the purposes of preparing flexible natural skeletons the alcohol is un- 
necessary. 


454 


Method in Use at Owen’s College, Manchester, Journal of Anatomy 
and Physiology, 1885, vol. xix., p. 171. 

Straus-Durckheim, H.: Traité pratique et théorique d’Anatomie com- 
parative, tome i., pp. 285-298. Paris, 1842. 

Wilder and Gage: Anatomical Technology, 2d edition, pp. 103-111. New 
York, 1886. F 


Simon H. Gage. 


SKIN, ATROPHY OF THE. Synonym: Atrophia cu- 
tis propria. Atrophy of the skin may occur as a sequence 
of certain well-defined cutaneous diseases which produce 
ulceration or absorption of tissue, such as syphilis, lu- 
pus, or favus. It is also observed to follow and depend 
upon certain injuries of nerve-trunks, forming the glossy 
skin of Paget and Mitchell. But neither of these two 
conditions is a true idiopathic atrophy, and they will, 
therefore, not be considered in the present article. 

Four forms or conditions of primary or idiopathic 
atrophy of the skin may be noticed, viz., atrophia cutis 
generalis, senilis, linearis, and maculosa. 

1. Atrophia Cutis Generalis. — General or extensive 
atrophy of the skin is very seldom met with, although it 
is recognized by authors, and instances of it are occasion- 
ally reported. Many of these cases, however, belong 
more properly to xeroderma, morpheea, and scleroderma. 
In those cases of unilateral atrophy of the face in which 
the skin appears drawn down and atrophied, the lesion 
is deeper and involves the subcutaneous tissues, muscles, 
and occasionally even the bone. These cases, therefore, 
should rather be excluded here, as they are due to deep 
nerve influence—possibly, as has been suggested, to per- 
manent irritation of the cervical sympathetic. 

2. Atrophia Cutis Senilis.—Senile atrophy of the skin 
is to.be looked upon as a physiological rather than a patho- 
logical condition, although the changes which take place 
with advancing years are such as predispose to certain 
diseases, notably pruritus senilis, and epithelioma. The 
skin of elderly persons loses its elasticity, the surface be- 
comes dry and wrinkled, and the hue changes from the 
well-known flesh-color to more nearly the appearance of 
parchment, with a tendency to the formation of pig- 
ment points and toslight desquamation. The anatomical 
alterations upon which these changes depend consist in 
an atrophy of all the component parts of the skin and 
subcutaneous tissue, expressed in a thinned epidermis, 
flattened papille, shrunken corium, and atrophied hair- 
follicles, either with or without fine lanugo hairs; the 
sebaceous glands have lost their activity, and are often 
found filled with dried epidermal masses. Another con- 
dition or form of atrophy is also described, in which the 
tissues undergo degeneration into a more or less homo- 
geneous mass, styled hyaloid or waxy degeneration, or 
they may become granular and pigmented. 

3. Atrophia Cutis Linearis.—Synonyms: Strix atro- 
phicee ; Atrophic lines. These consist in lines or streaks 
in the skin, of various dimensions, of an inch or more 
in length by half an inch in width; they are seen to be 
sharply defined in the healthy skin, slightly depressed, 
have a whitish or bluish-gray color, and give to the 
touch a sensation of being perceptibly thinned. When 
pinched up the surface presents fine wrinkles, very dif- 
ferent from those in the adjacent skin. 'The most com- 
mon and well-recognized form of this alteration is seen 
on the abdomen and breasts of women who have borne 
children, where the surface is more or less thickly cover- 
ed with these striations (linee albicantes). They occur, 
however, in many other conditions and situations as well, 
and may appear wherever the skin has been subjected to 
somewhat rapid stretching, as on parts which have been 
anasarcous ; also where there has been sudden increase 
and diminution in flesh ; they are seen principally on the 
thighs and buttocks. The streaks are usually more or 
less parallel to one another, and commonly parallel to the 
long axis of the body. Microscopically these patches 
show atrophy of the textures of the skin, thinned epider- 
mis, an almost entire absence of papille, and the connec- 
tive tissue and elastic fibres of the corium are gathered 
into very thin bundles, with a few slender blood-vessels 
between them. 

4. Atrophia Cutis Maculosa.—Synonyms : Macule atro- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Skeletons. 
Skin Diseases, 


phice ; Atrophic spots. This most curious condition is 
quite rare, but is occasionally met with in very marked 
form. It consists in well-defined spots, from an eighth 
to half an inch or more in their longest diameter, gen- 
erally roundish or oval, slightly depressed, whitish, 
smooth, and glistening, and suggestive of a very supple 
scar. Often but few will be seen, but occasionally sev- 
eral dozen may be observed scattered over various re- 
gions of the body. It is stated that these patches first 
manifest themselves as erythematous spots, and it is sug- 
gested that the condition is closely allied to morphea, 
although there is none of the lardaceous deposit preced- 
ing the atrophy, such as is seen in the latter disease. No 
cause for the affection has been discovered. 

The conditions here described are not such as generally 
call for treatment, and little or nothing can be done to 
affect them favorably. Local faradization and stimulants 
externally may arrest the increase of the linear and mac- 
ular varieties. LL Duncan Bulkley. 


SKIN DISEASES, CLASSIFICATION OF. The oldest 
forms of dermatological classification were based upon 
the seat of the affection, e.g., diseases of the scalp and 
diseases of the rest of the surface. Later, skin diseases 
were divided into the local or idiopathic, and the consti- 
tutional, general, or symptomatic. ‘‘ Unfortunately, not 
only may the same cutaneous affection be produced by 
the most different causes, but the most varied diseases of 
the skin may also be caused by one and the same morbid 
agent. And it is not possible in every instance to draw, 
from the form and appearance of a dermatosis, any certain 
inference as to its origin from a local or general cause ” 
(Hebra). 

Erasmus Wilson and others adopted an anatomico- 
physiological system, starting from the opinion that it is 
possible to ascribe distinct names and characters to the 
affections of the different tissues which make up the 
skin ; that is to say, of the epidermis, of the rete, of the 
papille, of the corium, and of the follicles, the vessels, 
the nerves, etc. But the integument isan organ of which 
the component tissues are very rarely separately affected 
by disease, so that it is very often impossible to say which 
strata are more, and which less, involved. Systems of 
this sort have been found so peculiarly unpractical that 
. they have never found many adherents. 
~The most popular classifications of skin disease in the 

past have been those which have for their basis the ex- 
ternal form of the disease. The most important of these 
classifications was that of Willan, which included all 
cutaneous affections under the several heads of: 1, Pim- 
ples; 2, scales; 3, rashes; 4, vesicles ; 5, pustules; 6, 
tubercles; 7, spots. At first sight this arrangement 
seems almost fascinating in its simplicity. But a single 
character is not enough for the determination of a dis- 
ease, especially when thus torn from its connection with 
the other symptoms with which it is associated, and 
when all other appearances presenting themselves in the 
course of the case are left unnoted. Perhaps no other 
one thing, unless it be the eccentric and singular nomen- 
clature devised by one or two great writers, has so hin- 
dered the study of diseases of the skin as this apparently 
simple classification. ; 

The system, however, which for many years, and until 
quite recently, has dominated the German and American 
schools of dermatology, is that of Hebra. Less imposing 
perhaps than others which pretended greatly to scientific 
accuracy and logicalness, or which assumed the airs of a 
‘‘natural system,” Hebra’s system has been found prac- 
tically useful, and it is only of late years, with the great 
advance made in the clinical and pathological study of 
diseases of the skin, that this system has begun to prove 
cramping and insufficient. As modified slightly by the 
American Dermatological Association, and still used 
by it as the official framework for its valuable annual 
statistics of dermatology, this classification is as fol- 
lows: Class 1, Disorders of the glands; class 2, inflam- 
mations ; class 38, hemorrhages ; class 4, hypertrophies ; 
class 5, atrophies ; class 6, new growths; class 7, newro- 
ses ; class 8, parasitic affections. 


In 1881 the late Professor Auspitz, of Vienna, put forth 
a system of classification more suitable to our present 
knowledge and needs than any one previously in use. 
As it cannot be clearly comprehended without the entire 


-series of subdivisions, the whole scheme, excepting only 


the names of the specific affections, is given below : 
FIRST CLASS. 
SIMPLE INFLAMMATORY PROCESSES OF THE SKIN (DER- 
MATITIDES SIMPLICES). © 
A. Superficial Inflammations of the Skin. 


(Dermatitides Catarrhales, Catarrhs of the Skin.) 


I. Faminy: Superficial Catarrhs of the Skin. 


1. Mere hyperemia prevailing. 
2. Sero-purulent exudation prevailing. 


II. Faminy: Hrosive Catarrhs of the Skin (Stigmatoses). 


1. Due to animal parasites : 
Parasitic stigmatoses. 
(a) Entomoses. — 
(b) Acarinoses. 
2. Due to wounds of other kinds: 
Traumatic stigmatoses. 


Ill. Faminy: follicular Catarrhs of the Skin (Perifolli- 
culoses), 


1. Only around the apertures of the follicles. 
2, Also around the excretory ducts of the follicle and 
the follicle itself. 
(a) Without simultaneous disease of the hair- 
sheaths and hairs. 
(b) With simultaneous disease of the hair- 
sheaths and hairs. 


IV. Faminy: Stasis Catarrhs of the Skin. 


1. With the termination of the formation of epidermis. 
2. With the termination of cicatrization. 

B. Deep-seated Inflammations of the Skin. 
(Dermatitides Phlegmonosee, Phlegmons of the Skin.) 


I. Faminy: Diffuse Phliegmons of the Skin. 


1. Due to burning. 
2. Due to freezing. 
8. Without external wounding. 


Il. Famrny: Otvrcwmscribed Phiegmons of the Skin. 
III. Faminy: Stasis Phiegmons of the Skin. 


SECOND CLASS. 
ANGIONEUROTIC DERMATOSES. 


Dermatoses with the character of an extended disturb- 
ance of the tonicity of the vessels, together with more 
or less marked inflammatory congestion on the surface 
of the skin. 


I. Faminy: Infectious Angtoneuroses of the Skin (Acute 
Exanthemata, Hruptive Fevers). 


1. With prevailing catarrhal character. 
2. With prevailing phlegmonous (diphtheritic) charac- 
ter of inflammation of the skin. 


Il. Famity: Torie Angiomata of the Skin (Medicinal 
EHxanthemata). 


1. With prevailing inflammatory congestion. 

2. With prevailing spasm of the vessels of the skin. — 

3. With obstruction of the vessels and termination in 
necrosis. 


III. Faminy: Essential (Idiopathic, Diathetic) Angvoneu- 
roses of the Skin. 


1. With prevailing inflammatory congestion. 

2. With prevailing spasm of the vessels of the skin. 

8 With dilatation of the vessels, and new growth of 
vessels. 


455 


Skin Diseases. 
Skin-Grafting. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


THIRD CLASS. 
NEURITIC DERMATOSES. 


Due to diseases of the sensory (and also trophic ?) 
nerve elements. 


TL. Faminy: Neuritic Dermatoses with Determinate Course. 


II. Faminty: Neuritic Dermatoses with Indeterminate 
Course. 

1. With prevailing inflammatory congestion (neuritic 
inflammatory processes in the skin). 

2. With prevailing spasm of the vessels of the skin 
(neuritic eedema of the skin). 

3. With prevailing atrophy of the skin (neuritic atro- 
phies of the skin). 

4, With actual necrosis of the skin (neuritic necrosis 
of the skin). 


FOURTH CLASS. 
Stasis DERMATOSES. 
Dermatoses with the character of passive circulatory 
disturbance and injurious vaso-lymphatic absorption. 
A, With Incomplete Stasis. 
I. Faminy : Hyperemic and Anemic Stases. 


Il. Faminy: JZransudation Stases. 


1. The transudation remains in fluid form. 
2. The transudation leads to induration and hypertro- 
phy of the connective tissue of the skin. 
3. The transudation leads to atrophy of the connective 
tissue of the skin. 
B. With Complete Stasis, 


Onuy Famity: YNecrotic Staets. 


FIFTH CLASS. 
Ha:MORRHAGIC DERMATOSES. 


Dermatoses resulting from increased passage of the 
red blood-corpuscles through the walls of the cutaneous 
vessels, without inflammatory congestion or local stasis 
in the latter. 


I. Faminy: Traumatic Hemorrhages. 
Il. Faminry: Hssential Hemorrhages (i.e., Independent of 
External Irritation). 


1. With the existence of slight general disturbance. 
2. With predominant general disturbance. 


SIXTH CLASS. 


Functional anomalies of the nerves of the skin with- 
out trophic changes of the skin. 


A. Sensory Neuroses of the Skin. 


I. Famity: Tactile Neuroses. 
II. Famity: Neuroses of Cutaneous General Sensation 
(Dermatalgia). 
1. The neurosis occurs in the form of pain. 
2. The neurosis occurs in the form of itching. 
B. Simple Motor Neurovoses of the Skin. 
Onty Famity: Dermatospasmus. 


SEVENTH CLASS. 


Anomalies of growth of the epidermis and its appen- 
dages. 


A. Anomalies of the Epidermis and Secretion (Kerato- 
noses). 


FIRST ORDER.—KERATOSES IN A NARROWER SENSE. 
I. Famity : Hyperkeratoses. 

1. Diffuse. 

2. Around the follicle. 

3. In areas, but independent of the follicles. 


Il. Famizty : Parakeratoses. 
Diffuse. 
Follicular. 


at oe 


456 


Ill. Faminy: Keratolyses. 


SHCOND ORDER.—TRICHOSES. 
I. Famity : AHypertrichoses. 
Il. Faminy : Paratrichoses. 
III. Faminy: Atrichoses. 
1. Diffuse. 
2. In areas. 
THIRD ORDER.—ONYCHOSES. 
I. Faminy : Hyperonychoses. 
II. Faminy: Paronychoses. 
III. Faminry: Onycholyses. 


FOURTH ORDER.—STEATOSES. 


I. Faminy : Hypersteatoses. 
Il. Faminy: Parasteatoses. 
Ill. Faminy : Asteatoses. 


FIFTH ORDER.—IpxKosEs. 
J. Faminy: Hyperidroses. 
II. Faminy : Paridroses. 
III. Famity: Anidroses. 


R. Anomalies of Pigment Formation in the Skin (Chro- 
matoses). 


I. Famity : Hyperchromatoses. 
1. Congenital. 
2. Acquired. 
Il. Faminy : Parachromatoses. 
III. Famrity: Achromatoses. 
1. Congenital. 
2. Acquired. 


C. Anomalies of the Prickle-cell Layer of the Epider- 
mis (Akanthoses). 


I. Faminy : Hyperakanthoses. 


1. Proliferation of the prickle-cell layer on the surface 
of the skin (warty akanthomata). 

2. Proliferation of glandular ducts (cutaneous ade- 
noma). 


II. Faminy: Parakanthoses. 


1. With distinct cornification of the newly-formed 
cells. 
2. Without cornification of the newly-formed cells. 


III. Faminy : Akantholyses. 


EIGHTH CLASS. 
CHORIOBLASTOSES. 


Anomalies of growth of the corium and of the subcu- 
taneous connective tissue. 


A. Excessive Development of the Connective-tissue 
Layer. 


Onty Famity : Hyperdesmoses. 


B. Paratypical Growth of the Connective-tissue Layer 
of the Skin (Paradesmoses), 


I. Faminy: Granulomas of the Skin. 
II. Famrny : Desmomas of the Skin. 


C. Atrophy of the Connective-tissue Layer, or Con- 
genital Deficient Development of the Same. 


SINGLE FAMILY : Adesmoses. 


1. Universal and diffuse. 
2. Partial. 


NINTH CLASS. 
. DERMATOMYCOSES. 
Fungous diseases of the skin and its appendages. 


I. Faminy: Mycosis Scutulaia. 

Il. Faminry: Mycosis Cireinata. 

_ IIL. Faminy: Mycosis Pustulosa. 
IV. Faminy: Mycosis Furfuracea. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Auspitz’s method in the construction of his classes has 
been to regard, first the sum total of the processes upon 
which the skin diseases depend, and then, selecting from 
these processes those which are most essential and funda- 
mental. to group the affections accordingly. The result 
has been an etiological division, rather as a necessary 
consequence of the method than from any original design 
on the author’s part. The most essential pathological 
processes prove also to be those which stand in a proxi- 
mate causative relation to the cutaneous affections. The 
method adopted by Hebra differed from this in that the 
skin affections were classified according to certain pre- 
viously observed rules of general pathology. Auspitz’s 
method reaches much further, and seeks to carry the in- 
quiry to what may be termed the prime motives of 
diseases (Bronson). 

By Auspitz’s classification the objects classified are not 
so much the skin affections themselves as the general 
morbid conditions which tend to the production of skin 
disease. 

Objection has been made to this classification on the 
score of its want of adaptability to dermatological study. 
But although not so simple as former systems, its mastery 
will give a command of the general subject which can be 
gained in no other way. : 

Within the last year or two Bronson has, in two able pa- 
pers, criticised Auspitz’s system, and has proposed some 
modifications which have yet to be acted upon by der- 
matologists. Reference is made below to these papers. 


BIBLIOGRAPHY. 


Hebra: Diseases of the Skin. N.S. Soc., vol. i., p. 43. 

Auspitz: System der Hautkrankheiten. Wien, 1881. 

Idem: Ziemssen, Hautkr., Ite Halfte. s. 268. Leipsic, 1883. 

Bronson: The Objects of Dermatological Classification, etc. 
and Ven. Dis., New York, 1884. 

Idem: A Study of the Considerations Relating to the Classification of 
Skin Diseases. Read before the Am. Dermatological Assn. ; Jour. Cut. 
and Ven. Dis., 1887. 


Jour. Cut. 


Arthur Van Harlingen. 


SKIN-GRAFTING (Greffe épidermique, Fr.; Hautiber- 
pflanzung, Germ.). By this term is meant the applica- 
tion of minute pieces of the outer layers of healthy skin 
to a granulating surface for the purpose of hastening its 
cicatrization. 

_ The principle of this method is that, if a piece of liv- 
ing epidermis be transferred to a proper soil it will grow 
there, and serving as a focus of cicatrization, will unite 
with other similar points, or with the cicatrizing edges 
of an ulcer, and thus close it more rapidly and with less 
subsequent contraction than if it be left to heal from the 
edges alone. Experience has further taught that this also 
stimulates the cicatrization at the edges to greater activ- 
ity. 

‘This little operation received its present general adop- 
tion as a surgical procedure in 1869, from Reverdin,! 
an interne in La Charité Hospital, in Paris, and was by 
him reported to the Société de Chirurgie on December 
8th of that year. His report excited great interest, and 
MM. Guyon, Gosselin, A. Guérin, Duplay, and Marc Sée 
offered him facilities for further trials, and others in 
France and other countries, notably Poncet,’? of Lyons, 
and Pollock,? of London, practised the operation. This 
was soon found so simple and useful that it immediately 
became recognized and practised throughout the profes- 
sional world. 

The operation is to be performed by first washing the 
surface of the ulcer with warm antiseptic solution (mer- 
curic bichloride 1 to 3,000, or carbolic acid two and 
one-half per cent.), and the surface from which the 
‘‘orafts” are to be taken with one of double that 
strength. A minute piece of skin from the cleansed sur- 
face is then seized with a pair of fine forceps, lifted up, 
and snipped off with a pair of fine scissors curved on the 
flat. For this purpose a pair of single-toothed forceps a 

little stronger than the ordinary iridectomy forceps, and 
the usual iridectomy scissors, are the most convenient 
and quickest to work with. M. Reverdin used a needle 
to lift the epidermis with and shaved the graft off with a 
thin, sharp scalpel. A combined forceps and scissors, 


placing it upon the thumb nail, previously disinfected 


Skin Diseases, 
Skin-Grafting, 


working together by a single motion, has been invented 
and is figured in most articles on this subject ; but I have 
found it not nearly so satisfactory as the less expensive 
and always obtainable separate forceps and scissors. 
The piece removed should be about the size of the head 
of an ordinary pin ; if larger, it may be made smaller by 
and cutting it into two or four pieces according to its 
size. Only the epidermic layer of the skin is to be taken ; 
the cut surface should not bleed, but should show the 
blood-vessels underneath. The rete Malpighii is the 
layer sought for application to the granulations. The 
little piece is immediately placed upon the granulating 
surface in the position removed, ?.¢., cut surface down- 
ward, pressed gently into it, with just sufficient firmness 
to allow it to adhere, care being taken not to cause the 
granulations to bleed. 

The grafts are best applied along the edge of the ulcer, 
from one-fourth to one-half an inch distant from it, and 
at equal distances from each other. If the ulcer be not 
too large they may be arranged in a series of parallel rows 
across it; or, if the outline be very irregular, a bridge 
may be thrown across a bay from cape to cape. The 
arrangement is immaterial, but they should not be ap- 
plied at a distance from already formed skin, though I 
have exceptionally found them to ‘‘ take” when in a 
group by themselves quite remote from the edge. 

After the grafts have been inserted a piece of thin 
gutta percha protective, previously placed in an antisep- 
tic solution for twenty minutes, is laid over the grafts, 
extending beyond them over the ulcer if it is large, and 
beyond the edges upon the skin. This is covered again 
by alayer of absorbent or borated cotton, and the whole is 
secured in place by a roller of sublimated gauze bandage. 
The part should be kept as motionless as possible, so as 
not to disturb the surface, and the dressing should not 
be removed for about three days, when the coverings 
down to the protective should be taken off to see if 
there be any considerable amount of pus secreted. If 
the edges of the cotton beyond the protective are soaked 
with pus, orif pus has dried upon the dressing to any con- 
siderable degree, it is all to be carefully washed with an 
antiseptic solution. A little stream of the solution from 
an irrigator is best, but the surface must not be wiped 
with anything, and if it all looks clean underneath the 
protective, fresh dressings above this are to be reapplied 
and allowed to remain for three days more. If, however, 
there be considerable pus, either under the protective or 
on the cotton, the former must be very carefully lifted 


_off, and a stream of the antiseptic solution allowed to 


run over the ulcer to wash the pus away. If the grafts 
are not washed away with the pus a fresh clean piece of 
protective is to be applied, and the other dressings added 
as before. This process is to be repeated at intervals of 
about three days or oftener, 
depending on the amount of 
pus found on the dressings, 
until the ‘‘ grafts ” are seen 
to have fairly ‘‘ taken,” as 
will be shown by the ap- 
pearance on their edges of 
an extremely thin, smooth, 
delicate, pellucid, pink line | 
of cicatrization, which in- 
dicates the growth of the 
epidermis over the granula- 
tion (Fig. 3532). The pro- |: 
tective may then be omitted, { 
and a simple dressing sub- 
stituted, vaseline or other 
bland, unirritating salve ap- 
plied on a piece of absor- 5) 

bent cotton or other sub- Fre, 8532.—Skin-grafts Growing. 
stance, according to choice. 

The grafts should be taken from a thin skin, ¢.e., where 
the external layers of epidermis are not superabundant 
or hard—the inside of the thighs, the flexure of the elbow, 
or the walls of the chest below the axilla—and where 
there are but few hairs or glands. 


457 


Skin-Graf tinge. 
Skin Transportation. 


The operation itself, therefore, is quite simple ; the es- 
sential point is the selection of the time when the granu- 
lations are in the proper condition to receive the grafts ; 
it is on this more than on any other one point that the suc- 
cess of the treatment depends. They must be suppurat- 
ing slightly, indicating activity in the blood-supply, but 
not profusely, or the grafts will be washed away before 
they have formed adhesions. ‘They should be florid and 
fresh-looking, soft and succulent, but not flabby nor exu- 
berant, not glazed over nor cedematous and overhang- 
ing the edges; nor must the ulcer be excavated or the 
granulations be hard, bright red, and irritable-looking. 
They must be in the condition most favorable for cica- 
trization at the edges, and the surgeon may derive some 
aid from the circumstance of peripheral cicatrization in 
determining the proper time to apply the grafts; but he 
should also be able to judge independently of this by the 
granulations themselves. The skill of the surgeon con- 
sists in bringing the granulations to the proper condition, 
and in recognizing this when he sees it, rather than in 
the technique of the trivial operation. 

As soon as one set has formed attachments and begun 
to grow, another set inside of this may be inserted, and 
again another inside of this, until the ulcer is closed. It 
depends on the size of the ulcer as to whether it may be 
entirely covered with the grafts or not ; and it is well, if 
tlie first set show that the granulations are in a favorable 
condition to nourish the grafts, to seize the opportunity, 
and at once Gover over a larger surface with them. The 
advantage of applying the grafts around the edges is that 
they will form adhesions with the skin of the edges, and 
thus become connected with the rest of the cutaneous 
circulation and have a better prospect of living; the sup- 
position being that the island formed by the growth of 
the graft will not extend indefinitely. The limit of this 
extension has been placed at an area of about the size of 
an English sixpence, but I have seen one over the crani- 
um, where the scalp had been torn off, that was much 
larger than this, and quite unattached at its edges. 

After the grafts have been applied for a few days, it 
will be noticed that they have become quite white and 
apparently lifeless, and a stream of water running over 
them will wash off the superficial layers, leading one to 
think that the graft has separated from its bed, and has 
not ‘‘taken;” careful observation, however, will show 
that the deeper layers are still attached, the external lay- 
ers of the epidermis only having separated ; while a spot, 
larger or smaller, pinkish in color and smooth on its sur- 
face, remains attached. It is from this that the remainder 
of the epithelial covering grows. 

Scrapings of the epidermis and shavings of corns are 
said to have been successfully‘ used for grafts, but this 
plan has not found general approval, as it is too uncertain. 
Grafts of this kind would naturally have less vitality, be 
less capable of proliferation, and have less reproductive 
power than the younger cells of the rete Malpighii. 

Do the grafts grow by a reproduction of their own ele- 
ments? Do the epithelial cells multiply by a duplication 
of their nuclei? Or do the grafts, 7.¢., the epithelial cells, 
act simply as stimulants to the granulations, 7.e., con- 
nective-tissue cells underneath, causing them to take on 
an epithelial growth? These questions have been ac- 
tively discussed by various investigators and pathol- 
ogists. It was thought that the question was settled 
when the experiment was made of engrafting the epi- 
dermis of a negro upon an ulcer on a white person,® the 
result being that a series of pigmented islands were 
formed, which gradually coalesced with the surrounding 
skin, leaving a black cicatrix. The observations, how- 
ever, have not been uniform, for in other cases the grafts 
have not been pigmented, and the results were therefore 
negative. ‘The counter-experiment of white grafts upon 
a negro is not so valuable, as it is well known that an or- 
dinary, non-grafted cicatrix of an ulcer on a negro is 
sometimes white, or perceptibly less pigmented. If we 
may argue by analogy from the development and growth 
of the tissues from the germinative-layers of the embryo, 
we certainly are not justified, in the absence of positive 
observation of the steps of the transformation, in regard- 


458 


REFERENCE HANDBOOK OF. THE MEDICAL SCIENCES. 


ing a transformation of connective tissue as ever taking 
place here. 

The newly-formed, like other cicatricial skin, remains 
thinner than the surrounding integument for some time, 
and is more liable to break down if subjected to any con- 
siderable irritation, or if the patient be attacked by an 
exhausting disease; but it gradually becomes thicker 
by the consolidation of the deeper with the superficial 
layers of the granulations, forming respectively the epi- 
dermis or cuticular layer, and the corium or connective- 
tissue layer. It serves the purpose of normal skin in 
protecting the parts below, and, except for the absence of 
all the glandular elements, hair-bulbs, sweat-glands, and 
sebaceous follicles, it is true skin. 

It does not seem to be necessary that the subject from 
whom the grafts are taken should be living at the time 
they are removed. Dr. J. H. Girdner,® in 1877, used 
grafts removed six hours after death, taking a large piece 
from the inside of the thigh of a young man dead from 
hemorrhage. This large 
piece was cut into minute 
grafts and inserted upon 
a large ulcer on the arm 
and back of a boy, ten 
years of age, who had 
been burned by lightning 
some months previous- 
ly, and the grafts took 
well. The limit of vital- 
ity of the piece of skin 
after it has been removed 
is of great practical in- 
terest, and has been the 
subject of much experi- 
mentation, Dr, E.. P. 
Brewer,’ of Norwich, 
Conn., found that thirty- 
six hours was the limit 
of vitality, out of eight 
trials in which he 
removed pieces of 
skin from ampu- 
tated limbs, and, 
without any es- 
pecial care in their 
preservation, after- 
ward cut grafts 
from these pieces 
and applied them 
in the usual way. 

Georges Martin® 
experimented with 
grafts kept at dif 
ferent tempera- 
tures, and found 
they preserved their vitality in inverse ratio to the degree 
of heat, though the longest period that he was able to 
keep a graft and have it live and take was ninety-six 
hours, the graft being kept at a temperature just above 
0° Centigrade (82° F.). There was a slight difference in 
favor of ‘‘confined” as distinguished from ‘“‘ free” air in 
M. Martin’s experiments. 

Grafts have been taken from the skin of animals (z0d- 
grafting), and have taken root on ulcers on the human 
subject. The preparation and selection of the skin is 
similar to that in the case of the human subject. The 
part is to be shaved, washed, and the grafts taken from - 
the deeper layers. It goes without saying, from what 
we know of the growth of the skin as already described, 
that there can be no expectation of a reproduction of 
hair or other adnexa. Liétevant® proposes a nomencla- 
ture for the different varieties as follows: Auto-epider- 
mic, when taken from the same person, hetero-epidermic, 
when from another person, and zoé-epidermic, when the 
skin of an animal is used. 

Of course, great care must be taken, in transferring 
grafts from one person to another (hetero-epidermic), that 
the one from whom the grafts are taken be free from any 
constitutional disease. The danger that syphilis might 


Fig, 3533.—Dr. Girdner’s Case of Grafts Taken 
from Dead Subject. 


REFERENCE HANDBOOK OF 


THE MEDICAL SCIENCES. Skin-Grafting. 


Skin Transportation. 


thus be communicated, led some surgeons, in the early 
days of the procedure, to regard the hetero-epidermic 
method as unjustifiable ; but the experience of thousands 
of operations has shown that by careful investigation 
such an unfortunate complication may be avoided. On 
the other hand, Deubel reports a case in the Gazette méd- 
tcale de Paris, No, 35, 1881, in which syphilis was com- 
municated to a father by grafts taken from his son, who 
was, unknown to the surgeon, the subject of this disease. 

In the year following the publication of the account 
of M. Reverdin’s operation, Dr. Frank H. Hamilton !° 
claimed precedence for the principle of skin-grafting by 
referring to an operation which he had performed in 
1854, having previously, in 1847, suggested a similar op- 
eration to another patient, which was declined. The ac- 
count of the operation was published in that year (1854). 
If anyone will, however, take the trouble to read the 
original description of Dr. Hamilton’s operation, it can- 
not be otherwise than evident that it was simply a plas- 
tic operation, a transplantation of the whole skin, after a 
new method, it is true, but certainly not the grafting of 
a minute particle of epidermis upon a granulating sur- 
face. He'! calls his operation elkoplasty, or ulcers 
treated by anaplasty. It was performed for the cure of 
a large ulcer of the right leg. It consisted in preparing 
a flap of integument, seven by four inches, from the op- 
posite (left) leg, ‘‘ extending in depth through the cuta- 
neous and cellulo-adipose textures, until the fascia was 
in sight,” and dissecting it from below, but leaving it at- 
tached ‘‘by a broad and thick base.” This flap he pre- 
vented from uniting with the surface from which it was 
‘‘lifted,” by a dressing inserted between them, and two 
weeks afterward, after granulations had formed upon the 
cut surface, he prepared the ulcer on the right leg for 
the reception of the flap ‘‘ by dissecting out the granula- 
tions and part of the cicatrix forming a deep 
bed” into which he inserted the flap after ‘‘removing 
the granulations” from its under surface. The legs 
were then fastened together, and two weeks after this, or 
four weeks after the commencement of the operation, 
‘‘the base of the flap was separated from the left leg, the 
flap having united through most of its edges and under 
surface.” 

This is the application of the principles of the Italian, 
or Taliacotian, operation to an ulcer which had been con- 
verted as far as possible into a fresh wound, not a graft- 
ing upon a granulating surface. It is true that Dr. 
Hamilton found, in the progress of the healing, that the 
margins of the flap grew into, or extended over, the re- 

_maining intact granulations, promoting the cicatrization 
of the rest of the ulcer; and so far his fourth proposi- 
tion is the recognition of a before unexpressed principle 
in the growth of the skin; but practically, he simply 
made another and fresher margin to the ulcer, and quite 
failed to appreciate the extent to which the principle of 
Reverdin’s epidermic grafts could be applied. Assum- 
ing, for illustration, the absurdity that a surgical proced- 
ure may be patentable, it is quite doubtful, if Reverdin 
had patented his method, whether Hamilton would have 
been able to claim an infringement ; or, if, on the other 
hand, Hamilton had patented his process, whether any 
court would have granted him an injunction against Re- 
verdin for infringement. : 

Presenting a much closer resemblance to Dr. Hamil- 
ton’s operation than Reverdin’s, is the method devised in 
1880 by Dr. E. Fischer,” of Strasburg, of grafting large 
strips of skin upon ulcers, both ulcer and skin-flap hav- 
ing been rendered bloodless by the application of an Es- 
march elastic bandage previous to the operation. Dr. 
Fischer first tried rendering the grafts ischemic, and 
found that not only was this plan followed by unusual 
success, but that he could also transfer much larger 
grafts than had heretofore been possible. Prompted by 
this, he conceived the idea of rendering the ulcer itself 
bloodless before making the transference, and he reports 
the success as even greater; for he found that ulcers 
of the leg treated in this way might be completely cov- 
ered with pieces of skin of almost any size, and that 
they immediately healed without any ‘‘secretion,” the 


dissolution and decomposition of the external layers 
of the epidermis of the grafts did not take place, the 
wound (ulcer) remained dry. The method was, after 
considerable experimentation, finally practised as fol- 
lows: Premising that there be a healthy, recently am- 
putated limb from which to take the strips of skin, the 
limb to be treated is rendered bloodless by Esmarch’s 
method, care being taken in the application not to 
wound the granulations of the ulcer, which should 
be protected by a piece of cloth (Dr. Fischer says silk). 
The limb from which the strips are taken is to be first 
carefully scrubbed with soap and warm water, the hair be- 
ing shaved off, and it is also to be rendered bloodless by 
the application of a rubber bandage. It is then washed in 
an antiseptic solution (1 to 1,000 of mercuric bichloride), 
after which the skin is cut off in strips of from two and 
a half to three centimetres in breadth, and as long as the 
ulcer requires. The strips are taken off very close, 7.e., 
free from subcutaneous tissue, the under surface being 
as smooth and flat as possible. As the strips are applied 
the surface of the ulcer should be cleaned off with an 
antiseptic solution from an. irrigator, but not wiped, lest 
the granulations be caused to bleed. The application 
need not be so extremely accurate, as it is expected that 
after uniting with the granulations the skin will grow 
from the edges into and over the remaining granulations, 
in the same manner as occurs in the case of the smaller 
grafts, and in this way fill up or cover over the remain- 
ing granulation surface. This is in accordance with the 
principle enunciated by Hamilton in his fourth proposi- 
tion, z.¢e.. ‘‘ If smaller than the chasm which it is intended 
to fill, the graft will grow or project from itself new skin 
to supply the deficiency.” A rubber protective is to be 
applied over the strips, secured in place by adhesive plas- 
ter, and then absorbent cotton and a gauze bandage are 
applied over all. 

This, it is evident, is much more nearly like Dr. Ham- 
ilton’s procedure than it is like Reverdin’s, or than Rever- 
din’s is like Hamilton’s. The methods of both the French 
and the German surgeon differ from Hamilton’s in that 
the grafts are applied to a granulating surface, and have 
all their connections severed before being applied to the 
open surface. They have a very close resemblance to 
the method of skin-transportation, to be described in the 
next article. 

BIBLIOGRAPHY. 

1 Reverdin: Bulletin de la Soc. de Chirurg., 1869; Gaz. des Hopitaux, 
1870; Brit. Med. Jour., December 10, 1870; Arch, Gén. de Médecine, 
1872; b. 4... pp. 216, 55d, (03; 

2 Poncet, A.: Lyon Médical, t. viii., p. 494 et seq., 1871. 

3 Pollock, @. D.: Transactions of the Clinical Society of London for 
1870, published in 1871. , 

4 Hogden, John T.: International Encyclopedia of Surgery, vol. ii., 
P: fees Thomas: Practice of Surgery, p. 166. Philadelphia, 1885. 

6 Girdner, John H.: Skin-grafting with Grafts taken from a Dead 
Subject, Medical Record, vol. xx., p. 119, July 30, 1881. 

7 Brewer, E. P.: On the Limit of Skin Vitality, Medical Record, vol. 
xxi., p. 488, May 6, 1882. 

8 Martin, Georges: Thése, Paris, 1875 (quoted by Dr. Christopher 
Johnston in International Encyclopedia of Surgery, vol. i., p. 548, arti- 
cle on Plastic Surgery). 

9 Lyon Médical, t. viii., p. 520, 1871 (quoted by Johnston, loc. cit.). 

10 Hamilton, Frank H.: New York Medical Gazette, August 20, 1870. 

11 Hamilton, Frank H.: New York Journal of Medicine, September, 
ie Fischer, ‘EB. : Ueber die kiinstliche Blutleere bei der Transplantation 
yon Hautstiickchen, Zeitschrift der Chirurgie, Bd. 13, p. 198, 1880, 


W. H. Carmait. 


SKIN, TRANSPORTATION OF. Dermanaplastze, 
Esmarch.! This isa method of performing plastic sur- 
gery, in which a piece of the whole thickness of the skin 
is entirely removed from one part and transferred to an- 
other distant part to fill up a gap. 

The term is used to distinguish it from any other form 
of plastic surgery or transplantation in which a continuity 
of the flap with the adjoining integument is preserved 
by a pedicle, of whatever shape or size it may be. The 
method is a happy development of Reverdin’s skin-graft- 
ing, associated with, and made possible only by follow- 
ing out the principles of, antiseptic surgery. Gruening 2 
proposes to distinguish this as the British method, in con- 


459 


Skin Transportation. pppARENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Skin Transportation. 


tradistinction to the hitherto well-known Italian and In- 
dian methods; and inasmuch as its birth-place is the 
same as that of Listerism, to which it owes so much of 
its success, the suggestion is quite pertinent. The author, 
Dr. J. R. Wolfe,? of Glasgow, acknowledges his indebted- 
ness to Reverdin for the idea of transporting small pieces 
of cuticle to distant parts, but he is entitled to the credit 
of originality in transporting large pieces to entirely fill 
up freshly-made wounds, with the intention to get im- 
mediate union at all points of contact, but especially un- 
derneath. He does not seek to plant a piece in favorable 
soil and have it increase in size, but to have it grow 
upon, to simply adhere to, the surrounding and underly- 
ing tissue. 

The operation is most frequently performed for the 
correction of deformities caused by the contraction of 
cicatrices from burns, in which there is no opportunity to 
perform one of the ordinary plastic operations. The most 
frequent seat of these operations has been about the face, 
where the contractions have so drawn upon the skin sur- 
rounding one or the other orifices, that the integrity of 
the contained organ (as the eye) is threatened, or the use- 
fulness of the part itself (as the mouth) becomes impaired, 
and when the difficulty of getting a piece of healthy skin 
from the immediate neighborhood, by sliding or trans- 
plantation, is great. Dr. Wolfe’s first cases were for the 
relief of ectropion of both eyelids of one eye. There is, 
of course, no other limit to its applicability in other situa- 
tions than that all the conditions of success be attainable. 
These are: 1, Perfect asepsis of both wound and flap ; 
2, perfect coaptation at all parts, undérneath and around 
the edges ; 8, undisturbed rest afterward until union has 
taken place. How much the size of the flap removed 
has to do with the success is still the subject of experi- 
ment, as is also the question whether there are other 
points than those above mentioned. 
uew as this it is impossible to anticipate all the obstacles 
that may arise. 

The antiseptic precautions to be taken pertain to both 
wound and flap, to the hands of the surgeon, of his as- 
sistants, and of the nurses, to the dressings, the instru- 
ments and sponges—in short, to everything used about 
the operation. 

There are now-a-days so many ways of achieving asep- 
sis that it may be superfluous to describe any at great 
length, and it would be presumptuous to make claim to 
any one particular method as infallible. My practice is 
to have both the part to be operated upon and the part 
from which the flap is to be taken scrubbed first with 
soap and water, and then, for twenty-four hours before 
the operation, washed every three or four hours with a 
solution of mercuric bichloride, 1 to 1000. At the time 
of operating I usually wash the parts with a saturated 
solution of iodoform in ether, 1 part to 8, or the solution 
recommended by De Ruyter,* of 1 part of iodoform, 2 
parts of ether, and 8 parts of alcohol. The instruments 
should be laid for half an hour before the operation in a 
two per cent. solution of carbolic acid ; solutions of mer- 
curic bichloride, 1 to 1006 and 1 to 3000, should be at 
hand for irrigating, and also hot water to add to these 
solutions as they may be needed in the course of the 
operation. 

Assuming that the operation is for the relief of a cica- 
tricial contraction, an incision is to be made through the 
skin in the most suitable “direction to relieve the de- 
formity, and carried through the subcutaneous connective 
tissue. It may be necessary to remove a piece of the 
cicatricial skin, if it be very much thickened and dis- 
torted, but it is a good rule to take: nothing away that 
will be likely to live. All contracting bands of the sub- 
cutaneous tissue, as well as of the true skin, are to be di- 
vided freely, or, if thick and likely to interfere with 
rapid union, they should be dissected out. In certain 
places, as in the axilla or neck, care must be taken that 
this dissection does not involve large vessels or nerves 
which may have been dragged into the cicatricial bands. 
This is by no means a theoretical source of danger, for 
uncontrollable hemorrhage has occurred from the axil- 
lary or jugular veins having been ruptured or cut. Loose 


460 


In an operation so- 


pieces of fat or connective tissue are to be removed, and 
all bleeding points secured ; hot water will usually con- 
trol capillary hemorrhage, but if a vessel requires liga- 
tion it should be tied with aseptic catgut rather than 
twisted, as a subsequent hemorrhage is fatal to success. 

When the preparation of the wound is thus completed 
a pattern of cloth is cut of ervactly the size of the wound ; 

the surface of the latter is then to be carefully irrigated, 
and covered with a cloth or sponge, wrung out in the 
warm antiseptic solution, and extending well beyond the 
circumference. The cloth pattern is then placed upon 
the skin to be removed to form the flap, and its outline 
accurately marked out upon the skin, allowing one-third 
in every direction for shrinkage after removal. It is 
necessary to maintain this proportion in every direction ; 
for instance, if the piece is one and one-half by three 
inches, twice as much must be allowed in the length as 
in the breadth, and the piece marked out must, therefore, 
be two by four inches. The incision is to be made per- 
pendicularly through the skin, and the edges all around 
the flap are to be dissected up from the underlying con- 
nective tissue, as little of the latter as possible being re- 
moved with the flap. Then, while the main part of the 
flap is still attached, it is much the best plan to make, 
according to a verbal suggestion made to me by Dr. E. 
Gruening, a row of punctures, or small incisions, all 
around the circumference, for the subsequent introduc- 
tion of the sutures. For this purpose I have had made 
a little punch, on the plan of an ordinary shoemaker’s 
punch, which makes incisions about two millimetres in 
length. These are made perpendicularly to the edge, 
about eight millimetres apart, all around the circumfer- 
ence, and as they are simply incisions there is no loss 
of tissue to be repaired, and they gape when the needle 
is introduced, but close up around the 
thread as soon as it is drawn taut, 
leaving no space which requires to be 
filled up by granulations. The accom- 
panying cut (Fig. 3534) gives a better 
idea of the instrument than a descrip- 
tion. It is made perfectly smooth, 
with an unlocking hinge, so that it can 
be taken apart and cleaned, and can 
be readily kept aseptic. I much pre- 
fer the use of the continuous catgut 
*(aseptic) suture, as facilitating a closer 
union than any other. If the surgeon, 
however, prefers interrupted sutures, 
whether silk or catgut, they should 
now be inserted, with a separate nee- 
dle for every suture, and after intro- 
duction through the flap, from witihout 
inward, they must be allowed to re- 
main threaded. 

The next step is the entire separation 
of the flap, which should be done ex- 
peditiously and smoothly by means of 
a very sharp knife, long sweeps being 
made with it as close to the true co- 
rium as possible, leaving no fat or 
shreds of connective tissue attached. 
In all manipulations about the flap 
avoid seizing it with forceps, using 
the fingers in preference when possi- 
ble; but if forceps must be used, let 

them be the single mouse-toothed forceps, which make 
but one bite or puncture, and not the ordinary dissecting 
forceps, which crush a considerable amount of tissue in- 
cluded in their grasp. Having removed the flap, place 
it quickly on the palm of the hand of an assistant, or on 
a warm cloth dampened with the antiseptic solution, 
with the epidermis downward and, smoothing it out, 
with a pair of sharp scissors curved on the flat, trim off 
all shreds of fat or loose connective tissue which may 
remain attached to it. This is an extremely important 
procedure, for the internal surface of the flap should be 
as smooth and free from every scrap or loose shred of tis- 
sue, which may by any possible chance become necrotic 
and serve as a focus of suppuration, as it is possible to 


Fie. 8534, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, SKi" Eransportation, 


Skin Transportation. 


get it. This trimming is a matter requiring a little pa- 
tience, owing to the elastic connective tissue of the skin 
causing it to curl or roll up at the edges. While lying 
thus with the raw surface upward, the flap should be kept 
irrigated with the warm antiseptic solution, and as soon 
as the preparation is completed it is to be turned over 
upon the wound, previously prepared and free from 
blood, and fitted accurately to it. The flap must not 
‘‘pucker” at the edges, neither must it under any cir- 
cumstances be put upon the stretch by the sutures; it 
must simply fill up accurately the whole wound. Unless 
there are angles or other points to determine quickly 
and accurately the proper adjustment, it is well, as soon 
as the flap is marked out, to indicate a couple of points 
upon it, either with ink or indelible pencil, or by means 
of a thread drawn through it, to correspond with like 
points on the skin in the vicinity of the wound, in order 
that no time may be lost, and that the flap be not sub- 
jected to unnecessary manipulation in fitting. As soon 
as it is fitted, it should be pressed down by a soft and 
warm sponge or cloth, to exclude all air from beneath it, 
and this pressure must be kept up firmly but gently 
during the introduction of the sutures, which must now 
be inserted all around it, without any sliding or other 
movement of the flap upon its bed. To this end the as- 
sistant must keep up the pressure with the soft sponge, 
uncovering only just enough of the edge to allow the in- 
troduction of the needle (curved). The advantage of 
the incisions previously punched in the flap will now be 
appreciated, for without them the insertion of the sharp- 
est needles would inevitably drag upon the flap, loosening 
and disturbing its contact with the parts below, and 
just so far interfering with the promptunion of the two 
fresh surfaces. The only reliable alternative is to have 
as many needles threaded as there are sutures to be intro- 
duced, and, as stated above, to insert them beforehand in 
the flap, so that the subsequent tying of each one’ may 
take but little time and make no dragging. The ob- 
jection to this plan is, that the flap. cannot be trimmed at 
its edges without interfering with the stitches already in- 
serted, and as. these should not be more than six milli- 
metres apart, ina flap of any: size the number of needles 
required would be considerable, and threads and needles 
would almost certainly become so entangled in the nec- 
essary manipulations, that valuable time would be con- 
sumed. I therefore prefer, as stated above, to use a con- 
tinuous catgut suture, which may be inserted very rapidly, 
and in. which the overlap keeps the edges together bet- 
ter. It is better to insert the needle through the incision 
in the flap first (from without inward), and carry it then 
through the sound attached skin from within outward, as 


this disturbs the flap less ; the operator can also see better: 


where to. insert the point of the. needle. than if he ap- 
proaches the little incision from below. The part is now 
to receive its final irrigation, and the permanent dressing 
is to be applied. The particular form of antiseptic dress- 
ing employed to prevent suppuration is to be determined 
by the principles of general surgery. There is of course 
a wide field for-the judgment of the individual opera- 
tor. In places remote from the eye or mouth, Billroth’s 
‘‘sticky”” iodoform gauze (consisting of 10 parts by 
weight of resin, 6 parts of castor-oil, 16 parts of alcohol, 
and 5 parts of iodoform, which are used to impregnate 
25 parts of gauze) may be placed over the surface, a com- 
press of absorbent or some medicated cotton applied 
evenly over this, and the. whole smoothly yet firmly 
bandaged over with antiseptic gauze to the exclusion of 
the air. 

The part is now to be left as quiet as possible for 
five or six days or more—nothing can be done to pro- 
mote union after the proper dressing is applied. Nature 
must now be depended upon to do the rest. In obe- 
dience to former surgical traditions, I at first applied ar- 
tificial dry heat to the outside of the dressings, but have 
lately discontinued it, and with as good results. It is 
cumbersome in application and adds materially to the 
subsequent care. The normal temperature of the body 
will keep the flap warm by contact under the protection 
of the cotton dressing, so that beyond this [am disposed 


to regard additional heat as detrimental, in stimulating 
putrefactive changes. 

The method of dressing described, or some other perma- 
nent antiseptic procedure, is, according to my experience, 
greatly superior to any other, but it would be presumptu- 
ous, in view of the good results obtained by other sur- 
geons, to say absolutely that it is the best. Wadsworth,® 
Matthewson and Pilcher,’ and Howe,? all used with suc- 
cess some form of transparent covering directly over the 
wound, viz.,court-plaster, gold-beater’s skin, or collodion, 
with pressure from cotton overit. Fryer ® dispensed with 
everything but his gold-beater’s skin. Dr. Bull! had the 
singular experience in all his cases of having points of 
suppuration at his sutures only. He used ‘‘ carbolized 
silk.” , All these cases just cited and most of the others 
were upon the eyelids, and it may be that the greater 
vascularity of the skin there gives a better chance for the 
flap to unite ; my experience, which has been upon the 
hands, neck, and scalp, has gradually led me to the adop- 
tion of the permanent antiseptic dressing, against which 
there can certainly be no theoretical objection. 

Care must be taken not to apply a dressing that will 
cause an absorption of the fluids of the flap and its subse- 
quent destruction. While the epidermis is intact the 
dressing above described, of iodoform gauze and absorbent 
cotton, answers well, but when the epidermis peels off early, 
as it may do in the course of a week, the dressing had 
better be modified by the interposition of a piece of india- 
rubber protective, or other impervious material, between 
the flap and the absorbent cotton or gauze. If this be 
not done the flap will become mummified as in dry gan- 
grene, turning black, and becoming as hard as tanned 
sole leather. I found this in one case, to my great dis- 
appointment. The protective may be applied directly 
against the flap, or, as I think better, between the sticky 
iodoform gauze and the absorbent cotton, extending well 
beyond the edges of the gauze. 

When the flap of skin is prepared for insertion in the 
wound, and afterward, it is of course quite bloodless, 
and the contrast with the surrounding skin is very 
marked, so much so as often to excite a fear, in one who 
is not familiar with the appearance, that it may indeed 
be dead and incapable of being again included in the cir- 
culation in its new situation. This appearance continues, 
indeed, long after adhesion with the parts beneath has 
taken place, and of course after the re-establishment of 
the circulation. The outer layers of the epidermis usu- 
ally become detached in more or less considerable flakes 
at different periods of from one to four weeks, giving 
rise again to the fear that the flap is sloughing away ; but 
an attempt to move it from its bed will show that union 
has taken place. 

My experience has been that union takes effect more 
readily and sooner beneath than at the edges; that the 
latter do not become firmly united with the main skin, 
indeed, until after the flap has become quite firmly at- 
tached, and whenever a portion only of the flap sloughs it 
is some part of the edge rather than the centre. Whole 
flaps may be lost by faulty preparation or after-treatment, 
but the central portion more frequently unites than the 
edge, showing that the supply of nourishment is derived 
from the bed of the wound rather than from the cutaneous 
circulation. Ina flap 44 x 2% inches, which I inserted 
into the skin of the neck just below the chin, for cicatri- 
cial contraction following a burn, the only loss sustained 
was at one end, which had been subjected to too much 
manipulation in the fitting ; the central portion preserved 
its vitality, being nourished of course only from be- 
neath. 

The experiences of the pioneers in this branch of sur- 
gery, Wolfe, Wadsworth, and others, have proved that 
a pedicle really plays but a subordinate réle in the 
nourishment of a skin flap; that the main source of 
supply is from the underlying exposed connective tissue. 
It would seem that this method of transportation of large 
pieces of skin is capable of wider application than it has 
heretofore received at the hands of surgeons, the modern 
methods of treatment being much better adapted to ob- 
taining union by first intention. 


461 


Skin Transportation. pprRRENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Skull. 


BIBLIOGRAPHY. 


1Esmarch, Prof. F.: Hautlappen Ueberpflanzung (Dermanaplastie), 
Transactions of the Fourteenth Congress of German Surgeons, 1885, p. 
107. 

2Gruening, E.: A Case of Blepharoplasty According to the British 
Method, Trans. of Am. Ophthalmological Society, 1883, vol. iii., p. 586. 

3 Wolfe, J. R.: A New Method of Performing Plastic Operations, Medi- 
cal Times and Gazette, No. 1358, June 3, 1876 (Ref. Klinische Monats- 
blitter, 1877, Bd. 15. p. 192). 

4De Ruyter, G.: Zur Iodoformfrage, Archiv far Klinische Chirurgie, 
Bd. xxxv., Hft. 1, p. 218 (Ref. Centralblatt fir Chirurgie, No. 37, Sep- 
tember 10, 1887. 

5 Von Langenbeck, in the discussion following Esmarch’s paper above 
cited, recommends leaving the Panniculus adiposus, 

6 Wadsworth, O. F.: Case of Ectropion Cured by Transplantation of a 
Larger Piece of Skin from the Forearm, Trans. of Fifth International 
Ophthalmological Congress, New York, 1876, p. 287. 

7 Matthewson, A., and Pilcher, L. §.: Annals of Anatomy and Surgery, 
1880, vol, iii., p. 21. 

8 Howe, Lucien: Trans. of Am. Ophthalmological Society, vol. iji., p. 
46, 1880, with Discussion by Agnew, Noyes, Knapp, and Wadsworth. 

9 Fryer, B. E.: Trans. of Am. Ophthalmological Society, vol. iii., p. 
641, 1884. 

10 Bull, Chas..S.; Trans. of Am. Ophthalmological Society, vol. iii., p. 


636, 1884. W. H. Carmailt. 


SKULL, JOINTS OF THE. The skull, as the en- 
closer and protector of the brain, is necessarily a closed 


¢ 


it is subject to a very rapid increase in size—which in- 
crease does not cease entirely until the age of puberty is 
reached—it is probable that the necessities of the economy 
would have long ago obliterated the joints between the 
bones. We know, in fact, that this must have occurred 
to a very considerable extent, for as we descend in the 
animal scale the joints of the skull become more and 
more numerous, reaching in the osseous fishes a maxi- 
mum far exceeding the number in man. ,The same phe- 
nomenon occurs in the fetus. Many of the bones which 
present a perfect union in the adult are found to be sep- 
arate in the foetus and in early childhood, and the sutures 
which represent this early separation may persist as ab- 
normal conditions. The frontal bone is. ossified from 
two separate halves ; the occipital bone from at least five 
portions ; the temporal from four (at an early stage from 
seven); while the sphenoid may claim to be formed from, 
at least ten distinct ossific integers. 

Again, as we advance in age there is a tendency for 
the sutures to become obliterated. Quite early the oc- 
cipital and the sphenoid join ; indeed, it is so unusual to 
find an adult skull in which they are separate, that some 
authors have described them together as a spheno-occipi- 


Fig. 38535.—The Anatomical Relations of the Brain to the External Parts of the Head. A, Fronto-parietal suture; B, fronto-sphenoidal suture; C, 
spheno-temporal suture; D, spheno-parietal suture; #, temporo-parietal, or squamous, suture; /’, mastoid suture; G, parieto-occipital suture ; 
H, temporo-occipital suture; J, fronto-zygomatic suture; H, mastoid process; ZL, mastoid groove; M, styloid process; NV, spinous process of the 
sphenoid bone; O, pterygoid process; P, occipital protuberance; Q, Y, semicircular line; R, zygomatic arch; S, frontal sinus; 7, thickness of 
the skull; U, inferior lobe of the cerebrum; V, superior lobe of the cerebrum; W, posterior lobe of the cerebrum ; X, superior lobe of the cerebel- 
lum; Y, inferior lobe of the cerebellum; Z, tentorium cerebelli; 1, superficial temporal artery; 2, middle temporal artery; 38, anterior superior 
auricular arteries; 4, zygomatico-orbital artery ; 5, temporo-frontal artery; 6, temporo-occipital artery ; 7, posterior auricular artery; 8, occipital 
artery; 9, supra-orbital artery; 10, frontal artery ; 11, middle meningeal artery ; 12, torcular Herophili; *, point for opening the temporo-frontal 
artery; **, incision for ligature of the superficial temporal artery; ***, upper incision for ligature of the occipital artery; ****, lower incision for 


ligature of the occipital artery. (From Bruns.) 


shell, affording exit and entrance only to such structures 
as are absolutely essential. Were it not that in fetal life 


462 


tal bone. The parietal bones unite early, and it is not 
very uncommon to find old skulls in which nearly all the 


REFERENCE HANDBOOK OF: 


THE MEDICAH -SCIENCRS: Suun. ne 


sutures have disappeared, and the cranium has become, 
what is doubtless more effective from the protective 
point of view, a bony case almost without joints. 

To this general statement one exception should be 
made. The mandible or lower jaw articulates by a joint 
that throughout life remains freely movable. Represent- 
ing as it does one of the branchial arches, this freedom is 
assured from the first. The hyoid bone is not, for the 
purposes of this article, considered as a bone of the skull, 
although from a morphological point of view it would 
be quite proper to so class it; for it is developed in one 


Periosteum... 


Periosteum.,. 
BONG Sra. a mee Bones seen. 
Intersutural ; Cartilage .. 
ligament, 


Aw RI, ee te z 
Fie. 3536.—Suture. Fie. 3537.—Synchondrosis, 
Fies, 8536 and 3537,—Synarthrodial Joints. _ 


of the branchial bars which appear to be the visceral 
arches of the same segments which form the cranium. 

The joints of the skull are then, with but one excep- 
tion, immovable. These immovable joints are usually 
classed together as sutures, but they do not all satisfy 
exactly the technical definition of that joint, the union 
between the occipital and the sphenoid at the base of the 
skull being rather a synchondrosis or union by cartilage 
(see article Arthrology and Figs. 3536 and 35387). 

The sutures form two distinct groups, one antero-pos- 
terior, another transverse, in direction. These again are 
subdivided. In the median line the entire vault is orig- 
_inally separated by the sagittal or inter-parietal suture 
which connects the two parietal bones, continued down- 
ward in early life through the frontal bone as the metopic 
or frontal suture, and still farther downward as the sep- 
aration between the nasal and superior maxillary bones 
in front and the palate behind. The perpendicular plate 
of the ethnoid, the vomer, and the sphenoid, also show 
traces of a bilateral separation at an early stage. 

Laterally, also, there is a system which runs in a gen- 
eral antero-posterior direction, formed by the frontal bone 
joining successively 
the nasal, maxillary, 
lachrymal, ethmoid, 
sphenoid, and malar 
bones in front, form- 
ing what is sometimes 
called the transverse 
suture ; by the parie- 
tal joining the great 
wing of the sphenoid, 
the squamous and 
mastoid portions of 
the temporal. This 
may be continued 
back and form a union 
with the same suture 
of the opposite side 
by a suture cutting off 
the upper part of the 
occipital bone, thus forming an interparietal bone (see 
Fig. 3538). This anomaly occurs so frequently in Peru- 
vian skulls that the supernumerary bone is sometimes 
called the inca bone (os Ince, of Tschudy and Ribero). 

The best marked transverse set is constituted by the 
coronal suture between the frontal and parietal bones, 
continued downward by the temporo-sphenoidal and oc- 


Fig. 8538.—The Interparietal Bone, as 
Shown in a Peruvian Skull. 


cipito-sphenoidal. This usually suffers a slight interrup- 
tion in man, the wing of the sphenoid pushing back so as 
to articulate with the antero-inferior angle of the parietal. 
In the orang the continuity is not interrupted, the tem- 
poral articulating regularly with the frontal, and this is 
the case in about five per cent. of human skulls. (Some- 
what more than this in African skulls, judging from 
an experience of some years in dissecting-rooms, where 
such subjects abound. See Figs. 3539 and 3540.) The 
lambdoid suture, between the occipital and the parietal 
bones continued downward to the base of the skull, as the 


Fie, 35389.—Orang’s Skull, Showing Temporo-frontal Suture. 


occipito-temporal is also transverse. In the face the in- 
dications of transverse sutures (indicating visceral arches?) 
are more obscure. The palato-maxillary and palato-sphe- 
noid are the principal ones belonging to this class. 

The primoidal skull, it should be remembered, is to 
be considered as a membranous capsule with a cartila- 
ginous base. This capsule is continuous and without 
joints, and the bones appear as secondary modifications. 
The increase of size of the capsule is not due to any in- 
crease of bone, but to the interstitial growth of the mem- 
brane in which the bone is formed. This membrane re- 


_ iz LLEIELE* ray, 
PP... 
See, 


Uy 

ills 
Pl 

fii Aad as 


iii 


cre 
nrssdes 


Fia. 3540.—The Same Suture from a Skull in the Author’s Possession. 


mains, spanning the surface between the bones as long as 
their growth is insufficient to encase the entire brain. 

The growth of the several bones by their edges varies 
considerably according to their thickness, the thicker 
bones growing faster. Welcker estimates the growth 
from birth to adult life as follows : 


Frontal-bone along coronal suture ...........2--22seeee2s 18-22 mm. 
Parietal gs SO) er ite Bir TRS ccs Ch EE RRR BG ba hae 
eh He SAS UbAL BULLE. helo cine aianiaienie sines 25-30) °° 
. s SQUAMOUS SULULE. «...)- lors cis ere sree = 4 i 
Le bs mastoid SCI ee Fas 5 Selciares AA 


Growth is arrested by the pressure of one edge against 
another, and, should there be an unusual growth of bone 


463 


Skull. 
Skull. 
at any time during childhood or feetal life, this pressure 
may be so great as to cause an early obliteration of the 
suture. This occasions a deformation of the skull which 
varies according to the sutures affected. In Figs. 3541 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, 


There are several types of scaphocephaly depending 
upon the portion of the parietal bones which first be- 
come united. It would appear that, wherever the union 
may be, it tends to form a constricting band which pushes 
the brain out forward and laterally. In this way are 
doubtless produced many of the deformities and asym- 


BS 


= 


Fie, 8541.—Trigonocephalic Skull. Front View. (After Welcker.) 

and 3542 there is a premature union of the medio-frontal 
or metopic suture. The skull thus deformed is known 
as trigonocephalic. The suture usually begins to close 
during the first year after’ birth and from above down- 


ward. It is very common to find traces of it in adult 


+5 


LlfZy 
LES 


{ 
ARR PR REY WY) iy LAMAN Varn Satie ~ 
Y V4 H 


BINS UY 


Rese 


Fia. 8542.—The Same. Top View. (After Welcker.) 


ite 


Fiq. 8543.—Scaphocephalic Skull, from Behind. 


“oat 


(Welcker. ) 


metries, which are known to be much more common than 
is generally supposed. An inspection of the outlines 
which are usually kept by hatters for the blocking of 
hats, affords convincing proof that irregularities in the 
contour of the head are frequent. One of the most 
common is the so-called annular type, shown in Fig. 3545. 

This consists of a circular depression situated just be- 


skulls. In the trigonocephalic skull it appears to com- 


mence to ossify at either end. 
By a premature union of the sagittal suture a keel- 


shaped form of skull is produced, termed scaphocepha- 
lic. Examples of this are seen in Figs. 3548 and 3544 ; 
and these are by no means uncommon, 


464 


(Welcker. ) 


Fia. 3544.—Scaphocephalic Skull, from Above, 


hind the coronal suture, and indicating that the sagittal 


‘suture first united at that point instead of further back, 


near the parietal foramina, as in normal cases. 
Another type of deformity is found by the premature 


‘ 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Skull. 
SKull. 


union of the coronal suture together with obliteration of 
the sagittal. The skull is then turned acrocephalic (see 
Fig. 3546), as it appears high and pointed. It is well known 
that the skull of Sir Walter Scott was of this class, as 


Fic, 3545.—Annular Scaphocephalic Skull. (Topinard.) 


may be seen by looking at his portraits. This leads to 
an interesting series of considerations as to whether these 
premature unions affect in any way the intellectual fac- 
ulties, It is clear that in many cases there is no positive 


Fie. 8546.—Acrocephalic Skull. (Topinard.) 


defect observable, but yet it must be confessed that the 
evidence on this point, gathered by taking cases of ex- 
ceptional men, is not conclusive. Statistics gathered 
from insane asylums show that there are a greater pro- 
portion of such deformities found there than in the 
population in gen- 
eral, and Lombro- 
so holds that there 
is a much larger 
proportion also 
among the crimi- 
nal classes, 

In case the ob- 
literation affects 
only a portion of 
the sutures in- 
volved, there is 
sometimes pro- 
duced a twisted 
appearance in the 
skull. Fig. 3547 
shows an instance 
of this, which is 
knownas the reni- 
form or plagioce- 
phalic skull. 

It has been alleged that the deformities here described 
are more frequent in the inferior races. Topinard doubts 
if this is the case, and considering the fact that they are 
probably not to be considered as phylogenetic characters, 


Vou. VI.—30 


Fic. 3547.—Plagiocephalie Skull. 


(Topinard.) 


but variations Gepending upon ante-natal conditions or 
accidental impressions, it seems unlikely that any ethno- 
logic value can be attached to them. 

As an opposite condition to early obliteration, undue 
persistence of foetal sutures may also occur. This is al- 
most always the case in cases of chronic hydrocephalus. 
The medio-frontal suture is the most frequently persist- 
ent, but the transverse occipital is also found (see Fig. 
3588) ; and occasionally the petro-squamosal portion of the 
temporal bone and the squamous portion may continue 
open. Fissures, indicating situations where ossification 
has been imperfect, may remain and simulate fractures. 

A very considerable difference occurs in sutures as re- 
gards their character. Some are perfectly simple, like 
those by which the vomer unites with the two superior 
maxillary bones; others exceedingly irregular, fitting into 
each other by jagged margins, sometimes saw-like, tooth- 
like, wavy, intricately involved with sinuous outlines, 
like the edges of leaves, This last is especially noticeable 
in the sagittal and the lambdoid sutures. The coronal 
suture is usually quite simple above and below, but full 
of intricate turns at the place where it covers the tem- 
poral line. The winding pattern which involves the 
outer table of the skull is not repeated by the inner table. 
This has a pattern of its own, and even the diploé be- 
tween the two has its own peculiar form of joining, 
which is different from both inner and outer tables. This 


Bre Kies 


Stephanior 
PaRIETAL 


/Prerioit 
TEMPORAL 
e,- 


7 ea 
MaxiLLary l| : 
iy 


y 


Wy 
Wi OCCIPITAL Inion 


i. 


Fria. 3548.—Diagram showing the Principal Craniometric Points on the 
Lateral Surface of the Skull. 


Mew e 


variety in the junction of the different parts lends great 
stability to the union of the bones, and it is rare that any 
of the common expedients for separating the sutures, like 
filling a skull with dried beans and then allowing them 
to swell in tepid water, does not break the bones apart 
instead of separating the sutures. 

The sutures are extensively used as landmarks from 
which craniometrical measures are taken. Broca, who 
may almost be said to be the father of modern craniology, 
invented a series of terms for the most useful points, and 
these are now generally used in works which treat of the 
measurements of the skull. A number of these points 
are shown in Fig. 3548. They are also useful as topo- 
graphical data for determining the situation of the con- 
volutions and sulci of the brain in relation to the skull. 
These relations are somewhat imperfectly shown in Fig. 
3535. The upper end of the fissure of Rolando, of the 
brain, lies nearly two inches behind the bregma (Fig. 
3548), or about one inch more than half-way back from 
the nasion to the inion. The lower end of the fissure of 
Sylvius is at the pterion, a little over an inch directly 
behind the external angular process of the frontal bone. 
The precentral sulcus lies just behind the coronal suture, 
and parallel to it. The inferior frontal runs forward 
from it, about on a level with the stephanion. The pari- 
eto-occipital fissure is just in front of the lambda. 

Fig. 8535 also shows the relation of the superficial 
arteries, viz., the temporal at 1, with its branches, trans- 
verse facial (4), antero-temporal (5), and middle tem- 


465 


Lambda 


hee REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


poral (6), the posterior auricular (7), and the occipital | cranium could not be felt. The operation was performed 
(8). The usual points of ligation are shown by stars. under strict antiseptic precautions, Ether was adminis- 
Frank Baker. tered as an anesthetic. Thetumor was circumscribed by 
a circular incision about an inch from its margins, which 
SKULL, PERFORATING TUMORS OF THE. ‘This | divided all the tissues down to the bone. On reflecting 
term is applied to tumors which originate in the cranial | the soft parts toward the tumor, a circular opening in the 
bones, and which, during their growth, destroy the en- | bone was found, about an inch in diaméter, with irregu- 
tire thickness of the bony wall; it is also applied to | lar, ragged margins, bevelled at the expense of the exter- 
extra- and intra-cranial tumors which cause perforation | nal table, and filled by a projection of the neoplasm. 
by pressure, atrophy, or invasion of the bone by the neo- | The chisel was now resorted to for the purpose of enlarg- 
plasm. With but very few exceptions this group is com- | ing the perforation, in order to ascertain the condition of 
posed of sarcomatous tumors of the coverings of the | the dura mater underneath. On reaching this membrane 
skull, the cranial bones, or the dura mater, which, from | it was found that the tumor had infiltrated its outer sur- 
a pathological and clinical aspect, present certain pecu- | face and had extended underneath the bone, so that the 
liarities that entitle them to separate consideration. whole tumor presented the appearance of a cuff-button, 
1. PERFORATING SARCOMA OF THE SKULL, OF ExtTrRa- | the constricted portion corresponding to the part occupy- 
CRANIAL ORIGIN.—An extra-cranial sarcoma has its start- | ing the perforation in the bone (Fig. 3549).* The chisel. 
ing-point in the skin, in the galea, or ling was continued until apparently 
in the periosteum. When it de- 5 healthy dura mater was. reached. 
velops in the skin primarily, it The shaving off of the tumor from 
is frequently found engrafted the dura mater was attended by 
upon a pigmented mole, or alarming heemorrhage, which 
a wart. Tumors of this was followed by a speedy 
kind, as a rule, belong collapse of the patient. I 
to the variety of spin- have since thought that 
dle-celled sarcoma the collapse, which was 
which manifests sudden and profound, 
a marked  ten- and which nearly 
dency to infiltra- proved fatal, might 
tion of the sub- have been due, in 
jacent — tissues. part at least, to the 
T hey apen é. introduction of air 
trate the galea, into some of the 
the periosteum, large venous 
and the cranial channels which 
vaultyip ATier bad ) been 
reaching the opened: “Pie 
dense, fibrous upper portion of 
structure of the the body was 
dura mater, lowered to favor 
their central ex- blood-supply to 
tension ‘usually the brain, and 
becomes limited, the hemor- 
but their growth rhage was final- 
extends over the sur- ly controlled by 
face of the dura mater, ligation, com- 
between this membrane pression, and the 
and the cranial vault. I free use of the ac- 
have seen two patients, both tualcautery. This 
men of middle age, suffering from operation was per- 
perforating tumor of the skull of such formed about ten 
origin, and which pursued this course. years ago, before the 
In one of the cases the tumor started as a time of heroic brain 
nodule in the scalp, painless and movable, surgery, hence no part 
which had begun, without any apparent cause, of the dura mater was 
twelve years before the patient came under my ob- me : removed. It was hoped 
servation. In the meantime seven operations had been | Fie. 3549.—Perforation in the Bone, that the portions of the 
performed. Every successive operation became more showing the Osseous Framework of tumor contained in the 
difficult, requiring the removal of more tissue. In the ae bag pa a eclah dura mater had been 
last two operations small portions of the skull were re- | thoroughly destroyed by the vigorous use of the cautery. 
moved, and in the last it was ascertained that the entire | The patient rallied from the operation, and, a few weeks 
thickness of the skull had been destroyed by the tumor. | later, the wound being nearly closed, he left the hospital. 
When the patient came under my care a pulsating tu- | I learned subsequently that the disease again recurred in 
mor, covered by a dense cicatrix, somewhat oval in shape, | the cicatrix two months after closure of the wound, and 
and about two inches in diameter, was found to occupy | that the patient died a year later, having manifested for 
the vault of the skull near the median line, about an inch | several weeks prior to death well-marked cerebral symp- 
posterior to the junction of the parietal bones with the | toms. In the other case the disease started in the scalp, 
frontal. Firm pressure diminished the size of the tumor, | at the junction of the left temporal with the frontal bone. 
but as soon as compression was removed the swelling re- | It pursued the same relentless course, proving fatal five 
sumed itsformer dimensions. The size of the tumor also | years after its commencement. During this time four 
increased on coughing, or when the head was placed in | or five operations were performed by several of the best 
the dependent position. After each of the previous | surgeons in the country. 
operations the wound had healed kindly, but within a One of the most prominent features of an extra-cranial 
few months the disease recurred, invariably in the cica- | sarcoma is its liability to return, even after what appears 
trix. Pulsation could be distinctly felt by the palpating | a most thorough operation. The recurrence is always 
finger over the entire surface of the tumor. On auscul- | local, in the cicatrix. Every successive operation be- 
tation a slight bruit could be heard, synchronous with the as 
heart's action. The margins of the tumor overlapped the * This and the following illustrations in the present article are taken 
bony defect to such an extent that the opening in the | from Von Bruns’ Chirurgischer Atlas. 


<4 


466 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


comes more difficult and serious as the disease penetrates 
deeper and deeper, following the blood-vessels into the 
bone, and causing a circular perforation. After it has 
reached the interior of the skull it spreads diffusely over 
the outer surface of the dura mater, and at the same time 
penetrates the meshes of this membrane. When the dis- 
ease originates in the galea or the periosteum it pursues a 
more rapid course, as the vessels of the diploé are reached 
earlier, a circumstance which favors early penetration and 
perforation. 

Pulsation is not a positive diagnostic evidence that per- 
foration has taken place, as a vascular pericranial sarcoma, 
like any other very vascular sarcoma, may pulsate inde- 
pendently of cerebral pulsation ; but in the latter event 
the pulsations are synchronous with the arterial pulse, 
and the respiratory pulsations, which are present in a 
perforating tumor which pulsates, are always absent. A 
number of such cases are reported by Bruns. <A. perios- 
teal sarcoma is almost always the seat of formation of 
new bone, which appears in spurs, traversing the tumor 
in all directions, imparting to it a degree of firmness pro- 
portionate to the amount of bone formed. Figs. 3550 and 
d0o1, 

2. PERFORATING SARCOMA OF THE SKULL OF DrpLozitc 
OriciIn.—A sarcoma starting in the diploé of any of the 
cranial bones is a true osteo-sarcoma, or, more properly 
speaking, a medullary sarcoma. A medullary sarcoma 


Fia. 3550.—Osteogenic Sarcoma; external surface. 


first destroys the structures in its immediate vicinity, the 
trabecule of.the diploé, before it affects either of the ta- 
bles of the bone. When the compact layers are reached 
the tumor will advance in the direction which offers the 
least resistance, which is usually toward the external sur- 
face of the skull, as the outer table yields more readily 
to pressure than the inner. The bone expands, and the 
location of the tumor at this time is indicated externally 
underneath the scalp by a slight elevation of the smooth 
.external surface of the cranium. The swelling by expan- 
sion is of short duration, as the disease infiltrates the com- 
pact portion of the bone along the course of the blood- 
vessels and soon causes a loss of continuity, the defect 
being covered at this stage by a number of fragments of 
the external table held together by the neoplasm. At this 
stage of the disease a crackling sensation is often elicited 
by the palpating finger. As soon as the tumor has per- 
forated the periosteum extensive and rapid infiltration of 
the superimposed soft parts takes place. This occasions 
such a stretching of the overlying skin that ulceration 
from pressure, atrophy, or some accidental external cause 
speedily ensues, an event which is followed by protrusion 
of a fungous, bleeding mass, the fungus heematodes of the 
older authors. While peripheral destruction is going on 
the disease also travels in a central direction by following 
the blood-vessels, thus reaching the dura mater and com- 
pleting the perforation. Only in exceptional cases is the 
dura mater perforated by the neoplasm. The brain symp- 
toms are usually due to compression caused by the bulg- 
ing of the tumor toward the cranial cavity, pushing the 
dura mater before it. In rare cases the disease appears 
multiple, or becomes so by regional diffusion. Regional 
infection of the lymphatic glands of the neck has never 


Skull. 
Skull, 


been observed, but systemic dissemination by metastasis 
frequently takes place, and death may finally be due to 
this cause. 

Histologically the medullary sarcoma of the cranial 
bones belongs to the round-celled, giant-celled, or net- 
celled variety of sarcoma, and very often it appears as a 
mixed tumor containing two or more kinds of cells. The 
tumor of the skull described by Kocher as a myxo-sar- 
coma did not only present pulsation, but on auscultation 
a distinct and loud bruit could be heard. Heineke, in his 
article on ‘‘Sarcoma der Schadelknochen,” describes a case 
of medullary sarcoma of the:skull that came under his ob- 
servation. The patient was a man, forty-one years of age, 
who, after having suffered a short time from headache, 
noticed a small elevation over the occipital region on the 
right side. This swelling increased quite rapidly in size, 
so that six months later it had attained quite large dimen- 
sions. At this time a swelling formed on the same side 
over the temporal region, which also increased rapidly in 
size. The pain in the occipital region ceased at this time, 
and shifted to the swelling in the temporal region. The 
general health was not impaired. Seven months later the 
tumors had attained the size shown in the illustration. 


Fig. 3551.—Osteogenic Sarcoma; internal surface. 


Both tumors were quite soft to the touch, immovable, 
but not adherent to the skin. The anterior portion of 
the ninth rib, on the right side, was also the seat of a tu- 
mor the size of an apple. During the operation for the 
removal of the first tumor it was found that it was sur- 
rounded by a distinct capsule. The hemorrhage occa- 
sioned by the incisions necessary for exposing the tumor 
was alarming. When the margin of the tumor was 
reached it was found to extend into the bone, and no 
further attempts were made to remove it. The hemor- 
rhage. was arrested and the wound closed. The patient 
remained in a comatose condition and died three days 
later. The post-mortem examination showed that the 
tumor had its origin in the interior of the occipital bone 
and contained a framework of bone. The tumor had en- 
croached upon the cranial cavity by pushing the dura 
mater before it. The internal location of the tumor was 
marked by a depression of the brain several lines in depth. 
Microscopically it was composed of an alveolar network 
of spindle-shaped cells, the spaces of which were filled by 
large nucleated, round, and polygonal cells. The alveoli 
contained also numerous blood-vessels, the walls of some 
of which appeared to be composed of the tumor cells. 
Where the tumor was attached the dura mater was infil- 
trated by numerous nodules of the same character as the 
primary growth. The spurs of bone in the tumor pene- 
trated into, but not through, the dura mater. The tu- 


467 


Skull. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Skull. 


mors in the right temporal bone and the ninth rib were 
of the same character and structure. Numerous small 
metastatic deposits were also found in the lung. 

But little is known in regard to the etiology of sarcoma 
of the cranial bones. It is said that it has been observed 
to follow an injury of the skull, but when we consider 
how frequently the skull is the seat of traumatic inju- 
ries, and how seldom this affection is met with, it is diffi- 
cult to trace a direct etiological relationship between the 
alleged cause and effect. Like sarcoma in any other lo- 
cality, the primary starting-point must be from an em- 
bryonal matrix of connective tissue, and a trauma may 
occasionally, but not always, act as an exciting cause 1n 
stimulating the matrix to tissue proliferation by dimin- 
ishing the physiological resistance of the adjacent tissues. 
The affection has been most frequently met with in young 
people, and in those of middle age. The diagnosis is not 
difficult if the tumor is examined at a time before perfo- 
ration of the superimposed soft tissues has taken place, as 
its deep location and its immobility leave no doubt as to 
its connection with the subjacent bone, while its rapid 
growth distinguishes it from any benign tumor of the 
cranial vault. Before the continuity of the surface of 
the bone has been destroyed by the tumor it might be 
mistaken for an exostosis, but its growth is more rapid 
and in a short time the external table of the bone gives 
way. <A periosteal sarcoma in the beginning is softer 
than a medullary sarcoma, as the latter is covered by 
the compact layer of the outer table of the bone before 
perforation outward has taken place. If the ttimor has 
attained a considerable size, it is often impossible to dif- 
ferentiate between a sarcoma of the extra-cranial tissues, 
of the medulla, or of the dura mater. If, by palpation 
or by exploratory puncture, it igs possible to prove the 
existence of a framework of bone in the tumor, it is pos- 
itive evidence that the primary growth started in the per- 
iosteum or in the diploé. 

The prognosis of a medullary sarcoma is more grave 
than is that of an extra-cranial sarcoma, as perforation 
toward the cranial cavity takes place earlier, an occur- 
rence in the history of the tumor which initiates a new 
source of danger by directly compromising the functions 
_of the brain. While life may be prolonged from five to 
ten years in cases of extra-cranial sarcomata, death fol- 
lows a medullary sarcoma of the diploé within a year, or, 
at best, within two or three years, from extension of the 
disease to the dura mater, unless the tumor is attacked 
early and vigorously by operative measures. 

3. PERFORATING SARCOMA OF THE SKULL STARTING 
FROM DuRA MaAtTrerR.—Sarcoma of the dura mater, the 
fungus dure matris of the older authors, is the most fre- 
quent form of perforating tumors of the skull. It occurs 
as a primary or secondary formation. As a secondary 
tumor it arises by extension of a sarcoma of the skull, or 
of the remaining envelopes of the brain, to the dura ma- 
ter, or by metastasis when a sarcoma exists in any other 
part of the body. Not infrequently metastatic sarcoma 
of the dura mater occurs as a multiple formation, and, 
as the disease, by farther dissemination from the primary 
tumor, affects at the same time other important organs, a 
fatal termination takes place before perforation of the 
skull can occur, Extension of the disease from a primary 
sarcoma of the arachnoid or pia mater to the dura mater 
seldom, if ever, leads to perforation of the skull, as the 
encroachment of the tumor in the direction offering the 
least resistance produces such extensive and serious le- 
sions within the skull as to result in death before perfo- 
ration can. occur. A primary sarcoma of the dura mater 
may also extend in a central direction, and produce a fatal 
result without any perforation taking place. In a num- 
ber of such cases it has been observed that not only no 
attenuation of the cranial vault takes place, but the over- 
lying bone becomes thickened by osteophytes which de- 
velop upon its inner surface. The cases, however, that 
present the greatest practical interest to the surgeon are 
those in which early extension takes place to the skull, 
resulting in perforation by pressure-atrophy, or by direct 
infiltration and destruction of the superimposed bone. 
In such cases the perforation becomes positive proof of 


468 


os 


the existence of a suspected endo-cranial neoplasm. In 
the beginning a sarcoma of the dura mater appears as a 
round nodule, which by pressure upon the adjacent bone 
causes pressure-atrophy, but perforation is always pre- 
ceded by a direct extension of the disease to the bone. 
Analogy and examination of recent specimens tend to 
prove that infiltration takes place along the course of 
pre-existing and new blood-vessels. When the neoplasm 
has reached the diploé, diffusion readily takes place 
along the numerous venous channels which normally ex- 
ist in this structure. The defect in the bone presents ir- 
regular, oblique margins, the obliquity being caused by 
the more extensive destruction of the internal than of the 
external table of the skull (Fig. 3553). As soon as perfo- 


Fic. 3552.—Perforation in the Bone from a Tumor without Osseous 
Framework. 


ration has taken place, the tumor can be felt externally, 
under the scalp, as a small, elastic, and often fluctuating 
swelling, which by pressure can be made to disappear 
completely. At this stage of the disease the defect in the 
skull can be readily ascertained by making deep pressure 
with the tip of the index finger, which by indenting the 
scalp can be insinuated into the opening. Soon after per- 
foration has taken place the tumor extends in a periph- 
eral direction between the cranium and the scalp, thus 
overlapping the margins of the opening, an occurrence 
which interferes with further digital palpation of the 
perforation in the skull, As soon as the tumor has be- 
come extra-cranial, it grows with great rapidity and en- 
croaches upon the superimposed soft coverings of the 
skull, becoming adherent to the tense scalp. Perforation 
of the scalp usually follows superficial ulceration caused 
by tension, due to pressure, and by the resulting defec- 
tive nutrition of the skin. When the skin has given way 
the tumor appears as a fungous, bleeding mass, which 
after exposure to the infective influences contained in the 
surrounding atmosphere, soon breaks down and disinte- 
grates, a rapid loss of substance taking place. The ne- 
crobiotic and necrotic changes in the tissues of the tumor, 
occurring in consequence of infection with pus microbes, 
is often followed by sepsis which hastens the fatal ter- 
mination. Until this occurrence has taken place, the 
patient may have had a healthy appearance, but he 
now presents a sallow complexion, a rapid, feeble pulse, 
and a rise of temperature indicative of the existence of a 
septic condition. The base of the tumor appears attached 
only to the external superficial layers of the dura mater, 
or it infiltrates the entire thickness of this membrane. In 
the former instance, it is easily separated from the dura, 
in the latter its removal is only possible by excising with 
the tumor the entire thickness of the dura mater. Sar- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


comatous tumors of the dura mater, located at the base 
of the skull are, as a rule, more liable to encroach upon 
the contents of the skull, while perforation is a frequent 
occurrence if they originate in that portion of this mem- 
brane which lines the vault of the cranium, Perforating 
tumors at the base of the skull often appear externally 
through the frontal sinus, nose, pharynx, or external ear. 
While sarcomata of the dura mater have often been 
found in connection with a sarcoma in some distant part 
of the body as secondary or metastatic formations, it is a 
well-known fact that a primary sarcoma is seldom the 
cause of more than a localized dissemination. Volkmann 
was the first one who claimed that primary malignant 
tumors of the dura mater were not carcinomatous in their 
structure and, behavior, but that they belonged clinically 
and histologically to the class of sarcomatous tumors. 

A sarcoma of the dura mater always appears as a cir- 
cumscribed tumor, surrounded by a distinct capsule, 
while a carcinoma, wherever found, is recognized readily 
by the absence of any distinct macroscopical boundary- 
line between the tumor and the adjacent tissues. Micro- 


scopical examinations of these tumors have shown that 


‘ 


Fic, 3553.—Perforation of the. Skull from within Outward, as seen in 
Cases of Sarcoma of the Dura Mater. 


they are generally composed of spindle-shaped cells, and 
more rarely contain giant-cells or myxomatous tissue. 
This affection is found most frequently in young adults, 
but is not limited to this period of life as it has been met 
with in young children and persons of advanced age. 
Among the early symptoms may be mentioned headache, 
vomiting, and vertigo, manifestations which point to the 
existence of meningeal irritation. If the tumor is situ- 
ated at the base of the brain, sight and hearing may be 
affected. When perforation has taken place, the cerebral 
pulsations can always be felt over the tumor, a symptom 
which disappears as soon as its external portion is large 
enough to overlap the opening in the skull. Arterial pul- 
sation may remain for a longer time, and when present is 
due to the arterial impulse of the vessels in the tumor. 
The external tumor may attain the size of a child’s head, 
and always presents a smooth surface and a semisolid 
consistence. Pseudo-fluctuation is often present, and may 
lead to a mistake in diagnosis and treatment. If the 
growth of the tumor encroaches upon the brain as well as 
the external surface, the signs of cerebral involvement be- 
come more prominent, and may include well-marked fo- 
cal symptoms, such as we observe from pressure due to any 
other endo-cranial cause. After ulceration has taken place 
the extreme vascularity of the protruding mass often 


Skull, 
Skull. 


gives rise to repeated and profuse hemorrhages, which 
rapidly undermine the patient’s strength, and which also 
favor local infective processes at the site of ulceration. 
The prognosis of a sarcoma of the dura mater is always 
grave. Without surgical interference the affection leads 
inevitably to a fatal termination within one or two years. 
The surgical treatment has so far been unsatisfactory, 
either because a correct diagnosis was not made early 
enough, or because the disease had advanced beyond the 
reach of the surgeon’s knife at the time the operation was 
performed. Before it was deemed safe and expedient to 
remove a corresponding piece of the dura mater with the 
tumor the operation necessarily proved a failure, as the 
neoplasm always invades more or less of this membrane, 
and hence portions of the tumor were left as starting- 
points for subsequent return én loco. We have also rea- 


son to believe that many of the operations proved fruit- 
less on account of imperfect exposure of the endo-cranial 


Fig. 3554.—Multiple Perforations from without Inward, in a Case of 
Periosteal Sarcoma. 


portion of the tumor by not removing a sufficiently wide 
margin of the overlying bone. Before the antiseptic 
treatment of wounds came into use the removal of an 
endo-cranial tumor was always an extremely hazardous 
procedure, as it was necessarily attended by many grave 
dangers incident to traumatic infection, more particu- 
larly septic thrombo-phlebitis and lepto-meningitis. The 
immediate cause of death in cases that are allowed to 
run a natural course is either cerebral pressure from 
extensive growth of the endo-cranial part of the tumor, 
or, after the extra-cranial portion has broken through 
the skin, exhaustion from recurring hemorrhage, or 
septic infection from the exposure of the tissues of the 
tumor to the deleterious influences of pathogenic germs 
brought in contact with the abraded, ulcerated surface. 
The medical treatment of sarcoma of the dura mater 
is merely palliative, and consists in the administration of 
such remedies as are calculated to meet the most urgent 
symptoms. In the operative treatment of a sarcoma of 


469 


€ 


Skull. 
Sleep. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the dura mater, whether perforating or otherwise, it is 
essential to remove the entire thickness of the dura with 
the base of the tumor, a step in the operation which 
is only possible after removal of the bony covering to 
the same extent by chiselling. In all operations upon 
the brain or its envelopes the strictest antiseptic pre- 
cautions must be observed, so as to protect the patients 
against septic infection. The entire scalp should be 
shaved, washed with warm water and potash soap, and 
thoroughly disinfected with a1 to 1,000 solution of cor- 
rosive sublimate. If the tumor has not perforated the 
entire thickness of the skull, the incisions through the 
soft parts are to be made in the same manner as for 
any other endo-cranial operation. If perforation has 
taken place, a circular incision should be made, at least 
an inch from the margin of the tumor down to the 
bone. After arresting the hemorrhage from the incision 
through the soft parts, the tissues are separated from the 
bone, as far as the seat of perforation, by an elevator, and 
then with chisel and Luer’sforceps the bone is removed 
all around until the endo-cranial portion of the tumor is 
freely exposed. After arresting the hemorrhage from 
the bone, which is apt to be quite profuse, by pressure 
and plugging of large vessels by a minute aseptic tam- 
pon, the surgeon is ready to remove the attachment of 
the tumor by excising the dura mater, being careful to 
carry his incisions from half an inch to an inch beyond the 
visible borders of the tumor. If the tumor is situated in 
close proximity to the superior longitudinal sinus, or if 
it lies directly over it, it becomes necessary to resort to 
prophylactic measures for the purpose of preventing en- 
trance of air, or a serious loss of blood on cutting 
through this large vessel. Volkmann lost a patient on the 
table from air-embolism, while he was removing a sarco- 
ma of the dura mater, having severed the superior 
longitudinal sinus in the dissection. The patient was a 
woman, sixty-three years of age, who was affected with a 
perforating sarcoma of the dura mater. The tumor was 
noticed about two years before the operation, and was lo- 
cated in the region of the posterior extremity of the sag- 
ittal suture, and for a long time gave rise to no incon- 
venience. For the last six months it had caused intense 
headache. On one occasion a physician, believing that 
it was an atheroma, attempted its removal, but as the first 
incision gave rise to copious hemorrhage he desisted 
from any further attempts, and the wound healed kindly. 
When the patient was admitted, under Volkmann’s care, 
into the Klinik at Halle, the tumor presented a lobulated 
appearance, being composed of three parts, each about 
the size of a plum, and was located over the posterior ex- 
tremity of the sagittal suture. To the touch the tumor 
was soft and elastic, and imparted to the finger a feeling 
of distinct pulsation. Gradual compression reduced its 
size one-half, but when the pressure was removed it re- 
sumed its former dimensions. On auscultation a blow- 
ing sound was heard, synchronous with the radial pulse. 
By pressing the end of the index finger deeply between 
the lobes of the tumor a bony defect in the skull was 
readily detected. The conclusion was reached that the 
tumor had sprung from the dura mater, and that per- 
foration of the skull had been caused by the prolonged 
pressure, leading to interstitial absorption of the cranial 
vault. During the patient’s stay in the hospital the tu- 
mor increased very rapidly.in size. As no brain symp- 
toms were present it was assumed that the substance of 
the brain was intact. In view of a speedily fatal issue, 
which of necessity would take place without operative 
interference, Volkmann decided to remove the tumor. 
The operation was performed on April 2, 1875. Under 
strict antiseptic precautions the tumor was exposed by a 
crucial incision, the flaps with the periosteum being re- 
flected to the margins of the opening in the skull. The 
aperture in the bone measured five and one-half by four 
and one-half centimetres in diameter. With a Luer’s 
cutting forceps the opening was enlarged to seven by 
eight centimetres. The tumor, when exposed, was nearly 
as large as a fist, and firmly adherent to the dura mater. 
The dura mater was carefully divided around the mar- 
gins of the tumor, which had now been liberated from 


470 


all its attachments, except the falx cerebri. It was now 
drawn forward through the opening in the skull, and the 
falx cerebri was divided, the incisions being made from 
before backward. This step of the operation was at- 
tended by alarming hemorrhage. As the blood was 
being sponged away to expose the field of operation, a 
peculiar and characteristic lapping sound was _ heard, 
which indicated to all present that air had entered the 
longitudinal sinus. At the same time the assistant, who 
was giving the chloroform, remarked, ‘‘ she is dying.” 
The wound was immediately compressed with a large 
carbolized sponge. The patient was in collapse, her 
breathing was interrupted and stertorous. After a short 
pause it was determined to complete the operation, but as 
soon as the tumor was again drawn forward and its attach- 
ment at the junction of the longitudinal with the trans- 
verse sinus was divided, air again entered, accompanied 
by the same characteristic sound. The tumor was sepa- 
rated rapidly from its remaining attachments, and a Lister 
dressing was applied in such a manner as to make com- 
pression sufficient for the double purpose of arresting 


Fig. 38555.—Almost complete Destruction of the Occipital Bone from a 
Perforating Tumor of the Base of the Skull. 


hemorrhage and preventing further ingress of air. At 
this time the patient was pulseless, with dilated pupils, 
and cold and blue extremities. Auto-transfusion, by 
constricting the arms and legs with elastic bandages, had 
the effect of momentarily stimulating the heart, but res- 
piration became more irregular and interrupted, and after 
afew brief moments the patient expired. At the post- 
mortem examination, which was held on the following 
day, the right side of the heart was opened under water, 


‘and air-bubbles escaped, showing conclusively that air 


had entered through the longitudinal sinus. The left 
side of the heart contained no air. Air was also found 
in the pulmonary artery and in the subpleural vessels. 
The left side of the brain had suffered more from com- 
pression by the tumor than the right. The defect in the 
dura mater corresponded to the opening in the skull. An 
additional source of haemorrhage was detected at the pos- 
terior margin of the defect in the cranium, where the 
opening of a vein in the substance of the bone, five milli- 
metres in diameter, could be seen. Under the micro- 
scope the tumor showed small spindle-shaped cells, with 
a very vascular intercellular substance. 

In my experiments on air embolism I determined the 
fact that entrance of air through a wound in the superior 
longitudinal sinus can take place only when the head is 
elevated, as in this position intravenous pressure is di- 
minished, and as, from the unyielding nature of the ves- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Skull. 
Sleep. 


sel walls, collapse cannot take place, the essential condi- 
tions for the admission of air are thuscreated. As long as 
the head is in a dependent position a wound in the longi- 
tudinal sinus gives rise to profuse hemorrhage, but air- 
embolism cannot occur, as the lumen of the vessel is 
constantly filled by an uninterrupted column of venous 
blood. In the same series of experiments I also proved 
the feasibility and practicability of ligation of the superior 
longitudinal sinus as a prophylactic measure against air- 
embolism and hemorrhage in operations which implicate 
this vessel, a practice which Kuester had adopted previ- 
ously in extirpating an endo-cranial sarcoma. It is not 
only advisable, but positively indicated, to resort to liga- 
tion of the superior longitudinal sinus in all cases of ex- 


CRS 


-F1q. 3556.—Sarcoma of the Diploé ; Tumor encroaching upon both Sur- 
faces of the Skull. 


tirpation of sarcomatous tumors of the dura mater when- 
ever it becomes necessary to traverse this vessel by the 
‘incision, thus guarding effectually against the two great 
risks attending such a procedure—air-embolism and pro- 
fuse hemorrhage. With a sharply-curved needle two 
catgut ligatures are passed beneath the sinus, about half 
an inch apart, and, after tying the ligatures, the vessel is 
divided between them, and the excision of the dura 
mater with the tumor is completed. It remains to be 
shown whether the practice of Macewen, of replanting 
fragments of bone, after trephining, could not be fol- 
lowed in these cases. This procedure, if it should prove 
successful, would repair the extensive bony defect that 
follows the ordinary methods of operating. After arrest- 
ing all hemorrhage and closing the external wound as 
nearly as possible, by suturing, it becomes necessary to 
apply a thick compress of an antiseptic hygroscopic 
dressing material, which should always be retained by a 
few turns of a plaster-of-Paris bandage, so as to prevent all 
possibility of exposing the wound to secondary infection. 
If no urgent indications present themselves the primary 
dressing should be allowed to remain for one or two 
weeks, after which time there will be but little liability 
to the occurrence of secondary infection, as the portion 
of the wound not closed by primary union will be found 
covered by a layer of granulation tissue, which furnishes 
the best protection against infection. 


LITERATURE. 

Heineke : Sarcom der Dura-mater, Pitha u. Billroth’s Handbuch der Chi- 
rurgie, Bd. III., 1. A., p. 106. 

Albert : Lehrbuch der Chirurgie, 1881, Bd. I. 

Bruns: Handbuch der prakt. Chirurgie, Bd. II., S. 613. 

Wenzel: Ueber die Schwimmige Auswiichse auf der 4ussern Hirnhaut. 
Mainz, 1811. 

Lebert: Traité d’anat. pathol., T. I., p. 204. 

Hueter: Grundriss der Chirurgie, Bd. II,, S. 41. Leipzig, 1882. 

Kuester: Zur Kenntniss u. Behandlung der Schiidelgeschwiilste, Berl. 
klin. Wochenschrift, 1881, No. 46. 

Genzmer: Extirpation eines faust-grossen Fungus Durse Matris, tédtlich 
verlaufen durch Lufteintritt in den gedffneten Sinus longitudinalis, 
Verh. der deutschen Gesellschaft fiir Chirurgie, Bd. VI., p. 32. 

Busch: Lehrbuch d. topogr. Chirurgie, Bd. II., 8. 70. j 

Senn: Experimental and Clinical Study of Air-embolism. Philadelphia, 


1885 . 
NV. Senn. 


SLEEP, DISORDERS OF. Sleep is a condition in 
which consciousness is normally lost, and in which the 
whole body, but particularly the brain, enjoys functional 
rest, while constructive and nutritive activity goes on. 
The most conspicuous phenomenon of sleep is the subsid- 
ence of the higher cerebral functions; yet other organs, 
notably the muscular system, also take part in the rest- 
ing process. The statement of Foster, that sleep is the 
diastole of the brain, is therefore only partially true, 


III. Statesof Imperfect or Partial 


Persons who lie quietly in bed all night without cerebral 
sleep get some muscular sleep and a measure of refresh- 
ment. For the essence of the state is functional rest and 
nutritive repair, similar to that which occurs in the cells 
of the pancreas or salivary glands in the intervals of their 
activity. We may even rationally assume that in sleep 
the brain-cells during repose are building up complex 
molecules, just as the salivary and other glands build up 
their mother-ferments or zymogen. 

The brain, during this period of rest, is slightly anemic, 
the deficiency in blood being a part of, but not the cause 
of, the phenomenon. The remote cause of sleep is,inher- 
ent in the nervous tissue itself, which follows the great 
rhythmical law common to all living tissue, of rise and 
fall in its irritability. It is probable that the immediate 
cause of drowsinessis the exhaustion of the irritability of 
the cortical cells and the benumbing of them by the cir- 
culation of waste products in the blood. While sleep in- 
volves so large a part of the economy, it is true that it 
is the highest organized tissue, that of the cortex of the 
brain, which is most affected in this state. 

Many facts in the history of the pathology of the brain 
point to the existence of a sleep centre, which, being 
especially acted upon, tends to inhibit the consciousness 
and draw the mind into a somnolent state. 

As sleep is only a function, and a passive or a negative 
one at that, it follows that we cannot speak of its diseases, 
but only of its disorders, and that these really form but 
a part of the diseases of the brain, or of general diseases. 
It is a matter of convenience, however, to discuss some 
of these separately. 

Custom has established the use of certain terms for the 
various disorders of sleep, and such terms must be for 
the most part adhered to. It will be proper, however, 
for the sake of completeness, to arrange the various 
disturbances we are to discuss in accordance with the 
modern methods of studying the pathological changes of 
bodily functions. We propose, therefore, the following 
classification, which indicates the various depressions, 
exaltations, and perversions of the function of sleep. 


I. State of Normal Sleep. Hyp- Somnus. 
nosis. 
II. States of Absence of Sleep. Insomnia. 
Ahypnosis, Egregorsis, 
Vigilance, 


Dreams, sleep-drunkenness or som- 
nolentia, night-terrors, night- 
mare. 


Sleep. AHypohypnosis. 


IV. States of Perverted or Artifi- 
cial Sleep. Parahypnosis. 


VY. States of Excessive or Frequent 
Drowsiness and Sleep. Ayper- 
hypnosis. 


Somnambulism, sleep-walking, hyp- 
notism, mesmerism, trance, som- 
nium, , 

Morbid drowsiness or somnolence, 
paroxysmal sleep, epileptic sleep- 
ing attacks, trance sleep, carus, 


cataphora, lethargy, sleeping- 
sickness of Africa. 


I. NoRMAL SLEEP varies much in accordance with age, 
sex, the individual, and, to a slight extent, with occupa- 
tion, race, and climate. The infant sleeps fourteen or 
sixteen hours out of the twenty-four, the adult needs about 
eight hours, while the aged live healthfully with but six. 
Women need half an hour or an hour more than men. 
A few persons, generally men, need nine, ten, or even 
twelve hours of sleep daily; others require only six. 
Brain-workers, as a class, take less sleep than laborers. 
Sleep is sounder and longer in cold climates and among 
northern races, 

II. Anypnosis.—J/nsomnia is a term given to condi- 
tions in which persons simply suffer from insufficient 
and restless sleep, or from entire absence of sleep for a 
long time. Such conditions result from a great variety 
of causes. It is my purpose to discuss only those forms 
in which the trouble is functional or nutritional, leaving 
out of consideration the symptomatic insomnia of organic 
brain disease, and that occurring as the result of painful 
diseases. ; 

Ahypnosis, entire absence of the capacity to sleep, oc- 
curs most often and typically at the onset or in the course 
of insanity. It is here a prominent and most distressing 
symptom, The length of time during which a person 


471 


Sleep. 
Sleep. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


can live without any sleep is about the same as that dur- 
ing which he can go without food, viz., three weeks. 
There are, doubtless, instances in which this period has 
been exceeded, but authenticated cases are certainly rare. 
Many hysterical, neurasthenic, or incipiently insane indi- 
viduals will assert that they have not slept for weeks, 
but careful examination shows that they have at least 
been in a drowsy, somnolent condition, which is, in a 
measure, physiologically equivalent to sleep. 

The cases in which persons can only get a troubled rest 
of a few hours are much more numerous. The young 
and the old, less often than middle-aged, suffer from this 
form of insomnia. It is a disorder of the third, fourth, 
and fifth decades of life. Women are less liable to suffer 
from it than men, and the laboring classes less than those 
engaged in business or professional pursuits. 

A frequent symptom of neurasthenia is an imperfect, 
and especially an unresting, sleep. In these neurasthenic 
cases there is a loss of vaso-motor tone, Ordinarily, as 
mental activity subsides and sensory excitations are shut 
out, the inhibitory vaso-motor centre asserts control and 
slightly exsanguinates the cortex of the brain; but in 
these insomnic states such action does not occur, the 
blood continues to flood the tissues concerned in the con- 
scious workings of the mind, and sleep cannot be in- 
duced. In gout and in the so-called latent gout, or lithe- 
mia, insomnia is a frequent symptom. One of the few 
nervous symptoms of secondary syphilis is insomnia. 
Insomnia may develop as a bad nervous habit, in per- 
sons who are neglectful of themselves. It occurs some- 
times asa hereditary neurosis. Iam personally acquainted 
with a family in which, for four generations, one or more 
of the members have suffered from chronic insomnia 
throughout life. 

In anemia and chlorosis there is often insomnia at 
night, combined with somnolence during the daytime. 
Disease of the heart and arteries may lead to insomnia, 
and under this head come the cases which occur in Bright’s 
disease with tense arteries and anemic brains. 

Disorders of the stomach lead to disturbed sleep oftener 
than complete insomnia, and the liver, when inactive, 
causes somnolence rather than the contrary. The poison 
of malaria, and the toxic agents of fever, must be added 
to the list of causes of imperfect sleep. 

It will be seen from a review of the foregoing that the 
causes of chronic functional insomnia may be classed un- 
der the following heads: 

1. Neurasthenic and vaso-motor, including hereditary 
and habit insomnia. 

2. Vascular and cardiac, including heart-disease, arte- 
rial fibrosis, and general anemia. 

3. Auto-toxic or diathetic, including lithemia, gout, 
and uremia. 

4, Toxic, including syphilis, lead, malaria, tobacco, 
and various drugs, such as coffee, tea, and coca. 

In many cases there exists a combination of these causes. 

The forms and degrees of insomnia vary greatly. In 
children it is accompanied usually with much mental 
and physical disturbance. The patient is restless, ex- 
cited, talkative, or querulous and irritable. The insom- 
nic child is more ill than the insomnic adult. 
thenic insomnia there is a tumult of thoughts which 
prevent sleep, or sleep is superficial, unresting, and inter- 
rupted by dreams. In many cases of insanity insomnia 
is characterized by great motor restlessness. In old peo- 
ple insomnia is generally of the quiet kind. 

Treatment of Insomnia.—As insomnia in all its phases 
is often a symptom of some general disorder, treatment 
of acurative kind must be directed to this. Anemia, 
lithemia, ursemia, malaria, and the other toxic influ- 
ences must be removed by remedies adapted to these con- 
ditions. But besides constitutional treatment there is a 
symptomatic treatment which will be discussed here. 

The older physicians, in treating insomnia, used to de- 
pend largely on hyoscyamus, camphor, opium, and the 
fetid drugs, such as assafcetida, musk, and valerian. Hy- 
oscyamus is still used. It is to be given in large doses, 
such as five or ten grains of the extract, or even more, 
and from ten to twenty drops of the fluid extract. The 


472 


In neuras-_ 


hydrobromate of hyoscine, in doses of gr. 744 to gr. x45 or 
more, is one of the best forms. Crystalline hyoscyamine 
does not have so much of the narcotic principle; and 
amorphous hyoscyamine, which is much like hyoscine, is 
said to be variable in composition. Hyoscine is indicated 
in the insomnia of the insane, especially in forms accom- 
panied with motor activity. Chloral hydrate still holds 
its own as one of the surest of hypnotics. The dangers 
involved in its use have been somewhat exaggerated, 
though they are sufficiently real. Doses of gr. x. and 
gr. xv. are often quite large enough, but in alcoholic in- 
somnia it may be given in twice the above amounts, 
guarded with carbonate of ammonia. The taste is best 
disguised by raw whiskey, ice, or a licorice elixir. Not 
a few persons find that chloral has bad effects. The pa- 
tient awakes with a dull, heavy sensation in the head, 
slight headache, or gastric disturbance. 

The various bromides are efficient and safe hypnot- 
ics if properly used. The immediate effect of them is 
simply sedative, and sleep is not produced unless very 
large doses are given. Some persons are even kept 
awake by average doses (gr. xv.—xx.). In insomnia, there- 
fore, bromides are best prescribed in doses of gr. xv. three 
timesaday. By the second evening sleep is generally se- 
cured. The bromide habit is rarely formed, and is in it- 
self not so seriously injurious as the chloral or opium 
habit. The drug in some cases can be taken in moderate 
doses for years without doing much harm. Still, in most 
persons it produces a disagreeable hebetude, anorexia, 
foul breath, and acne, so that its continual use may 
prevent the attempts at restorative treatment which are 
being.made. The bromides alone are hardly strong 
enough hypnotics for alcoholic insomnia, or the-insom- 
nia of insanity. I have found them to fail in the insom- 
nia of the aged. While there seems to be advantage 
to the stomach in varying and combining the bromides, 
there is no essential difference in their action. The 
bromide of sodium is the most palatable, the bromide of 
nickel the least so. Hydrobromic acid causes less acne 
and hebetude, but it involves the taking large amounts 
of a strong mineral acid. The bromides are sometimes 
advantageously combined with ergot (3j. dose) or co- 
nium (TMLx.-xx. of fluid extract). Paraldehyde ranks 
close to chloral in its value as a hypnotic. In some per- 
sons it disturbs the stomach, but not in all, and it may 
be used as a hypnotic for months without its power being 
impaired. It is ‘a disagreeable drug, and there is nothing, 
so far as I know, that palliates its offensiveness. I prefer, 
however, to prescribe it in 3j. doses, poured upon a 
teaspoonful of powdered sugar. Doses of 3 ss. are suffi- 
cient to cause sleep in many cases, and collapse may be 
caused by 3 ij. given to weak patients: Urethan, in doses 
of a scruple or more, is a mild and agreeable hypnotic, 
but not so certain as paraldehyde, and it is at present 
date very expensive. Amylene hydrate is a hypnotic of 
similar properties to paraldehyde, but less disagreeable. 
It is given in doses of about one drachm. 

Hypnone, so called, has found no favor as a sleep-pro- 
ducer. Much the same may be said of the various active 
principles derived from cannabis indica. Lupulin in 
large doses, gr. x. to gr, xx., is said to be agood hypnotic. 
Among the antispasmodics are several drugs which oc- 
casionally answer well in the insomnia due to nervous 
irritability. A drachm of the fluid extract of valerian, 
or of spirits of lavender, for example, may be prescribed. 
In some forms of insomnia—perhaps best in those due to 
fever, or pain, or some rheumatic or gouty trouble— 
antipyrin in twenty-grain doses acts well. It is known 
that in many cases of mild types of insomnia a dose of 
whiskey, brandy, or beer will put the patient to sleep. Be- 
sides drugs, there are many hygienic or mechanical meas- 
ures to which the physician may successfully resort— 
listening to monotonous noises, reading dull or heavy 
books, counting, or keeping before the fancy some blank 
or wearying picture— 


** A flock of sheep that leisurely pass by, 
One after one; the sound of rain and bees 
Murmuring ; the fall of rivers, winds and seas, 
Smooth fields, white sheets of water, and pure skies.” 


The mechanical remedies have nearly ail for their pur- 
pose the withdrawal of the blood from the brain to the 
skin and abdominal viscera. Hot foot-baths, or warm 
general baths, cold douches down the spine, beating the 
limbs with rubber hammers, brisk exercise, a light meal, 
massage, all are at times efficient hypnotics. Persons 
who suffer from insomnia should sleep in cold rooms, 
the head should not be too high nor very low, and in 
most cases they are better without late suppers, even 
though these be light. Mental work should be laid aside 
several hours before retiring, and the evening devoted to 
quiet conversation and reading, or amusements that do 
not actively excite the nerves. Many persons live in 
good health though they sleep in the day and stay awake 
at night. Journalists and editors, whose work obliges 
them to go to bed in the early morning, often con- 
tinue for years without impairment of physical vigor. 
Yet despite this, it is true that the best time for sleep is at 
night, and that the old maxim, ‘‘early to bed,” is a sound 
one. The human system requires a certain amount of 
sleep, and should have it. The industrious and ambi- 
tious often try to train themselves to shorter hours, but, 
though they may succeed for a time, nature will not be 
cheated out of her due, and health suffers in the end. It 
is a widespread custom in some countries to take a short 
nap in the daytime, and the custom is a good one, 
America has not adopted it, but might do so with benefit 
to the health of her brain-working class. Many from 
childhood up do not get a sufficient amount of sleep. 

III. DisonDERS OF THE HYPOHYPNOTIC STATE.—These 
are: dreams, sleep-drunkenness or somnolentia, night-terrors, 
nightmare. Sleep is said to reach its deepest stage in 
from one to two hours after it begins, There is then after 
this a gradual lessening of the depth of sleep. Probably 
there are great variations in this rule, for many persons 
seem in soundest slumber several hours after falling 
asleep. But, at any rate, there are lighter stages of sleep 
at its inception and toward its end. These are the favorite 
times for dreams, and at this period also there develop 
the peculiar phenomena of sleep-drunkenness. 

Dreams.—W hen sleep is perfect and profound, dreams 
afterward remembered do not occur. Dreaming is, there- 
fore, a morbid symptom, although often of trivial sig- 
nificance, especially if it occurs at about the time of nat- 
- ural waking, when slumber is, in its physiological course, 
passing into the lighter stages. In sleep, no matter how 
light, the action of the regulating centre which directs 
thought, controls emotion, and exhibits itself in volition, 
is suspended ; the psychical mechanism, if excited to ac- 
tion at all, works without purpose, like a rudderless ship 
at sea. Ideas and emotions succeed each other by the 
laws of association, but are not properly correlated, and 
judgment and logical reasoning are gone. As a rule, 
dreams are made up of somewhat ordinary ideas and 
fancies incoherently associated, and shifting too rapidly 
to call up much feeling. When from some point in the 
body painful sensory excitations do excite disagreeable 
images, emotions of a most violent kind may be felt. 

Dreams, when painful, depressing, or unusually vivid 
in character, are called morbid, and Hammond speaks of 
symptomatic morbid dreams and essential morbid dreams, 
or nightmare. But while there are, doubtless, cases of 
nightmare in which the trouble is a pure neurosis, or vice 
in nervous structure and nutrition, yet, as a rule, the char- 
acteristic symptoms of nightmare are excited by some 
agent which is recognizable. It is, therefore, also symp- 
tomatic. 

In the earlier stages of civilization, among primitive 
people, dreams were comparatively rare. When they 
did come with vividness they were regarded with im- 
portance, and often were considered visitations of spirits. 
Civilized man dreams more, but he has learned to treat his 
fancies with corresponding indifference. The attempts 
of scientific men to formulate laws regarding them have 
been productive of small results. Some diseases, how- 
ever, produce, as a rule, dreams of a more or less peculiar 
kind. Thus heart disease is accompanied with dreams of 
impending death. Previous to attacks of cerebral hemor- 
rhage, patients have dreamed of experiencing some fright- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sleep. 
Sleep. 


pe 

ful calamity, or of being cut in two. Dr. Thos. More 
Madden states that intermittent fever is often announced 
by persistent dreams of a terrifying character. Ham- 
mond (‘‘ Treatise on Insanity ’’) has collected a large num- 
ber of what he terms prodromic dreams, all going to 
show that, before recognizable signs of disease are pres- 
ent, morbid dreams of various kinds may occur. Albers, 
quoted by Feuchtersleben, has given a complete sum- 
mary of his views regarding the significance of dreams. 
Among his dicta are these: ‘‘ Frightful dreams are signs 
of cerebral congestion. Dreams about fire are, in women, 
asign of impending hemorrhage. Dreams about blood and 
red objects are signs of inflammatory conditions. Dreams 
of distorted forms are frequently a sign of abdominal ob- 
structions and diseases of the liver.” Lyman asserts 
with truth that in certain somnolent states the brain be- 
comes extraordinarily sensitive to external impressions, 
hearing in particular being greatly intensified. He as- 
serts that at one time he always was awakened nights 
several minutes before his bell rang. When thus awak- 
ened he could at first hear nothing, but felt perfectly 
sure that the bell would ring shortly. Dr. Lyman would 
explain some of the cases of alleged thought transferrence 
on this theory of somnolent exaltation ; but here we are 
treading in regions of the undemonsirated. 

Nighimare.—That nightmare is a disorder incident to 
the hypohypnotic state, or that of incomplete sleep, is, I 
believe, strictly true ; for though the cause of nightmare 
may act upon the patient while sleeping soundly, it must 
first bring him into the somnolential state before he ex- 
periences his sufferings. 

Nightmare is one of those minor ills that are nearly al- 
ways symptomatic of an irritation in some part of the 
body. The usual causes of it are some digestive disturb- 
ance (repletion) and cardiac disease. Persons of a ner- 
vous temperament are more subject to it; and there are 
individuals whom it makes suffer all their lives. The 
popular belief that sleeping on the back favors it, is, in 
general, a correct one. When nightmare occurs in car- 
diac disease a certain position, semi-recumbent or on the 
right side, must be maintained, or the painful fancies 
awaken the patient. 

Healthy people can get sound sleep whether lying upon 
the back, the side, or the stomach. But light sleepers, 


-and those with sensitive abdominal viscera, generally find 


that the position on the right side is the most comfort- 
able, and less provocative of unpleasant dreams. Pro- 
longed mental or physical strain, excitement, and worry 
predispose to nightmare. Farinaceous foods, excessive 
use of strong liquors, coffee, and tobacco, all have a sim- 
ilar tendency. 

Nightmare occurs also in anemia and malaria, and it 
may, in fine, be excited by painful sensations in any part 
of the body. It sometimes occurs about the menstrual 
period in women. Its most common feature is a sense of 
suffocation or impending death. 

Pavor nocturnus, or night-terrors, is a sleep disorder 
peculiar to children. It is allied to nightmare on the 
one hand, and sleep-drunkenness on the other. It differs 
from the former condition in that the child continues to 
suffer from the distressing fancies for some time after he 
is awake. Night-terrors occur usually one or two hours 
after sleep has begun. The child wakes up screaming 
with fright, and perhaps runs about the room or seeks its 
parents for protection against some imagined harm. 

The disorder occurs in weakly, anemic, nervous, or 
rheumatic children. It is due sometimes to lithzemia, or, 
as the older writers put it, rheumatism or gout of the 
brain. Digestive disturbances, worms, dentition, heredi- 
tary syphilis, mental strain, fright, and excitement are 
placed among the causes. It sometimes appears to be 
a paroxysmal neurosis allied to epilepsy. The disorder 
is usually harmless, and the prognosis favorable. 

Somnolentia, sleep-drunkenness, Schlafentrunk, is a 
condition of incomplete sleep in which a part of the 
faculties are abnormally excited, while the others are 
buried in repose. It is a kind of acted nightmare. 
The person affected is incoherent, excited, and often 
violent. He experiences the delusion of some impending 


473 


Sleep. 
Sleep. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


danger, and while under it acts of violence have been 
committed. The condition is one of medico-legal im- 
portance, therefore, and has been discussed by writers 
on that science (Wharton and Stillé). Minor degrees of 
it are often noticed in children, and in adults who are 
roused from a very profound sleep. It at times becomes 
a habit, and a most annoying or dangerous one. The 
disorder, in its severe form, is fortunately a very rare 
one. Some of the classical cases are the following : 

A sentry, on being suddenly awakened from sleep by 
an officer, made a violent attack upon him with a sword, 
and would have killed him but for the interference of 
others. 

A laborer who had been sound asleep was awakened 
by his wife. He sprang up and dealt her a fatal blow. 

A woman dreamed that her little boy told her the 
house was on fire. She jumped up and threw him out 
of the window. 

Although sleep-drunkenness is a phenomenon of im- 
perfect sleep, and belongs to the states of hypohypnosis, 
yet it seems often to occur in those who sleep very pro- 
foundly, and is, therefore, somewhat different etiologi- 
cally from the states of dreaming and nightmare. 

The treatment of morbid dreams, nightmare, and pavor 
nocturnus must be directed to a removal of the causes. 
Tonics, cardiac stimulants, laxatives, anti-rheumatics, at- 
tention to diet, are called for according to the condition 
of the patient. Change in surroundings is often neces- 
sary. Among symptomatic remedies the bromides are 
the best, except in lithemia, when alkalies and salicyl- 
ates may prove more serviceable. In somnolentia the 
patient should be prevented from getting into too pro- 
founda sleep. He may be awakened once or twice during 
the night, or take a nap in the daytime. The head in 
sleeping should be raised high, and the body not too 
heavily covered. 

IV. Paraunypnosis. — Somnambulism, Sleep-walking, 
Somnium, Hypnotism, Trance, Mesmerism. 

Somnambulism.—Some authors have regarded somnam- 
bulism as an incomplete sleep (Symonds, Hartmann, and 
others), Dr. Chambers thinks it is a condition of unusu- 
ally profound sleep. It appears to me to be a condition 
peculiar to itself, and not to be classified under the heads 
of incomplete or too profound slumber. Hence I adopt 
the term for it of parahypnosis. 

Somnambulism is a condition similar to hypnotism or 
the mesmeric state. In it volition is abolished, and the 
mind acts automatically under the dominance of some 
single idea. Sight, hearing, and nearly all the avenues 
of sense are closed. The sleep-walker avoids obstacles 
and performs ordinary acts automatically, like an absent- 
minded man, which in reality he is. All those mechan- 
isms which have been trained by constant repetition to 
act automatically, like that which preserves equilibrium, 
are preserved, and their powers may even be heightened, 
so that the somnambulist may walk along roofs or on 
dangerous roads, and thread intricate passages without 
harm. The automatism of the somnambulist may con- 
tinue for hours, until a journey has been performed or a 
task completed. He may carry out with success intri- 
cate mathematical calculations, write a letter, or work 


upon a picture, but he only follows along the lines es- 


tablished by constant iteration in his waking moments. 
He can originate nothing new. He is roused from his 
state with difficulty, and when out of it he remembers 
nothing of what has occurred. 

Somnambulism usually arises, according to Chambers, 
from overeating. Sleeping with the head too low is an- 
other cause. Violent emotions, according to the author 
referred to, act only indirectly by disturbing digestion. 
The habit being once established, however, attacks occur 
without apparent cause. The disorder occurs oftenest in 
young people about the age of puberty, and it then attacks 
the sexes alike. Later in life women are more often 
affected. The disease is fostered sometimes at school by 
the attentions of the school-mates. In most cases a con- 
dition of morbid nervous sensitiveness underlies it. The 
patients are neurotic. Hereditary somnambulism has been 
observed. Its attacks have alternated with those of cata- 


474 


lepsy. They are likely, after a time, to become periodi- 
cal, occurring every week, fortnight, or month. 

The somnambulic state may come upon a person in the 
daytime. It is then regarded as spontaneous trance, or 
hypnotism. It is not the case, however, that persons 
who are easily hypnotized are usually somnambulists, 
though the reverse may be true. 

Somnambulism is a term that should include not only 
sleep-walking, but sleep-talking, and Chambers even con- 
siders that spermatorrheea and nocturnal enuresis are dis- 
orders allied to it. In this, however, it seems to me he 
is mistaken. 

The treatment of somnambulism is very much like that 
for sleep-drunkenness. The patient’s surroundings must 
be investigated, and unfavorable influences, such as may 
occur at school or from injudicious nurses, be removed. 
He should be prevented from sleeping too soundly, the 
head should be raised, the clothing light, the diet regu- 
lated. Remedies like iron, quinine, phosphorus, and cod- 
liver oil may be given. When the patient is discovered 
in the somnambulistic state, he should not be awakened, 
or at least not until he is safely back in bed. 

Hypnotism, Trance, Mesmerism.—This is a state in 
which phenomena allied to those of perturbed sleep are 
exhibited. 

Definition: Hypnotism is a thorbid mental state char- 
acterized by (1) perversion or suspension of conscious- 
ness ; (2) abeyance of volition ; (3) automatic response to 
commands or external sense impressions ; and (4) intense 
concentration of the nervous force in some particular 
direction. 

Susceptibility and Causes. —Hypnotic states are generally 
produced artificially by causing the patient to concentrate 
the attention on an object, while certain muscles, gener- 
ally the eye muscles, are kept on a strain. 

Young persons, the hysterical, those of sensitive nervous 
organization, of deficient education, and weak will-power 
are most subject to the state. About one in every ten or 
fifteen adults is susceptible to the condition, It can be 
produced in the lower animals. Those who have been 
mesmerized once are more easily affected afterward, and 
may even pass into the state involuntarily. Indeed, by 
cultivation almost anyone can train himself to enter it 
at will. 

Symptoms.—T he person who has been hypnotized at first 
sits or lies quietly in the position he had assumed during the 
manipulations of the operator. No notable physiological 
changes occur, as, for example, in the pulse, respiration, 
temperature, pupils, skin, etc. Some increase in the 
cerebral blood-supply, however, is said to be present. 
The patient will now respond automatically to any out- 
side command, or will be dominated by any idea which is 
suggested to him, He will talk, or walk, or run, or ges- 
ticulate, assume expressions of fright, anger, or joy, en- 
tirely in accordance with the command given. Apart 
from these commands he is entirely dead to the outside 
world. He hears, sees, smells, tastes, and feels nothing. 
He can be burned, cut, or injured without showing any 
signs of feeling. At asuggestion he may be made cat- 
aleptic, somnambulic, or paralytic. This state is termed 
somnambulistic trance. If left to himself, he gradually 
sinks into a deep sleep, from which he can with difficulty 
be roused. After a time, rarely more than one or two 
hours, he awakes as from ordinary slumber. This latter 
state is called trance-coma, or lethargic hypnotism. The 
attempts of some French writers to divide hypnotic phe- 
nomena into three forms, the somnambulic, cataleptic, 
and lethargic, are hardly successful. Sensitive subjects 
can be thrown at once into lethargy, catalepsy, or som- 
nambulic states, at the command of the operator. 

The phenomena of hypnotism depend upon the won- 
derful sensitiveness and quickness of the subject in re- 
sponding involuntarily, with all his nervous energy, to 
outside suggestion. Dishonest persons may learn the 
latter trick and thus simulate the hypnotic state. Trav- 
elling mesmerizers utilize such persons largely, hence no 
confidence can be placed in the phenomena exhihited by 
them. 

The best method of inducing hypnotism is to hold for 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sleep. 
Sleep. 


five to ten minutes some bright object at a distance of six 
to eight inches from the eyes, and a little above the hori- 
zontal plane of vision. 

Hypnotic states may be self-induced, by rigorously fix- 
ing the attention upon some object. The ecstatic states 
of the saints, and the nirvana of the Buddhists, are forms 
of hypnotism ; so also are the trance states into which 
some Clairvoyants and spiritualistic preachers place them- 
selves; this same curious phenomenon is at the bottom 
of the so-called ‘‘mind-healing” science, and it enters 
into rational therapeutics and orthodox religion. The 
capacity of the human mind for hypnotism or semi-hyp- 
notice states is, therefore, a most curious and important 
fact. 

After a time, as already stated, subjects who have been 
hypnotized learn to pass into the state much more easily ; 
even a word of command being sufficient. 

The practice of hypnotizing persons is injurious to 
them, tending to exhaust the nervous force, and weaken 
the will. It should be done only with the greatest care. 
Its utility in therapeutics I greatly doubt. It may re- 
lieve symptoms in the hysterical for a time, but it can- 
not be of permanent benefit, and is likely to lead to 
actual harm. The popularization of mind-cures, Chris- 
tian science, etc., accomplishes its results at the expense 
of mental demoralization, and faith-healing institutes are 
more pernicious elements in society than gin-mills. 

Patients naturally come out of the mesmeric. state 
through the channel of deep sleep or lethargy. Ordi- 
narily they are dehypnotized by word of command, or by 
a pass of the hand, or any such impression which the pa- 
tient expects to be used for the purpose. 

Hypnotized persons have been observed to have a 
diminution in the spinal reflexes, and a muscular hyper- 
excitability. They sometimes show a most extraordi- 
nary exaltation of visual, auditory, or other special sense. 
The statements of Luys and other French observers, that 
they are sometimes susceptible to the action of medicines 
at a distance, enclosed in sealed vials, can hardly be cred- 
ited. The alleged phenomena must be explained at pres- 
ent on the theory of unconscious suggestion. 

Something may be properly said here regarding the 
physiology of the hypnotic state. 

Phystology.—1. There exists in each of us what the 
philosopher Locke well described as a ‘‘ power to begin 
or forbear, continue or end the several actions of our 
minds and motions of our bodies, barely by a thought or 
preference of the mind.” This power is called the Will. 
It is not thought by modern psychologists, or even by all 
of the older schools, to be a separate and distinct force 
enthroned within us. Exactly what it is, however, is a 
question that we need not enter upon now. We do 
know that every man can check, regulate, or set in ac- 
tion, such muscular movements, or such trains of thought 
as he wishes. One can understand that if this power 
were taken from us, it would materially limit our phys- 
ical and mental being. We should be very much like 
machines, acting only, or chiefly, under certain stimuli 
applied from without. Our actions would then be essen- 
tially reflex in character. The reflexes would differ 
much in complexity, however, and they may be roughly 
divided into three classes : 

(a) The first embraces the simple reflex actions, which 
are processes belonging pre-eminently to the spinal cord 
and medulla. 

(0) The second class embraces higher centres and more 
complex activities. Human beings all possess more or 
less of certain dexterities, such as riding, walking, the 
playing on musical instruments, etc. There are a few of 
these, such as suckling, which are possessed even at the 
time of birth. But the most are acquired by practice. 
Whatever their kind, the individual goes through the va- 
rious complicated movements pertaining to them, for the 
most part unconsciously. Thus, a person can walk, or 
dance, or play, and be entirely unconscious of expending 
any voluntary effort. We characterize these acquired 
and these inborn dexterities as automatic ; and such, in- 
deed, they are, using the term automatic in perhaps a 
rather loose sense. They are machine-like in character. 


Once being started they go on as a clock does when it is 
wound up. And we suppose that the particular place 
where this machinery is located is in the lower ganglia 
and hinder part of the brain. The cells and connecting 
fibres in these ganglia have become arranged into definite 
groups, each corresponding with and governing certain 
classes of muscular movements. All that is needed to 
set or keep these groups at work is the proper stimulus 
or successive stimuli; they then go on discharging effer- 
ent impulses, and producing the definite motor results. 

We have an example of this in the inception and con- 
tinuance of an ordinary walk, or in playing a well-known 
piece of music. It isa case like that of setting a ma- 
chine going by the turning of a key. The brain’s co- 
ordinating mechanism is generally set in motion at first 
by conscious impulses from the higher brain-centres, 
themselves roused by the visual sense. But after a time 
it may also be stimulated by afferent impulses that do 
not rise to consciousness. When the impulses go to and 
fro without exciting consciousness, we suppose that they 
do not pass up to the cortex at all, and that only the 
lower ganglia are active. The reflexes are genuine, but 
more complicated than those of the spinal cord. We 
may class them as reflexes of the second order, or of the 
middle projection system. 

(c) There is still a third and higher system of reflexes. 
Thus, a person sees an object which excites in him emo- 
tions of fear, or hears a suggestion which excites an idea, 
and which in turn excites the desire to cry out. In the 
former case we trace the afferent impulse along the optic 
nerves to the part of the brain concerned in sensation 
and ideation, and that process of linking the two which 
is called perception. From these higher centres efferent 
impulses start down to the facial or other muscles, and 
the expression of fear is seen upon the countenance. 

In the second case the process is a similar one. The 
afferent impulses give rise to a-sensation which links it- 
self to the previously impressed sensations (now become 
ideas), and a train of thought is aroused. After travel- 
ling through this i]l-understood nexus between the affer- 
ent and efferent impulses, the latter excite the organs of 
speech. 

In these various processes there is normally almost al- 
ways a consciousness of the changes that are going on. 
The changes include sensation, perception, ideation, and 
what is known as volition. ' 

Again, here, as in the second class of reflexes, the af- 
ferent impulse need not be constantly acting. It may 
start the machinery of ideation, which will then continue 
to act and send out more or less of expressive efferent 
impulses. Thus, a single frightful sight may give rise 
to prolonged feelings of terror, which in turn are ex- 
pressed through various efferent channels for a long 
while. 

In the first class of reflexes, consciousness and volition 
never enter. 

In the second class, consciousness and volition may at- 
tend the inception of the process, but not necessarily, or 
generally, the rest of it. 

In the third class, consciousness is always, in normal 
conditions, present, and acts of volition generally modify 
the play of afferent and efferent impulses. 

In hypnotic conditions the mental state is made up en- 
tirely of the reflex phenomena described above, entirely 
undisturbed by volitional interference. 

2. The nervous system is a mechanism for liberating, 
and at the same time co-ordinating and regulating, the 
various special energies or functions of the body. That 
it may do this more perfectly, and perhaps for other 
reasons, the brain, with its highly complicated powers, 
is developed. This nervous system seems capable of 
bringing into activity (or making kinetic) a certain 
amount of energy, which is normally distributed through- 
out the nervous system, more or less equally. Thus, it 
can at once move muscles, and can keep all the special 
senses and the mind itself moderately active. We can 
walk about, can see, hear, feel, and think at nearly the 
same moment. But it cannot make any of the special 
functions of the body particularly active, it cannot lib- 


475 


Sleep. 
Sleep. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


erate nervous energy largely in one particular direction 
without the other parts suffering. While watching in- 
tently, we cannot feel, or taste, or hear with any great 
degree of perfection. While reflecting deeply, the spe- 
cial senses are somewhat dulled. If the nervous system 
is busy in sending out powerful or delicately adjusted 
motor impulses, its other duties are somewhat neglected. 
I am only expressing, in physiological language, the very 
commonplace fact that we can only do one thing well at 
atime. And, furthermore, that we have the power, by 
exercise of our will, of directing the nervous energies 
almost exclusively in one or two directions. That is to 
say, we have the power of concentrating the attention 
and our muscular movements, 

Now, this mobility, so to speak, of the nervous or 
mental energies, this capacity of being turned into one 
channel and acting very powerfully there, is most con- 
spicuously brought out in the phenomena of trance. It 
is a leading characteristic of the state, as was shown by 
Dr. George M. Beard. 

Morbid Anatomy.—The underlying changes of the hyp- 
notic condition are unknown, and will probably long re- 
main so. Hypnotism is no doubt associated with changes 
in the vascularity of different parts of the brain, and 
with rapid breaking down of nerve tissue. Animals con- 
stantly subjected to hypnotic influence become demented 
(Harting, Milne-Edwards). 

Diagnosis.—As hypnotic states may be imitated, and 
as injuries or crimes may be done during this state, it is 
very important to be able accurately to distinguish it. 
Since the phenomena are all subjective, this is very dif- 
ficult. The methods of value are these: 1. Careful ex- 
amination of the general phenomena by experts while 
the subject is in the alleged hypnotic state. 2. Testing 
the muscular hyperexcitability by percussing motor 
points. 3. Tests of alleged aneesthesia by sudden burning, 
or pinching, or injuring the subject. 4. Tests of the 
tetanic muscular rigidity by the revolving tambour. In 
the hypnotic state the hand may be extended and held 
with perfect steadiness, while in conscious states a 
tremor soon appears. 5. Tests with glasses and other 
apparatus may be made to determine alleged aneesthesize 
of the special senses. 

V. THe HyPperayPnoses.— Drowsiness, Morbidly Pro- 
longed or Profound Sleep, Narcolepsy, Abnormal Attacks of 
Sleep, Lethargy, Coma, Carus, Cataphora, the Sleeping 
Sickness.—Persons may be subject to sensations of drowsi- 
ness which continue with them nearly the whole of the 
day, or come on at certain times during the day. 

Other persons sleep too profoundly, or too long. 

Again, certain individuals are attacked suddenly with 
a desire to sleep, which they cannot resist. These par- 
oxysms come and go like epileptic seizures, and they may 
even take the place of such seizures. Sometimes these 
paroxysms simply affect the sleep at night. The person 
goes to bed, but can with difficulty be awakened the next 
day, aud if left unmolested, he sleeps till noon or later. 
He phenomena may be repeated for several successive 

ays. 

Finally, cases occur in which persons pass into a state 
of apparent sleep, which lasts for weeks or months. 

nee different states will be discussed under the heads 
of : 

1. Morbid drowsiness. 

2. Morbidly deep sleep. 

3. Paroxysmal somnolence, narcolepsy, and epileptic 
somnolence. 

4. Hysterical or trance sleep. 

5. We have besides, symptomatic morbid somnolence, 
from organic brain disease, including the sleeping sick- 
ness of Africa. 

1. Morbid Drowsiness.—This is a very common symp- 
tom, which may be due to any one of the following causes: 
1. Old age, when there is a weakened heart or diseased 
arteries, with cerebral mal-nutrition. 2. The diseased 
vascular conditions which precede cerebral hemorrhage. 
3. The cerebral mal-nutrition or inflammations occurring 
before or during certain forms of insanity. 4. Various 
toxemie, ¢.g., malarial, uremic, cholemic, and syphi- 


476 


litic. 65. Dyspepsia and gastric repletion. 6. Diabetes. 
7. Obesity. 8. Insolation. 9. Cerebral anemia and hy- 
peremia. 10. Exhausting diseases. 11. Concussion of 
the brain. 12. Climatic conditions, cold, etc. 

A very common cause of drowsiness is dyspepsia at- 
tended with some torpidity of the liver, the condition 
popularly known as ‘‘biliousness.” Another frequent 
cause is malarial infection, which perhaps acts indirectly 
by impairing the functional activity of the liver. 

Drowsiness from these causes oftenest comes on in the 
afternoon. 

Anemia is attended with drowsiness during the day, 
while there is often insomnia at night. 

Syphilis is more likely to cause insomnia, but in its 
third stage somnolent conditions may be produced which 
are of serious significance. 

Drowsiness occurs from the effects of severe cold. It 
sometimes develops when persons change their surround- 
ings, especially on going to the seashore, for low levels 
and a high degree of atmospheric pressure seem to pro- 
mote sleep. The drowsy state that sometimes follows 
concussion of the brain is a familiar phenomenon. 

Some persons, no doubt, acquire the habit of drowsi- 
ness. At first the trouble may have been induced by in- 
digestion, ‘‘ biliousness,’ or malarial infection, but it 
persists after the cause is removed. Such persons can 
hardly sit through a lecture, a church service, or any 
exercise requiring quiet and attention. As the morbid 
drowsiness here described is only symptomatic, its treat- 
ment need not be discussed. Such remedies as coca, 
coffee, tea, atropia, glonoin, do not»produce results equal 
to expectations. 

2. Morbidly Deep Sleep.—Certain persons, when they 
sleep, pass into an almost lethargic slumber. In this 
state the spinal centres do not appear to share, but are ab- 
normally excitable, from the lessening of cerebral inhibi- 
tion. Consequently emissions occur, or there is nocturnal 
enuresis. As we have already stated, it is believed by 
some that sleep-drunkenness and even somnambulism oc- 
cur in those states of morbidly deep sleep. Persons who 
sleep in this way often sleep a longer time than normal. 
They are awakened with difficulty, and then suffer with 
headache or disagreeable sensations throughout the day. 

This disorder of sleep is most liable to occur in the 
young and in those of nervous temperament. It often 
seems to be a congenital condition, for which nothing 
can be done. In other cases it results from over-feeding 
and indolent habits. Treatment is much the same as 
that indicated for sleep-drunkenness and somnambulism. 

The following case, described to me by Dr. Sibert, of 
South Hill, Ala., illustrates this type: A married woman, 
aged twenty-eight, of good family history and in good 
health, except for some anemia from lactation, had suf- 
fered from excessive sleep since six years previously, 
when she was first confined. The hyperhypnotic state 
was manifested only during the night, and only as a pro- 
found slumber, from which it was exceedingly difficult, 
even by the roughest handling and the infliction of pain, 
to arouse her. There was no history of vascular, diges- 
tive, or cerebral disorder. It was thought that the con- 
dition was due to cerebral anemia, induced by protracted 
nursing, but the difficulty was not worse during lactation 
than it was during the intervals. She improved after 
weaning her child, under blood and nerve tonics. 

Instances in which persons retire at the usual hour, 
but can with great difficulty be roused in time for 
the ordinary duties of the day, are not rare. Some of 
these are illustrations of the vice of indolence, but in 
other cases there is an absolute need of nine, ten, or even 
fourteen hours of sleep. Here is a case in point: A 
young officer, otherwise healthy, could not possibly get 
along without fourteen hours of sleep. He slept until 
noon every day and lost his commission in consequence 
(Quoted by T. More Madden: Dublin Journal of Medical 
Sciences). 

Some cases of this kind, it should be remembered, are 
prodromal of insanity. 

3. Paroxysmal Sleep, Narcolepsy, Sleep-epilepsy.—It 
sometimes happens that persons suffer from sudden at- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sleep. 
Sleep. 


tacks of unconquerable drowsiness ; they fall off into 
slumber despite every effort of the will. These are more 
than drowsy sensations, for sleep, or a state resembling it, 
cannot be kept off. Some of these cases are of a purely 
nervous character, 2.e., the trouble is not due to a humoral 
poison or to organic disease, but to a paroxysmal change 
in the nervous centres, of a vascular or chemical char- 
acter, causing sleep. It may be that the patient is epi- 
leptic and the sleep-seizure takes the place of the or- 
dinary epileptic spasms. An illustration of this is the 
following : 

The patient was about twenty years of age, and had been 
subjected for a couple of years toattacks of falling asleep 
for a few minutes in any position, often while standing, 
and when not tired. There did not appear to be anything 
pathological about them except their occurrence when 
the patient was not tired. She married at about the age 
of twenty-two or twenty-three years, and then began to 
suffer from infrequent, well-marked epileptic attacks. 
Her brother subsequently was found to be also suffering 
from epilepsy. The patient herself appeared to be en- 
tirely healthy in all other respects (L. Putzel). 

Other cases are illustrations of a pure sleep neurosis 
or narcolepsy, as described by Gelineau. A case in 
point is the following : 

The patient was a man aged thirty-eight. 
early personal history good. No syphilis. Married, and 
had two children. Moderate drinker. Had had acute 
articular rheumatism. Three years ago had a fight and 
a fall. Two years ago his symptoms began. He would 
fall asleep whenever he undertook to eat, walk, or go to 
the theatre. Anything particularly exciting his attention 
would throw him into a sleep. He would sleep a little, 
then wake. He had one or two attacks daily, accom- 
panied by dizziness. He often had attacks of dizziness. 
Intelligence, memory, and consciousness were not lost 
during the attacks (Gelineau : Gazette des Hop., July 8, 
1880). 

While Gelineau’s case might have had something of a 
hysterical or mesmeric element, the following is quite 
free from such causes. It was apparently neurasthenic 
in origin : 

The patient was a physician who had suffered from 
this condition for fifteen years. He was habitually over- 
come by an uncontrollable desire to sleep during the day- 
time, no matter how mal apropos the time or place ; this 
desire he would fight against with all his power of con- 
trol, but would finally yield to sopor. Even in the 
dentist’s chair, while a sensitive tooth was being 
‘‘scraped,” he had fallen asleep. Often in the rounds 
of daily practice he would feel this lethargy creeping 
over him at critical moments, as, for instance, when his 
services were most needed at confinements, and would 
be forced to yield to it and sleep. It was impossible, for 
the same reason, for him to read for but a short time, 
and he had been obliged to abandon study and mental 
work entirely. He had other symptoms of brain ex- 
haustion, such as forgetfulness, frontal headache, etc. 
There was no evidence of organic disease (W. J. 
Morton). 

Cases of epileptic sleep, narcolepsy, and allied forms 
are not of frequent occurrence. Females are rather more 
often affected than males, and the susceptible age is from 
fifteen to forty. The disorder is brought on sometimes 
by fright, over-strain, and humoral poisons acting on a 
predisposed nervous system. 

The course is chronic, and relief is not always obtained. 
It should be remembered that syphilis, malaria, or an- 
semia, and indigestion may be elements in the trouble 
which are important, if not fundamental. Bromides are 
often useful factors in treatment. Change of occupa- 
tion, of mode of life, or of climate, may be essential to 
a cure. 

4, Hysterical, Oataleptic, or Trance Sleep, Lethargy.— 
Most of the so-called cases of prolonged sleep, lasting for 
days or weeks, are cases of spontaneously developed 
mesmeric sleep in hysterical women, or cases of incipient 
insanity (Katatonia or stuporous melancholia). The phe- 
nomena in these cases may take almost any of the forms 


Family and 


of the mesmeric condition. The patient may be catalep- 
tic, or lethargic, or in a somnambulic condition. The 
mental state is essentially the same as that in hypnotism, 
and, though reported as cases of prolonged somnolence, 
as sleeping girls, etc., these really are to be classed among 
the parahypnotic. 3 

The subjects of trance sleep are mostly women. Among 
26 cases collected by myself, the males were 5; females, 
21. The age ranged from sixteen to thirty-two. 

Trance sleep shows itself in several ways : 

Thus there is a'set of cases of trance lethargy so-called, 
in which the patients are plunged into a deep and pro- 
longed unconsciousness, lasting from one day to several 
years. These are ‘sleeping girls,” and fasting girls. 

Another class includes those who apparently are the 
victims of a too ready susceptibility to mesmeric sugges- 
tion, or who get -into a morbid habit of going into mes- 
meric sleep spontaneously. 

A third class includes the patients who suffer from 
somnolence or drowsiness in other irregular forms. 
These patients are evidently hysterical, but their somno- 
lent symptoms appear in peculiar ways. 

In these states there may be a lowering of bodily 
temperature, slowing of respiratory and heart action, 
and excessive sluggishness of the action of the bowels. 
The patients can hear and may respond to suggestions, 
but they are apparently insensible to painful impressions, 
and do not appear to smell, taste, hear, or see. The eyes 
are closed and turned upward, and the pupils contracted 
as in normal sleep. Many variations, however, occur 
in the physiological phenomena of these states. 

The duration of the attacks of trance lethargy is 
from a few hours to ten years (case of sleeping girl of 
Trouville, Lancet, June, 1881). Ordinarily, however, 
profound trance sleep lasts not more than a few days, 
while those cases in which the sleep is from mesmeric 
suggestion last but a few hours. 

Cases illustrating the above types are here given : 

CasE I.—A woman, aged twenty-four, large, well 
formed. At the age of eighteen she fell into a trance 
sleep lasting forty days; at the age of twenty another at- 
tack lasted fifty days. All the latter time she was in- 
sensible, could not be roused, and had to be fed. When 
twenty-eight years old she fell into another lethargy, 
which lasted several months. The respiration was very 
shallow, pulse slow, organic life at a low ebb (M. 
Blondet: Gaz. hebdomadaire, October 28, 1864, p. 726). 

CasE IJ].—A young lady, aged seventeen, while in 
church was suddenly seized with a desire to sleep. She 
went home, went to bed, and slept three days. No cat- 
alepsy. She awoke, was well for a month; then went 
into a sleep again (Laségue: Gaz. des Hép., January 3, 
1882). 

CasE III.—Mrs. M., aged thirty-two, mother of six 
children, of good family and personal history. Had 
had no symptoms of hysteria. Six weeks after confine- 
ment she suddenly fell into a trance sleep, which lasted 
for several months. Reflexes were not quite abolished 
at first, and she could then swallow food. Later she had 
to be fed. She slept within her trance, 7.e., at night she 
would snore. No cataleptic or other rigidity. She had 
some color (W. T. Gairdner : Lancet, December 22, 1888 ; 
January 5 and 12, 1884). 

CasE IV.—Laségue cites the case of a young lady who 
used to fall asleep at 8 P.M. precisely, no matter what 
she did or how much she slept at other times ; also the 
case of a Belgian countess, who for two years fell asleep 
daily at 9 p.M., no matter what she was doing. 

Under this head of mesmeric sleep, I would refer to 
the curious facts of sleep following some mechanical irri- 
tation. I have known a young man who would fall 
into apparent sleep whenever a cleansing solution was 
thrown into his antrum. Dentists can relate many in- 
stances of unconquerable somnolence in patients on 
whom they are operating by no ordinary soporific meth- 
ods. 

5. Morbid Sleep from Organic Disease.—Prolonged and 
excessive sleep occurs as the result of syphilis of the 
brain, brain tumors, and the degenerative changes in old 


477 


Sleep. 
Small=-Pox. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


age and insanity. Morbid somnolence and stupor are not 
very frequent in cerebral syphilis, but are quite charac- 
teristic. The patient in some cases lies or sits all day in 
a semi-soporous state ; in other cases he walks about, but 
continually falls asleep at his task. This state of par- 
tial sleep may pass off or end in complete stupor (Wood). 
It does not necessarily signify a serious issue, even 
though it last for weeks. 

Somnolence or sleep is arare symptom in cases of cere- 
bral tumors other than syphilitic. Conditions of drow- 
siness or stupor have been noted especially in tumors of 
the corpora quadrigemina, and the parietal lobes (Put- 
nam-Jacobi). 

Organic diseases of the brain tend to produce con- 
ditions of mental weakness, hebetude, or comatose states, 
rather than anything allied to sleep. 

The Sleeping Sickness, Sleeping Dropsy, Maladie du Som- 
meil.—This is a peculiar disorder apparently infectious in 
character, which occurs among the negroes of the west- 
ern coast of Africa. The disease has been transported to 
other regions, but is endemic only in Africa. It begins 
gradually with some headache and malaise. Soon there 
is felt a drowsiness after meals. This increases until the 
patient lies for nearly the whole time in a stupor. When 
awake he is dull and apathetic. There seems to be no 
fever, and the temperature may even be subnormal ; the 
pulse, too, is not rapid ; the skin is dry, the tongue moist 
but coated, the bowels regular. The eyes become con- 
gested and prominent. The cervical glands are enlarged. 
The disease ends in coma, and finally death. Recovery 
rarely occurs. Sometimes the course of the disease is 
more violent, and toward the end there are epileptic con- 
vulsions and muscular tremors, Autopsies have revealed 
no definite pathological changes. The history of the dis- 
ease has been given by Clark, ‘‘ Trans. of London Epi- 
demiolog. Society ;” Guérin, De la Maladie du Sommeil, 
1869. 

ACCIDENTS OF SLEEP.—Owing to the fact that sleep is 
a resting state of the organism, and that many of its 
functions are lowered, or their cerebral control lessened, 
peculiar crises, or physiological and pathological disturb- 
ances of nervous equilibrium occur. Attacks of gout, 
of asthma, and of pulmonary hemorrhage are most lia- 
ble to occur during the early morning hours. Deaths 
and suicides occur oftener in the forenoon, but births 
oftener at night. Epileptic and eclamptic attacks occur 
with much frequency at night. Involuntary emissions 
of spermatic fluid, orgasmic crises, incontinence of urine, 
are among the pathological incidents of sleep. 


BIBLIOGRAPHY. 


Maury, A.: Le Sommeil et les Réves. 

Lyman: Insomnia and other Disorders of Sleep. 

Winslow, F.: Obscure Diseases of Brain and Mind. 

Hammond: Sleep and Its Derangements, 

Moreau: Réves, Grand Dict. de Méd. 

Macario: Du Som., des Réves, et du Somnambulisme, 1857. 

Lemoine: Du Sommeil. 

Guérin: De la Mal. du Sommeil, 1869. 

Wharton and Stillé: Medical Jurisprudence. 

Hoffbaur. 

Dana: Morbid Somnolence, Jour. of Nerv. and Mental Dis., April, 1884. 

Barth, H.: Du Sommeil non naturel, Thése de Paris, 1886. 

Richer: Etudes clinique sur l’Hystero-epilepsie ou grande Hysterie. 
Paris, 1881. 

Brémand : Des Différentes Phases de l’Hypnotisme et en particulier de 
la Fascination. Paris, 1884 

Bernheim: De la Suggestion dans I’Htat hypnotique et dans l’Etat de 
Veille. Paris, 1884. 

G. Liegeoris: De la Suggestion hypnotique dans ses Rapports avec le 
Droit civil. Paris, 1884. 

Pitres: Des Suggestions hypnotiques. Bordeaux, 1884. 

Dumontpallier: Comptes-rendus de la Société de Biologie, 1882, 1883, 
1884. 

Berillon: Hypnotism expérimental, Thése de Paris, 1884. 

Descourtis: L’Encéphale, 1885, p. 51. 

Sull’ Ipnotismo, Giovanni, L’Encéephale, 1585, p. 229. 

Luys: L’Encéphale, 1887. 

Baiimler : Der sogenannte animalische Magnetismus. Leipzig, 1881. 

Beard, G. M.: Nature and Phenomena of Trance. N, Y., 1881; Study 
of Trance, N. Y., 1882. 

Braid, J.: Neurypnology. London, 1843. 

C. Rieger: Der Hypnotismus, Jena, 1884. 

Tamburini and Sapelli: Anleitung zur experimental Untersuchung des 
Hypnotismus. Wiesbaden, 1882. 

Tuke, D. H.: Sleepwalking and Hypnotism, Phila., 1884, Journ. Ment. 
Sciences, xxvi., 531. 


478 


Heidenhain: Artificial Hypnotism, Pop. Sc. Monthly. 1880-81, 362. 
Charcot: Compte-rendu, Acad. des Sciences, Paris, 1882, xciv.. 403. 
Charcot and Richer: Archives de Neurologie, 1881, 82, 83. 

Mobius ; Schmidt’s Jahrb., 1881, p. 73. 


Charles Loomis Dana. 


SMALL-POX. Synonyms: Latin, Variola; French, 
Petite vérole ; German, Pocken. 

DEFINITION.—Small-pox is an acute febrile, eruptive, 
contagious disease, the product of a specific poison in 
the blood of a patient suffering from this malady. It is 
generated solely by means of a specific virus, and is com- 
municated by this virus from one individual to another, 
after direct or indirect contact. The exanthem of small 
pox passes through four stages, namely, papule, vesicle, 
pustule, and scab, and usually leaves the face perma- 
nently scarred. The disease runs a definite course, and 
cannot be cut short by medicines. One attack of variola 
usually destroys the susceptibility of the individual to 
the disease during the remainder of his life. 

History.—Smail-pox, by reason of the malignant nat- 
ure of the poison, and the general susceptibility to it of 
individuals of all ages, races, classes, and conditions, is 
the most loathsome and fatal disease known to man. It 
is a very ancient malady, though its origin is unknown. 
It is no part of the purpose of this treatise to enter into 
an exhaustive examination of the question as to when 
variola first appeared among mankind. De Haen, Wil- 
lan, Moore, and Barron, contend that it was known to 
the ancient Greeks and Romans; while, on the other 
hand, Friend, Mead, Good, and Adams, insist that the 
ancient Greeks and Romans were unacquainted with it. 
Rhazes, an Arabian physician, who practised medicine 
about the year 910 A. D., was one of the most celebrated 
of the earlier writers on small-pox. The natural history 
of the disease was delineated by him with remarkable 
perspicuity when we consider the date of his writings and 
the status of medical knowledge at that time. Rhazes 
contends that Galen was familiar with variola, and quotes 
extracts from his first, fourth, ninth, and fourteenth books 
as evidence of the fact. He says: ‘‘ Asto any physician 
who says that the excellent Galen has made no mention 
of the small-pox, and was entirely ignorant of this 
disease, surely he must be one of those who have either 
never read his works at all, or who have passed them 
over very cursorily.””. Rhazes mentions Ahrun of Alex- 
andria, and Mesue of Bagdad, among other previous 
writers on small-pox. Variola cannot be positively traced 
to a period anterior to the Christian era. Since its first 
appearance among mankind small-pox has never disap- 
peared, and from Europe and Asia has been carried to 
the uttermost parts of the inhabited world. Small-pox 
existed in England in the first part of the thirteenth cen- 
tury, and in Germany in the latter part of the fifteenth 
century. From Europe the disease was brought to the 
United States soon after the discovery of America. It 
appeared in Mexico in 1527. Wherever it has existed it 
has been the greatest scourge of mankind. For centuries 
prior to Jenner’s discovery of vaccination in 1798, small- 
pox had been regarded as the king of fatal diseases. M. 
de La Condamine says that small-pox was the cause of 
one-tenth of all the deaths among the human race. He 
further says: ‘‘ Among those who outlive it many either 
totally or partially lose their sight or hearing ; many are 
left consumptive, weakly, sickly, or maimed ; many are 
disfigured for life by horrid scars, and become shocking 
objects to those who approach them, Immense numbers 
lose their eyesight by it.” Half a million deaths were 
annually caused in Europe from small-pox prior to the 
discovery of vaccination. Macaulay, in speaking of 
small-pox in England, says: ‘‘ The havoc of the plague 
had been far more rapid, but the plague visited our shores 
only one or twice within living memory, but the small- 
pox was always present, filling the church-yards with 
corpses, leaving on those whose lives it spares the hid- 
eous traces of its power, turning the babe into a change- 
ling at which the mother shuddered, and making the eyes 
and cheeks of the betrothed maiden objects of horror 
to her lover.” 

Rosen says that in Sweden one-tenth of all the deaths 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sleep. 
Small-Pox. 


were from small-pox. We are assured that this disease 
concurred with fire and sword, and famine and blood- 
hounds, to complete the depopulation of Santo Domingo. 

In the sixteenth century small-pox fell upon Mexico, 
and in a few years three million five hundred thousand 
of the population yielded up their lives to it, leaving in 
some places scarcely enough people alive to bury the 
dead. Brazil, in 1653, was invaded by small-pox, and in 
some instances whole races of men were carried to their 
graves by it. The Province of Quito, in a few years, 
lost one hundred thousand of her Indian population by 
this one disease. In 1707 Iceland was invaded by small- 
pox, and desolation and ruin followed in its wake for 
years, causing in that year the death of eighteen thou- 
sand out of a total population of fifty thousand. The 
fearful fatality of the disease is evidenced by the follow- 
ing extract: ‘‘In one island they found one girl, with 
the small-pox on her, and her three little brothers ; the 
father having first buried all the people in the place, had 
laid himself and his smallest sick child in the grave, 
raised with stones, and ordered the girl to cover him.” 
Greenland, in 1734, lost more than two-thirds of her 
population by small-pox. We are told, also, that one- 
sixth part of the inhabitants of Ceylon died of small-pox 
during one epidemic. Siberia has an equally lamentable 
history, and Kamschatka has also suffered severely from 
this terrible disease. One-tenth of all deaths in France, 
-prior to the discovery of vaccination, were from small- 
pox. This country has been most cruelly and fearfully 
scourged by small-pox, the details of which must be too 
well known to need repetition here; whole tribes of our 
Indian population were swept out of existence by it. Eu- 
rope, in the century preceding the discovery of vaccina- 
tion, lost in deaths from small-pox 50,000,000 of her 
population. But it is unnecessary to continue the recital 
of such details. Enough has been presented to justify 
Macaulay in calling small-pox ‘‘the most terrible of all 
the ministers of death.” Whenever and wherever it ap- 
peared in the past, in a community unprotected by vac- 
cination, it was, as so well described by Alexander Mc- 
Kenzie, ‘‘ as a fire consuming the dry grass of the field. 
The infection spread with a rapidity which no flight 
could escape, and with a fatal effect which nothing could 
resist.” This disease had but one feature which was not 
repulsive ; that one was that it was no respecter of per- 
sons. Reaching to the royal throne of France it laid 
Louis XV. in the grave. In Mexico it treated the Em- 
peror similarly. In England it invaded the household of 
William III., killed his wife Mary and several others of 
his family, and would not leave the palace until it had 
attacked the king and maimed and disfigured him for 
life. The hovel of poverty was in this respect the equal 
of the palace of wealth, for small-pox was the terror of 
every household. 

Long-suffering mankind eventually became hopeless 
of escape from the dread monster. When civilized man 
was thus hopeless, need we wonder that the untutored 
savage despaired also? McKenzie says of the Indians: 
‘* Tt was not uncommon for the father of a family whom 
the infection had not reached, to call them around him, 
to represent the cruel sufferings and horrid fate of their 
relations, from the influence of some evil spirit who was 
preparing to extirpate their race, and to incite them to 
baffle death, with all its horrors, by their own poniards. 
At the same time, if their hearts failed them in this nec- 
essary act, he was himself ready to perform the deed of 
mercy with his own hand, as the last act of affection, 
and instantly to follow them to the common place of rest 
and refuge from human evil.” 

After centuries of havoc from small-pox variolous in- 
oculation was introduced, and the mortality was in con- 
sequence greatly lessened. 

Lnoculation.—In no field of human research can a more 
curious phenomenon be found than is shown here. That 
a man should be compelled to take small-pox in order to 
save his live is surprising indeed, but such was the in- 
tention, and the wonderful reduction of mortality among 
the individuals so treated fully testified to the propriety 
of the measure. Inoculation is the placing of the virus 


of small-pox, by puncture, under the skin, in the blood 
of the subject inoculated. The purpose of inoculation 
was to produce a modified form of small-pox which 
would afterward confer upon the subject so treated ex- 
emption from a malignant attack. This weapon is of 
great antiquity. Kirkpatrick says of it, ‘‘Some poor, 
unlearned, but heaven-taught mortal, some Chinese, 
Hindoo, or Circassian, first hit upon it.” It is admitted 
to have been practised for a long but unknown number of 
years in Hindoostan. ‘The Chinese had for hundreds of 
years used crusts or scabs of small-pox, placed in the 
nose, for the purpose of inoculation. Of inoculation, in 
1717, the wife of the English Ambassador to the court of 
Turkey, writing to her home, says, ‘‘The small-pox, so 
fatal and general among us, is here entirely harmless by 
the intervention of engrafting, which is the term they 
give it. Every year thousands undergo the operation, 
and the French Ambassador says pleasantly, that they 
take the small-pox here by way of diversion, as they take 
the waters in other countries. There is no example of 
any one who has died of it.” Dr. Simon says of this 
measure, ‘‘to the present time it remains one of the most 
interesting and least explained facts of pathology that 
the specific contagion or ferment of small-pox, so uncon- 
trollable in its operations when it enters a man in the 
ordinary way of his breathing an infected atmosphere, 
becomes for the most part disarmed of its virulence when 
it is artificially introduced into the system through a 
puncture of the skin.” By resort to inoculation the mor- 
tality among those so treated was reduced from one 
death in every three cases of natural small-pox, to one 
death in every three hundred cases of inoculated small- 
pox. Some authorities give the protective powers of in- 
oculation as representing one death in every one thou- 
sand cases. Thus it will be seen that the practice of 
inoculation offered to the individual, doomed to take 
small-pox, a far greater security against death than any 
measure in use prior to the introduction of vaccination. 
While the security against death to the individual in 
whom small-pox was inevitable was most wonderfully 
augmented by inoculation, yet to the country at large 
the practice of variolous inoculation was a curse instead 
of a blessing—for inoculated small-pox lost none of its 
fatal power of conveying malignant variola to all unpro- 
tected persons. The Royal College of Physicians of 
London, in 1807 (report on vaccination) says, ‘‘ However 
beneficial the inoculation of small-pox may have been to 
individuals, it appears to have kept up a constant source 
of contagion, which has been the means of increasing the 
number of deaths by what is called the natural disease.” 
Dr. Heberden says that, in the first thirty years of the 
eighteenth century, before inoculation became general, 
the deaths from small-pox to every 1,000 deaths were 74 ; 
for an equal period during the general practice of inocu- 
lation, at the end of the eighteenth century, the deaths 
from small-pox were 95 to 1,000 deaths—an increase in 
the proportion of 5to 4. After the discovery of vaccina- 
tion, it being so much superior to inoculation, the latter 
practice was made unlawful. 

Vaccination.—Of this weapon of defense against small- 
pox, Simon, after speaking of the mysterious effects of 
inoculation, says of vaccination: ‘“ Equally strange and 
inexplicable is the further and greater change which this 
ferment undergoes in passing through the textures of a 
cow ; a change which renders it incapable, when retrans- 
planted to the human system, of any longer propagating 
itself by effluvia, while it retains its capability of propa- 
gation by inoculation, and its power of protecting the 
system against its own further action thereon.” 

Vaccination differs entirely in purpose and value from 
inoculation. The objects of vaccination are: 1, Preven- 
tion of small-pox ; 2, control of that disease when preven- 
tion is not obtained. As already seen, the only purpose 
or value of variolous inoculation was the mitigation of 
the severity of small-pox in the subject inoculated. 

Vaccination will be briefly considered in the latter part 
of this treatise. ‘ 

Errotogy.—Small-pox is disseminated by breathing 
an atmosphere infected with the virus, by contact with an 


479 


Small-Pox. 
Small-Pox. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


infected person, clothing, bedding, etc., or by direct in- 
oculation of an unprotected individual. It is a disease 
sui generis, and can be propagated solely by its own spe- 
cific virus. The poison of variola resides in the exan- 
them, the breath, and the exhalations of the body. At- 
tempts to produce the disease by vaccinations with the 
blood and secretions from the body of a small-pox patient 
have resulted negatively. Variola is transmissible by 
inoculation with the contents of the pustule ; but the pus 
of a small-pox pustule may be rubbed on the skin of an 
unvaccinated person without producing the disease, un- 
less the skin has been abraded. If, however, the matter 
from the pustule be brought in contact with the mu- 
cous membrane, variola will almost certainly be con- 
tracted. The disease may be transmitted to persons who 
have never been in immediate contact with small-pox pa- 
tients or with infected materials. Competent observers 
claim that the disease may be disseminated over a city 
through the medium of the atmosphere. I have never ob- 
served any fact tending to confirm this statement. Cases 
are recorded in which the disease has been contracted 
when individuals have never approached nearer than 
within three feet of the small-pox patient in the open air. 
The virus of variola is tenacious of life ; it is not always 
killed by the process of drying, and when protected from 
the atmosphere has been known to retain its vitality for 
years. The poison clings to clothing, bedding, etc., and 
will remain active for a long time in these articles if they 
are not chemically disinfected or exposed to the disinfect- 
ant power of the atmosphere. The disease is therefore 
portable. The virus of small-pox enters the system by 
absorption through the mucous membrane of the respira- 
tory tract. The effect of the poison of variola, as to the 
lightness or severity of symptoms, varies with the consti- 
tutional condition or degree of susceptibility of the indi- 
vidual. If an unvaccinated person be exposed to vario- 
loid he may contract malignant small-pox, and, on the 
other hand, an individual who has never been vaccinated 
may be exposed to malignant variola and only take 
varioloid. This inequality of individual predisposition 
has been observed from the earliest period of the written 
history of the disease. A small fraction of mankind 
seems to be wholly insusceptible to small-pox. Every 
practitioner of experience has met with occasional in- 
stances in which unvaccinated individuals have been 
repeatedly exposed to variola and yet failed to take it. 
I have known two physicians who could never be suc- 
cessfully vaccinated, notwithstanding repeated efforts to 
inoculate them with vaccinia. These physicians have on 
several occasions attended cases of small-pox and failed 
to take the disease. These instances of individual insus- 
ceptibility to vaccinia and variola are among the rare ex- 
periences of medical practice, and only serve to illustrate 
occasional exceptions to the rule of well-nigh universal 
susceptibility of the human race to both diseases. Some 
few individuals evidence a remarkable susceptibility to 
small-pox. While in the vast majority of persons one 
attack of the disease is fully protective against a second 
one, yet there are some few who have had several attacks 
of variola. Well-authenticated cases have been recorded 


in which individuals have had as many as four attacks of . 


small-pox. I have seen only four cases of second attacks 
of variola, two of which proved fatal. In the latter in- 
stances a long number of years intervened between the 
invasions, but in each person the face was badly ‘‘ pock- 
marked” by the first attack. Asa general rule, a subse- 
quent attack of variola in the same individual runs a 
mild course, though in some instances it is more malig- 
nant than the first one. 

A successful vaccination generally protects the indi- 
vidual against small-pox during life, though the excep- 
tions to this rule are numerous, and therefore revaccina- 
tion should be universally practised. If a person has 
been successfully vaccinated in infancy or childhood, re- 
vaccination should be practised at puberty. Nothing 
definite is known as to the exact nature of the small-pox 
poison. Much speculation has been indulged in by the 
pathologists on this point, but every investigator has 
failed to solve the problem. Cohnheim and Weigert 


480 


claimed that the micrococci in the vesicles are the spe- 
cific contagious elements of variola. We have no satis- 
factory proof that either vegetable germs or bacteria 
constitute the essential elements of the disease. Much 
difference of opinion exists among practitioners as to the 
earliest time at which a small-pox patient can infect an 
unprotected person. Many believe that the poison is 
given off during the primary fever; others that it be- 
comes active during the suppurative period, and this 
opinion is generally entertained by the profession ; there 
are, however, a few practitioners who claim that it oc- 
curs at the period of desiccation. 

Morpsip Anatomy.—The description of the lesions of 
small-pox by Loomis (‘‘ Practical Medicine’’) is of such 
excellence that I have taken the liberty of quoting it en- 
tire in this section: ‘‘ Besides those anatomical lesions 
which occur upon the mucous membranes and skin, there 
is more or less intense congestion of the lungs, brain, 
liver, spleen, and kidneys. In the hemorrhagic form of 
small-pox small hemorrhages occur in nearly all the 
viscera, With ecchymoses in the serous membranes, and 
blood-stained fluid in the serous cavities. The mucous 
membrane of the stomach and rectum is oftenest the seat 
of these extravasations. 

‘‘'The characteristic anatomical lesion of small-pox is 
to be found upon the mucous membranes and upon the 
skin. This lesion is usually spoken of as the eruption. 
It does not differ essentially in the different varieties ; 
the modifications which are met with are due rather to 
its duration and the order of its development. These 
surface lesions pass through regular stages of develop- 
ment and decline. 

‘“The first step in the formation of a small-pox pustule 
is congestion of the skin in discrete spots; the vessels of 
the corium are dilated and tortuous, and the connective 
tissue of the papille, in the centre of the congested zone, 
shows more or less cedema. The non-elevated red spot 
(looking at first like a flea-bite) isa macule. Next, the 
skin is elevated at these (macular) points and a papule 
forms, from changes in the cells of the rete Malpighii. 
Soon the papule becomes a vesicle ; in its centre the epi- 
dermis becomes distended with serum and cells. As the 
effusion increases the cells change; the horny layer 
above is raised, and the summit of the papule becomes 
the centre of the vesicle. The changed cell elements are 
pressed, separated, and massed into groups from press- 
ure of the effusion, and a stringy meshwork is formed in 
the vesicle. Meanwhile proliferation of the adjoining 
cells forms a peripheral wall for the vesicle, the contents 
of which soon become turbid. 

‘‘Umbilication of the vesicles now occurs. Trabec- 
ulee slowly spread from roof to floor of the vesicle, and 
hold down its centre, while marginal cell-proliferation 
and the accumulation of serum bulge out its periphery. 
After the vesicles are fully formed, pus-cells appear in 
them, and, as a result, the vesicles change in color, and 
become pustules, At the same time an inflammatory 
process, more or less extensive, is going on in the walls 
of the pustule, and in the surrounding cellular tissue, 
which terminates in a destruction of tissue at the point 
where the papillary congestion first occurred. If only 
the superficial. layer of the skin is involved, the infiltra- 
tion of pus-cells into the vesicle and the formation of the 
pustule may take place without extension of the inflam- 
mation into the cellular tissue beneath, and necrosis or 
death of the part will not follow; but if the inflamma- 
tion extends into the deeper tissues, a slough will be pro- 
duced, which necessarily will be followed by a cicatrix 
and pitting. After the pustule is formed the inflamma- 
tory products begin to dry down, and a crust is formed 
which contracts in the central portion, and the same um- 
bilicated appearance is presented that is seen in the um- 
bilicated vesicle. The incrustation begins at the centre. 
The crusts are made up of dried pus-cells and detritus. 
After a time these crusts are separated by the ordinary 
changes which occur in the subsidence of an inflammatory 
process, and recovery is complete, except that there is left 
behind a cicatrix like that formed under any other cir- 
cumstances. These pustules may be formed upon any mu- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Small-Pox. 
Small-Pox. 


cous membrane. They occur oftenest in the nose, mouth, 
trachea, bronchial tubes, and larynx. 

“There is nothing specific or essentially different in 
the development of the pustules in hemorrhagic small- 
pox, except that they contain blood instead of serum or 
pus. In the hemorrhagic variety larger or smaller heemor- 
rhages take place into the cellular tissues and into the 
cutis; in the milder forms they take place only in the 
layer beneath the papilla, while in the severer forms 
they take place beneath all the cutaneous layers; even 
the subcutaneous fat may be infiltrated with blood. No 
changes in the walls of the vessels have as yet been discov- 
ered which will account for these hemorrhages. These 
extravasations most frequently occur in those cases in 
which death takes place before the period of pustulation 
is reached. In hemorrhagic variola blood extravasa- 
tions occur into the substance of all the organs, the mar- 
row of the bones, and on mucous and serous surfaces, 
and infarctions in the lungs are the rule. Hyperemia 
and cedema of the brain sometimes occur.” 

SYMPTOMS AND CouRSsE.—During the period of in- 
cubation, which is ordinarily nine days in inoculated 
small-pox, and fourteen days in the non-inoculated va- 
riety, the health of the patient is about as usual. 

The first stage of variola is ushered in with achill, high 
fever, severe head-ache, and intense pain in the lumbar 
and sacral regions. The chill is more violent than is 
witnessed in any other eruptive disease. The temperature 
reaches 102° F. to 103° F. onthe first day ; on the second 
day 104° F., and on the third day the thermometer may 
indicate 106° F. With the elevation of temperature the 
pulse becomes full and frequent, beating from 120 to 
140 or 160 per minute. The patient complains of nausea, 
vomiting, sore throat, and photophobia. The high fever 
and severe constitutional disturbance cause great restless- 
ness and occasionally delirium. Convulsions not infre- 
quently occur in children. The face is flushed, the con- 
junctivee are congested, and the carotid arteries throb 
violently. By the end of the second day redness and 
swelling of the tonsils and soft palate are observed. The 
redness and swelling may extend into the larynx, when 
hoarseness with stridulous cough occurs. ‘The initial 
fever and the constitutional perturbation reach their 
greatest height by the end of the third day, when the 
eruption begins to show itself. The prodromal symp- 
toms are usually very severe, but the intensity of the 
initial symptoms is not always indicative of the severity 
of the attack, for it is occasionally observed that the 
prodromal symptoms of mild cases are of considerable 
violence. During this period in the history of the disease 
there are no symptoms present by which a diagnosis of 
variola may be positively made, for there are no char- 
acteristic affections of the mucous surfaces in the pro- 
dromal stage of variola, such as may be detected in the 
initial stage of scarlet fever or of measles. The violent 
pain in the sacral and lumbar regions is, however, so 
characteristic of variola that we should suspect the ex- 
istence of the disease when it is present. 

Stage of Hruption.—On the third day from the com- 
mencement of the initial fever the exanthem begins to 
appear on the face, scalp, and neck. When the eruption 
first makes its appearance it is in the shape of slightly 
elevated papules about the size of millet-seeds, and of a 
reddish color. Whenever the exanthem is copious the 


red spots lie close together and almost unite with one . 


another, resembling the eruption of measles, and the 
disease is liable at this stage to be mistaken for measles. 
Usually within twelve hours after the papules have ap- 
peared on the face they extend to the trunk and limbs, 
though the eruption on these parts is not so copious as 
on the face. The eruption on the mucous membranes 
generally begins at the same time as upon the skin, but, 
in consequence of the slight disturbance it at this time 
produces, is frequently not detected. The papules in the 
mouth soon cause increased flow of saliva, in the pharynx 
difficulty in swallowing, in the larynx hoarseness and 
cough, and on the conjunctive lachrymation and photo- 
phobia. By the end of the first day of the efflorescence 
the papules become larger, have a more livid color, and to 


_ Vou. VI.—381 


the finger passed over them impart a sensation as if there 
were shot beneath the skin, These papules gradually en- 
large, and on the third day become vesicular, The vesicles 
soon become umbilicated and contain a lactescent fluid. 

Stage of Suppuration.—By the sixth day of the efflo- 
rescence the vesicles begin to lose their umbilicated ap- 
pearance, assume a globular shape, and become turbid ‘ 
from admixture of purulent matter. By the eighth day 
the pustules are fully matured. The skin surrounding 
the eruption becomes red, swollen, and cedematous ; each 
pustule has a broad base, and in case of confluent or 
semi-confluent small-pox is closely set against, or runs 
into its fellows. During this stage the patient suffers 
from profuse salivation, swallowing is accomplished 
with great difficulty, the nose is plugged up with pus- 
tules, the voice is husky or inaudible, the cough croupy 
and distressing, and there is marked dyspneea ; the eyes 
are red, discharging muco-pus, and are extremely sensi- 
tive to even a faint light. When the exanthem covers 
the face it is swollen into a shapeless mass, the eyes are 
closed, and the features of the patient are unrecognizable. 
No more repulsive sight can be witnessed than that of a 
patient in this stage of variola. The eyes, nose, lips, ears, 
cheeks, hands, feet, and genitalia, present one mass of 
horrid deformity. The suppurative or secondary fever 
comes on with the maturation of the pustules. <A chill 
ordinarily precedes the secondary fever. This fever is 
distinctly remittent in type, reaching its greatest height 
in the evening. The temperature is usually higher than 
in the initial stage, and may reach 107° F. The pulse 
increases simultaneously with the temperature, ranging 
from 120 to 150 beats per minute. At this time the pa- 
tient is in the most critical period of the disease ; the high 
fever and constitutional perturbation continue until the 
stage of desiccation. The temperature and pulse begin 
to decline as desiccation commences, and when the crusts 
are being thrown off have about reached the normal. <A 
subsequent marked elevation of temperature is indicative 
of some complication, such as erysipelas, pneumonia, etc. 

Stage of Desiccation.—The process of desiccation ordi- 
narily commences on the twelfth day, and is first ob- 
served on those parts of the body on which the eruption 
appeared earliest. The desiccative process usually oc- 
cupies from eight to fourteen days, the length of time 
being governed by the degree of pustulation. Just prior 
to, or at the time of the beginning of, desiccation many 
of the pustules rupture, and the exuded fluid dries into 
hardened brown or yellowish crusts. This crust may be 
so extensive as to cover the entire face. As desiccation 
advances the swelling of the skin lessens, and the consti- 
tutional disturbance markedly subsides. Cicatrization of 
the pustules advances beneath the crusts, and the crusts 
are finally separated and thrown off, leaving the site of 
each of the pustules of a reddish-brown or violet color, 
with elevated margins and depressed centre. If the skin 
has not been deeply invaded these blotches gradually lose 
their abnormal color, leaving only shining white scars 
which sooner or later disappear ; if, however, the skin 
beneath the pustules has been destroyed the face will be 
permanently pock-marked. By the time desiccation has 
been completed the patient is convalescent, and usually 
regains his former health within a month. 

The above history is an outline of a typical case of 
variola discreta, and is the type most usually met with 
among the unvaccinated. It is unnecessary to attempt 
to present an outline of the history of each type of vari- 
ola met with, and described by various writers. But 
three other types will be described, viz., variola conflu- 
ens, variola heemorrhagica, and varioloid. 

VARIOLA CONFLUENS.—This type differs from the dis- 
crete variety in that the eruption and constitutional 
symptoms are much more severe than in variola discreta. 
Ordinarily the initial fever is much more violent than in 
the discrete variety, and is of shorter duration, usually 
lasting not more than two days. The initial fever fre- 
quently reaches 106° F. or 108° F. for a limited period of 
time, and then falls to 108° F. or 104° F, Likewise the 
development of the eruption in this type occurs from 
twelve to eighteen hours earlier, and spreads over the 


481 


Small-Pox. 
Small=-Pox. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


body more rapidly, frequently appearing at the same 
time on the face, trunk, and limbs. The papules which 
first mark the disease are often so thickly set upon the 
face, scalp, neck, and hands on the first day of eruption 
that they run into one another. By the end of the sec- 
_ond day the skin is intensely red and greatly swollen, 
and large flat vesicles rapidly develop and coalesce into 
large tracts of eruption. Suppuration rapidly ensues. 
The entire face has one continuous covering, the patient 
having the appearance of one wearing a mask. Notwith- 
standing complete coalescence of the exanthem on the 
face and hands, the eruption on the remainder of the 
body is usually either discrete or semi-confluent. Where 
the eruption on the body generally is confluent, there is 
scarcely any hope of the patient’s recovery. Pustulation 
of more than one-fourth of the body will, as a rule, pro- 
duce death. Confluent variola is a very fatal disease, the 
mortality ranging from fifty to seventy-five per cent. In 
the onset, and throughout the entire course of the disease, 
the confluent type shows a marked difference in the inten- 
sity of symptoms from the discrete variety. In addition 
to the more vehement fever and delirium the nervous 
and muscular systems show the greater depression of the 
vital powers. The mucous membranes are attacked with 
greater severity, the eruption in the mouth and throat is 
confluent, and frequently a diphtheritic exudation spreads 
over the soft palate, tonsils, posterior wall of the pharynx, 
and the nasal cavity. The larynx is usually invaded, 
and the marked severity of this complication is often evi- 
denced by submucous abscesses, necrosis of the cartilages, 
or edema glottidis. The eyes are more severely affected 
in this type, the eruption appearing thickly upon the lids, 
and the severe inflammation not infrequently results in 
keratitis with perforation. In the mouth the severity of 
the disease is manifested by profuse salivation, great dif- 
ficulty in swallowing food or medicine, and not infre- 
quently by inflammation of the parotid gland. Variola 
confiuens is prone to a number of complications, such as 
bronchitis, pneumonia, pleurisy, pericarditis, diarrhea, 
albuminuria, etc. The secondary fever is greater than 
in the discrete type, frequently reaching 108° F. Many 
patients succumb before the eruption makes its appear- 
ance, but the majority who die live until the stage of 
desiccation is reached—death resulting then from ex- 
haustion or from one of the numerous complications 
which beset this type of variola. In those who live the 
process of desiccation is more slowly accomplished, and 
the face is horribly pock-marked. The hair is ordinarily 
destroyed and permanent baldness is a frequent sequel of 
this affection. Convalescence from variola confluens is 
tedious and protracted. 

VARIOLA Ha#MoRRHAGICA.—The difference between 
variola hemorrhagica and the other types of small-pox is 
in the character of the eruption, and not in the initial 
fever nor in the constitutional symptoms. It is simply 
a modification of the other varieties of small-pox. The 
hemorrhage into the eruption is observed to take place 
under various circumstances. In some cases the exan- 
them becomes hemorrhagic upon the appearance of 
the papules,in other cases when the vesicular stage is 
reached, while in yet other cases, only when the pustules 
are fully formed. In some cases the entire eruption is 
hemorrhagic, while in others one-half, or even a very 
small portion of the efflorescence, shows this complica- 
tion. ‘The hemorrhagic eruption, as a rule, begins upon 
the lower limbs. Petechize and ecchymoses usually ap- 
pear between the hemorrhagic pocks, and livid spots or 
patches, on the mucous membranes, particularly in the 
mouth and throat. Diphtheritic exudations frequently 
form in the tonsils, pharynx, and nasal cavity. The 
gums become spongy, and readily bleed as in scurvy. 
Hemorrhages take place from the nose, stomach, lungs, 
kidneys, rectum, or uterus. The amount and persistency 
of the hemorrhage vary with different cases. Prior to 
the appearance of the hemorrhage, it is impossible to 
predict this form of small-pox. The initial fever is or- 
dinarily mild, and throughout the subsequent course of 
the malady the temperature will rarely exceed 102° F.; 
when the hemorrhage has been profuse the temperature 


482 


falls below the normal. The contrast between the tem- 
perature and pulse-rate is marked ; while the temperature 
is but little above, at, or below the norm the pulse is 
feeble, and beating from 140 to 160 per minute. The 
breathing is rapid, the countenance pinched and sunken, 
and occasionally there is delirium, but, as a general 
rule, the intellect remains clear to the end of the scene. 
This is a very fatal disease ; the vast majority of patients 
die, death usually occurring on or before the fifth day. 

VARIOLOID.—Varioloid is small-pox modified by a pre- 
vious attack of vaccinia, a previous attack of variola, or 
by a degree of personal insusceptibility. There is no 
ground whatsoever for the old claim that it is essen- 
tially different from variola vera. Varioloid is milder in 
its course and shorter in duration than is the unmodi- 
fied variety, and it presents many striking departures 
from a typical case of variola. The duration of the ini- 
tial fever is usually two days; the temperature rarely 
reaches 102° F., falling ordinarily to the normal by the 
end of the second day. Occasionally the initial fever is 
as high as in unmodified small-pox. The secondary fever 
of variola is frequently absent in this type, and when 
it occurs is but slight, and continues ordinarily not more 
than twenty-four hours. The exanthem in its develop- 
ment and character differs markedly from that of va- 
riola. Unlike variola the eruption in varioloid usually 
appears simultaneously on the face, chest, and limbs. 
The exanthem rarely passes through all the stages usu- 
ally witnessed in the unmodified variety ; it may not pro- 
gress beyond the papular stage, or it may, and usually 
does become vesicular ; not infrequently it becomes pus- 
tular, but the pustules are dwarfed, and, while they are 
surrounded by a distinctly red areola, the skin is neither 
tense nor cedematous, and the pustules readily dry up. 
Desiccation usually commences from the fifth to the sev- 
enth day. The pitting usually resulting from variola 
rarely occurs after varioloid, though occasionally deep 
and permanent scarring of the face is witnessed. The 
eruption on the mucous membranes is but slight, and 
causes markedly less disturbance than in unmodified 
small-pox. When the exanthem passes through all the 
stages of variola the distinction between the two affections 
is to be found in the milder constitutional symptoms, 
and the smaller number of pocks in varioloid. The mor- 
tality from varioloid is very small. 

DIFFERENTIAL Dragnosis.—Until the characteristic 
exanthem of the disease appears it is impossible to make 
a positive diagnosis of small-pox. It is, of course, im- 
portant to make a diagnosis as early as possible in order 
that the necessary sanitary precautions against the spread 
of the disease may be instituted. On the other hand, the 
physician should not be too hasty in making a diagnosis, 
for if he should arrive at an incorrect opinion the patient 
may be taken to a small-pox hospital and thereby con- 
tract the disease, when he would not have been subjected 
to such an unwarrantable risk had the medical attendant 
waited—as he should have done—until a positive diagno- 
sis could have been made. In mistakes of this kind, 
which have not been infrequent in the history of medi- 
cine, the physician is, under the law, liable to pecuniary 
damages, and will suffer much detriment to his reputa- 
tion for professional skill and acumen. There is no jus- 
tification for undue haste in diagnosticating this malady. 
The medical attendant will have discharged his full duty 
by isolating the patient and awaiting the development of 
the stage of variola at which he can prudently decide the 
nature of the disease. How soon can small-pox be rec- 
ognized? <A practitioner who has had considerable ex- 
perience in small-pox may occasionally be able to detect 
it the second day after the first appearance of the erup- 
tion, but such a diagnosis is always, and under all cir- 
cumstances, unless there be knowledge of direct exposure 
of the person to variola, extremely hazardous, and the 
doctor who values his reputation will never be guilty of 
such rashness. At this stage of the affection there is 
nothing in either the initial symptoms or the exanthem 
by which he can positively reach a diagnosis. In the 
absence of a knowledge of direct exposure to variola the 
only prudent course is to isolate the patient and await 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the vesicular stage of the exanthem before expressing a 
positive opinion on the subject. The wisdom of this 
course is abundantly attested by the experience of the 
London Small-pox Hospital. Marson says on this sub- 
ject: ‘‘ Upward of twenty diseases have been mistaken 
within the past few years, in the early stage of the dis- 
ease, for small-pox, and the patients have been sent as 
having small-pox to the small-pox hospital.” Such mis- 
takes show an appalling amount of ignorance or careless- 
ness on the part of their authors, and should serve as 
warnings to practitioners who pride themselves on their 
ability to make an early diagnosis in variola. When the 
characteristic eruption has appeared there are but few 
diseases which are liable to be mistaken for small-pox. 
These diseases are: measles, varicella, pustular syphilis, 
and febrile lichen. 

Diagnosis of Small-pox from Measles.—Prior to the ve- 
sicular eruption of variola it is liable to be mistaken for 
measles. Ifthe physician awaits the time for the vesicles 
to appear, and under these circumstances he should inva- 
riably do so, such a mistake would beinexcusable. Dur- 
ing the papular stage of variola the eruption of measles 
simulates that of the former. The catarrhal symptoms 
(bronchial, nasal, and conjunctival) of measles should suf- 
fice to point out to the doctor the probable nature of the 
disease, for these symptoms are invariably absent in the 
early stage of uncomplicated small-pox. Thethermometer 
ofters valuable assistance in making a diagnosis between 
these affections. In variola the temperature declines when 
the papular eruption appears, while in measles the ther- 
mometer shows that the fever continues to rise after the 
exanthem appears. Furthermore, the temperature of 
variola is ordinarily two or more degrees higher than that 
of measles. As a rule, the exanthem of small-pox. ap- 
pears on the third day, while in measles it appears on the 
fourth day. Then, too, the eruption of measles is more 
superficial, and is not so distinctly felt asin variola. The 
intense pain in the sacral and lumbar regions is so charac- 
teristic of small-pox that this symptom should cause the 
attendant to suspect small-pox. 

Diagnosis of Variola from Varicella.—W hile some writ- 
ers of the present day contend for the identity of variola 
and varicella, the great majority of the profession deny 
this assertion. In the whole range of medical science no 
proposition can be more clearly established than that var- 
icella is a disease suz generis. The diagnosis of varicella 
from light cases of small-pox is often a perplexing and 
difficult problem. While they are essentially different 
diseases, they frequently prevail as epidemics at the same 
time, and, as the characteristic eruption of each affection 
closely resembles that of the other, the diagnosis of va- 
riola from varicella is a problem frequently presented 
to the physician for solution. The distinction between 
these diseases is well-defined, and by the exercise of care 
they should not be confounded. In varicella the initial 
fever is, as arule, absent, but when it occurs it is very 
slight, while in variola it is invariably present and more 
intense than in the former. In varicella the initial fever 
rarely extends beyond twenty-four hours, while in the 
lightest cases of variola it lasts fully two days. Intense 
pain in the sacral and lumbar regions is almost invariable 
in variola, and absent in varicella. But it is in the char- 
acter of the eruption that the most striking difference be- 
tween the two diseases is manifested. In varicella the 
eruption has less hardness than in variola, and the shotty 
feel of variola is absent. Furthermore, there is but a 
slight red base, if any, to the pock of varicella, while in 
variola the red base is prominent and always present. 
The exanthem of varicella becomes vesicular within 
twenty-four hours from its first appearance as a papule, 
and it rarely proceeds beyond the stage of vesiculation, 
while in variola the eruption only occasionally stops with 
the development of the vesicular stage. Umbilication of 
some of the vesicles is observed in varicella, while in va- 
riola umbilication is found in nearly all the pocks. 
Again, the vesicles of varicella are much larger than in 
variola, and have a superficial appearance as if the skin 
had been raised by having had boiling water spattered 
over it. 


Small-Pox. 
Small-Pox. 


Diagnosis of Variola from Febrile Lichen. — Febrile 
lichen bears a close resemblance to the papular erup- 
tion of variola. The exanthem of febrile lichen ap- 
pears as small, slightly red papules, ordinarily of the 
size of millet-seeds. In diagnosticating small-pox from 
lichen, time is an important factor. The eruption of 
lichen follows within from twenty-four to forty-eight 
hours after the initial illness, and never passes through 
the papular, vesicular, and pustular stages characteristic 
of variola. In lichen the eruption practically contains 
no fluid, and even when this is present it is so unlike 
that of variola that after two or three days from the be- 
ginning of the exanthem it would be impossible for a 
skilful physician to mistake it for small-pox. 

Diagnosis of Variola from Syphilis.—Occasionally the 
practitioner is called upon to diagnosticate variola from 
pustular syphilitic eruptions. At times this is a very 
difficult task. In June, 1887, I saw, in consultation with 
my brother, Dr. W. H. Foster, a negro man affected 
with a pustular syphilitic eruption which was in all ap- 
pearances like a severe case of discrete variola on the 
eighth day of the eruption. The face, trunk, and limbs 
were thickly studded with pustules, fully four-fifths of 
which were umbilicated. The man had high fever, 
(104° F.), pulse 140 per minute, severe pain in lumbar 
region, nausea, vomiting, sore throat, nasal catarrh, and 
marked redness of the eyes. The first symptom noticed 
by the patient was a hard chill. I have for years been 
familiar with the exanthem of variola, and yet must con- 
fess that we arrived at a diagnosis only by exclusion. 
Inquiry developed the fact that the patient had contract- 
ed syphilis four months previously, and that the eruption 
in question appeared a week or ten days prior to the time 
I saw him. Examination showed an indurated chancre 
beneath the prepuce. Upon the syphilitic history and 
the absence of contact with variola we were enabled to 
exclude small-pox. This eruption continued upon the 
man fully three months, In 1885, I saw, with Dr. G. C. 
Dugas, another very similar case. 

It is unnecessary to enter into a discussion of the differ- 
ential diagnosis of small-pox and scarlatina, typhus fever, 
meningitis, acute miliary tuberculosis, etc. If the phy- 
sician awaits the appearance of the characteristic erup- 
tion of small-pox he can never confound these diseases 
with variola. As previously stated, the practitioner is not 
warranted in proclaiming a positive diagnosis of small- 
pox until the vesicular stage is reached, unless there is 
evidence of contact with variola. 

Proenosts.—In prognosticating the result of a given 
case of small-pox the practitioner should be guided by a 
consideration of the following points: 

Age.—The age of the patient materially affects the 
prognosis. The mortality among infants is frightful, 
reaching fully 90 per cent. In childhood, up to twelve 
years of age, the mortality will reach 40 per cent. of un- 
vaccinated cases. Likewise old age is an important fac- 
tor, the mortality reaching 75 per cent. of all persons 
beyond sixty years of age. 

Sex.—In non-pregnant females the mortality will not 
exceed that of the male sex. Pregnant females, however, 
show a vastly greater death-rate, for, superadded to the 
disease, abortion, miscarriage, or childbirth has great in- 
fluence upon the results of variola. 

Vaccination.—Vaccination is a most important factor 
in determining the chances of death from variola. 

The death-rate in cases of post-vaccinal small-pox varies 
greatly with the length of time which has intervened 
between the attacks of vaccinia and variola, and the 
shorter this period is, the less will be the mortality. Mar- 
son claims that the mortality in post-vaccinal small-pox 
is greatly influenced by the number of insertions of the 
vaccine virus. From an examination into 4,896 cases of 
variola, following vaccination, he says the percentage of 
mortality was as follows 


Per cent. 
. . . : ne 
Having 1 vaccine Cicatrix ........00cescesecssreeenee: "Gs 7 3 
SR RCICATKICER.f tate.seindecacie acto? tsi’) ermine 4,70 
ip po the Co Pattee, fog an cd eee are oes 1.95 
‘6 4or more SORE Sac cheats dorset ae arent 0.55 


Small-Pox. 
Small-Pox. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


I do not agree with Marson as to the influence of the 
number of vaccine cicatrices. In this section vaccinia is 
introduced by only one puncture, and I have never seen a 
fatal case of variola in a person who had been vacci- 
nated within ten years prior to the attack of small-pox. 

Marson shows by elaborate statistics that the ratio of 
death risk, where there has been no vaccination, to that 
after the most defective vaccination, is as three to one; 
to that after the best vaccination, as seventy to one. 

The Type of Small-pox.—There can be no question that 
the type of variola has great influence in determining the 
death-rate. Taking a large number of cases the mortality 
will reach fifty per cent. in the confluent variety, ten per 
cent. in the semi-confluent type, and seven per cent. in the 
discrete variety. Marson, from the records of the Lon- 
don Small-pox Hospital from 1836 to 1851, inclusive, re- 
ports that among 2,654 cases of confluent, semi-confluent, 
and discrete varieties of small-pox there were 996 deaths, 
being a mortality of thirty-seven per cent. Recovery 
from hemorrhagic small-pox is rarely witnessed. Death 
from varioloid is almost unknown at the present day. 

Constitutional Condition.—The condition of the consti- 
tution of the patient at the time of contracting small-pox 
has an important bearing upon the prognosis. In per- 
sons suffering from consumption, scrofula, syphilis, the 
hemorrhagic diathesis, etc., recovery is very exceptional. 

Lesions of the Mucous Membranes.—Lesions of the 
mucous membranes exert a decided influence upon the 
death-rate. Cidema glottidis, diphtheritic exudations, 
pneumonia, etc., increase greatly the fatality of the orig- 
inal disease. 

TREATMENT.—The treatment of small-pox embraces 
two important, though widely divergent indications, viz: 

1. Palliative treatment, and 

2. Prophylaxis. 

Palliative Treatment.—There is unquestionably no cura- 
tive treatment known to medical science for small-pox. 
The treatment is wholly symptomatic, and must be pre- 
scribed with a view of palliating the severity of the symp- 
toms. The idea of a former generation, that medicines 
could cut short the course of this malady, has very prop- 
erly been abandoned. Sweating, vomiting, purging, and 
bleeding the patient, with a view of aborting variola, are 
not advocated by any reputable physician of the present 
time. Stiemer has recently, however, asserted that the ad- 
ministration of large doses of quinine during the stage of 
invasion will modify and shorten the course of small- 
pox. Quinine when given in large doses will reduce the 
temperature, but cannot cut short the course of the dis- 
ease. While we have no medicine which can shorten 
the course of variola, I nevertheless, from personal ex- 
perience, subscribe to Marson’s claim of the abortive 
power of vaccination, if performed within three days 
after the first exposure of the patient to small-pox. 
Marson says, on this point: ‘‘Suppose an unvaccinated 
person to inhale the germ of variola on Monday ; if he 
be vaccinated as late as the following Wednesday, the 
vaccination will be in time to prevent small-pox being 
developed ; if it be put off until Thursday, the small-pox 
will appear, but will be modified ; if vaccination be put 
off until Friday, it will be of no use; it will not have 
had time to reach the stage of areola, the index of safety, 
before the illness of small-pox begins; this we have seen 
over and over again, and know it to be the exact state of 
the question.” 

I can add several cases from my own experience which 
demonstrate the correctness of Marson’s statement. I 
vaccinated two children, aged twelve and fourteen years 
respectively, three days after exposure to semi-confluent 
small-pox. In each case the vaccinia pursued a typical 
course, yet the inital fever of variola appeared and lasted 
two days. The temperature reached 101° F. and 108° F. 
in these cases. One patient developed five pustules of 
variola, the other fourteen pustules. Secondary fever 
was absent in both cases. Furthermore I have on three 
occasions vaccinated persons who were sleeping in the 
same room with small-pox patients, and those so vacci- 
nated failed to take variola. But to thus successfully 
combat small-pox, vaccine virus must be used which will 


484 


develop a vaccine vesicle that will reach the areola stage 
within ten days—the period of incubation in small-pox 
is fourteen days. The lymph of humanized vaccine 
virus rarely shows delayed vaccinal results—bovine virus 
frequently does. Dry lymph from any source has this 
objection of delay in ‘‘ taking.” The greater certainty 
of humanized virus to ‘‘ take” promptly gives it a great 
advantage over bovine virus. In all cases coming to the 
physician’s attention at the time.of exposure it is his 
solemn duty to put Marson’s suggestion into practice. 

As soon as a person has contracted small-pox he should, 
if possible, be placed in a large, well-ventilated room, 
from which all books, unnecessary clothing, bedding, 
furniture, and other household articles have been pre- 
viously removed. The temperature of the room should 
be kept constantly at 65 or 70 degrees Fahrenheit. The 
old plan of keeping the patient heavily covered and con- 
stantly sweating, and the room dark and unventilated, is 
a great mistake and should be scrupulously avoided. 
The covering of the patient should be light, and the bed- 
ding and clothing frequently changed. When the chill 
comes on he should be warmly covered, and sinapisms 
should be applied to the whole length of the spinal col- 
umn. During the febrile stage high temperature should 
be combated with large doses of quinine and digitalis. 
For an adult forty grains of quinine may be given within 
four hours, together with twenty-drop doses of tincture of 
digitalis every eight hours until the temperature is mark- 
edly reduced. The antipyretic power of quinine in the 
exanthemata cannot be denied by any one who has fully 
tested it. But to produce this effect it must be given in 
large doses, 7.¢., ten grains every hour until forty grains 
shall have been taken. The antipyretic effect of the 
quinine will be manifested within six hours after its ad- 
ministration, and in twelve hours the maximum reduc- 
tion of temperature will be reached. The temperature so 
reduced will generally remain stationary for at least 
twelve hours. 

The temperature can be lowered at least two degrees 
by this treatment. If the fever again rises to 104° F., the 
quinine and digitalis should be repeated. Antipyrine has 
a wonderful effect in reducing temperature. When ad- 
ministered for this purpose it should be prescribed in 
twenty-grain doses, hourly, for three hours, to an adult. 
Thus administered it will reduce the temperature for a 
period varying from twelve to twenty hours. Whenever 
the fever reaches 104° F., a general warm bath at 100° F. 
will temporarily reduce it. These baths should be con- 
tinued for from five to ten minutes, and should be repeated 
as found necessary. During the febrile stage of variola 
convulsions frequently occur in children. This fact 
should be constantly borne in mind by the practitioner, 
and their occurrence should be forestalled by the admin- 
istration of hydrate of chloral and bromide of potassium, 
or paregoric. 

After the appearance of the exanthem the treatment 
must be varied to meet the type of the disease to be com- 
bated. 

In varioloid, medicines are scarcely ever indicated. 
The patient should have milk, eggs, and other easily di- 
gested articles of food. Confinement to bed is ordina- 
rily unnecessary in this type of variola. 

In severe cases of small-pox both local and internal 
treatment must be prescribed. 

Local Treatment.—After trials with various agents as 
local applications to the exanthem on the surface of the 
body, I am satisfied that a mixture of carbolic acid and 
glycerine is the best. A mixture composed of thirty-two 
grains of crystallized carbolic acid to one pint of glycerine 
should be brushed three times daily over those portions 
of the body most thickly studded with pustules. This 
mixture, owing to the anesthetic properties of carbolic 
acid, markedly controls the itching and pain of the erup- 
tion, and the glycerine softens the hardened crusts. Va- 
rious plans of treatment have been advocated for pre- 
venting the face from being pock-marked. With some 
writers the old plan of the Arabs, of opening each pustule, 
is advised ; others recommend the opening and cauteriza- 
tion of each pustule ; some advocate painting the surface 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Small-Pox,. 
Small-Pox. 


with tincture of iodine, with the view of aborting the 
vesicles by producing coagulation of their contents ; others 
recommend mercurial plasters, solutions of gutta-percha, 
nitrate of silver, collodion, etc. After various trials I 
am thoroughly convinced that no local treatment has the 
power to prevent pitting @f the skin. If the papillee are 
invaded by the variolous inflammation deep and perma- 
nent pock-marks result, no matter what local treatment 
has been used. If, however, the pustules are superficial 
the pock-marks will be very slight, even when no local 
applications have been made. I have repeatedly wit- 
nessed very slight pitting follow severe variola where no 
local treatment had been used. Ziilzer says the internal 
use of xylol will coagulate the contents of the pustules 
and thereby cut short their development. This claim 
lacks confirmation. I have never tried it. 

The exanthem in the mouth and throat causes pain and 
difficulty in swallowing. For the relief of these symp- 
toms gargles of warm water, or astringent solutions 
should be used. This treatment is of course only pallia- 
tive, for we can no more abort the eruption in the mouth 
and throat than on the skin. The diet of the patient 
should be carefully directed by the physician. The dis- 
ease will tax the strength to the utmost, and therefore 
nutritious food properly prepared should be freely ad- 
ministered. Milk, eggs, soup, beef tea, gruel, oatmeal, 
prunes, baked or stewed apples, etc., furnish excellent 
food for the variolous patient. 

Delirium, restlessness, weak and rapid pulse, shrunken 
features with marked prostration, demand free and fear- 
less use of alcoholic liquors. This treatment offers the 
patient the only hope of recovery. The amount of alco- 
holic stimulants to be administered in adynamic states 
of variola must be decided by the degree of vital depres- 
sion to be combated. 

Constipation should be relieved by mild saline purga- 
tives or enemata. If diarrhcea exists it should be con- 
trolled with opium. 

If sleeplessness is marked it should be relieved with 
a mixture of hydrate of chloral and bromide of potas- 
sium, or morphine ; where copious expectoration or sali- 
vation exists, opiates should be given with caution. 

Abscesses frequently form in the subcutaneous tissues 
_ during the course of variola. The scalp is a favorite lo- 
cation of these abscesses, which when they first appear 
are small, but continue to enlarge and show but little 
disposition to point. They should be freely opened when 
first discovered. When the eruption is copious on the 
head, or when abscesses form under the scalp, the hair 
should be cut close to the skin. Numerous boils, termi- 
nating in foul ulcers with free discharge of pus, occur in 
many cases of variola. Boils should be promptly lanced. 
The depressing effects of suppuration should be com- 
bated with full doses of quinine, iron, wine, and concen- 
trated nourishment. As a local application to these ab- 
scesses, lint kept wet with black wash is the best. 

If erysipelas, pleurisy, pneumonia, etc., complicate an 
attack of small-pox they should be treated on general prin- 
ciples. Among the most serious complications of small- 
pox are ophthalmia and ulceration of the cornea. Vario- 
lous ophthalmia should be treated by frequently washing 
the eyes with warm water, and by an astringent collyr- 
ium of sulphate of zinc used after each washing. <A 
solution of atropine should be dropped into the eyes as 
found necessary, when the inflammation is intense. To 
mitigate the irritation on the eyelids the vesicles should 
be punctured and the lids frequently covered with cold 
cream. When the cornea is implicated and perforation 
is threatened, attempts should be made by local treat- 
ment to subdue the inflammation and stop the advance 
of the ulcer. Atropine should be freely dropped in the 
eyes, and the lids kept closed with a compress bandage. 
The eyes should be cleansed several times daily, and a 
mild solution of sulphate of zinc, two grains to the ounce 
of water, should be instilled after each cleansing. 

Prophylaxis.—Judged by mortuary statistics, the pres- 
ent therapeutic management of small-pox in unvaccinated 
patients shows but slight improvement over that of one 
hundred years ago. By judicious symptomatic treatment 


many cases can be conducted to a favorable termination 
which would otherwise prove fatal. Prevention is the 
end to be reached in combating this malady. In the 
whole field of sanitary science the prevention and control 
of small-pox are the most certainly attainable, if the 
efforts of the sanitarian are wisely planned and faithfully 
executed. In the prevention of the spread of variola the 
most important of the hygienic considerations to be re- 
garded, are: 1, Isolation; 2, disinfection; 8, vaccina- 
tion. 
Isolation.—No matter how absolute the protection af- 
forded by vaccination there will always be great and in- 
surmountable difficulties in the way of enforcement of 
this measure among the people generally in this country, 


' where individual ignorance and prejudice are allowed to 


contravene the public welfare. Therefore, the sanitarian 
must be prepared to enforce additional measures of pre- 
vention and control of small-pox. If a case, or cases, of 
variola be introduced into a community, the disease can- 
not spread if the patient be promptly isolated and all in- 
fected materials immediately disinfected or destroyed. 

Whenever a case of small-pox occurs in a family, the 
physician’s first duty is to isolate the patient and provide 
nurses and attendants who have been successfully vac- 
cinated or have previously had the disease. If others in 
the family have not yet been vaccinated they should be 
vaccinated at once. Those who have previously been 
vaccinated should be promptly revaccinated. If the 
small-pox patient be so situated that he can be safely iso- 
lated and provided with proper attention, he may be per- 
mitted to remain at home for treatment, but the sanitary 
authorities should furnish a reliable guard to compel 
isolation and compliance with all necessary sanitary pre- 
cautions. If isolation at home is impossible, then a prop- 
erly organized hospital is the only place where such a 
patient can, with due regard to public safety, be treated. 
For such purpose a public small-pox hospital is a neces- 
sity in every city. It should be located remote from the 
thickly settled parts of the city, and, if possible, beyond 
the city limits. This institution should be provided with 
every necessary comfort, so as to induce patients to 
cheerfully seek shelter therein. Whenever a case of va- 
riola is allowed to remain at home, a large poster should 
be placed on the door to warn people not to enter or 
linger there. 

In the management of this disease among the poor the 
greatest possible care and vigilance must be exercised 
on the part of the municipality. Whenever a case has 
been found and is to be conveyed to hospital this should 
be done in a closed ambulance—to use an open convey- 
ance would be criminally negligent. Infected clothing, 
bedding, etc., may be taken with the patient to the hos- 
pital, though it is safer to burn them in the sick-room. 
When the clothing and household articles of the poor 
have been destroyed, the public treasury should replace 
them, for they were destroyed in furtherance of public 
safety. In burning infected articles and replacing them 
with new ones, the sanitary authorities will make a most 
prudent and economical expenditure of money—an ex- 
penditure which will be returned to them more than a 
thousandfold. When infected persons or materials are 
being taken to hospital, the ambulance should be rapidly 
driven through the most sparsely inhabited portions of 
the city contiguous to the hospital, and the police should 
go ahead and clear the streets until the ambulance has 
passed. Isolation of small-pox patients is absolutely 
necessary in preventing the spread of the disease. With- 
out doubt variola can be promptly ‘‘ stamped out” of a 
community. But to do this the first cases must be im- 
mediately dealt with by isolation, disinfection, and vac- 
cination. To obtain early information of the existence 
of small-pox the municipality should require physicians 
and families to promptly report to the sanitary authori- 
ties all cases known to them. When a case is found its 
source must be traced, and thus other cases will be de- 
tected. When a case of variola is found the sanitary 
officer should carefully ascertain the name and residence 
of every person who has been exposed to it. An officer 
should be specially charged with the duty of finding every 


485 


Small-Pox. 
Snails. 


such exposed person, and should make daily visits to 
every one of them until the period of incubation is passed. 
Every person who has been exposed to the disease should 
be vaccinated, and if formerly vaccinated the operation 
should be repeated. Every such person refusing to be 
vaccinated should be quarantined for fourteen days—the 
period of incubation in variola. Where a person has been 
exposed to small-pox, and is living in the same house 
with other families, such family should be quarantined 
until the period of danger is over. To safely quarantine 
such persons it may be necessary to confine them in a 
quarantine station. For this purpose every municipality 
should maintain a quarantine hospital, near the small- 
pox hospital, but sufficiently distant to insure safety to 
its inmates. The sanitary ofiicer should remove persons 
to the quarantine hospital only when public safety ab- 
solutely demands the exercise of this precaution. 

Disingection.—Watson truly says ‘‘there is no conta- 
gion so strong and sure as that of small-pox.” The con- 
tagious element exists in the exhalations of the body and 
in the vesicles, pustules, and scabs. These sources of 
the disease contaminate the air of the sick-room, and 
strongly adhere to everything therein. The vitality of 
the small-pox poison is truly remarkable, if protected 
from the air, as in instances where infected clothing has 
been packed away, it can retain its infective power for 
several years. 

The sanitarian has in chemistry, under these surround- 
ings, an indispensable ally. There is no question of our 
ability to kill every particle of the contagion of small- 
pox if chemical action is properly adjusted to its task. 
To do this successfully disinfectants must be brought di- 
rectly in contact with the contagious matter. Every dis- 
charge which passes from the mouth, nose, kidneys or 
bowels of the patient must be received in suitable recep- 
tacles charged with a powerful disinfectant. Every 
handkerchief, towel, sheet, article of clothing, drinking- 
or eating-vessel must be purified by heat and disinfect- 
ants. If the patient is kept at home, a sheet saturated 
with a strong solution of carbolic acid should be hung 
over the door openings outside the sick-room, to prevent 
the contagious exhalations from passing into other parts 
of the house. 

The sputa and excretions of the kidneys and bowels 
should be received into vessels containing a sufficient 
quantity of strong copperas solution, two pounds to the 
gallon of water. Under nocircumstances should excreta 
be passed into a water-closet or thrown into the privy 
vault or yard until an additional quantity of copperas 
water has been added to them. The quantity of the dis- 
infectant should be at least eight times more than that of 
the excreta. 

All eating- or drinking-vessels used in the sick-room 
should be thoroughly disinfected with a disinfectant so- 
lution, and afterward washed in hot water before being 
carried from the room. Such of the articles as are nec- 
essary should be kept and used in the sick-room until the 
recovery and discharge of the patient. 

Every piece of bed- or body-linen from the patient or 
nurses, or which has been in any part of the sick-room, 
must be kept in a solution of carbolic acid for two hours 
and boiled in water for half an hour, before being taken 
from the patient’s room. 

Bits of cloth, instead of handkerchiefs, should be used 
and burned immediately when soiled. 

The patient should not be regarded as free from liabil- 
ity to infect others until every scab or scale has been re- 
moved. ‘The hair should then be carefully combed so as 
to remove all particles adhering to the scalp. The whole 
body should then be washed in a weak disinfectant solu- 
tion and the patient should hastily go into an adjoining 
room and dress with clothing undoubtedly free from 
contagious particles. 

Immediately upon the patient leaving the room it 
should be disinfected and cleaned. To effectually purify 
the clothing, bedding, etc., hang every article upon lines 
placed across the room. If there is a carpet on the floor 
take it up and burn it in the fireplace. Then stop up the 
fireplace and shut down the windows. Put two pounds 


486 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


of sulphur in an iron pot overa larger vessel holding 
water, and drop a quantity of live coals into the pot con- 
taining the sulphur, and then hastily leave the room and 
close the door behind you. The room should now be 
closed for twenty-four hours in order that the disinfect- 
ant thus generated may invade every crevice and fully 
impregnate all materials therein. After twenty-four 
hours open the windows (closing all others adjacent 
thereto), and then have the clothing and bedding, which 
can be washed, put into tubs containing solutions of car- 
bolic acid, chloride of zinc, or copperas, and boiled for 
one hour in water. These articles should then be taken 
into a large open space, as far from the thickly inhabited 
portion of the town as possible, and sunned. There is al- 
ways danger in the pillows and mattresses, for they can- 
not be thoroughly fumigated nor can they be washed, 
therefore these articles should be burned. All stuffed 
furniture in the room should be taken apart and the up- 
holstering materials burned. Wash all the furniture 
and the floor with a disinfectant solution. If the walls be 
papered wash off every particle of such covering and 
then whitewash the walls. The walls, even when painted, 
should be washed with a disinfectant solution. After the 
above precautions are taken, open the windows for free 
ventilation and leave the room unoccupied for one month. 

If the patient should die, the corpse should be thor- 
oughly washed with a strong solution of chloride of zinc 
or carbolic acid and water, and the body should be 
wrapped in a sheet fully saturated with one of these dis- 
infectants, and buried at once. Under no circumstances 
should the body of such a patient be permitted public 
burial; nor should the corpse be transported from the 
city by public conveyance—such as cars, boats, etc. 
Every hearse, hack, or other vehicle in which the body 
has been conveyed, should be disinfected under the su- 
pervision of the sanitary authority immediately after the 
corpse is removed therefrom. 

n waging war against small-pox no alarm or excite- 
ment must be felt ; it should be met calmly and deliber- 
ately. If real skill should direct, and scrupulous con- 
scientiousness execute, the above specified measures of 
prevention and control, small-pox might simultaneously 
be introduced into every city in America, and it would be 
impossible for it to attack any one citizen not already in- 
fected. 

Vaccination.—In the broad field of natural science no 
fact is better established than that vaccination, if univer- 
sally practised, is capable of effectually preventing the 
appearance of small-pox in man. The history of vac- 
cination, as well as the technique of the operation, will 
not be discussed in this treatise, inasmuch as the subject, 
Vaccination, has been assigned to another writer. I must, 
however, say that, after a large personal experience ac- 
quired in making five thousand vaccinations in the pub- 
lic service, Jam impressed with the conviction that hu- 
manized vaccine virus is decidedly preferable to bovine 
virus. The facts upon which this opinion is founded are 
fully presented in a paper, entitled ‘‘ The Relative Merits 
of Humanized and Bovine Vaccine Virus,” read by me 
before the Medical. Association of the State of Georgia in 
1882. This paper may be consulted by referring to the 
‘‘Transactions of the Medical Association of Georgia, 
1882.” In view of the prophylactic power of vaccination 
it should be regarded as an especial and solemn duty 
upon the part of municipal authorities to annually pro- 
vide gratuitous vaccination for the indigent poor, and 
whenever small-pox threatens the community no expendi- 
ture of money, within the line of duty compatible with 
the public good, should be spared by the authorities in 
order to protect the people under their charge. 

The time has not yet arrived, and in democratic Amer- 
ica, where the cry of infringment of personal liberty is 
the shibboleth of the demagogue, the day may never 
come, when it would be wise to resort to compulsory 
vaccination. There can be no question but that every 
unvaccinated person is liable to contract small-pox, and 
thereby disseminate it among his fellows. This fact con- 
stitutes every unvaccinated person a public enemy, and 
he or she should be dealt with as such. Satisfactory 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Small-Pox. 
Snails, 


evidences of successful vaccination should be required 
of all persons before being allowed to enter public schools, 
asylums, hospitals, charitable institutions, or municipal, 
state, or national service. Every immigrant should be 
required to exhibit like proof before being allowed to 
land in this country. Hugene Foster. 


SMELL, THE SENSE OF. The olfactory nerve (so- 
called) is, like the optic, a prolongation of the cerebrum. 
Its minute structure is that of the brain-substance, and not 
of the ordinary cerebro-spinal nerves. It arises by three 
roots from the posterior part of the anterior lobe of the 
brain, and forms the olfactory tract which terminates in 
the bulb, or olfactory ganglion; resting on the cribriform 
plate of the ethmoid bone. The development of this 
ganglion is always in proportion to the acuteness of the 
scent in different animals. It is made up of gray matter, 
z.é., it is chiefly composed of ganglionic cells. 

From it arise about twenty nerve-filaments, which pen- 
etrate the cribriform plate and are distributed to the up- 
per third of the anterior nasal chamber. It is the sum 
total of these fibres which might be more properly called 
the olfactory nerve. These fibres anastomose freely, they 
subdivide, and are finally distributed to the “ olfactory 
membrane.” 

This membrane is considerably thicker than the rest 
of the nasal mucous membrane. It is only to be found 
in the upper third of the nasal fosse, where it extends 
over the upper, and a portion of the middle, turbinated 
bones, the septum, and the roof of the fosse. In ani- 
mals with acute scent the olfactory region is more exten- 
sive than in man. To this membrane exclusively are 
distributed the terminating branches of the olfactory 
nerve (see Fig. 2508, on page 212 of Volume V.). 

The epithelial covering of this membrane consists of 
truncated epithelium-cells, and between these, at regular 
intervals, are to be found peculiarly shaped, slender, 
nucleated cells ending in rods. These are presumed to 
be the terminating peripheral apparatus of the olfactory 
nerve, although their connection with the nerve-filaments 
has never been satisfactorily demonstrated, owing to the 
extreme delicacy of the latter. They are analogous to 
the rods and cones of the retina, and to the hair-cells in 
the organ of Corti. Inthe frog they are ciliated. Nu- 
merous racemose mucous glands, which keep the mem- 
brane in a moist condition, are distributed throughout 
the olfactory region. 

The remaining portion of the nasal chambers is cov- 
ered by a thin layer of mucous membrane, bearing cili- 
ated columnar epithelium, which is innervated by the 
fifth nerve. It is provided with simple glands secreting 
a serous fluid. 

That the olfactory region is the one exclusively capa- 
ble of receiving odorous impressions, and that, conse- 
quently, the olfactory is the only nerve endowed with 
specific olfactive properties, has been proved both by 
physiological experiments and by pathological anatomy. 
Dogs in whom the olfactory nerve has been cut refuse 
meat wrapped up in paper, and are incapable of finding 
it when hidden. Persons suffering from anosmia due to 
absence, atrophy, or injury of the olfactory tract or gan- 
glion are deprived of the sense of smell, although they 
are capable of detecting certain pungent substances, such 
as bromine, iodine, chloroform, acetic acid, ammonia, 
etc. There is a difference between the pungent and 
odorous substances. The former impinge only on the 
nerve-endings of the fifth nerve, which subserves general 
sensation ; they are not perceived by dogs in whom the 
nasal branches of that nerve have been divided. 

The mechanism of the perception of odorous substances 
is as little understood as is that of visual and auditory im- 
pressions. We know nothing about the nature of odor- 
ous substances, and it is impossible to classify them simi- 
larly to substances productive of gustation. If we want 
to describe a certain odor we have to give the name of 
the substance which produces it. 

The act of smelling takes place by the contact of air, 
laden with odorous particles, with the olfactory portion 
of the nasal chambers. The diffusion of this air is facili- 


tated by the projecting inferior turbinated bone. By it 
the ascending air-current is directed against the septum 
nasi; striking this, it is again deflected, and scattered 
throughout the recesses of the upper anterior fosse, 

Odorous particles give rise to olfaction only when sus- 
pended in gaseous media. Scented water poured into the 
nose (the patient being in the recumbent position), and 
kept there by the reflex closure of the nasal fossa by the 
soft palate, is not smelled, nor does a scented air-current 
passing from the pharynx through the nares give rise to 
an odorous impression, Thus, persons having habitually 
an offensive breath do not perceive it themselves. There 
is, however, another explanation of this: An odor start- 
ing from the air-passages is perceived in the beginning of 
the trouble, but soon the olfactory nerve becomes accus- 
tomed to it, and there is no further perception of it. A pa- 
tient having cancer of the stomach was greatly annoyed at 
first by the offensive smell of the material vomited ; but 
soon he became accustomed to the bad odor, and ceased 
to be aware of it. 

Smell is intensified by sniffing. Within certain limits 
it may be stated that the more quickly the air containing 
odorous substances passes over the olfactory membrane, 
the more acute is olfaction. Persons on whom tracheot- 
omy has been performed, and who breathe through a 
cannula, do not smell at all. Continuous smelling of the 
same substance, especially when fragrant, gives rise to 
discomfort and pain in the forehead. At the same time 
the nerve becomes exhausted, and the sense of smell for 
that particular substance istemporarily lost. Water, when 
kept in contact with the olfactory membrane, will also 
abolish olfaction for a short time. Probably it causes 
the delicate olfactive rods to swell up, and interferes in 
this way with their function. 

When several odorous substances are mixed, we do not 
smell a mixture of them, but we perceive them alter- 
nately and individually. 

Whether an impression can be produced on the olfactory 
membrane by mechanical or electrical stimulation, cor- 
responding to the visual and auditory sensations excited 
by the same means, is questionable. It is claimed by 
some that electrical stimulation of the olfactory region 
excites a sensation resembling that produced by the ema- 
nations from phosphorus. 

Subjective odorous sensations are quite frequent, and 
occur even in the healthy ; but most often they are met 
with in the hysterical and the insane. 

In regard to acuteness of smell, man is inferior to 
most of the higher animals; this is partly due to the neg- 
lect of the cultivation of this sense. Hysterical patients 
are sometimes endowed with a remarkably acute sense of 
smell ; persons who are both blind and deaf, and who are 
consequently compelled to cultivate and rely on the other 
senses, have been known to almost equal the dog in the 
acuteness of smell. 

There is an intimate relation. between smell and taste, 
and, in fact, all so-called taste, except that of sweet, sour, 
bitter, and salt substances, is in reality smell. Delicate 
flavors that make so many dishes attractive cannot be 
appreciated when the nose is plugged, or when a person 
suffers from coryza or anosmia. Thus, vanilla, freshly 
prepared roast beef, the bouquet of wines, etc., can be 
relished only by those whose olfactory sense is unim- 
paired. 

That there is an anatomical connection between the 
organs of smell and taste is evinced by the fact that the 
odor of sapid substances produces reflexly a flow of saliva. 

For perfect olfaction a moist condition of the olfactory 
membrane is indispensable. 

Asmight beexpected, carnivoraare possessed of a more 
acute smell for animal substances than the herbivora, who 
have a quicker perception of the odor of plants. 

L. Bremer. 


SNAILS. <A popular term applied to those forms of 
the gasteropod mollusks, belonging chiefly to the order 
Pulmonata, which are provided with a shell. They are 
divided into the land, fresh-water, and marine species, 


' belonging respectively to the sub-orders Geophila, Lim- 


487 


Snails. 
Snakeroot. 


nophila, and Thalassophila. There are some few terres- 
trial species and a large number of fresh-water and marine 
forms, belonging to the order Azygobranchia, to which 
the term snail is also sometimes applied. The fresh-water 
and marine forms are perhaps more commonly known 
as periwinkles and whelks, while allied genera not pro- 
vided with a shell are ordinarily spoken of as slugs. 

The order Pulmonata is characterized by a lingual 
membrane provided with numerous teeth arranged in 
many uniform transverse rows ; mouth usually supplied 
with one or more horny jaws, a respiratory organ in the 
form of a closed chamber lined with pulmonic vessels on 
the back of the animal and covered by the shell when 
present—the edge of the mantle being attached—the en- 
trance to the air-chamber being through an opening in the 
side closed bya valve. The operculum is almost univer- 
sally absent. The tentacles and eye-peduncles are re- 
tractile or contractile. The shell varies in form, and is 
sometimes rudimentary or wanting. They are hermaph- 
rodites, with reciprocal impregnation, generally ovipa- 
rous, and all forms, whether terrestrial, fluviatile, or ma- 
rine, respire free air. 

The American species of terrestrial snails live mostly 
in the forest sheltered under’the trunks of fallen trees, 
layers of decayed leaves, stones, or in the soil itself. 
They are, as a rule, solitary in their habits ; only excep- 
tionally, as sometimes in the early days of spring, do 
they congregate in considerable numbers in warm and 
sunny situations, but these assemblies do not last more 
than a few days ; they then scatter and again resume for 
the rest of the year their solitary mode of living. They 
are rarely seen abroad except on damp dark days or at 
twilight, and, indeed, they almost disappear as the for- 


Fia. 3557.—Helix Pomatia Linn.; the European Vineyard Snail, the one 
most extensively eaten. (From Keferstein. ) 


ests are cut down, and seem to flee the approach of man. 
The European species, on the other hand, follow in the 
track of cultivation and are common in gardens and 
fields, on walls and hedges, and other places exposed to 
the action of light. It is probably owing to this radi- 
cal difference in their habits of life that the large major- 
ity of our species are so plain and uniformly dull-col- 
ored, while the European species are brightly colored. 
In size the snails vary from those minute species a quar- 
ter of an inch or less in length to the gigantic African 
species belonging to the genera Achatina and Balinus, 
which sometimes attain the length of eight inches. 

The eggs are laid in the early spring. Some few 
forms are viviparous. As soon as hatched, which takes 
place in from twenty to thirty days, the young snail de- 
votes himself strictly to the business of eating. He first 
devours his own shell, and then, according as his instinct 
leads him, begins on either vegetable or animal food. 
The majority of them prefer vegetable food, though it is 
certain that some forms are also fond of animal food, 
and sometimes prey upon earthworms, their own eggs, 
or even upon each other. The amount they can eat is 
enormous, as can well be testified to by the gardener, who 
often finds a whole field of vegetables almost destroyed 
in a single night. As might be expected from this, their 
rate of growth is very rapid, and they frequently double 
in size within a week. At the first approach of frost they 
retire into secluded and sheltered spots under logs, stones, 
or partially burrow into the soil, withdraw into their 
shells, and dispose themselves for their annual sleep or 
hibernation, only to be awakened again in from four to 
six months by the warmth of spring. 


488 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


They possess the power of secreting a mucus-like ma- 
terial from the general surface of the body at will. The 
slugs have this function developed to a much greater 
degree, and it is used by them as a means of defence. 
Whenever a foreign substance touches them they secrete 
a quantity of the mucus, which forms a kind of mem- 
brane interposed between themselves and the irritating 
substance. This mucoid material is a non-conductor of 
heat and impervious for a time to liquids, so that by its 
means they are enabled for a considerable time to with- 
stand the action of corrosive gases, alcohol, and even 
boiling water. The fresh-water and marine forms live 
on the rocks and aquatic plants at the bottoms of ponds 
and rivers, and along the sea-shore, where they may be 
seen in immense numbers when at any time, as at ebb- 
tide, the rocks are exposed. 

There are a large number of species of snails which 
have been used as food. Most of these belong to the 
genus Helix, of which more 
than twelve hundred species 
have been described. Few 
of the American forms have 
been so used, partly for the 
reason that it has never be- 
come the custom here, and 
partly, probably, from the 
curious fact already men- 
tioned, that the forms indig- 
enous to this country are 
mostly solitary and do not 
collect in herds or communi- 
ties. Many of the European 
species, on the contrary, herd 
together in immense numbers and so are very easy to col- 
lect and peculiarly adapted to colonization. The ‘“‘ edi- 
ble snail,” Helia pomatia, is the one most commonly eaten 
in Europe, but H. aspersa and H. hortensis are also very 
generally used. The first of these has, I believe, never 
been introduced into this country, but aspersa and hor- 
tensis both have been, and are now found in considerable 
numbers in certain localities. They retain their habits 
of congregation, and will no doubt in time be much 
more generally used as an article of diet than they are at 
present. 

The ancient Greeks and Romans considered snails as 
one of their greatest delicacies, and imported them from 
all parts of the then known world to be reared and fat- 
tened in their extensive snail-ponds. In many parts of 
Africa the large species which are indigenous there are 
used as a daily food all the year round. At the present 
time in Austria, France, Switzerland, Spain, and Italy, 
the collection, rearing, and preparing them for market 
affords occupation to a large number of people. An 
idea of the extent of the industry may be gained from 
the fact that from Ulm alone some 4,000,000 are annually 
exported, and about 90,000 pounds are 
sold in the Paris markets every year. 

The wild snails are collected and 
placed in small plots of land cleared 
of trees and covered with heaps of Y 
moss and pine-twigs, and separated “J 
from each other by moats, or trails of 
sawdust, for which snails have a natu- 
ralantipathy. ‘They are kept here and 
fed on fresh grass, cabbage-leaves, 
mint, and other aromatic herbs. In the course of a week 
or ten days they have become quite obese and, besides, 
have attained a very delicate flavor ; they are then starved 
for a few days to allow them to get rid of excrementi- 
tious matter, when they are ready for the market. To 
prepare them for the table they are well washed, then 
broiled, baked, or boiled, shell and all, when they are 
either extracted and served with various suitable sauces, 
or are placed on the table entire, to be removed at the 
time of eating by placing the shell to the mouth and 
drawing out the animal by sucking it. 

The sea-snails are not so extensively used as food, 
though in England the common periwinkle (Littorina lit- 
torea) is consumed in immense quantities by the poorer 


Fie. 38558.— Pomatia Aspersa. 
(From Binney.) 


Fie, 38559. — Tachea 
Hortensis. (From 
Binney.) 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


¢ 
classes on the coasts as well as in London. About three 
thousand tons of them, valued at £15,000, are annually 
shipped to London alone. 

There has been a number of cases of poisoning from 
eating snails which have been allowed to feed on hem- 
lock and belladonna, so that now there has been an in- 
spector appointed in Paris whose business it is to see 
that they are in fit condition for consumption. 

In some persons the ingestion of snails brings on marked 
attacks of urticaria—the same as is seen in certain cases 
after eating clams, oysters, and other shell-fish. In these 
cases it will be understood that there is a more or less 
marked idiosyncrasy in the person. 

An idea of the nutritive value of these mollusks may 
be gained from the following analysis of the ‘edible 
snail,” made by Mr. Charles Mene: 


AAVAOREENES 2m o.clty $y. eJSRM Ete cro tore Re ten eae ea 42.747 
INICLOMETICOUS TNBLLERE © wk. ic ir a: ee pm. eee oe 17.652 
HB GGYISRDSCATICOR Tren suey enti. soe dnsiac koe oe atl 1.125 
Non-nitrogeneous matter... .........ccccceccuecees 6.300 
SLC trrcteeret tern Pots Ae cioie Siete sis ees oe once ee 2.176 
INICEOP ED erettciicise com aoeiecie ts boda ee eden cee 2.823 


In some parts of the world the snail has more or less 
of a reputation as a “‘cure” for consumption, concerning 
which it is only necessary to say that it may be consid- 
ered as a food of some value as affording a change of 
diet. William Barnes. 


SNAKEROOT, BLACK (Cimicifuga, U. S. Ph.; Cimi- 


cifuge Rhizoma, Br. Ph. ; Black Cohosh, etc.) ; Cémie7- 


fuga racemosa Elliott ; order Ranunculacee (Actea race- 
mosa Linn.), This is a large, perennial herb, arising 
from a thick, knotted, horizontal, fleshy rootstock, which 
gives off numerous cylindrical, branched rootlets from 
its lower surface, and develops several leafy stems and 
buds upon the upper. The aérial stems are slender, up- 
right, from one to two and a half metres high, smooth, 
and cylindrical ; they bear two or three ternately com- 
pound leaves, the lower very large, twice or thrice pri- 
mate; the upper ones successively smaller and more 
simple ; leaflets pointed, serrate, ovate, or more or less 
three-lobed. Inflorescence of one or several long, slen- 
der, upright, cylindrical racemes (25 to 50 centimetres 
long). Flowers very numerous, something over a centi- 
metre across, consisting of four white, concave sepals, 
which drop as they expand ; very numerous, free, slen- 
der, spreading stamens, and a single, one-celled, ovoid, 
pistil, containing several ovules. Petals none, a few of 
the outer stamens somewhat petaloid. 

Black Snakeroot is a common American plant, grow- 
ing in Canada and in most of the United States. It is 
collected in various parts of the country, and has been 
used as a medicine for nearly a century. 

The officinal description of the dried rhizome is as fol- 
lows: ‘‘The rhizome is horizontal, hard, two inches (5 
centimetres) or more long, about one inch (25 milli- 
metres thick, with numerous, stout, upright, or curved 
branches, terminated by a cup-shaped scar, and with 
numerous wiry, brittle, obtusely quadrangular rootlets, 
about one-twelfth of an inch (2 millimetres) thick ; the 
whole brownish-black, nearly inodorous, and having a 
bitter, acrid taste. Rhizomeand branches have a smooth 
fracture, with a large pith, surrounded by numerous, 
sublinear, whitish wood-rays, and a thin, firm bark. The 
rootlets break with a short fracture, have a thick bark, 
and contain a ligneous cord branching into about four 
rays” (U. 8S. Ph.). Cimicifuga, it is said, should be col- 
lected in the autumn; it should be used moderately 
fresh, as it grows much less active with the lapse of 
time. 

Composition.—Not satisfactorily determined—siarch, 
sugar, gum, resin, which were early recognized, are com- 
mon vegetable derivatives, and found in most plants. 
Couard obtained a neutral, crystalline, very acrid sub- 
stance (allied perhaps to anemonin). Trimble, working 
more recently, was unable to get. Couard’s crystals, but 
obtained an acrid, amorphous substance. No alkaloid 
appears to be present, unless Couard’s crystalline sub- 


Snails. 
Snakeroot. 


stance proves to be such, as surmised by Mr. Falck, who 
has recently (1884) obtained it from the fresh rhizome. 

ACTION AND Usz.—There is no question that recently 
dried, or still better, fresh, Cimicifuga is an active sub- 
stance. Vomiting, diarrhoea, and cardiac depression are 
caused by large doses ; faintness, restlessness, and dizzi- 
ness, foul breath, and dryness of the pharynx are com- 
mon results. Smaller doses are said to be tonic, to im- 
prove the appetite and digestion, and to strengthen the 
heart’s action. It is reputed to be aphrodisiac and 
ecbolic, but is not at all reliable in these directions. The 
most important and acknowledged uses of Cimicifuga 
are, however, established empirically. It has for many 
years had a reputation in chorea, and is generally believed 
to be useful in that-obstinate disease. It is also given 
in chronic rheumatism, and occasionally in pulmonary 
troubles. 

ADMINISTRATION.—The dose is one or two grams of 
the dried drug ; a Fluid Extract (Hetractum Cimicifuge 
Hluidum, U.S. Ph.), and a Tincture (Tinctura Cimici- 
Suge, U. 8. Ph.; strength, +) are available preparations. 
The precipitated resin, miscalled cimée¢fugin, is in gen- 
eral use by the ‘‘ Eclectics,” and occasionally called for 
by other physicians. Dose about a decigram. 

ALLIED PLANTs.—See ACONITE. 

ALLIED Drues.—Colchicum, various alteratives, etc., 
besides several other Ranunculacee. W. P. Bolles. 


SNAKEROOT, VIRGINIA (Serpentaria, U. S. Ph.; 

Serpentarie Rhizoma, Br. Ph.; Aristoloche Serpentaire ow 
Serpentaire de Virginie, Codex Med.). Aristolochia Ser- 
pentarta Linn., order Aristolochiacee, is a perennial herb, 
a foot or so high, from a knotty, horizontal, aromatic rhi- 
zome. The stems are slender, flexuose, branching at the 
base. The leaves of various shapes between ovate and 
narrow-lanceolate, with heart- or halberd-shaped bases ; 
petiolate entire. Flowers lateral, on slender, straggling, 
crooked peduncles in the axes of bracts, near the surface 
of the ground, about an inch long, consisting of a dull 
purple, single perianth (calyx), whose curved stube has 
a wasp-like constriction near the middle, and a very ob- 
lique, spreading, three-lobed border, of six short stamens 
connected with the style in three pairs, and a three- 
celled, many-ovuled, inferior ovary. It is a native of 
the United States, especially of Pennsylvania, Virginia, 
and Kentucky, where much of the drug is collected. In’ 
the South and West A. veticulata Nutt. furnishes a some- 
what larger and coarser product. Serpentary is one of 
the numerous, usually innocent, remedies which have a 
historical reputation for snake and mad-dog bites. It 
has been known in medicine for about two hundred 
rears. 
: The rhizome, as collected for use, is about an inch long, 
and an eighth or more in diameter, brittle, and tortuous. 
Section shows excentric wood. Its upper surface has the 
remains or scars of several stems; its lower is covered 
with a dense skein of long, slender, fibrous rootlets. All 
have a dull brown color, an aromatic odor, and a warm, 
bitter, camphoraceous taste. » The rootlets of Arzstolochia 
reticulata Nuttall, the Southern or Red River snakeroot, 
also officinal, are coarser, longer, and less matted together 
than those above described. Snakeroot is often carelessly 
collected, leaves and stems may be mixed with it, or Pink- 
root, Ladies’ Slipper, and other similar-looking rhizomes 
may be collected with it by accident or for fraud. They 
are easily distinguished with a little care. 

Composition.—Half a per cent. of essential oil, about 
as much resin, a little tannin, and a bitter principle are 
found in this drug ; to the first and last it probably owes 
its value. 

AcTION AND UskE.—It is difficult to make this out as 
anything more than a pleasant, aromatic, bitter tonic. 
In ounce doses it deranges the digestion, and may cause 
vomiting, colic, and diarrhea. Its former employment 
has been largely as an alterative in various chronic dis- 
eases, in rheumatism, and intermittent fever. It is one 
of the ingredients of the Compound Tincture of Cin- 
chona. Dose, of the powdered drug itself, say two or 
three grams, Its preparations are: a Fluid Extract (Zz- 


489 


Snakeroot, 
Soapwort, 


tractum Serpentarie Fluidum, U. 8. Ph., strength, +), and 
a Tincture (Zinctura Serpentarie, U. 8S. Ph.; strength, 
ys). 

‘ALLIED PLANTS.—The genus is a large one, of one 
hundred and eighty, mostly tropical, plants, of both 


Fie, 3560.—Virginia Snakeroot, about one-half natural size. 


hemispheres. A number of them have aromatic-bitter 
properties similar to the above, and have been used as 
medicines. The neighboring genus Asarum, represented 
here by Asarum canadense Linn., and in Europe by A. 
europeum, has similar aromatic-bitter properties. 
ALLIED Druas.—Sweet-Flag, Ladies’ Slipper, Casca- 
rilla, Boldo, and many others. W. P. Bolles. 


SOAP. When natural fats or oils are decomposed by 
treatment with salifiable bases, they split up into the al- 
coholic body glycerin, on the one hand, and a series of 
acids on the other—principally oleic, palmitic, and ste- 
aric acid, in varying proportions, according to the nature 
of the fat, which acids then unite with the base used in 
effecting the decomposition of the fat, to form salts— 
oleates, palmitates, or stearates, or all combined, as the 
case may be. Such salts are generically called soaps, but 
in common parlance the name soap is applied only to 
the fatty salts of the alkali bases—potassa, soda, and am- 
monia, which, in contradistinction to the soaps derived 
from earthy and metallic bases, are soluble in ‘‘soft” 
water and in alcohol. Of the alkali soaps, furthermore, 
ammonia soap is used only in the preparation called lind- 
ment of ammonia, or volatile liniment (see AMMONIA), so 
that the soapsin common use as such are narrowed down 
to soda and potassa-soaps. 


490 


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Me Nas 
ww ti 
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PN 
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me vie. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Between soda-soaps and potassa-soaps, as distinct 
classes, the broad distinction is that soda-soaps tend to be 
comparatively hard, and potassa-soaps soft, so that the 
phrase hard soap is applied generically to soda-soaps, 
and soft soap to potassa-soaps. But the consistence of 
soaps is also markedly affected 
by the nature of the fat used in 
the manufacture, in the way 
that fats rich in olein, as is the 
case with oils, tend to yield soft- 
ish soaps, whereas those rich in 
stearin and palmitin, typified by 
the solid fats, such as tallow, 
furnish soaps of greater consis- 
tence. 

Soaps are bodies of a well- 
known characteristic odor and 
disagreeable alkaline taste. 
They dissolve in alcohol and in 
“soft” water, but in ‘‘ hard” 
waters they suffer decomposi- 
tion by the calcic salts present, 
and the lime-soap resulting 
floats in insoluble flocculi on 
the surface of the water. Soaps 
are, in general, decomposed by - 
acids, by earthy bases and salts 
of the earths, and by the heavy 
metals. The useful property 
of soaps is that they attack 
grease, dirt, and dried animal 
débris, probably by virtue of 
their free alkalinity, and so 
affect those substances as to 
render them soluble in water, 
and thus readily removable. 

The kinds of soap officinal in 
the U. S. Pharmacopeia for 
use in technical medicine are as 
follows: Under the simple title 
Sapo, Soap, is recognized ‘‘ soap 
prepared from soda and olive- 
oil.” Such a soap corresponds 
to what is commercially called 
Castile, or Spanish, soap, and is 
described as ‘‘ a white or whitish 
solid, hard, yet easily cut when 
fresh, having a slight, peculiar 
odor free from rancidity, a dis- 
agreeable, alkaline taste, and an 
alkaline reaction. Readily solu- 
ble in water and in alcohol” 
(U. S. Ph.). This description 
applies to the so-called white Castile soap, which is a 
purer and daintier soap than the marbled variety, al- 
though, containing, as it does, more water, it is not so 
strong. The marbling of the latter kind of soap is due 
to streaks of an insoluble iron soap, whose presence con- 
stitutes an impurity. 

Castile soap is locally detergent, and, by virtue of its 
free alkalinity, mildly irritant to tender surfaces, Taken 
internally, it is innocent in moderate quantity, and tends 
only to relax the bowels and neutralize acid in the pri- 
Locally, free ablutions of soap and water are 
beneficial in certain forms of skin-disease, such as acne, 
and, as regards internal giving, the principal application 
of soap is as a ready and innocent alkali to administer in 
cases of poisoning by any of the strong acids. A strong 
aqueous solution—one part of soap to four or five of 
water—should in such cases be very freely administered 
pending the arrival of more powerful and appropriate 
alkaline antidotes. Soap and water is also much used as 
a cathartic enema, but in sensitive conditions of the rec- 
tum may irritate. Pharmaceutically, soap is much used 
as an excipient in pill-composition, but due regard must 
be paid to its chemical susceptibilities, as above detailed. 
From Castile soap are made the following officinal prepara- 
tions: Hmplastrum Saponis, Soap Plaster, is compounded 
of soap, one part, and lead-plaster, nine parts, mutually 


GF, 
SAUATA 
" J 4 

oF 
7 
fd) 
A 
il) vs 
fy 
Sh 
i 
if 
b, 


(Baillon.) 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Snakeroot,. 
Soapwort. 


incorporated when in the fluid condition, and the product 
evaporated to the proper consistence. Soap-plaster is a 
feebly active plaster, devoid of specific medicinal proper- 
ties. Linimentum Saponis, Soap Liniment, contains, in 
one hundred parts, ten of soap, five of camphor, one of 
oil of rosemary, seventy of alcohol, and the rest water. 
This preparation makes an excellent gently stimulant 
embrocation, and takes the place of the camphorated soap 
liniment, or so-called opodeldoc of older revisions of the 
Pharmacopeeia, an article substantially the same in com- 
position as the present, but prepared from the common 
white soap made of animal fat, instead of from Castile 
soap. 

The second variety of soap officinal is entitled Sapo 
Viridis, Green Soap, and is defined to be ‘‘ soap prepared 
from potassa and fixed oils.” The definition is a broad 
one, including all potassa (‘‘ soft”) soaps, but the varie- 
ties suitable for medical use are those made from vege- 
table oils, in contradistinction to those prepared from 
animal fats. Green soap is thus described: ‘‘A soft, green- 
ish-yellow, unctuous jelly, having a peculiar odor, which 
should be free from rancidity, and an alkaline reaction. 
Soluble in water and in alcohol, without leaving more 
than a small residue of insoluble matter” (U.S. Ph.). 
The green soap in common medicinal use is of German 
importation, as is also its medicinal reputation. This 
form of soap is. more strongly alkaline, and therefore 
more detergent, on the one hand, and more irritating to 
sensitive tissues on the other, than the hard soda-soaps. 
Severe pain is easily excited upon tender surfaces, such 
as that of an eczematous patch of skin, by applications of 
green soap. The medicinal use of the soap is as a deter- 
gent and ‘‘alterative” application in certain forms of skin- 
disease, notably in eczema rubrum. The part is com- 
raonly washed with the green soap, and afterward dressed 
with some bland substance, such as ointment of oxide of 
zinc. 

From green soap is prepared an officinal 7inctura Sa- 
ponis Viridis, Tincture of Green Soap, which is an alco- 
holic solution of green soap, sixty-five per cent., and oil 
of lavender, two per cent. The preparation is used as a 
local application to the skin, instead of an extemporane- 
ous solution of the soap. Edward Curtis. 


SOAP BARK (Quiillata, U. S. Ph. ; Panama, Bois de, 
Codex Med.), the bark of Qudllaya Saponaria Molini, 
order Rosacee, is a good-sized, evergreen tree, with al- 
ternate stipulate, ovate, leathery leaves, polygamous ; 
regular flowers arranged in small cymes, and a stellate 
fruit of five diverging carpels. The perfect flowers have 
a five-lobed, valvate calyx; five imbricated, narrow, 
spatulate petals, a conspicuous five-lobed glandular disc ; 
between the lobes of this disc are five stamens opposite 
the petals, and arising from the lobes five more opposite 
the sepals. Ovary five-celled, many-ovuled. Seeds flat- 
tened, conspicuously winged. The central flower of 
each cyme is perfect, the lateral are usually staminate. 
This species is a native of Central America and of the 
tropical parts of South America, Peru, Brazil, Chili, etc. 
It is of common occurrence, and its bark has been known 
to be useful in washing for a long time. 

Soap Bark is imported in considerable quantities, for 
various purposes connected with manufacture—sizing, 
cleansing, etc.—and has of late found a not very com- 
mendable place in syrups for aerated waters, and in beers, 
to make them hold their froth. It is a recent addition 
to the officinal list, and is described as follows: ‘‘ Flat, 
large pieces, about one-fifth of an inch (5 millimetres) 
thick ; outer surface brownish-white, often with small 
patches of brown cork attached, otherwise smooth ; 
inner surface whitish, smooth ; fracture splintery, check- 
ered with pale brownish bast-fibres, embedded in white 
tissue ; inodorous, very acrid and sternutatory.” 

This bark contains, as its only valuable derivative, Sa- 
ponin (Quillain) to the extent of eight per cent.—a white, 
amorphous, neutral powder, of, at first, a sweetish, after- 
ward sharp, burning taste. It is odorless, but provokes 
violent sneezing. Water dissolves it readily, and even 
with so little as one-tenth of one per cent. holds its bub- 


bles like soap-suds. Strong alcohol dissolves it but little, 
ether almost none. Saponin is a glucoside, and yields 
Sapogenin upon treatment with diluted acids. It is also 
claimed by recent analysts that it is not a pure compound, 
but a mixture of quillate acid, sapotoxin, and others, of 


Fie. 3561.—Soap-bark Tree. 


(Baillon). 


which the two named are active muscle-poisons, espe- 
cially if administered subcutaneously. 

Usrs.—Soap Bark, or an infusion or tincture made 
from it, is useful as a detergent in washing fine linens, 
laces, etc., cleaning the surface of paintings and other 
fine work of that kind. It is also an ingredient of some 
cosmetic preparations—lotions, hair-washes, etc. Its 
use in syrups has been referred to; it has been further 
employed to a small extent as an emulsifying agent. 
Physiologically it is a pretty active substance, paralyzing 
voluntary muscles with considerable rapidity, and pro- 
ducing local anesthesia. It is also a local irritant. 
These properties have not, however, been put to thera- 
peutic use. Asan expectorant, in small doses, it has been 
recommended, also as an alterative in place of sarsapa- 
rilla, but its value is at least doubtful. 

ALLIED PLANTS.—See Rosks. 

ALLIED Druas.—SoaAPworT (see next article). Sa- 
ponaria officinalis Linn., and numerous other plants of 
the Pink family contain saponin in their roots. So do 
the Polygalas (see SENEGA). It is also found in individ- 
ual species of several other orders. There is some doubt 
as to the exact identity of the saponin of these different 
plants, as the different names given to it will show— 
Struthiin, Polygalin, Githagin, Monninin, etc. 

See also SARSAPARILLA. W. P. Bolles. 


SOAPWORT (Saponaire officinale, Codex Med. ; 
‘Bouncing Bet”), Saponaria officinalis Linn., order 
Caryophyllacee, is a very well-known European per- 
ennial herb, freely naturalized here, and often a trouble- 
some weed around the edges of gardens and in rich waste 
places. It is about two feet high, with ovate, opposite, 
usually sessile, three- or five-nerved leaves, and cymes ot 
large white, or pink-colored, pink-like flowers clustered at 
the top of the stem. All parts of the plant, but especial- 
ly the roots, contain the neutral, amorphous, white, acrid, 
sternutatory substance saponin, described in the preced- 
ing article. Soapwort may be used, like Quillaia, to make 


491 


Soapwort. 
Sodium, 


a viscous suds-like solution for washing or sizing. It 
is also said to be employed in the preparation of muci- 
laginous expectorant teas (tésanes). 

ALLIED PLANTs.—The order to which Saponaria be- 
longs contains a large number of rather bland, muci- 
laginous, or at least saponin-containing plants, few of 
which have any medicinal value, but many of them are 
favorite and beautiful flowers, e.g., Pinks, of many kinds. 
Agrostemma and Gypsophila are genera notable for the 
amount of saponin they contain. 

ALLIED Drues.—Quillaia, Sarsaparilla, Senega. 

W. P. Bolles. 


SODEN, Province of Hesse-Nassau, Prussia. This 
watering-place, lying in the valley of the Taunus, at an 
elevation of four hundredand sixty feet above tide- water, 
is well protected on the north from cold winds, and enjoys, 
in consequence, a very mild climate.. In midsummer, 
indeed, it is sometimes too hot for comfort, and the pleas- 
antest times of the year for a stay at Soden are the spring 
and fall. 

The mineral springs are twenty-four in number, and 
differ considerably in the proportion of mineral ingredi- 
ents and in the temperature of their waters. The waters 
are saline, and contain also varying proportions of alka- 
line and ferrous carbonates. 
chloride.runs all the way from 2.4 to 14.6 parts per 
thousand, and that of ferrous carbonate from 0.009 to 
0.04 part ina thousand. The temperature of the differ- 
ent springs varies between 59° and 86° F. 

The diseases for the relief of which Soden is visited 
are chiefly chronic affections of the respiratory organs. 
Advanced pulmonary phthisis is, however, seldom bene- 
fited by a stay at this resort. Chronic catarrhal affec- 
tions of the digestive tract, and anzemia and debility 
occurring during convalescence from acute diseases, also 
furnish indications for a course of treatment at Soden. 
The therapeutic methods employed are similar to those 
in use in other German spas. The season extends from 
May to November. TAN ER ek 


SODIUM. I. GeneRAL MEDICINAL PROPERTIES OF 
THE COMPOUNDS OF SopiuM.—From the close chemical 
alliance between sodium and potassium, theory would 
assign to compounds of sodium physiological properties 
similar in kind tothe corresponding potassic compounds, 
but less strongly pronounced. The prediction is true in 
that the sodic effects, such as they are, are potassic ef- 
fects weakened ; but an inference that all the potassic 
effects, in kind, will be reproduced to some degree in 
the action of sodium, will not hold. Referring to the 
article Potassium, the notable effects of that metal are 
irritation, catharsis, cardiac paresis, general motor pa- 
resis, oxidation quickening, and, toxicologically, general 
toxemia. Sodium, in comparison, is irritant, salt for salt, 
in decidedly less degree ; is purgative in only slightly 
less degree ; paralyzes heart and motor function so very 
little that the action only appears at all in excessive dosage 
in animal experimentation ; scarcely seems to quicken 
oxidation at all, nor, even in fullest dosage, to impoverish 
the blood after the manner of potassium. So far, how- 
ever, as concerns those compounds of sodium that are 
alkaline in reaction, or which, as in the case of citrates, 
acetates, and tartrates, are converted into an alkaline 
compound in the blood, the degree of alkalinity is but 
little less than that of the analogous potassic compounds, 
and hence the effects that follow, simply from the fact of 
such alkalinity, are, with sodic compounds, well pro- 
nounced. . But yet, therapeutically, so far as constitu- 
tional alkalizing is concerned, the diseases calling for 
alkaline medication are also specifically benefited by the 
specific potassium effects, so that in their case sodic salts, 
though efficiently alkaline enough, still cannot compete 
in curative power with their potassic rivals. 

II. Tae MEpDICINALLY USED COMPOUNDS OF SopiUM. 
—As in the case of potassium, those compounds only 
will be here discussed whose effects are either sui generis 
to the compound, or are determined mainly by the basic 
radicle. Such salts, officinal in the U. 8. Pharmacopceia, 


492 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


The proportion of sodium . 


are the following: Hydrowide (hydrate), carbonates, nor- 
mal and acid, (pyro-) borate, acetate, potassio-sodic tartrate, 
sulphate, phosphate, pyrophosphate, nitrate, and chlorate. 
Of these the potassio-sodic, tartrate (Rochelle salt) will be 
found discussed under the title PoTasstum. Other sodic 
salts, whose properties are mainly derived from the acid 
radicle of the composition, are treated of under the title 
of such radicle. Such pharmacopeeial salts are the fol- 
lowing: Arseniate, see ARSENIC ; benzoate, see BENZOIC 
AciIpD ; bromide, see BROMIDES ; chloride, see CHLORIDES ; 
hypophosphite, see HYPOPHOSPHITES ; hyposulphite, see 
SULPHITES ; zodide, see loDIDES ; salicylate, see SALICY- 
LIC ACID ; santoninate, see WORMSEED ; szlicate, see SILI- 
CATES ; sulphite, see SULPHITES ; sulpho-carbolates, see 
SULPHO-CARBOLATES. 

Sodic Hydroxide (Hydrate): NaOH.—This substance, 
commonly called Caustic Soda, is officinal in the U. 8. 
Pharmacopeeia, in solid condition, under the title Soda, 
Soda, and in about five per cent. aqueous solution, as 
Liquor Sode, Solution of Soda. Soda is ‘‘a white, hard, 
opaque solid, generally in form of fibrous pieces, or of 
white cylindrical pencils, deliquescent in moist air, but 
in dry air becoming dry and efflorescent, odorless, having 
an intensely acrid and caustic taste, and a strongly alka- 
line reaction. Soluble in 1.7 part of water at 15° C. 
(59° F.), and in 0.8 part of boiling water; very soluble 
in alcohol. When heated nearly to a red heat, it melts, 
forming an oily liquid. Ata strong red heat, it is slow- 
ly volatilized unchanged. Its aqueous solution dropped 
into solution of tartaric acid, so that the latter remains 
in excess, produces neither a precipitate nor cloudiness ” 
(U. 8. Ph.). Soda ‘‘should be kept in well-stopped bot- 
tles made of hard glass.” Soda is commonly made by 
evaporating an aqueous solution of the substance, until 
the water is driven off and the hydroxide remains in a 
state of fusion, and then either pouring the viscid fluid 
into cylindrical moulds or allowing it to harden en masse. 
Solution of soda may be made by dissolving sodasin wa- 
ter, but is commonly prepared from the carbonate by de- 
composition with lime in the presence of water. Calcic 
carbonate precipitates, and the solution of soda, clarified 
by straining and settling, is separated by siphonage. 
Solution of soda is ‘‘a clear, colorless liquid, odorless, 
having a very acrid and caustic taste, and a strongly al- 
kaline reaction. Specific gravity about 1.059” (U. S. 
Ph.). 

Soda and its solution are powerfully alkaline and caus- 
tic, like potassa, but to asomewhat inferior degree. Soda 
is available as a caustic, to be used after the manner of 
potassa, but potassa being the stronger agent, is generally 
preferred. Solution of soda is possible as a local alkali 
for the skin or the stomach, but the carbonates are almost 
always used in preference. If given internally, the dose 
of solution of soda would range from 1.00 to 4.00 Gm. 
(fifteen to sixty minims), largely diluted. In consider- 
able quantity, undiluted, solution of soda would prove a 
caustic poison, with symptoms generally similar to those 
of poisoning by potassa. 

Normal Sodic Carbonate: NazCO3.10H.O.—Sodie car- 
bonate in crystals or effloresced powder is officinal in 
the U. S. Pharmacopeeia as Sodit Carbonas, Carbonate of 
Sodium ; and the effloresced powder, baked ‘‘at a tem- 
perature of about 45° C. (113° F.)” until it has lost one- 
half its weight by the driving off of its water of crystal- 
lization, is also officinal under the title of Sodiz Carbonas 
Hesiccatus, Dried Carbonate of Sodium. Sodic carbo- 
nate is the salt commonly called sal soda or washing soda, 
and is obtained in part from natura] deposits—‘‘ native 
soda,” so called—in part from the ashes of certain plants 
growing in or near the sea, the impure yield of which 
constitutes barilla or kelp, and in part by artificial mak- 
ing from sodic chloride, sodic sulphate, or the mineral 
eryolite. Sodic carbonate occurs as ‘‘ large, colorless, 
monoclinic crystals, rapidly efflorescing in dry air, and 
falling into a white powder, odorless, having a sharp, al- 
kaline taste, and an alkaline reaction. Soluble in 1.6 
parts of water at 15° C. (59° F.), in 0.09 part at 38° C. 
(100.4° F.), and in 0.25 part of boiling water; insoluble 
in alcohol. When heated to about 35° C. (95° F.), the 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Soapwort,. 
Sodium. 


salt melts; on further heating, all the water (62.9 per 
cent.) gradually escapes, and, at a red heat, the anhy- 
drous residue fuses. A fragment of the salt imparts an 
intense yellow color to a non-luminous flame. The aque- 
ous solution strongly effervesces on the addition of an 
acid” (U.S. Ph.). The dried salt of the Pharmacopeceia, 
a fused mass as first prepared, finally presents itself as a 
white powder. Both forms of the carbonate should be 
kept in well-stopped bottles. 

Sodic carbonate combines, very purely, strong alkalinity 
with absence of specific qualities of any kind except the 
irritation or even causticity in concentrated application 
which is inherent in a powerful soluble alkali. Its uses 
are solely those of a local alkali, and are practically con- 
fined to external employment in lotion or ointment in 
skin-affections. Lotionsaverage two per cent. in strength, 
and ointments between two and ten, the basis being lard. 
For internal use, the acid carbonate, next to be described, 
is preferred, because of its more agreeable flavor and 
milder action. In considerable quantity and strong solu- 
tion the normal carbonate is a corrosive poison. 

Acid Sodic Carbonate: NaHCO ;.—This salt, the well- 
known cooking-soda, so called, is officinal in the U. S. 
Pharmacopeeia in two grades of purity. One, corre- 
sponding to ninety-five per cent. of the pure salt, is en- 
titled Sodiit Bicarbonas Venalis, Commercial Bicarbonate 
of Sodium; and the other, made from this commercial 
variety by a process of purification, and corresponding 
to ninety-nine per cent. of pure salt, is called by the un- 
qualified title Sodi Bicarbonas, Bicarbonate of Sodium. 
This carbonate is derived primarily from the normal salt 
by artificially forcing upon the latter carbon dioxide gas. 
Bicarbonate of sodium occurs as ‘‘a white, opaque pow- 
der, permanent in the air, odorless, having a cooling, 
mildly saline taste, and a slightly alkaline reaction. 
Soluble in twelve parts of water at 15° C. (59° F.), and 
insoluble in alcohol. It is decomposed by hot water. 
When heated to about 70° C. (158° F.), the salt begins to 
lose moisture and carbonic acid gas, and, on continued 
heating, loses about thirty-seven per cent. in weight. At 
a red heat the anhydrous residue melts ; and a fragment 
of the salt imparts an intense yellow color to a non-lu- 
minous flame. The aqueous solution, on being heated 
disengages carbonic acid, and finally contains carbonate 
of sodium” (U.S. Ph.). 

The bicarbonate of sodium, is purely alkaline, like the 
normal salt, but to a less degree, and by reason of that 
fact is far less irritant. In all ordinary dosage it is in- 
deed practically free from danger. Its taste also is mildly 
~mawkish only, instead of harshly alkaline. For these 
various reasons this salt is a favorite one for stomachic 
alkalizing, asin acid dyspepsia or diarrhoea. It is also 
much used to make alkaline lotions for the skin. In- 
ternally from 1.00 to 4.00 Gm. (fifteen to sixty grains), 
may be given at a dose in water, and externally washes 
or ointments may be made in the same manner and of 
the same strengths, as in the case of the normal carbo- 
nate. Both of the carbonates are incompatible with acids 
and acidulous salts, lime-water, ammonic chloride, and 
salts of the metals, and metals of the earths. 

Troches of the bicarbonate—Tvrochisci Sodii Bicarbo- 
natis—are officinal in the U. 8. Pharmacopeeia, each 
troche containing 0.20 Gm. (three grains) of the salt. 
The salt is also an ingredient of the pharmacopeeial prep- 
arations, Mistura Rhei et Sode, for which see Rhubarb, 
and Pulvis Hffervescens Compositus, for which see Potassio- 
Sodic Tartrate, under Potassium. 

Sodic (Pyro-) Borate: Na,B,O7, 10H,.O.—This salt—the 
familiar substance boraz—is officinal in the U. 8. Phar- 
macopeeia as Sodit Boras, Borate of Sodium. It occurs 
as ‘‘ colorless, transparent, shining, monoclinic prisms, 
slightly efflorescent in dry air, odorless, having a mild, 
cooling, sweetish, afterward somewhat alkaline taste, 
and an alkaline reaction. Soluble in 16 parts of water at 
15° C. (59° F.), and in 0.5 part of boiling water ; insoluble 
in alcohol. At 80° C. (176° F.) it is soluble in one part 
of glycerin. When heated, the powdered salt begins to 
lose water, then melts ; on further heating, swells up and 
forms a white porous mass, which, at a red heat, fuses to 


a colorless glass, with complete loss of water of crystalli- 
zation (47.1 per cent.). A fragment of the salt imparts 
an intense yellow color to a non-luminous flame. The 
saturated aqueous solution, on the addition of sulphuric 
acid, deposits shining crystalline scales, which impart a 
green color to the flame of alcohol” (U. 8. Ph.). Borax 
occurs native in Persia and adjacent neighborhoods as a 
saline efflorescence of the borders of lakes, and in Cali- 
fornia as a crystalline deposit at the bottom of a small 
lake. It is also made from other native borates. 

Borax is locally bland and constitutionally innocent, 
and its medicinal virtues seem to reside in the combination 
of feeble alkalinity with a fair degree of antiseptic power 
derived from its acid radicle. Borax works well as a 
mild detergent alkali in skin-diseases or catarrhs, and 
ulcerations of mucous membranes, particularly of the 
mouth. <A lump held in the mouth and slowly sucked 
seems to excite the secretions of pharynx and larynx, 
and in case of huskiness from dry catarrh of these parts 
temporarily restores something of the natural quality to 
the voice—an important matter to a singer or speaker 
affected with a cold. Internally, borax may be used as 
a feeble alkali, and it has been accredited also with a 
power to promote menstruation, correct dysmenorrhea, 
and excite uterine contractions—a power which until bet- 
ter substantiated than at present, it is wisest not to trust 
to in an emergency. Borax may be given internally in 
doses of from 1.00 to 3.00 Gm. (fifteen to forty-five grains), 
and, externally, may be applied in lotions ranging from 
one to six per cent. in strength (limit of solubility in 
water), or in ointment of thirty per cent. strength. Borax 
has been experimented with, among a host of other sub- 
stances, for the purposes of ‘‘ antiseptic surgery,” and has 
been experimentally found to prevent the development 
of microzymes in aqueous solution of from one-half to 
one per cent. strength.! 

Sodic Acetate: NaC.H;0,..8H.O.—The salt is officinal 
in the U. 8. Pharmacopeeia as Sodii Acetas, Acetate of 
Sodium. It occurs as ‘‘large, colorless, transparent, 
monoclinic prisms, efflorescent in dry air, odorless, hav- 
ing a saline, bitter taste, and a neutral or faintly alkaline 
reaction. Soluble in 3 parts of water, and in 380 parts 
of alcohol at 15° C. (59° F.); in 1 part of boiling water, 
and in 2 parts of boiling alcohol. When heated, the salt 
melts, and on further heating loses all its water (89.7 
per cent.), and falls into a white powder. Ata higher 
temperature this powder again melts, and, at a red heat, 
it is decomposed, with the evolution of empyreumatic, 
inflammable vapors, leaving a blackened residue of an 
alkaline reaction, which imparts to a non-luminous flame 
an intense yellow color, not appearing more than tran- 
siently red when observed through a blue glass. On add- 
ing sulphuric acid to a concentrated solution of the salt, 
and heating, vapor of acetic acid is evolved. A solution 
of the salt is rendered deep red by ferric chloride, and, 
on boiling, a red precipitate is formed” (U. 8S. Ph.). 
Sodic acetate hardly merits the foregoing detailed de- 
scription, since it is very rarely used in medicine. Its 
purpose would be as a constitutional sodic alkali, its acid, 
as in the case of other alkaline acetates, undergoing con- 
version, in the blood, to carbonic. It may be adminis- 
tered in doses of from 2.00 to 4.00 Gm. (thirty to sixty 
grains). 

Potassio-sodic Tartrate. (See under PoTASssIuM.) 

Normal Sodic Sulphate: Na.SO..10H.O0.—This salt, 
commonly called Glauber’s Salt, is officinal in the U.S. 
Pharmacopeia as Sodit Sulphas, Sulphate of Sodium. 
It occurs in ‘‘large, colorless, transparent, monoclinic 
prisms, rapidly eforescing on exposure to air, and ulti- 
mately falling into a white powder, odorless, having a 
cooling, saline, and somewhat bitter taste, and a neutral 
reaction. Soluble in 2.8 parts of water at 15° C. (59° F.), 
in 0.25 part of water at 38° C. (91.4° F.), and in 0.4 part 
of boiling water ; insoluble in alcohol. When heated to 
about 30° C. (86° F.), the salt melts, and, on further heat- 
ing, gradually loses all its water (55.9 per cent.). Ata 
red heat the anhydrous salt melts without decomposition. 
A fragment of the salt imparts to a non-luminous flame 
an intense yellow color, not appearing more than tran- 


493 


Sodium. 
Soils. 


siently red when observed through a blue glass. The 
aqueous solution yields, with test-solution of chloride of 
barium, a white precipitate, insoluble in nitric acid” (U. 
S. Ph.). The salt should be kept in well-stopped bottles. 
Sodic sulphate is formed as a by-product in the manu- 
facture of many chemicals. It is a salt of low diffusion- 
power, and hence in full dose, in comparatively strong 
solution, is a purgative. As such it is, like the other al- 
kaline sulphates, powerful in action, producing watery 
stools, with nausea and griping. From its sickening taste 
it has been almost wholly superseded by the less disagree- 
able magnesic sulphate (Epsom salt). From 15.00 to 30.00 
Gm. (half to one ounce) is a full purgative dose, to be 
taken in aqueous solution, aromatized or slightly acidified 
to disguise the nauseous bitter taste of the salt. Sodic 
sulphate is a purgative ingredient of many mineral wa- 
ters. 

(Di-) Sodie (Ortho-) Phosphate: Na,HPO,4.12H.0.— 
This salt, the common tribasic phosphate, so called, or 
tasteless purging salt, is officinal in the U. 8. Pharmaco- 
poeia as Sodit Phosphas, Phosphate of Sodium, It occurs 
in ‘large, colorless, transparent, monoclinic prisms, 
speedily efflorescing and becoming opaque on exposure 
to air, odorless, having a cooling, saline, and feebly alka- 
line taste, and a slightly alkaline reaction. Soluble in 
six parts of water at 15° C. (59° F.), and in two parts of 
boiling water; insoluble in alcohol. When heated to 
about 40° C. (104° F.) the salt melts, yielding a clear 
liquid, and, on continued heating to near 100° C. (212° F.), 
it loses all its water of crystallization (60.3 per cent.). A 
fragment of the salt imparts to a non-luminous flame an 
intense yellow color, not appearing more than transiently 
red when observed through a blue glass” (U.S. Ph.). 
Sodic phosphate is made from the calcic phosphate of 
calcined bone, by decomposition by sulphuric acid. It 
should be kept in well-stopped bottles in a cool place. 

Sodic phosphate is a bland salt, of low diffusion-power, 
whose prominent physiological properties are to purge 
mildly, and, as animal experimentation has shown,’ to 
quite notably excite the secretion of bile. At the same 
time it is feebly alkaline, and possessed of a clean, non- 
nauseous, salty taste, quite like that of common salt. 
Therapeutically this phosphate may be used for the gen- 
eral purposes of the milder saline purges, and, more 
specially, has also proved of avail, even in non-purgative 
doses, to correct bowel-derangements associated with 
acidity and assumed sluggishness of the liver. From its 
mildness and not unpleasant taste it is particularly con- 
venient for giving to young children. Mixed with foods, 
such as soup, in lieu of common salt, it may be admin- 
istered in moderate quantity without suspicion. As a 
purge the dose for an adult is about 30.00 Gm. (one 
ounce) ; but for corrective purposes, much less—even so 
little as 0.65 Gm. (ten grains)—given a number of times 
through the day, may suffice. 

Normal Sodic Pyrophosphate: Na,P.07.10H.O.—The 
salt is officinal in the U. 8. Pharmacopoeia as Sodit 
Pyrophosphas, Pyrophosphate of Sodium. It is not used 
in medicine, and is officinal for pharmaceutical purposes 
only to prepare ferric pyrophosphate. 

Sodic Nitrate: NaNO;.—The salt is officinal in the U. 
S. Pharmacopeeia as Sodiz Nitras, Nitrate of Sodium. 
It occurs in ‘‘ colorless, transparent, rhombohedral crys- 
tals, slightly deliquescent in damp air, odorless, hav- 
ing a cooling, saline, and slightly bitter taste, and a neu- 
tral reaction. Soluble in 1.3 part of water at 15° C. (59° 
F.), and in 0.6 part of boiling water ; scarcely soluble 
in cold, but soluble in 40 parts of boiling alcohol. When 
heated to about 312° C. (594° F.), the salt melts, and on 
further heating it is decomposed, giving off oxygen and 
leaving a residue which emits nitrous vapors on the addi- 
tion of sulphuric acid. Thrown upon red-hot coals the 
salt deflagrates. A fragment of the salt imparts to a non- 
luminous flame an intense yellow color, not appearing 
more than transiently red when observed through a blue 
glass” (U. S. Ph.). The salt should be kept in well- 
stopped bottles. Sodic nitrate is the salt called cudic 
nitre, and is obtained from South America, where it oc- 
curs native. It is a salt of high diffusion-power, and in 


494 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


its physiological relations closely resembles ordinary 
nitre (potassic nitrate), except that it is, of course, devoid 
of the characteristic properties of a potassic salt as such. 
Its use in medicine has so far been an empirical employ- 
ment in dysentery, in which disease 30.00 Gm. (one 
ounce) of the salt has been given divided in frequent 
doses throughout the day, in dilute aqueous solution. It 
is not a standard medicine. 

Sodic Chlorate: NaClO;.—The salt is officinal in the U. 
S. Pharmacopeia as Soddi Chloras, Chlorate of Sodium. 
It occurs in ‘‘ colorless, transparent, tetrahedrons of the 
regular system, permanent in dry air, odorless, having a 
cooling, saline taste, and a neutral reaction. Soluble in 
1.1 parts of water, and in 40 parts of alcohol at 15° C. 
(59° F.); in 0.5 part of boiling water, and in 43 parts of 
boiling alcohol. When heated, the salt melts and after- 
ward gives off a portion of its oxygen, finally leaving a 
residue of a neutral reaction completely soluble in water. 
A fragment of this residue imparts to a non-luminous 
flame an intense yellow color, not appearing more than 
transiently red when observed through a blue glass” 
(U. S. Ph.). The salt ‘‘should be kept in well-stopped 
bottles, and should not be triturated with readily oxidiz- 
able or combustible substances.”’ Sodic chlorate has the 
peculiar medicinal properties of the potassic salt of the 
same acid, except in regard to the effects of potassium 
compounds as such. It is important only because of its 
excess of solubility as compared with potassic chlorate. 
The medicinal uses are the same as those of the latter- 
named salt, which see under Potassium. 

Hdward Curtis. 


1 Sternberg: Am. Journal of the Med. Sciences, April, 1888, p. 324. 
2 Rutherford: The Practitioner, vol. xxiii., p. 414. 


SOILS IN THEIR RELATION TOHEALTH. It would 
be impossible to thoroughly understand and predict the 
effect of soils on health, under the constantly varying 
conditions of civilized life, without a knowledge of their 
origin, composition, and characteristics. 

DEFINITION OF Sori.—Soils may be defined as débris 
resulting from the action of natural forces on the rocks 
covering the surface of the earth. This disintegration is 
constantly going on ; mountains are being broken down 
by the action of frost and heat ; the disrupted pieces are 
being carried down the slopes and broken into finer 
pieces by the streams and torrents ; and the finer parti- 
cles are being carried still farther by the rivers, till they 
are deposited either along the banks in alluvial flats, or 
in deltas. In the early history of this planet the ocean 
was the great destroyer, beating against the rocks that 
had been elevated by the shrinking of the earth’s crust ; 
breaking them down and grinding them into fine parti- 
cles and finally carrying away the lighter portions and 
depositing them in quiet bays and lagoons. It might be 
supposed that soils would resemble the underlying rocks, 
7.é., sandy soils superimposed on sandstone, marls on 
limestone, and the like. This, however, is not always 
the case ; soils of different kinds being scattered seem- 
ingly at random over the face of the globe. 

STRUCTURE OF SorLs.—‘“‘ Soil, examined mechanically, 
is found to consist entirely of particles of all shapes and 
sizes, from stones and pebbles down to the finest powder, 
and on account of their extreme irregularity of shape, 
they cannot lie so close to one another as to prevent there 
being passages between them, owing to which circum- 
stance soil in the mass is more or less porous.” Even 
the smallest particles are ‘‘not always solid, but are 
much more frequently porous, like soil in the mass.” 
‘‘A considerable portion of this finely divided part of 
the soil, the impalpable matter as it is generally called, is 
found, by the aid of the microscope, to consist of broken- 
down vegetable tissue ; so that when a small portion of 
the finest dust from a garden or field is placed under the 
microscope, we have exhibited to us particles of every 
variety of shape and structure” (‘‘ Minutes of Informa- 
tion on Drainage”). The spaces that exist between these 
particles, or the ‘‘ pores” of the soil, may be divided into 
two classes : ‘‘ First, the large ones which exist between 
the particles ; and, second, the very minute ones which 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


occur in the particles themselves.” ‘‘ The larger pores— 
those between the particles of soil—communicate most 
freely with each other, so that they form canals ; the 
small pores, however freely they may communicate with 
one another in the interior of the particle in which they 
occur, have no distinct connection with the pores of the 
surrounding particles.” 

COMPOSITION OF Sorts.—The particles described above 
may be divided into two great classes : Organic and inor- 
ganic. ‘‘ The organic part of soils, called ‘humus’ by 
some writers, is derived chiefly from the remains of 
vegetables and animals which have lived and died in or 
upon the soil; which have been spread over it by rains ; 
or which have been added by the hands of man for the 
purpose of increasing its natural fertility ” (‘‘ Elements 
of Agricultural Chemistry and Geology,” J. F. W. John- 
son). The proportion of this organic matter varies in 
different soils ; as, for instance, in peaty soils it forms 
fifty to seventy per cent. of the whole weight, while in 
ordinary good soil it does not rise much above eight per 
cent. Humus furnishes carbonic acid, ammonia, and 
some other compounds. 

The tnorganic part of soils may be divided into those 
substances which are soluble and those which are not 
soluble in water. The soluble portion consists mainly of 
common salt, gypsum, sulphate of soda, and sulphate of 
magnesia, with traces of the chlorides of calcium, mag- 
nesium, and potassium, and of soda, potash, lime, and 
magnesia in combination with nitric and phosphoric, and 
with humic and other organic acids. This soluble por- 
tion is so great in some countries as to form a white in- 
crustation on the surface of the ground in hot seasons. 
The insoluble portion of soils rarely forms less than 
ninety-five per cent. by weight, and consists mainly of 
silica, alumina (usually thirty to thirty-tive per cent.) 
and lime, in the form of sand, clay, and lime. 

CLASSIFICATION OF Soris.—Soils are classified accord- 
ing to the proportion of these three constituents (sand, 
clay, and lime), as they are ‘‘all either sandstones, lime- 
stones, or clays of different degrees of hardness, or a mixt- 
ure in different proportions of two or more of them.” A 
sandy soil is any dry soil not unusually rich in vegetable 
matter, and containing not more than ten per cent. of clay. 
A sandy loam is similar to the above, but contains from 
ten to forty per cent. of clay. A loamy soil contains sev- 
enty to eighty-five per cent. of clay ; a clay loam seventy 
to eighty-five per cent. A proportion of from eighty-five 
to ninety-five per cent. of clay makes a strong clay soil, 
and where no sand is present we have a pure agricultural 
“clay. Soil containing more than five per cent. of car- 
bonate of lime is called a mar7l, more than twenty per 
cent., a calcareous sovl. 

PHysIcaAL CHARACTERISTICS.—The density of different 
soils varies greatly, as, for example, dry peaty soils weigh 
less and are less dense than sands and marls. The ab- 
sorbing power also varies greatly, strong clays taking up 
aud retaining nearly three times as much water as sandy 
soils. The temperature of dry soils is usually ten degrees 
higher that than of wet soils. A dry soil may have a 
temperature of 90° to 100° F. when the thermometer reg- 
isters 60° or 70° F. in the shade in the air above it. By 
capillary action water rises from ten to eighteen inches 
in different kinds of soils. Where this action is great, a 
wet subsoil will render the soil above it cold. Hvapora- 
tion takes place from soils as it does from the surface of 
water, but its rate varies according to the nature of the 
soil. A silicious sand, for instance, loses its water three 
times as rapidly as a clay soil. All soils diminish in bulk 
or shrink more or less in drying. Sand scarcely shrinks 
at all, while peat loses one-fifth of its bulk. Clay, in 
shrinking; cracks ; a property that is of great service in 
draining cold, retentive soils. Absorption of motsture 
from the air by soils takes place at night, when they ex- 
tract from it a portion of the water they have lost by 
evaporation during the day. This power, however, va- 
ries in different soils, as do all other physical character- 
istics, sand absorbing the least and peat the most. 

WATER IN THE Sorm.—Water in the soil is principally 
derived from rain or snow, which, falling on the sur- 


Sodium, 
Soils. 


face, sinks into the ground until it meets with either 
an impervious stratum or with the upper level of the 
‘“‘ ground-water,” after which its movements are goy- 
erned by identically the same laws as those affecting the 
flow of water on the surface of the ground. Moisture 
in soils is that condition in which the pores of the parti- 
cles (already described) are filled with water. The term 
‘“‘ ground-water ”’ is applied to the water filling the inter- 
stices between the particles. This ground-water may be 
likened to a vast subterranean lake ; its level constantly 
rises and falls as a consequence of the influx of sur- 
face-water, evaporation, influence of the tide, and many 
other causes. The height of the ‘‘ plane of saturation,” 
as the surface of the ground-water is called, is shown by 
the depth of the surface of the water in wells below the 
ground. This is not always a certain indication, as local 
causes at times influence the height of water in wells. 
Friction in the pores of the soil retards the flow and 
gives an inclination to the plane of saturation, varying 
with the nature of the geological formation, but in all 
cases as great as that of the streams flowing along the 
adjacent lines of natural surface-drainage. The inclina- 
tion of the plane of saturation is about fifteen feet per 
mile in chalk ; in sand, as on Long Island, N. Y., it is 
between five and eight feet per mile. When the slope is 
less than that of the adiacent stream, the stream dries up. 
That ground-water is constantly flowing into streams 
throughout their entire course was shown by a series of 
measurements of the Cache la Poudre River, Colorado, 
made by G. G. Anderson in connection with irrigation- 
works. The inflow from the ground, in a distance of 
forty miles in which no tributaries entered the river, no 
allowance being made for evaporation or other loss, was 
sixty-eight per cent. of the quantity of water flowing in 
the river at the head of the section under examination. 

The inclination of the surface of the underground water 7s 
independent of the position of the underlying strata or of the 
inclination of the surface of the ground. 

‘« The rapidity with which rain-water sinks through the 
soil evidently varies with circumstances ; in rather dense 
chalks it has been supposed to move three feet down- 
ward every year ; but in the sand its movements must be 
quicker ” (Parkes). 

The quantity of water the soil will absorb from rain is 
dependent on : 1, The character of the soil, whether po- 
rous or otherwise; 2, the inclination of the surface, a 
steep slope allowing the water to pass off rapidly, while 
amore gentle slope gives time for it to be absorbed by 
the ground ; 3, the quantity of water already in the soil ; 
4, the character of the rainfall, whether gentle and not 
overtaxing the absorbing power of the soil, or heavy and 
flooding the surface and passing rapidly to the nearest 
water-course ; 5, the season of the year, evaporation being 
more rapid in summer than in winter. 

The temperature of the ground-water approximates 
the mean temperature of the atmosphere for the year. 

The evidences of a saturated soil are: 1, Wet spots on 
dry land ; 2, cracks and fissures of the surface in dry 
weather ; 8, a wet condition of the land remaining after 
rains. 

The disadvantages of an excess of moisture in the soil, 
as given in the Second and Third Reports of the Metro- 
politan Sanitary Commission, are : 

‘‘1. Excess of moisture, even on lands not evidently 
wet, is a cause of fogs and damps. 

‘©2. Dampness serves as a medium of conveyance for 
any decomposing matter that may be evolved and adds 
to the injurious effects of such matter in the air; in other 
words, the excess of moisture may be said to increase or 
aggravate atmospheric impurities. 

‘3. The evaporation of the surplus moisture lowers 
the temperature, produces chills, and creates or aggra- 
vates the sudden and injurious changes or fluctuations of 
temperature by which health is injured.” ‘ 

‘“The influence of humidity of the soil on diseases 
usually affected by this condition seems to be very much 
modified in localities with a stratum through which salt- 
water freely percolates, such as the flat, sandy sites of some 
sea-side towns. Investigations have determined this 


495 


Soils. 
Soils. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


point, at least so far as phthisical complaints are con- 
cerned. The principal reason assigned is the free circu- 
lation of the water through the pores of the soil, caused 
by the alternate rise and fall of the tide, whereby stag- 
nation of water and changes in the soil, which would 
otherwise occur, are prevented. The peculiar character 
of the water and the conditions of the atmosphere may 
have some modifying influence. In such places deep 
subsoil drainage is impracticable, even by the aid of 
pumping” (Ford). 

WELLS are devices for reaching or collecting ground- 
water to be used for the wants of man. Water cannot 
be drawn from wells unless they are deep enough to 
reach the level of saturation in the soil. For this reason 
wells vary in depth. All the conditions affecting the 
purity of the soil affect also the purity of the well-waters 
of that locality, for well-water is ground-water. Wells 
may be likened to a drain set on end, into which the 
ground-water flows from all directions. The soil thus 
drained resembles a cone in shape, with its apex at the 
bottom of the well and its base at the surface of the 
ground. The distance from which wells draw water 
depends on the porosity of the soil, on the depth below 
the plane of saturation to which they are carried, and 
on the draft made on them by man. In sand, the water 
of a well has been affected at a distance of three hundred 
feet from the source of contamination. The less rain 
there is, the lower the plane of saturation sinks, and the 
greater, then, will be the distance from which a well 
will draw its water. Hence it is that in droughts there 
is more danger of pollution than during rainy seasons, 
Fox, in his ‘‘ Sanitary Examinations of Water, Air, and 
Food,” says: ‘‘ The water of wells is greatly influenced 
(1) by the height of subsoil water, which is always vary- 
ing ; (2) by the amount of water that is passing through 
the subsoil of a country ; and (3) by heavy downfalls of 
rain or periods of drought. I have many times found a 
water pure at one time and impure at another, and this 
occasional pollution of a water is often due to the period- 
ical washing of filth into a well by heavy rains. The 
disagreement in the opinions of able analysts inspecting 
the purity of samples of water, taken perhaps within a 
short interval of time from the same well, is often due 
to these causes, which are not sufficiently recognized.” 

In a series of exhaustive experiments on the supply of 
wells, made in 1884, by J. C. Hoadley, C.E., it was de- 
monstrated that the quantity of water available was the 
same whether it was pumped from an open well or from 
an iron tube driven into the ground to the same depth. 
It was also shown “‘ that the convergent flow of ground- 
water not already in contact with the exterior surface of 
a suction pipe, from any point or from all points, toward 
and up to wetting contact with such pipes, is due alone 
to gravitation acting upon a slope toward a depressed 
surface produced by drawing water out of the pipe and 
from immediate contact with its outer surface. The 
sole impelling force is the earth’s gravitation. An ob- 
structing force, in addition to the viscidity of water— 
namely, the interstitial friction of the soil—retards the 
water-flow, and causes the water surface to take a sensi- 
ble slope, steeper as the interstitial friction is greater, 
less steep as the friction is less.” 

Von Fodor, in order to determine the effect of natural 
waters on animals when injected hypodermically, sub- 
jected rabbits to the influence of comparatively pure 
well-water, impure water, and sewage. The symptoms 
produced were wide fluctuations in temperature, with 
diarrhoea, varying with the impurity of the water. These 
experiments seemed to show that although the most im- 
pure waters, in themselves, possess but slight infecting 
power, their effect on the individual must be to derange 
the system and undermine the health and predispose to 
attacks of disease. 

Wells of fresh water near the sea-shore are supplied by 
the flow of fresh water underground on its way to the 
sea. The greater pressure of the ground-water, due to 
the altitude of its gathering-grounds, prevents the passage 
of sea-water into the soil. Springs of fresh water have 
been found, forcing their way to the surface, far out at 


496 


sea. Nichols asserts that ‘‘ the freshness of the water is 
not due to the removal of saline matter from infiltering 
salt-water, and the rise and fall of the water of such 
wells with the tide is due to the indirect influence of the 
tide in offering more or less resistance to the outflow of 
ground-water.” 

SPRINGS are the natural outbursts of subsoil water in 
motion, on the surface of the ground. They exist under 
one of three conditions : 

1. The outcrop of a porous or ‘‘ water-bearing” stratum 
between two impermeable strata. The water absorbed 
by the porous stratum at a greater elevation (it may be 
miles away) is confined in its flow underground by the 
impermeable strata above and below, until the lower 
outcrop is reached, when it flows out over the surface as 
from a pipe. 

2. The outcrop of the rim of a depression in an imper- 
vious stratum, or ‘‘ punch-bow],” over which the ground- 
water, collected in the cavity, flows on the surface. 

3. At the base of a hill the inclination of the surface 
of the plane of saturation becomes suddenly less, the 
friction in the pores of the soil exerts a greater influence 
on the velocity, and the ground-water, being unable to 
pass off entirely through the soil, is forced to the surface 
by the pressure of the water behind it on the slope. 

Springs of the second and third classes are far more 
liable to be polluted than those of the first class, and 
in sanitary examinations, considerations that apply to 
wells should with equal reason be applied to them. 

AIR IN THE Sort.—The intestices between the particles 
of soil situated between the level of the ground-water and © 
the surface of the ground are filled with air, the quan- 
tity of which is dependent on the porosity of the soil. 
This air being free to move in every direction is in con- 
stant motion. As the level of the ground-water sinks, 
air is drawn into the pores of the soil ; as it rises, the air 
is forced into the atmosphere to make room for the in- 
coming water. ‘‘ The diurnal changes of heat in the 
soil,” the state of the winds and of the atmosphere, are 
all factors in this movement. The composition of this 
air varies greatly in different localities and under differ- 
ent circumstances. As a rule, however, it is very rich 
in carbonic-acid gas, besides containing marsh gas and 
some sulphuretted hydrogen. To determine the com- 
position of ground-air and the laws governing the distri- 
bution of its elements, Professor W. R. Nichols, in 1875, 
made a series of experiments in the “ Back Bay ” district 
of Boston, Mass., on land made by filling in large areas 
of mud flats. He says, ‘‘ The gaseous products of decay 
which might be expected to be produced from such a 
mixture of animal and vegetable matter are sulphuretted 
hydrogen, ammonia, carbonic acid and marsh gas; the 
first, sulphuretted hydrogen, was not detected even in the 
air taken fourteen inches from the surface of the ground, 
z.é., less than six inches from the top of the decaying mat- 
ter ; ammonia was not found in any appreciable amount ; 
there seemed to be a small amount of marsh gas formed, 
and of carbonic acid a very large quantity was produced. 
The amount of carbonic acid was greatest in the neigh- 
borhood of the decaying matter, and decreased in amount 
toward the surface of the ground.” The observations 
were repeated at a later period, and showed that the 
amount of carbonic acid was steadily decreasing, and 
that marsh gas had entirely disappeared, due probably 
to the gradual resolving of the organic matters into their 
elements by the action of oxygen. The effect of diffu- 
sion into the atmosphere was shown by the fact that ‘‘ at 
a few feet from the ground no excess of carbonic acid 
could be detected.” Other experimenters have found 
that while the carbonic acid increases with the depth be- 
low the surface, the oxygen in the ground-air decreases, 
so that ‘‘at a depth of four metres (thirteen feet) the air 
would be irrespirable, and would extinguish a light.” 

To prevent the entrance of ground-air into a dwelling 
is a matter of the greatest importance. The usual meth- 
od is to coat the floor of the cellar with cement, con- 
crete, asphalt, or coal-tar pitch. It is a.fallacy to sup- 
pose that the first two substances accomplish the purpose ; 
they are porous, and the writer’s experiments show that 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


they have little effect in preventing the ingress of ground- 
air. The last two are, however, admirable for the pur- 
pose, as they are impermeable. No building should be 
erected without a damp-proof course, and the outer-face 
of the walls below the surface of the ground should be 
coated with coal-tar pitch. In damp soils it is well, in 
addition, to lay a tile drain entirely around, and distant 
some five feet from the house, at a sufficient depth to be 
below the foundations and to intercept the water in the 
soil before it reaches the walls. Bailey Denton recom- 
mends that a narrow area should be constructed entirely 
around the building to the depth of the footing courses of 
the foundations. 

The experiments above mentioned are cited to show 
how greatly contaminated ground-air may become by 
the presence of decomposing organic matter, and from 
what has been seen in regard to the movement of the air, 
it can be readily understood how important it is that 
ground in the vicinity of dwellings should be as pure as 
possible. 

CHEMICAL ACTION OF Sorts.—The action of soils, ex- 
cept the hottest and driest, on animal refuse, as sewage, 
for example, is to convert the carbon, hydrogen, and 
nitrogen into carbonic acid, water, ammonia, nitrates 
and nitrites, and fatty hydrocarbons; most of the sulphur 
unites with the iron in the soil. ‘‘ All these compounds 
are eagerly absorbed by vegetation.” If the organic 
matter is covered constantly with water, decomposition 
takes place with extreme slowness. 

Water in the soil holds in solution organic and saline 
substances. Piefke has shown that in the passage of 
surface water for a considerable distance through sand 
or gravel, the organic matter is gradually destroyed by 
the action of the undissolved oxygen in the pores of the 
soil. The experiments of the Rivers Pollution Commis- 
sion of Great Britain, and of Nichols and other investiga- 
tors, have proved that the action of sand and gravel on the 
saline matter is nz/, except in the case of substances that 
are susceptible to chemical change under these condi- 
tions. Bicarbonate of lime, for example, may part with 
some of its carbonic acid, and deposit carbonate of lime 
in the pores of the soil. 

As an illustration of the purifying qualities of soil may 
be mentioned the fact, said to have been learned from 
Indians, that ‘‘the fetor of the skunk can be removed 
from clothing by burying it in the earth.” 

In connection with the chemical action of soils, the 
difference between discharging sewage into cesspools and 
discharging it a few inches below the surface of the 
ground, as in sub-surface irrigation, should be borne in 
mind. In both cases are present the four factors in the 
production of decomposition: heat, air, moisture, and 
the presence of decomposable organic matters. In the 
latter case there are two powerful and beneficial agencies 
at work, active oxygen and vegetation; in the former 
neither is present, and the products of decomposition, 
under conditions favorable to the propagation of disease- 
germs, are allowed to pass away unchanged ; the gase- 
ous by diffusion into the atmosphere, and the liquid into 
the ground-water, to come to the surface once more in 
water drawn from the nearest well. 

MECHANICAL ACTION OF Sorits.—One of the most im- 
portant characteristics of soils from the sanitary point of 
view is their filtering capacity, or their ability to elimi- 
nate foreign matters, especially low vegetable organisms, 
from either water or air. 

As mechanical filters, soils, and especially sand and 
gravel, have been used for years; but it is well known 
that after a time they become saturated with the mate- 
rial retained and then cease to operate. In such a case 
the passage of comparatively pure water through the 
saturated filter so taints it that it becomes unfit for use. 

In order to study this filtering capacity of soils, Pro- 
fessor Raphael Pumpelly made, in 1881, a very exhaust- 
ive series of experiments, which appeared in supple- 
ment No. 18 of the National Board of Health Bulletin. 
The points brought out by this investigation were : 

‘¢1, The rate of flow of water and of air under given 
conditions. pers, 


Vou. VI.—82 7 


Soils, 
Soils, 


“2. The capacity of soils as filters in eliminating or- 
ganic and inorganic substances from liquids. | 

‘* 3. Their capacity as filters in eliminating the living 
low forms of vegetable life, both germs and adult organ- 
isms, from ground-water and ground-air.” 

The bearing of these experiments on health is clearly 
put by Professor Pumpelly at the beginning of his re- 
port. 

‘‘ When we consider that every vault, cesspool, and 
cemetery is a centre of pollution to the ground-water 
which supplies our wells, and, to a certain extent, also 
the reservoirs for cities, we can appreciate the importance 
of ascertaining to what extent soils are capable of elimi- 
nating the injurious properties contributed by the pol- 
lution. 

‘‘Through the cellars our houses become, especially 
in winter, the ventilating chimneys for the surrounding 
ground, sucking in from all directions the air that has 
been nearly stagnant in the pores of the soil during the 
summer. In view of the fact that the ground-air is pol- 
luted by vaults, cesspools, and cemeteries in the country, 
and by the garbage of made ground and defective drains 
and sewers in cities, it is important that we should de- 
termine the extent to which different soils are able to 
filter the injurious properties out of the air passing 
through them.” 

The test employed in these experiments was the rapid- 
ity with which an infusion of beef was infected by either 
air or water passed through the filtering material, which 
had previously been sterilized. The filters used were 
sand, charcoal, animal charcoal, asbestos, a mixture of 
sand and kaolin, kaolin, coal ashes, and loess. 

The result of these experiments, as given on page 18 
of the Supplement, ‘‘ shows conclusively the utter worth- 
lessness of sand as a filter for germinal matter,” ‘‘nor do 
the sandy or even clayey soils afford us a safeguard 
against germ-contamination of our well waters, as the 
experiments with loess, clay, and clay mixtures would 
probably justify us in concluding, although it must be 
admitted that we have not here strictly the same physi- 
cal conditions asin a natural soil which has not been 
subjected to heat.” 

‘“Not only does the amount of radiation differ in dif- 
ferent soils, but a change is produced in the heat by the 
kind of soils. The remarkable researches of Tyndall 
have shown that the heat radiated from granite passes 
through aqueous vapor much more readily than the heat 
radiated by water (though the passage is much more ob- 
structed than in dry air). In other words, the lumi- 
nous heat rays of the sun pass freely through aqueous 
vapors, and fall on water and granite; but the absorp- 
tion produces a change in the heat, so that it issues 
again from the water and granite changed in quality ; it 
will be most important for physicians if other soils are 
found to produce analogous changes” (Parkes). ‘‘ With 
regard to the effect of temperature of the soil on disease, 
it can hardly be doubted that it powerfully influences 
malaria, and probably also aids the progress of cholera.” 

PoLLUTION OF THE Sorit.—Having described at some 
length the characteristics of soils and of the water and 
air that they contain, the innumerable causes of pollu- 
tion will be readily comprehended. Dr. Ford, in Buck’s 
‘‘Hygiene,” divides them into four groups: 1, Excreta ; 
2, interments ; 8, coal gas; 4, surface pollution. 

1. Pollution of the soil by excreta is the most frequent 
and most dangerous of all causes. Broken sewers and 
leaking cesspools allow liquids saturated with decompos- 
ing animal matter to pass into the soil and contaminate 
both ground-air and ground-water ; the latter in all prob- 
ability to drain into some well, with results that have al- 
ready been described. 

2. The drainage from cemeteries is liable to pollute the 
water of wells and springs, and it has been shown that, 
in one or two instances, injury to health has been pro- 
duced. F 

3. Soil pollution by coal gas is met with only in large 
towns and cities; there, however, it is of constant occur- 
rence. Severe illness, somewhat resembling typhoid fe- 
ver, has been caused by this, 


497 


Soils. 
Soils. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


4. The causes of surface defilement are too numerous 
and too well known to require enumeration. Among 
them may be mentioned manure heaps, pig-styes, dirty 
streets, collections of refuse, badly constructed slaughter- 
houses, etc. 

DIsEASES AFFECTED By Sort.—The diseases influenced 
by the condition of the soil are: Consumption, paroxys- 
mal fevers, typhoid fever, cholera, dysentery, diphtheria, 
yellow fever, bilious and remittent fevers. 

Consumption is greatly affected by excess of moisture 
in the soil; in fact, this may be said to be one of its 
prominent causes. Since the announcement of this re- 
lationship, years ago, all observations have gone to prove 
its truthfulness, and at the present it is so thoroughly 
understood that space will not be wasted in detailed ex- 
planations. A reduction in consumption frequently fol- 
lows the introduction of systems of sewerage in towns, 
by which the drainage of the town site is an incidental 
result. In this way the general death-rate of Newport, 
South Wales, was reduced twenty-three per cent., while 
that from phthisis was reduced thirty-two per cent. At 
Salisbury, England, the general death-rate was reduced 
nine per cent., and that due to phthisis, forty-nine per 
cent. Although such gratifying results have attended 
the introduction of sewers, it is unsafe, for reasons that 
, will be given further on, to combine sewerage with soil 
drainage. Each should be effected by pipes entirely in- 
dependent of the other. . 

Malaria.—One of the most potent factors in the pro- 
duction of malaria is soil moisture ; decomposing organic 
matter must also be present, even if only in small quan- 
tities. 

The effect of soil moisture and drainage on malarial 
fevers is very curiously illustrated in the case of the irri- 
gated lands of California. These lands are divided into 
four general classes : 

1. Uplands. The soil is a gravelly clay which, owing 
to the regular slope of the surface, ‘‘remains moist but 
not water-soaked after irrigation.” These lands are al- 
most entirely free from malaria. 

2. River bottoms of sand or alluvium, with a subsoil 
of coarse gravel and a fair surface slope. ‘‘ The lands of 
the second class show its existence, but not to a sutticient 
degree to form a marked feature in the endemic causes 
of disease. eS 

3. The sandy bottoms of the San Gabriel River, hav- 
ing the same general characters as Class 2, but having a 
much less rapid slope, the level of the ground-water be- 
ing much nearer the surface. The lands: of this class 
‘“ show the presence of malaria in a notably active form, 
giving a well-marked type to the summer diseases.” 

4. Cienaga lands or open plains, with a heavy soil of 
the adobe type, ‘‘ with occasional springs and bogs, with 
natural ponds of water,” in winter very wet, and in sum- 
mer irrigated extensively by artesian wells. These lands 
‘develop, with irrigation, a very active form of malaria, 
the disease being largely of a pronounced malarial type 
and running often a severe course.” The following tab- 
ular statement will serve to show the connection between 
the soil, the malaria, and the drainage of the irrigated 
lands in California. 


Lands. Class 1, Class 2. Class 8. Class 4. 
Distance from) 
OCCAN Ru fn Jeet oe Great. C on sider- | Slight. Slight. 
able. 
Summer tempera- 
BUY OSes cure, ohh acts High. High. Moderate. | Moderate. 
MIODO Bete reas ote C ae sider- | Slight. Very little. | Slight. 
able. 
SUDSOiL eet te ae os Pervious. Pervious. Pervious. Impervious. 
Effect of irrigation.| No malaria. | C onsider- | Malaria. Much ma- 
able ma- laria. 
laria. 
Effect of drainage .| (No drain- | Malaria dis-| (No drain- | Malaria dis- 
age.) appears. age.) appears, 


‘“The whole history of irrigation in Southern Cali- 
fornia goes to impress this lesson: that to escape malaria, 
drainage must go hand in hand with irrigation ; that un- 


498 


less it does, the water which brings wealth brings also 
disease and death.” : 

Typhoid Hever.—The spread of this disease is caused 
principally by impure air and water in the soil. Fre- 
quent fluctuations in the plane of saturation force ground- 
air, loaded with the products of the decomposition of 
organic matter, and carrying with it the germs of the 
disease, into the atmosphere, to be taken into the sys- 
tem in breathing. Water from wells and other sources 
of supply is contaminated by the infiltration of polluted 
ground-water, which, if carrying germs of disease, be- 
comes the vehicle of spreading the contagium. Typhoid 
fever becomes more prevalent as the quantity of water in 
the ground diminishes, and gradually disappears on the 
return of wet seasons. The introduction of systems of 
water-supply and sewerage in towns materially reduces 
the mortality from disease. 

The relation between ground-air and ground-water and 
typhoid fever is receiving such constant illustration in 
practice that more than the mere statement of the facts is 
unnecessary. 

Diphtherta.—Although lack of drainage of the subsoil 
has not been shown to be the cause of diphtheria, there 
is no doubt that it is a powerful factor in its production 
under certain conditions. The disease begins to show it- 
self after a long season of dry weather, when the rains 
begin, and the level of the ground-water is gradually 
raised. The following case seems to show that diph- 
theria may be propagated by water: Dr. R. C. Newton, 
U.S.A., describes the results of drinking polluted wa- 
ter from two wells near an army post at the West. The 
wells were sunk ‘‘in the most advantageous position to 
receive the drainage of two filthy cattle yards.” In the 
house supplied with water from one of these wells were 
five children, four of whom were attacked, three dying. 
The fifth, the child of a servant in the house, was not al- 
lowed by its mother to drink the water and was not at- 
tacked. In the family using the other well were a man, 
his wife and two young children, one a baby eighteen 
months of age. The father was generally away and was 
not attacked. The mother and oldest child had chills, 
and the baby was attacked with diphtheria, but recover- 
ed. <A careful examination showed that neither of these 
families could have been exposed to the contagion of 
diphtheria. 

Cholera may be propagated by the pollution of sources 
of water-supply. This was illustrated during a recent 
outbreak of the disease in Spain. Madrid, Seville, and 
Barcelona have pure water-supplies, and, although chol- 
era appeared, it did not gain headway and soon disap- 
peared. The towns of Aranjuez, Valencia, and Granada, 
on the other hand, depend largely on wells for their wa- 
ter-supply. All suffered severely from the epidemic. 

Although both ground-air and ground-water are con- 
sidered activeagents in producing certain specific diseases, 
as typhoid fever, etc., it nevertheless remains that the 
fluctuation of the water level is absolutely necessary for 
the development of these diseases. Pettenkofer has shown 
that changes in the level of subsoil water are the certain 
forerunners of epidemic outbreaks of both cholera and 
typhoid fever; while Baldwin Latham goes so far as to 
say that the excremental pollution of a soil is ‘‘ inopera- 
tive in producing epidemic disease ” if unaided by fluc- 
tuations in the plane of saturation. It must not be under- 
stood from this, however, that all fluctuations of subsoil 
water are dangerous to health. Provided the water is 
constantly moving, very healthful results may be pro- 
duced by a fluctuation of level, aiding as it does the aéra- 
tion of the soil. It is the rising and falling of stagnant 
water that is so pernicious. Acting on these principles, 
Mr. Latham was able to predict an outbreak of typhoid 
fever in an English town, which occurred in a violent 
form three weeks after his notice to the authorities, warn- 
ing them to be on their guard. 

HEALTHFULNESS OF LocaALitres.—As has already been 
seen, there are many factors that go to make the health- 
fulness of localities, making prediction in many cases a 
matter of great uncertainty. There are, however, certain 
physical features of the earth’s surface that, as has been 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Soils. 
Soils, 


shown by experience, may be taken as fair indications of 
the salubrity of the locality in which they occur. Among 
these may be classed : 

Healthy Localities. Near the top of a slope; a ‘‘sad- 
dle-back ;” sands and gravels; granite; metamorphic 
and trap formations ; slate ; sandstone formations ; salt 
marshes, etc. 

Suspicious Localities. Gravels and sands filled with 
water ; clay ; dense marls ; alluvial soils, etc. 

Unhealthy Localities, Enclosed valleys; ‘‘ punch 
bowls” or depressions in impervious strata; locations 
among hills where the air is liable to stagnate ; ravines— 
‘‘the worst ravine is a long narrow valley, contracted at 
its outlet so as to dam up the water behind it;” plains 
at the foot of hills; depressions in plains; fresh-water 
marshes at any altitude ; soils containing much organic 
matter and exposed to alternate wettings and dryings ; 
made soils, etc. 

Proximity to ponds and streams does not of necessity 
render a locality unhealthy. If the water is pure and 
stagnation does not occur, they will not be detrimental 
to health. If, on the other hand, the surface of a pond 
is subject to fluctuation in level, whereby large areas of 
soil are alternately covered and laid bare by the water, 
evaporation will project into the atmosphere large quan- 
tities of impurities from the decaying organic matter in 
the soil and render the locality unhealthy. 

The drainage of a country through its valleys and 
streams, though naturally good, may be seriously inter- 
fered with by the erection of dams, embankments for 
railroads and common roads, bridge piers, and the like. 
Unless special precautions are taken, the obstruction of 
the natural outlets by such works causes the raising of 
the level of both surface and subsoil water, with the over- 
flow or saturation of large areas of land. An increase in 
malarial fevers, and in many instances the appearance of 
these diseases where they were never before known, is the 
certain result. : 

Salt marshes are healthy asarule. If, however, they 
are underlaid by clay or other impervious strata in which 
depressions are likely to exist, the ground-water will be- 
come more or less stagnant and the locality will be un- 
healthy. 

The filling in of low waterlogged lands, marshes, and 
similar localities is to be condemned, unless the land is 
thoroughly drained as a preliminary measure. By filling 
in without draining, although the level of the ground is 
raised above the surface of saturation, all other condi- 
tions remain the same, and a locality already unhealthy 
is rendered more so. 

All the benefits of a healthy locality may be nullified 
by a damp cellar. In an examination recently made by 
the Wisconsin Board of Health, it was discovered that 
seventy-five per cent. of the cellars in the cities, towns, 
and villages of that State are either ‘‘ habitually damp or 
damp in rainy weather.” 

Granite, trap, and metamorphic rock, if the slope of the 
surface is great, allowing water to run off rapidly, make 
healthy localities. If, however, they contain cracks, 
‘‘ faults” or depressions, ground-water collects in them 
and, being unable to flow away, stagnates, and malarial 
conditions are the result. 

Limestones also make a healthy locality, when the sur- 
face-slope is steep. Marshes, however, are of frequent 
occurrence, owing to the retention of ground-water in 
cavities that have been gradually hollowed out by the ac- 
tion of the carbonic acid in the rain falling on them. 

Chalk, if free from clay, is said to be healthy. Chalk 
marl is impermeable, cold, and unhealthy. ‘‘ Some of 
the most unhealthy districts in America are on chalk.” 

Sandstones are usually healthy. If, however, the for- 
mation is a thin stratum superimposed on one of an im- 
permeable character, it becomes unhealthy. 

Clay is one of the most unhealthy of soils. Ridges of 
clay are cold and every depression is a marsh. 

“ Gravel is the healthiest of all sites” (Parkes). Both 
sand and gravel are extremely healthy when there is no 
obstruction to the flow of the ground-water through 
them. They become unhealthy when underlaid by im- 


pervious strata, or when they contain decomposing or- 
ganic matter. Sand and gravel, when containing impuri- 
ties, are perhaps more unhealthy than less porous soils, 
as the passage of water and air through them causes the 
contaminating influence to spread to great distances. 

Alluvial soils are unhealthy, as the atmosphere above 
them is rendered moist by the rapid evaporation ; they 
contain large quantities of organic matter, and there are 
numerous marshes, especially when the soils are inter- 
spersed with clay or other impervious formation. : 

With the knowledge now in our possession, there is 
no excuse for building in an unhealthy locality or on an 
unhealthy site ; particularly is this true of isolated build- 
ings where the surrounding ground is under the exclu- 
sive control of the owner. In urban districts there is 
more excuse, but, even there, much may be done to in- 
crease the salubrity of the individual houses, if general 
improvements are impossible. 

Vegetation exerts a powerful influence on the health of 
localities. Marsh miasma is intercepted by a forest, so 
that ‘‘ persons living in localities so screened are exempt 
from attacks of malarial fever.” The eucalyptus-tree is 
a remarkable prophylactic against malaria. The effects 
of trees on the atmosphere and the soil are: 1. To mod- 
ify the extremes of temperature. 2. To prevent floods. 
3. To aid the drainage of the soil. 

Trees are a disadvantage when they are so dense as to 
prevent the free circulation of air, and when so close 
to.a house as to materially obstruct the sunlight. In 
temperate climates, under these circumstances, they ren- 
der a house damp. The fibrous roots of trees often- 
times are of great benefit ; traversing the soil in every 
direction, they increase its porosity and improve its 
drainage. Vegetation also seizes on and appropriates to 
its own use organic matter that would otherwise, by 
slowly decomposing, pollute the soil-air and ground- 
water. : 

IMPROVEMENT OF UNHEALTHY LOCALITIES. — The 
methods that may be employed to increase the health- 
fulness of a site or locality are concisely stated by Dr. 
Ford as follows : 

‘‘1. By thorough surface and subsoil drainage. 

“2. By free access of air and sunlight. 

‘©3. By the use of the well-known means to insure 
perfect dryness of the walls and basement, and the ex- 
clusion of ground-air. 

‘‘4. By the regulation of vegetation ; that is, by re- 
moving or planting trees, etc., according to circum- 
stances of soil, climate, etc., etc. 

‘¢5. By preventing the pollution of the soil by the use 
of the best means for carrying off the surface-water, 
house-water, and all house-offal, as rapidly as possible.” 

Since, of all the factors that affect the relationship be- 
tween soil and disease, ground-water is the most potent 
and the most readily removed, it follows that the under- 
drainage of land is of the greatest importance. Sir 
Edwin Chadwick has said: ‘‘ In considering the cir- 
cumstances, external to the residence, which affect the 
sanitary condition of the population, the importance of 
a general land-drainage is developed, by the inquiries as 
to the cause of prevalent diseases, to be of a magnitude 
of which no conception had been formed at the com- 
mencement of the investigation. Its importance is man- 
ifested by the severe consequences of its neglect in every 
part of the country, as well as by its advantages in the 
increasing salubrity and productiveness wherever the 
drainage has been skilful and effectual.” 

Drains.—The drainage of land, being more within the 
province of the engineer than of the physician, will re- 
ceive but a passing notice. Draining is usually accom- 
plished by small porous, earthen pipes, laid in rows with 
open joints at a depth of about five feet below the sur- 
face of the ground. The rows are usually laid in the 
direction of the steepest slope and between thirty and 
sixty feet apart. The water in the soil overflows into 
these drains and passes away to a neighboring water- 
course or other convenient outlet provided for it. When 
all the water in the soil above the drains has flowed off 
—which requires a length of time dependent on the po- 


499 


Soils. 
Sparta Springs. 


rosity of the soil—the level of the surface of saturation 
will become unvarying and will correspond to the depth 
of the drains below the surface of the ground. From 
what has already been said of soils, it is evident that 
drainage removes the conditions most favorable to the 
propagation of disease. 

In regard to the effect of drainage on the temperature 
of the atmosphere, the following is taken from ‘‘ Min- 
utes of Information on Drainage:” ‘‘ A farmer, being 
_asked the effect on temperature of some new drainage- 
works, replied that all he knew was, that before the 
drainage he could never go out at night without a great- 
coat, and that now he could; so that he considered it 
made the difference of a great-coat to him.” 

Drainage-works, while in course of construction, may 
in certain cases cause outbreaks of fever, which, as soon 
as the drains begin to do their duty, gradually subside, 
and at last disappear. A case of this kind, cited by 
Douglas Galton, occurred in India in 1860, when the 
peninsula of Kowloon was occupied by the British 
troops asa Sanitarium. Although it was of granite for- 
mation and freely exposed to the winds, the troops suf- 
fered severely from fever, which was attributed to ‘‘ the 
disturbance, in a tropical climate, of the surface of soil 
impregnated with decaying organic matter.” After a 
time the fever subsided and did not reappear. 

The drainage of a town should be entirely separate 
and distinct from the sewerage. Sewers need not be 
very far below the surface ; but drains should be laid as 
much as fifteen feet below, to insure the drainage of the 
deepest cellars. The inverts of sewers are often made 
hollow to convey away the water that is lable to accu- 
mulate in the trenches during construction. These drain 
the subsoil to a certain extent; but they are not to be 
desired, as, owing to leaks, they are likely to carry as 
much sewage as subsoil water. Then, again, sewers are 
obliged to follow certain lines of grade, while drains, to 
be most effective, as before stated, should be laid in the 
direction of the steepest slope. Sewers have sometimes 
been the occasion of malarial diseases by damming up 
underground waterways by the trench-fillings, which 
are more or less puddled and therefore impervious. 

If the sewers themselves are intended to drain the sub- 
soil, they must of necessity be made so as to allow the 
water to enter. This it will do in wet weather, when 
the head of water outside is greater than that inside the 
sewer. But during dry weather the reverse will be the 
case, and the soil will become saturated with sewage. 
Even should the sewer carry nothing but clear water, 
the fluctuations in the level of the surface of saturation 
caused by the above, would produce conditions favor- 
able to the development of disease. 

If malaria reappears after works of drainage have 
been instituted, there is some good and usually remov- 
able cause for the occurrence. Mr. William Marshall 
tells of the reappearance of ague in the Fens some time 
after it had ceased to exist, though in the auéwmn, instead 
of the spring of the year as formerly, and explains it by 
the fact that ‘‘ the drainage had been carried beyond the 
point of prudence, so that in the summer months, and 
especially toward harvest, the Fen ditches became nearly 
dry, and the consequence was that we once more got an 
exhaling surface and a noxious effluvium arising from 
decaying vegetable matter. This state of things is now 
quite altered, and the ague has vanished, owing to the 
farmers making it a rule to let water in from the rivers 
during the summer months, so as to ‘keep a water’ al- 
ways in the Fen ditches.” 

EXAMINATION OF LocALITIES.—Dr, Parkes gives the 
following method for examining a locality : 

“1. Conformation.—Height above sea-level and eleva- 
tion of hills above the plain. (Determine by mercurial 
barometer or aneroid, or, if possible, get the heights from 
an engineer.) Angle of declivity of hills; amount of hill 
and plain ; number, course, and characters of valleys and 
ravines in hills; dip of strata; geological formation ; 
water-sheds and courses; exposure to winds; situation, 
amount, and character of winds; sunlight, amount and 
duration ; rain, amount and frequency ; dust. 


500 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


‘© 2. Composition.—Mineralogical characters. Presence 
of animal or vegetable substances ; amount and charac- 
ters. 

‘* 3. Covering of soil by trees, brushwood, grass, etc. 

““4, Points for Special Hramination.—Amount of air; 
of moisture. Height of subsoil water, at the wettest and 
driest seasons. Changes in level, and rapidity of change 
of subsoil or ground-water. Condition of vegetable con- 
stituents ; examination of substances taken up by water, 
EtG. 4 Frederick N. Owen. 


SORRELL (Osezdle commune, Codex Med.). =Rumez ace- 
tosa Linn., order Polygonacee. This, the common Sor- 
rell of Europe, is a larger plant than our Red Sorrell, and 
has more divided leaves, but its properties are practically 
the same. Both contain oxalic salts, which give a pleas- 
antly sour taste to the herbage, and both have bitter roots. 
Sorrell has been used as a diuretic, and as a pleasant 
salad, or flavor for soups. It has no medicinal value. 

ALLIED PLANTS, etc.—See RHUBARB, DOCK, etc. 

W. P. Bolles. 


SPA, or Spaa, situated in Belgium, not far from the 
Prussian border, was formerly one of the most popular 
and fashionable watering-places on the Continent, being 
a favorite resort with the nobility of all Europe. It lies 
at an elevation of about one thousand feet above the sea ; 
the climate is not particularly mild, and sudden changes 
of temperature are common. There are eight chalyb- 
eate springs of which therapeutic employment is made, 
which are known respectively as the Pouhon, Géronstére, 
Groesbeck, Barisart, Dundas, Sauveniére, Tonnelet, and 
Prince de Condé. The following is the composition of 
the Source de Pouhon. A litre of water contains: 


Gramme 

Sodiamibicarbonatel-.. ico. s ce cee ee eee eae 0.1266 
Potassiuny bicarbonate. 26 eee ee ee tee 0.0105 
Magnesium "bicarbonate 5.9). .casecemar ashi ele «setae ae 0.1674 
Calciuimabicarbonates.4oss. cee eee eee eee eee 0.1730 
Ferrous bicarbonate ce soncce tes tsce mee ei 0.0714 
Sodium sulphate ........:.... eres ee ee eee eae 0.0203 
Sodium chloride............. ee eas sors eh At ee ae 0.0256 
Silica. 4) ctl coat phd ae ee tats See eee Ger eee eee 0.0629 
Total BOlIdS areas Fo Oe eee coe ote ee hate 0.6577 


The waters are athermal. In addition to the water, 
employed in the ordinary ways, mud-baths are often pre- | 
scribed. The principal indication for a course of treat- 
ment at Spa is anemia. The season extends from the 
first of June to the middle of October. i Mew Ba. 


SPANISH FLIES (Cantharis, U. S. Ph.; Br. Ph.; Can- 
tharides, Ph. G.; Cantharide, Codex Med.). This rather 
inaccurate name is given to Cantharis vesicatoria De 
Geer (Lytia vesicatorta), order Coleoptera, a_ brilliant 
green beetle, with a 
long, cylindrical 
body, a disagreeable 
odor, and powerfully 
irritant properties. It 
is about an inch in 
length, and from one- 
fifth to a fourth in 
breadth. It has a 
good-sized, ovoid, 
heart-shaped head, 
filiform, black anten- 
ne of eleven joints, 
a distinct, rounded 
thorax, and long, 
straight wing-covers. 


Fie, 3562.—Blistering Beetle, Natural Size ; F Ceag DIRE) ed t musth 
a, Eggs, somewhat enlarged; 6b, a single ve K arsal jOInts, €x 
egg, greatly enlarged. (Moquin-Tandon.) cepting the two pos- 

terior ones, which 
have only four. Wings large, brown, translucent. The 
odor, even when long dried, is strong and characteristic. 

Its larva is -yellowish-white, soft, elongated, thirteen- 

jointed ; it has a rounded head, short antenne, and stout 

jaws; there seems to be uncertainty whether it feeds 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Soils. 
Sparta Springs, 


upon roots, honey, bees, or other insects. The perfect 
beetle appears in great numbers in its native countries, 
about the middle of summer, upon poplars, ashes, lilacs, 
privets, and even upon roses and several other domestic 
shrubs, whose leaves it devours. The acrid efluvium 
emitted from it can be smelled at a considerable distance, 
and when the insects are abundant, it is said to be danger- 
ous to persons sitting under the trees where they are. 

This beetle is a native of Southern and Middle Europe, 
Western Asia, ete. It is abundant in Spain, France, 
Germany, Italy, etc., and in these countries is collected 
for use. During the middle of warm days it is very ac- 
tive and alert, but in the night and early morning, be- 
numbed by cold and wet, it is very heavy and clumsy. 
Advantage is taken of this time for collecting the beetles, 
when they can be beaten or shaken from the shrubs where 
they hang and caught in sheets or bags held under the 
boughs. They are then killed by boiling water, steam, 
vinegar, ether, or some such treatment, and carefully 
dried by moderate heat. 

The drug, as usually found in the market, consists of 
these bodies whole, excepting what the friction of the 
‘transportation has done in the way of rubbing off the an- 
tenne and legs. Ground, it gives a disagreeable-smelling, 
grayish powder, sprinkled with bright metallic-green 
specs—the fragments of wing-cases and body. Taste, 
resinous and acrid. 

Blistering beetles were known to the ancients, and have 
been used for centuries in many different countries, but 
they have not been generally of this particular species, 
whose employment is comparatively modern. This, how- 
ever, from its abundance, and the ease with which it can 
be collected, as well as on account of its quality, has 
generally supplanted the others in English and American 
commerce, at least. 

Composition.—A great variety of ordinary animal 
products, nitrogenous tissues, fat, oil, watery extract, 
etc., and about one-fourth to one-half per cent. of a well- 
defined, crystalline, active principle named Cantharidin. 
This energetic poison crystallizes in tables or flakes, is 
white, colorless, and odorless, and at first has but little 
taste. It dissolves in twenty-five parts of water, and in 
upward of three thousand of alcohol; in ether and chlo- 
roform it is almost insoluble. Cantharidin is about thirty 
times as active as cantharides. 

AcTION AND UsgEs.—Cantharides is an intense irritant, 
whether applied internally or externally ; taken into the 
stomach, it causes heat and burning of the fauces on its 
way down, then vomiting, often of bloody mucus, in- 
tense pain and burning of the stomach and bowels, diar- 
rhea, fibrinous and bloody stools, and finally urinary 
distress, strangury, bloody urine, and other evidences of 
renal and vesical irritation. The genitals are also ex- 
cited—priapism in the male, swelling of the vulva, etc., 
in the female ; uterine tenesmus or abortion may follow. 
Erotic sentiments may be, but are not necessarily, 
aroused. A small, quick pulse, rapid breathing, a hot, 
dry skin, headache, delirium, coma, and death may fol- 
low its introduction. Two grams (80 grs.) of powdered 
cantharides, or five centigrams (2 gr.) of cantharidin, 
would be a dangerous dose. Applied externally, can- 
tharides produces, after a few minutes, redness and slight 
burning of the skin, followed, in from one-half to five or 
six hours, by small blisters just beneath the cuticle, 
which rapidly separate it from the skin and soon coa- 
lesce into one large bleb over the whole surface covered 
by the blister. A small amount of cantharidin is ab- 
sorbed through the skin, as strangury, hematuria, etc., 
are rather apt to follow very extensive blistering. This 
medicine, like most active substances, has been given in 
a great variety of conditions—vesical catarrh, gonorrhea, 
dysuria, incontinence of urine, and as a general nervous 
stimulant. For none of these things is it now in vogue. 
Externally applied, it is the safest, surest, and in all ways 
the best vesicant known; easy, comparatively painless, 
and superficial; never leaving a scar. Large and re- 
peated blisters were formerly used, with a view of 
‘drawing off” serous effusions from the pleura, perito- 
neum, the joints, etc.; but as derivative effects are not ac- 


complished in so simple and direct a way, it is now prin- 
cipally used as a means of simple counter-irritation. 

ADMINISTRATION.—If it is desired to give Cantharides 
internally, the Tincture (Zinctura Cantharidis, U. 8. Ph., 
strength, +37) is a suitable form, but the numerous ce- 
rates and liniments which follow, show how almost ex- 
clusively it is employed externally : Ceratum Canthar- 
idis, U. 8. Ph., strength, 7335; and Ceratum Eatracti 
Cantharidis, U. 8. Ph., strength, +5; as well as Charta 
Cantharidis, strength, -!;, are used for blistering. Lini- 
ment of Cantharides, Lindémentum Cantharidis, U.S. Ph., 
(fifteen per cent.), is moderately stimulating ; and the Col- 
lodium cum Cantharide, U. 8. Ph., (Blistering Collodion), 
containing sixty per cent., is a fairly active blister, if ap- 
plied thickly with a brush. For the last dozen years or 
more the cantharidal cerates of the Pharmacopeia have 
been almost superseded by a Cantharidal Plaster, prepared 
upon a large scale by manufacturing pharmacists, with 
a rubber basis instead of the simple fatty one of those. It 
is scarcely as uniform or quick in its action as the others, 
but on account of its convenience, its durability, and ease 
of handling, it is likely to continue in use. The Tincture 
of Cantharides, considerably diluted, is a frequent ingre- 
dient of ‘‘ hair renewers ” and other cosmetics. 

ALLIED ANIMALS.—The tribe Cantharide contains nu- 
merous poisonous beetles, whose acrid secretions have 
been put to use as vesicants. Some of these are even 
more irritant than Cantharis itself. C. Vittata, our Potato 
Beetle, and other species of Cantharis, Meloe, the oil- 
beetles, several species of Mylabris (‘‘ M. Chiccorii” the 
‘Chinese blistering fly ”) are examples. 

ALLIED Drues.—All local irritants: Mustard, Pepper, 
etc., Croton-oil, Tartar emetic, Iodine, etc., as well as 
Turpentine in all its various forms. 

W. P. Bolles. 


SPARKLING CATAWBA SPRINGS. Location and 
Eg Sparkling Catawba Springs, Catawba County, 

AccrEss.—By the Western North Carolina Railroad to 
Hickory ; thence by stage to the springs, six miles. 

ANALYSIS (Howe).—The waters are said to be suiphur 
and chalybeate. 

These springs are situated in Western North Carolina, 
near the Catawba River, at an elevation of one thousand 
feet, amid the eastern foot-hills of the Blue Ridge, which 
form in the distance a pleasant feature in the landscape. 
The hotel accommodations, consisting of several large 
buildings and cottages, are ample. There are also plunge, 
shower, and vapor baths. 

Ga bal, 


SPARTA SPRINGS. 
Monroe County, Wis. 

Accress.—By the Chicago & Northwestern, or the Chi- 
cago, Milwaukee & St. Paul Railway. 

ANALYsIs (J. M. Hirsh).—One pint contains : 


Location and Post-office, Sparta, 


Grains 

Carbonate: ot sodastennpetrree aceite ane cei cas « 9,026 
Carbonate OL magnesia wearers em etter. teat r 0.503 
@arbonate of iron severest eee ee ee hte ee eee ree 1.792 
Carbonate of manganese, s.4)2 28. oh e.. cea. week foes trace 
Carbonate: oflime ane rata. tee rc. et 2 tole ci telet 0.050 
CarbonateoPammoniawen sew see eee eclee octet as oe trace 
Carbonaterol LEhiait.. wre oe teen tee eee kee 0.0038 
Carbonate of strontia........ ° Abra ORE nee lc 0.002 
Carbonate of baryta Pies os. ccs sitet elect nsincle ase cine trace 
Sulphatelohpotassar eraser en seers ne orceioc setae: 0.080 
Sulphatetot/nodate a. teen soe tte eee pe ae areas 0.277 
Siilphateror limes oetersels oe us cet s aetna ctaies Gre 0.022 
Chioridevotisodiunieee Vesa see at. tes sa icles dele sieess 0.018 
Chiovidetoficalciaini ore veuee ries oe eel sieeve oetenate:e 0.075 
Phosphate ot/sodauye: sce es ses eee oe Relay rs Sh he es 0.008 
Phosphateoiialuminave cee. cise oa. oe mish eee 0.007 
TRodige; OL SOG ees ctr cree ace lo lets ae wanes ornielolete e/oie's trace 
PePUIKORY, Gris cic patria bic BBA ET CGD DIED Cer OR eR es SOOT aoe 0.035 
TOGA eee rer anos ticles Bold & caleheeln dake svcd wie 2.898 


THERAPEUTIC PROPERTIES. —An unusually strong, 
chalybeate water. f 

These springs are situated in the southwestern portion 
of Wisconsin, two hundred and fifty miles from Chicago. 


501 


Sparta Springs. 
Spectacles. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


The town of Sparta, of about two thousand five hundred 


inhabitants, affords good hotel accommodations. 
G. B. F. 


SPEARMINT (Mentha Viridis, U. 8. Ph.; Menthe verte, 
Codex Med.). The flowering tops and leaves of Mentha 
viridis Linn. (Mentha Sylvestris, glabra Koch). Spearmint 
has narrower, more sessile leaves, slenderer and more spike- 
like flower clusters, smaller flowers, and a different odor 
from peppermint, which it otherwise closely resembles. 
It is a European and Asiatic plant, and has been long 
under cultivation. It grows in the same gregarious way 
as peppermint. The following officinal description will 
serve to distinguish it from other mints: ‘‘ Leaves about 
two inches (5 centimetres) long, subsessile, lanceolate, 
acute, serrate, glandular, nearly smooth ; branches quad- 
rangular, mostly light-green ; flowers in terminal, inter- 
rupted, narrow, acute spikes, with a tubular, sharply 
five-toothed calyx, a light purplish, four-lobed corolla, 
and four rather long stamens; aromatic and pungent.” 
Spearmint contains a composite oil analogous to that of 
peppermint, and it is applicable to the same uses. The 
oil, and a water, and spirit made from it, are officinal. 

ALLIED PLANTS, ETC.—See PEPPERMINT. 

W. P. Bolles, 


SPECTACLES. * JBesicies,+ luneties, French; die 
Brille, t German; occhiali, Italian; perspecellum, con- 
specillum, vitrum oculare, oculartus, medieval Latin—are 
first mentioned about the close of the thirteenth cen- 
tury. § Seneca mentions the fact that ‘‘letters, how- 
ever minute and indistinct, appear larger and clearer 
when viewed through a glass globe filled with water,” !! 
and Pliny notices the use of a sphere of crystal,!? or glass 
globe filled with water,!? as a burning glass. | The first 
mention of a lens, properly so called, is attributed to the 
Arabian mathematician Alhazen (0d¢. 1088),5 who de- 
scribes the magnifying property of a segment of a sphere 
of glass.'® Roger Bacon (circa 1267) also mentions the 
magnifying property of convex lenses,{{ and suggests 
the benefit to be derived from their use by old persons 
with weak sight.18 The step from the use of a convex 
lens, as a magnifier, to the construction of binocular eye- 


* Chaucer uses the word in the singular number: @ spectakel.1 

+ From the old French form Uericle, diminutive of berille; Latin, 
berillus, beryllus ; Greek, BypvaAdos, the beryl.? 

t From berillus, beryllus, BypvdAdos, the beryl; ‘‘the colors of the 
beryl range from blue through soft sea-green to a pale, honey yellow, 
and in some cases the stones are entirely colorless; ° 3 ocularii vitri aut 
berillorum.: Guy de Chauliac (1563).4 The most available material for 
spectacle-lenses, excepting glass, is rock crystal or quartz, and it is high- 
ly probable that this mineral, still largely used under the name of pebble, 
was the berillus of the older opticians ; c/., the derivation of ‘‘ brilliant ” 
—French, driller, etc.—from berylius.§ 

§ Spectacles, both convex and concave, were in common use by the 
Chinese before the opening of commerce with Europe. They were made 
of a transparent stone, of a color like that of a strong infusion of tea, 
called scha-chi (tea stone), and were tied upon the head by silken cords. é 
Chinese spectacles are now made of rock crystal, and are mounted in 
heavy frames, evidently borrowed from old European models. Several 
pairs of Chinese spectacles, of comparatively late fabrication, are pre- 
served in the Museum of the Old Hast India Marine Society, at Salem, 
Mass. 

The common use of some form of magnifying-glass by the ancients is 
wellnigh proved by their perfect workmanship, as displayed in the en- 
graving of gems, and a crystal wrought in the form of a convex lens has 
been actually discovered by Layard, in the ruins of Nimroud.7 On the 
other hand, it appears clearly, from the notice on presbyopia and my- 
opia, by Paulus Aegineta (seventh century, a.D.),8 that they had not 
applied lenses to the relief of persons laboring under these disabilities, 

Pliny’s description of the visual defect of the Emperor Nero 9 strongly 
suggests a case of compound myopic astigmatism, with the meridian of 
greatest refraction approximately vertical. The statement that Nero 
was accustomed to view the conflicts in the arena in or upon a smarag- 
dus (Nero princeps gladiatorum pugnas spectabat in zmaragdo),1° taken 
in connection with what is said of this gem in the same chapter, would 
seem to be best explained upon the supposition that the emperor pos- 
sessed a large and highly polished emerald, very probably of unequal cur- 
vature in its two principal diameters, and that he viewed the combatants, 
in the strong light of the amphitheatre, by reflection from its convex 
surface. This theory would imply that the use of the gem for this pur- 
pose was the result of an observation made by Nero himself, who may, 
therefore, be accredited with the accidental discovery of an eye-glass 
suited to the correction of myopia, or of compound myopic astigmatism ; 
the invention would appear to have died with the inventor. 

|| Pliny also mentions the fact that objects seen reflected in a concave 
mirror appear enlarged. !4 

4 It has been contended that Roger Bacon may haye derived his 
knowledge of lenses from Flanders. !7 


502 


glasses or spectacles, to be worn by presbyopes in read- 
ing, implies a considerable development of the optician’s 
art, in the direction of grinding lenses of relatively long 
focus. The invention of spectacles is variously attrib- 
uted to Salvino degli Armati, a Florentine (odt. 1317),!9 
and to Allessandro della Spina, a Dominican monk of 
Pisa (0dt. 1813). The use of concave glasses, similarly 
mounted in pairs, as a help to myopes in distant vision, 
must have followed at no very long interval ; the date of 
their first employment is, however, unknown. The ne- 
cessity for the selection of lenses of different focal length 
for different persons, as well as for the same person at 
different periods of life, must also have been very early 
recognized ; but there is no reason for believing that the 
choice was ever made in any better way than by trying 
glasses at random, until a pair was found which appeared 
to be suited to the kind of work for which they were to 
be used. * Certain it is that spectacles had been in 
common use for at least a hundred and fifty years before 
the theory of their action was explained,+ and it is only 
since the middle of the present century that anything 
like a complete understanding of the subject has been 
reached. 

Spectacle lenses, as late as the eighteenth century, 
were always, so far as is known, of the plano- or double- 
convex, or of the plano- or double-concave form.*”? Both 
the plano-convex and the plano-concave glasses were 
probably mounted, sometimes with the plane surface and 
sometimes with the curved surface next the eye. Con- 
cavo-convex lenses (menisci), with the convex surface 
ground to the shorter radius of curvature, were used to 
some extent in the last century, but with varying prac- 
tice as regards the side turned next the eye. t?? Under 
the name of periscopie spectacles, concavo-convex lenses, 
with the concave surface turned toward the eye, were 
brought into common use by Wollaston (1804).*4 <A spe- 
cial construction of double-convex and double-concave 
spectacle lenses, made by grinding the two surfaces of 
the glass to cylindrical curves of equal radii, but with 
crossed axes, was introduced (before 1880) by Galland de 
Cherveux ;*”> such lenses are still manufactured, but the 
special advantage once claimed for them, over the sevy- 
eral forms of lenses with spherical surfaces, is altogether 
illusory ; their existence in commerce made it possible, 
however, to furnish a cylindrical surface, on demand, at 
a time when plano-cylindrical lenses were not yet obtain- 
able. Cylindrical lenses proper, as used for the correc- 
tion of astigmatism, were first employed by G. Airy, As- 
tronomer Royal (1827),?° who was himself the subject of 
compound myopicastigmatism. Airy discussed the relative 
advantages, in compound astigmatism, of a bi-cylindrical 
lens of unequal radii of curvature, and a spherico-cylin- 
drical lens ; he gave the preference to the latter combi- 
nation, for reasons which are still generally accepted as 


* Bartisch (1583) protests strongly against the widely spread abuse of 
spectacles which prevailed at his time.?° 

+ ‘*Maurolicus, in his treatise de lumine et umbra (1554), considers 
the crystalline as the principal instrument of vision, and as transmitting 
to the optic nerve the images of objects; and he explains why some 
persons are long-sighted and others short-sighted, according to the less 
or greater convexity of the surfaces of the crystalline, showing that in 
the former case the rays have not been converged to a focus when they 
reach the retina, while in the latter they have been converged before 
they reach it. He explains, also, how the convergency may be hastened 
in the long-sighted eye by the use of a convex glass, and delayed in the 
short-sighted by a concave one. These observations of Maurolicus were 
not known to Kepler, when it was proposed to him, as a question by his 
patron, Dietrichstein, in what manner spectacles assisted sight? The 
first answer he gave, as he tells us in his ad vitellionem+paralipomena 
(1604), was, that convex glasses were of use by making objects appear 
larger. But his patron observed, that if objects were by them rendered 
more distinct, because larger, no person would be benefited by concave 
glasses, since these diminished objects. . . . He now gave a clear 
account of the effect of lenses, whether within or without the eye, in 
making the rays of a pencil of light converge or diverge ; and explained, 
that convex glasses assist the sight of presbyopic persons, by so altering 
the direction of rays diverging from a near object, that they fall upon 
the eye as if they had proceeded from a more remote one, that concave 
glasses benefit the myopic, by producing a contrary effect upon rays 
which diverge from a distant object, making them fall npon the eye as 
if they proceeded from a near one.” 21 

¢ Aside from the misinterpretation of special optical formule, caprice 
has played a conspicuous part in determining many eccentricities of 
practice; the business of selling spectacles appears always to have been 
deeply tainted with quackery. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


valid. The common use of cylindrical spectacle lenses 
dates from the special study of astigmatism by Donders.*" 
Quite recently Mr. Borsch, an ingenious practical opti- 
cian of Philadelphia, has undertaken the manufacture of 


C 
—— 


‘ 
\ 
\ 
| 
! 
/ 


Fie. 3563. 


spectacle lenses with a convex or concave surface of un- 
equal radius of curvature in its several meridians, thus 
combining in one surface the effect usually obtained by 
the combination of a cylindrical with a spherical sur- 
face.*° The curved surface of such a convex lens repre- 


a b 


‘sents a small area cut out from a large surface of revolu- 
tion corresponding to the rounded rim of a wheel ; the 
concave surfaces produced by this method are such as 
may be worked upon a grinding tool having the form of 
such a wheel. * Prismatic glasses, first suggested to 
Donders by his colleague, Krecke, as a possible means 
of re-establishing binocular vision when it has been lost 
through the deviation of the visual axes in strabismus, 


—_——_— —— i i 


-b 


Sparta Springs, 
Spectacles, 


Fie. 3564. 


—C 


external muscular apparatus of the eye. The decentra- 
tion of ordinary convex or concave lenses, in order to 
give to the combination of the two spectacle glasses some 
measure of prismatic effect, was also discussed by Don- 
ders.*!_ Decentrated convex lenses had already been used 
in the dissecting spectacles of Briicke,** and in the re- 
fracting stereoscope of Brewster.** Stenopzic spectacles 
—from orevds, narrow, and émq, a peep-hole—were also 
introduced by Donders,** chiefly for the purpose of ad- 
mitting to the eye such rays only as correspond to a se- 
lected limited area of the cornea or crystalline. Like 
the so-called panoptic spectacles of Serre d’Uzés,* they 
are essentially the same thing as the very old but long 
disused strabismus goggles (Schielbrillen — lonchettes). 
The snow-goggles of the Esquimaux, which cover the 
entire front of the eyeball, with the exception of a nar- 
row horizontal slit, are also properly to be regarded as 
stenopexic spectacles, although designed merely as pro- 
tectives against the injurious effects of strong sunlight 
reflected from the snow. 

The several forms which have been or may be given 
to spectacle lenses are shown, for concave and convex 
lenses respectively, in Figures 3564 and 3565. Of the 
convex lenses (of positive focus), a and g (Fig. 3564) are 
menisci, and may be designated as convex-concave and 


concave-convex, according as the convex or concave 
surface is turned toward the eye; 6 and jf, which have 
one surface plane, may similarly be designated as con- 
vex-plane and plane-convex ; ¢ and é are double-convex 
lenses, with surfaces of unequal radii of curvature ; and 
d is double-convex, with surfaces of equal radii. In 
concave lenses (of negative focus), we recognize the 
corresponding forms: Fig. 8565, -a, concave-convex, 


-e =f -J 


Fie. 3565. 


were made the subject of special study by Donders,* 


and have since held a place among the recognized means 
of dealing with conditions referable to disorders of the 


+ 


* The entire surface of revolution, as shown in section, takes one of 
the three forms, Fig. 3563, @, 0, c, the last of which is an open ring ; the 
interior surface of such a ring gives a surface (c’)convex in one principal 
meridian and concave in the other, and applicable, therefore, to the 
correction of mixed astigmatism.?9 


and -yg, convex-concave; -), concave-plane, and -f, 
plane-concave ; —c and -e, double-concave, with surfaces 
of unequal radii of curvature, and -d, double-concave, 
with surfaces of equal radii. Of these forms, the two 
shown in Fig. 3564, g (positive meniscus, with the con- 
cave surface turned toward the eye), and in Fig. 3565, 
-a (negative concave-convex), are especially designated 
as periscopic (from mept and cxoréw) glasses ; they offer a. 


503 


Spectacles, 
Spectacles, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


slight advantage when the eyes are so turned as to look 
obliquely through the right or left half of both glasses. 
These several forms of lenses, other than the plano- 


sponding to the axis is that of greatest, and that at right 
angles to the axis is that of the least (positive or nega- 
tive), focal length. Cylindrical lenses are someiimes 


ig g h 


Fie. 8566. 


spherical, may all be resolved into combinations of two 
lenses, each with a spherical and a plane surface, placed 
with their plane surfaces in contact (Fig. 3566; a, 0, c, d). 
Inasmuch as a smaller effective area than that bounded 
by the usual setting is quite sufficient for most of the 
uses for which spectacles are worn, it is possible greatly 


made to order with two cylindrical surfaces of unequal 
radii of curvature and with crossed axes, but the same 
optical effect can always be produced with greater ease, 
and at less cost, by a combination of a single cylindrical 
(convex or concave) surface with a spherical (convex or 
concave) surface, * 


Laas 


Fie@. 3567. 


to reduce the weight of the glasses, when required to be 
of very short focus, by the adoption of forms like those 
shown in Fig. 3566, e, f, g and A. 

Cylindrical lenses are found in trade of two forms, 


Fie, 8569. 


namely, plano-convex and plano-concave (Fig. 3567, a - 
and b); the dotted line represents the axis of the cylin- 
drical surfaces, which is parallel to the axis of the cylin- 
der of which the lens-surface is a segment. Any re- 
quired spherical surface, convex or concave, is ground to 
order by the optician, 
upon the plane sur- 
face of any convex or 


Fia. 3568. 


Prismatic glasses, with plane surfaces, are of the form 
shown in Fig. 3568; any desired curvature, whether 
spherical or cylindrical, may be given to either surface, 
or to both surfaces, of the prism. <A prismatic lens with 
one surface, or both surfaces, ground to a spherical cur- 
vature, is equivalent to a lens cut out from a peripheral 
zone of a spherical lens of greater diameter, as shown 
in Fig. 3569. A moderate degree of prismatic. effect 
may, therefore, be obtained by the simple expedient of 
decentering an ordinary spectacle glass ; such effects are, 
in fact, often produced without design, and not infre- 
quently with injurious results, from carelessness in 
mounting spectacle glasses. 

The stenopeic effect may be embodied in any lens, by 
simply painting over some part of its surface, next the 
eye, with an opaque, lustreless, black varnish. <A partial 
opacity of the cornea, or a portion of its surface present- 
ing an abnormal curvature, whether original or acquired, 
may be thus excluded from participation in the forma- 
tion of the retinal image, with the effect, in some cases, 
of materially improving the definition of the object.* 

Tinted glass is occasionally used in the manufacture 
of spectacle lenses, which, however, present an unequal 
density of tint in different parts, according to the varying 
thickness of the glass. In the case of concave glasses, 


concave, plano -cy- 
lindrical lens. The 
L focal length of a 

plano - cylindrical 

lens varies, in its 
several meridians, from infinity, in the meridian corre- 
sponding to the axis, to a least focal length (positive or 
negative) in the meridian at right angles to the axis. In 
a spherico-cylindrical lens, with both surfaces of the 
same kind, ¢.e€., convex or concave, the meridian corre- 


Fria. 3570. 


504 


ak et Tee ar A. 


SS ae eee a Sie Se ek abe ie Oa = ee Se es, = es ee B 


which are thinnest in the centre, this is often rather an 
advantage than otherwise ; in the case of convex glasses 
the inequality of tint may be avoided by making use of 
a plano-convex lens to the plane surface of which a thin 
plate of tinted glass is cemented by means of Canada 


* Cylindrical lenses with two cylindrical surfaces, with axes at some 
other than a right angle, are sometimes prescribed. Such lenses, as well 
as bi-cylindrical lenses with crossed axes, can always be represented by an 
optically equivalent combination of a spherical with a cylindrical sur- 
face.°6 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


balsam. A more elaborate device consists in the cement- 
ing of a thin plate of tinted glass between the plane sur- 
faces of two plano-convex (or plano-concave) lenses. Am- 
ber has been used as a material for spectacle lenses, 
notably at Kénigsberg, about the end of the seventeenth 
century ; the transparency of the amber is said to have 


Spectacles. 
Spectacles. 


mica ‘4! (Cohn, 1868) are especially to be recommended 
for miners, quarrymen, stone-cutters, boiler-makers, and 
others engaged in similar dangerous employments. Gog- 
gles of finely woven wire-gauze, generally with the fronts 
glazed with tinted plane glass, are used by railway trav- 
ellers and others as a protection against flying sparks; 


L ¥ 


Fie. 3571. 


been increased by the careful application of heat in a 
bath of oil or sand.** 

Tinted glasses with parallel surfaces are in common 
use to temper the light which reaches the eye; they are 
made either with plane surfaces, like window-glass, or 
with curved surfaces, like a watch-glass (coquilles). 
Green was formerly a favorite color, probably from its 
assimilating the light passing through it to the color of 
grass and the foliage of trees; blue (the color of the sky) 
gradually superseded green, and is still much used. <A 
neutral tint, known by the name of London-smoke, has 
latterly come into common use, and is, in many cases, to 
be preferred to 
blue. Glasses of 
an amber color are 
also to be found in 


goggles made of glass bent to acylindrical curve of about 
six inches radius, and furnished with cloth-covered rims 
to fit closely around the margins of the orbits, are some- 
times used as a protection against dust in driving. 
Coquille spectacles and eye-glasses, both colorless and 
tinted, are made also in the meniscus form (with positive 
focus) and in the concave-convex form (with negative 
focus) ; as kept in the shops, they range from about 
+ 8. dioptrics (+ +) to — 8. dioptrics (— 4). Owing to 
the shorter radius of curvature of the (concave) surface 
turned toward the eye, these glasses are more perfectly 
periscopic than those commonly sold under that name. 
The office of spectacles and eye-glasses, other than 
mere protectives, is, primarily, to supplement impaired 
accommodation (convex glasses, in presbyopia and in 
accommodative paresis and paralysis), to relieve the ac- 


the shops, gener- 
ally ground to a 
dull surface, with 
the exception of a 
small,central area. 
-Amber-colored and, still more perfectly, red glasses, by 
excluding all but the least refrangible rays of the spec- 
trum, may serve (in a strong light) to improve the defini- 
tion of the retinal image in very low grades of myopia ; 
blue reading glasses, on the other hand, may render some 
slight degree of aid in low grades of hypermetropia and 
of presbyopia.*® Tinted glasses should, as a rule, be 
mounted in large, oval settings, so as to cover the entire 
front of the orbit; the coquille form of glass affords 
more perfect protection than a glass with plane surfaces. 
Darkly tinted (London-smoke) coquilles are of great use 
to persons who are exposed to very strong light reflected 
from sand or from snow, or from the surface of water. 
Inasmuch as such regularly reflected light is always 
highly polarized, protective spectacles fitted with 

thin slices of tourmaline should render valuable 

service by cutting off the polarized rays, while 
permitting the unpolarized light, by which ob- 

jects are actually seen, to pass comparatively un- 
obstructed.*? London-smoke glass, of so dark a 

‘color as to appear quite black in ordinary light, 

is used in the protective spectacles worn by work- 

men employed about electric-arc lights, and spec- 

tacle glasses made up of several layers of glass f 
of different colors have been found especially useful in 
observing the intensely brilliant scintillations attending 
the conversion of pig-iron into steel by the Bessemer pro- 
cess. 

All spectacles afford some degree of protection against 
mechanical injury, and in certain trades it is only by 
the use of special protectives that the liability to grave 
accidents to the eyes can be averted. Millers have long 
been in the habit of wearing large spectacles fitted with 
thick window-glass when employed in the dangerous 
work of dressing millstones. Protective spectacles of 


Fie. 3572. 


commodation of an excessive burden, by supplementing 
deficient refraction (convex glasses, in hypermetropia), 
to correct excessive refraction (concave glasses, in 
myopia), and to correct asymmetrical refraction (convex 
or concave cylindrical glasses, in astigmatism). These 
several effects are, moreover, often variously combined, 
asin the use of strong convex glasses, in reading (by 
hypermetropes with defective accommodation), of par- 
tially correcting concave glasses, or, perhaps, of weak 
convex glasses, in reading (by myopes with defective ac- 
commodation), and of glasses of asymmetrical refraction 
(in compound and mixed astigmatism, and in presbyopia 
or other accommodative defect occurring in connection 
with astigmatism), 

The action of a convex glass, as used by a presbyope, 
in reading, is shown in Fig. 3570. Rays emanating from 


Fia. 3573. 


a printed page at A, at such distance from the eye O that 
the retinal image of the print shall be of sufficient size 
to admit of its being easily deciphered, are refracted in 
passing through the lens L (whose focal length must be 
not less than the distance L A), and are rendered either 
less divergent—-as if they had originated from some point 
more distant than A—or parallel—as if coming from an 


505 


Spectacles. 
Spectacles, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


| 
infinite distance. When the focal length of the lens L | the same pencil upon the retina of the hypermetropic 


is equal to the distance L A, the pencils entering the eye 


— —- ~~ + ee ee a a a wr ee ee er wren 


eye, at N’ (in all grades of hypermetropia less than H 


Sy Man en oe a ee Ag 
\ O, from an object at A, will consist | absolwta), the accommodation must be brought into action, 


of parallel rays, and a sharply de- 
fined retinal image will be formed 
at N, without exercise of the ac- 
commodation. If the focal length of the lens L is greater 
than the distance L A, the rays forming the several pen- 
cils emanating from the object at A will, after refraction 
by the lens L, be rendered less divergent, as if coming 
from an object at some distance greater than L A, and 
the eye O will then be enabled to focus such pencils 
through the exercise of less accommodation than would 


Fra. 3574, T,, 


either wholly or in part.* The neutralizing convex 
lens L converts the parallel rays of the pencil into rays 
of such degree of convergence that the hypermetropic 
eye O can focus them accurately at N’ without using any 
part of its accommodation ; the entire accommodation is 
thus rendered available to meet the requirements of near 


i. 
ae 
ae 
--- 
eee a 
a= 
= 
Pt ed 
=e 
—-——" 


Fra. 3575. Ae 


be required to focus pencils emanating from A. The 
former of these two cases represents the condition of an 
emmetropic eye in extreme presbyopia, or in complete 
paralysis of accommodation ; the second case is that of 
an emmetropic eye in lesser grades of presbyopia, or in a 
state of weakened accommodation. 

The presbyopic eye, when thus adjusted by the con- 
vex lens L for the reading distance L A, is, by the very 
action of the lens, thrown out of adjustment for distinct 
vision at a distance ; a presbyope wearing glasses for 


see 
---_. 


=-- 
wwe am ee 


reading, or other near work, must, 

} therefore, remove his glasses in 

L order to see distinctly at a dis- 
tance. 

Fig. 3571 shows the effect, in distant vision, of a neu- 
tralizing convex glass in hypermetropia. A pencil of 
parallel rays A A, emanating from a distant object, is 
focussed by an emmetropic eye, without exercise of the 
accommodation, upon its retina at N. In order to focus 


Fra. 3576. 


506 


nr 


~~ --... 
<<. 
-——— 
Ree ne ae 


—_—_——=— 
-——-——— 
a“-c-" 
—— 
----" 
-<-o" 
--- 
---" 
--- 
-- 


~--4.. 
Se een satel 
~ 
~ 
——. 


Cy a 
-~<-. 


vision, and the hypermetropic eye, with its neutralizing 
glass, becomes virtually emmetropic. 

In the extreme case of total presbyopia, or of complete 
paralysis of accommodation in the hypermetropic eye, 
a lens equal in power to the sum of the two lenses L 
(Fig. 3570) and L (Fig. 3571) will be required for dis- 
tinct vision at the distance L A (Fig. 3570), 


A, 


A 


A hypermetrope, wearing neutralizing convex glasses, 
sees distinctly, and without conscious effort, at all dis- 
tances ; when, however, he becomes also presbyopic, the 
neutralizing convex glasses cease to afford sufficient 
help in reading, and stronger glasses become necessary. 
These stronger reading glasses are, however, too strong 


* In absolute hypermetropia the total accommodation is insufficient 
to focus parallel rays, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, Bd Sepeadcatetl S 


Spectacles, 


for distinct vision at a distance ; hence, an elderly hypermetrope requires, as a rule, two pairs of convex glasses, 
the one, neutralizing, for distinct vision at a distance, and another pair, of shorter focus, for reading. 

Fig. 3572 shows the-use of a neutralizing concave glass, in distant vision, in myopia. The pencil of parallel rays, 
A A, emanating from a distant object, is focussed by the myopic, as by the emmetropic, eye at the normal position 
of the retina at N ; the actual position of the retina, in the myopic eye, i is, however, farther back, as at N’. 
The myopic eye, in a state of complete accommodative relaxation, can ;\ focus only divergent rays, as from an 
object at some short distance L B, upon its retina, and, by the exercise H of its accommodation, can also focus 
rays diverging from some still nearer point, somewhat within the distance | ; of nearest distinct vision (P) for an 
emmetropic eye. The neutralizing concave lens L converts the parallel | | rays of the pencil A A into rays of 

such degree of divergence as they would 

have if emanating from B, and thus the my- *: 
opic eye O is enabled to focus them upon its ¢* ve 
retina at N’. The farthest point of distinct vision (7) is . 
thus carried off, by the neutralizing concave glass, to an 
infinite distance, and the near-point (p) is removed to 
about the distance of the near-point in emmetropia. fs 

When the myopic eye becomes restricted in its range 
of accommodation, as a result of advancing age, the neu- 
tralizing concave glasses must either be laid aside in 
reading or exchanged for concave glasses of greater focal “ 
length (¢.é., weaker concave glasses); in myopia of alow ¢; 

grade, it may even become necessary, in read- 
sa ing, to make use of convex glasses, but 
weaker than those which would be required % 

by an emmetrope of the same age. 

A myope wearing neutralizing concave glasses, like the hypermetrope 
sees distinctly at all distances. Only wher. he becomes presbyopic does 
lay aside his concave glasses, in reading, or to exchange them, temporarily, 
weak convex glasses. 

Comparing Figs. 3571 and 8572, it will be seen that the pencil of ‘ parallel rays A A (Fig. 3571) is of 
notably greater diameter than the pupil, and, conversely, that the pencil A A (Fig. 3572) is of less diameter than 
the pupil. As the areas of the cross-sections of the two pencils are to each other as the squares of their diameters, 
it follows that there must be a very considerable gain in the brightness of the retinal image in the case of hyper- 
metropia corrected by convex glasses, and a corresponding loss of illumination in the case of myopia corrected by 
concave glasses. These two conditions are, in fact, essentially the same as in looking through an opera-glass in the 
proper direction and in the reversed direction. Hypermetropes, wearing convex glasses, see somewhat better than 
emmetropes, by moonlight or starlight, and myopes, wearing concave glasses, see less perfectly under the same 
conditions ; in the higher grades of myopia the disability from this cause is sometimes so great as to simulate night- 
blindness (see Hemeralopia). 

Objects viewed through convex glasses appear larger than do the same objects when their images are focussed 
by the exercise of the accommodation, and, conversely, objects viewed through concave glasses under accommo- 
dative tension appear smaller than do the same objects when viewed without exercise of the accommodation. 
Hence, a:presbyope, using convex glasses in reading, sees the print not only clearer than without glasses, but 
also larger than it appears to an emmetrope under normal exercise of the accommodation. So, also, a hyper- 
_ metrope, wearing convex glasses, sees all objects larger than when he views them without glasses, and a myope 

---, using concave glasses in reading sees the print smaller than when he reads without glasses. 

1 ! In (axial) hypermetropia, however, the actual size of the retinal image is smaller, as in 

' 1 (axial) myopia it is larger, than in emmetropia; and it is a fact now well established that 

‘| both hypermetropes and myopes wearing neutralizing glasses at the usual distance from 
VI 
f 
i 
vt 


LS lan en 


b a 


-~—_________—- A. 
Fia. 3577. 
wearing neutralizing convex glasses, 


he find himself compelled either to 
for weaker concave, or, possibly, for 


‘ 
| 
1 
J 
' 
! 
| 
! 
‘ 
! 
! 


' 
’ 
| 
! 
' 
1 
\ 
\ 
\ 
1 
\ 
\ 
\ 
‘ 


the eye see objects of about the same apparent dimensions as does an emmetrope without 


glasses. 
F’ 
4 coed Aa 
a 
Ay 
at 
: | A‘. 
oi ia 
ay Ey, re 
as | A 
. | ee eee 
| ER See ee ian os A ’ 
a, wrt ae F 


! Fia. 3578. 
t 
é i fective power with any increase in its 
he eye, and, conversely, a concave lens loses in effec 
pede ‘Lhe bre care of practice is to Tene the ate as aay ahh wet fats 
owi i relas distan 
s. allowing sufficient room for the free play of the eyelashes. | 
~4 ri iicer get the vertex of the cornea fulfils this condition in most cases, and hn 
same time allows the correcting lens to be placed almost exactly at the anterior sea I eiteniee he a we a 
iti ‘nal image, whether in hypermetropia or in myopia, becomes practically equal 
CB Ae ase ra Ra foc ) tropi Whenever a hypermetrope inclines to remove 
i me object when focussed by an emmetropic eye. \ er oe 
his ee acece oe ahs, distance from the eye than thirteen millimetres it may be assumed that the glasses are 


507 


' 
i] 
A convex spectacle lens is increased in effective power by increasing its distance from 
i] 

H 

i} 

\ 

\ 


! 
i 
I 
‘ 
i 
! 
| 
tL 


Spectacles, 
Spectacles. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


somewhat 
too weak 
fully to 
correct his 
hyperme - 
trope, 
and, con- 
versely, d 
when a myope inclines to wear his (concave) 
glasses at a distance greater than thirteen mil- 
limetres from the eye it may be assumed that 
the glasses are somewhat too strong. This 
particular mode of correcting the effect of 
badly selected glasses in distant vision is but 
rarely adopted, except in the presence of de- 
fective accommodation, as, for instance, by 
elderly hypermetropes or myopes, and espe- 
cially by persons who have undergone an 
operation for cataract. In presbyopia it is a 
not uncommon practice to slip the (convex) 
reading glasses far down toward the tip of 
the nose, in order to make a weak glass do 
the office of a stronger glass in improving 
the distinctness of the print, and also in in- 
creasing its apparent size; in this position 
of the glasses it is also easy to look over them at distant 
objects. 

The increase or diminution in the apparent size of ob- 
jects viewed through a 
convex or concave lens is 
not uniform in all parts 
of the visual field, but is 
notably greater at its pe- 
riphery than at its centre. 
Thus, a large object 
viewed, centrally, through 
a spherical convex lens is 
seen more highly magni- 
fied in its peripheral than in its central portions; a 
square, for example, whose angles are more distant from 
the centre than is the middle of each side, is seen as if 
bounded 
by curved 
lines with 
their con- 
vexity 
turned to- 
ward the 
centre of 
the field. 
The same square, when viewed through a 
concave lens, is seen diminished in size, but 
most diminished in its peripheral portions, 
so that it appears as if bounded by curved 
lines with their concavity turned toward 
the centre. Fig. 3573 shows at 6 and ¢ the 
distortion under which a large square figure 
a—a window, for example—is seen through 
a convex and a concave lens, respectively ; 
it will be observed that the distortion of the 
smaller squares increases from the centre 
toward the periphery of the field. 

It has been often remarked that myopes, 
in selecting concave glasses, are very apt to 
err by making choice of glasses of some- 
what too short focus, which cause objects 
seen through them to appear very sharp- 
ly outlined. This phenomenon appears to 
be a result of the chromatic aberration of 
the eye, causing the object, when viewed 
through a concave glass under a full cor- 
rection for the most highly refrangible (vio- 
let) rays of the spectrum, to be seen as if 
bounded by avery narrow red border, in- 
stead of by a broader violet fringe, as when 
the eye is focussed for the least refrangible 
(red) rays. If a distant point of light is 
viewed by an over-corrected myopic eye through a piece 
of cobalt-blue glass, the light will appear blue, with a 


Fie. 3579, 43 


JAMES W. QUEEN & CO., PHILA. 


Fia. 3580. 


508 


narrow red halo ; if the eye is under-corrected by its con- 
cave glass, the light will appear red, with a broader vio- 
let halo. 3 

A convex or concave cylindrical lens, as used for the 
correction of astigmatism, simply elongates or shortens 
the retinal image in a direction at right angles to the axis 
of the lens; thus, the relation of the two diameters of the 
object appears altered, a circle appearing elongated or 
shortened to an ellipse, etc. The distortion from this 
cause in regular astigmatism, when the direction of the 
two principal meridians happens to be asymmetrical in the 
two eyes, may give rise to such difference in the two ret- 
inal images as to evoke a great variety of stereoscopical 
illusions from the fusion of the two impressions in binoc- 
ular vision; illusions of this kind are, however, very 
soon corrected by experience, as the wearer of the cylin- 
drical glasses becomes accustomed to the new conditions. 

Incidental to the action of convex and concave glasses 
in modifying the exercise of the accommodation is the 
effect which they exert upon convergence as associated 
with accommodation. Convex glasses, by relieving the 
accommodation of a part of its load (in hypermetropia), 
exert at the same time a positive effect in diminishing 
the correlated convergence ; hence, they rank first among 
the therapeutic agents at our disposal for arresting the 
development of convergent strabismus, and even, in many 
cases, for its cure. Concave glasses, on the other hand, 
by increasing the demand made upon the accommodation 


Fie. 3581. 


in near vision (in myopia), evoke 
also increased action of the recti-in- 
terni muscles, with correlated relax- 
ation of the recti-externi, and thus 
afford relief in many cases of mus- 
cular asthenopia and of crossed dip- 
lopia, and even of divergent strabis- 
mus. 

. Spectacles, whether convex or con- 
cave, may be so mounted as to exert 
also a direct action upon convergence. 
This effect may be developed acci- 
dentally, as a result of imperfect 
centration of one or both glasses, 
and may then be attended with more 
or less harmful consequences, or it 
may be produced designedly, and 
applied with advantage to the treat- 
ment of muscular insufficiency. 

This action of convex and concave 
glasses is shown, for three particu- 
lar cases, in Figs. 3574 to 8576. The 
large convex lens L (Fig. 3574) re- 
ceives divergent rays from the point 
A, situated at a distance equal to its 
principal focal length, which rays 
are rendered parallel by the lens. 
An emmetropic eye at O, behind the centre of the lens, 
sees an object at A by looking directly at it, in the direc- 
tion O A; but an eye at D, or at §, in order to see the 
same object, must look in the direction D Ad, or S As, 
parallel toO A. 

In Fig. 3575 the large convex lens L receives the par- 
allel rays of the pencil A" A,, coming from a distant ob- 
ject, and renders them convergent. A hypermetropic eye 
at O, behind the centre of the lens, sees the object lying 
in the direction O A, by looking directly at it; but an 
eye at D, or at S, in order to see the same (very distant) 
object, must look, not inits true direction, D A’,orS Au, 
but in the direction D Ad, orS Aa. 

In Fig. 3576 the large concave lens L receives the par- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


allel rays of the pencil A’ Ay, coming from a distant ob- 
ject, and renders them divergent. A myopic eye at O, 
behind the centre of the lens, sees the distant object 
lying in the direction O A, by looking directly at it ; but 
an eye at D, or at 8, in order to see the same (very dis- 
tant) object, must look, not in its true direction, D A’, 
or S A,, but in the direc- 
tion’ DD Ajrons 7A: 

If we take D and S as 
representing the right and 
left eye, the effect of the 
lens, in the three cases un- [ 
der consideration, will be 
(1) to associate parallelism 
of the visual axes with 
full relaxation of the ac- 
commodation in looking 
at a near object (in emme- 
tropia, Fig. 3574) ; (2) to 
compel divergence of the 
visual axes (or else toevoke 
homonymous diplopia, in 
looking at a distant object 
(in hypermetropia, Fig. 
3075); or (3) to compel 
convergence of the visual 
axes (or else to evoke 
crossed diplopia) in look- 
ing ata distant object (in 
myopia, Fig. 3576). In all 
three cases the conditions 
thus evoked are unnat- 
ural, and the second and 
third involve a divorce- 
ment of the allied adjust- 
ments of accommodation 
and convergence. The ar- 
rangement shown in Fig. 
3074 is that employed in 
so-called. cosmoramas, or 
peep-shows, to produce 
the double illusion of in- 
creased size and greater 
distance in looking at a 
' photograph or other pict- 
ure through a large con- 
vex lens. In the arrange- 
ment shown in Fig. 3575 
single vision with the two 
eyes is impossible, except 
in the abnormal condition 
of divergent strabismus, 
which, however, is only 
exceptionally found asso- 
ciated with hypermetro- 
pia. In the arrangement 
shown in Fig. 3576 the ex- 
cessive convergence inci- 
dental to looking through 
the marginal portions of 
the concave lens tends to 
evoke some measure of 
accommodation also, and 
thus to impair the distinct- 
ness of distant vision when 
the lens is of such focal 
length as exactly to cor- 
rect the myopia. 

The proposal to make use of decentrated lenses, as 
shown in Figs. 38574 and 3576, in uncomplicated pres- 
byopia and myopia,” is irrational. In presbyopia com- 
plicated with marked falling off in the acuteness of vision, 
the principle illustrated in Fig. 3574 may be utilized to 
relieve the recti-interni muscles of undue strain in read- 
ing,at exceptionally short range, with convex glasses of 
very short focal length. The dissecting spectacles of 
Bricke * are constructed on this principle. 

The action of decentrated lenses, when the centre of 
each lens is removed to the temporal instead of to the nasal 


Spectacles, 
Spectacles, 


side of the eye, is shown, for convex and concave lenses 
respectively, in Figs. 8577 and 3578. In Fig. 3577 the 


two halves of a convex lens, divided through its centre, 
are transposed, so that the right eye looks through what 
was originally the left half of the lens, and the left eye 
through the right half. 


The parallel rays A, Ao, As, 


Fig. 3582, 44 


Ay, and A’,, A's, A’s, A’,, of the two pencils, after 
traversing the two halves of the lens, become convergent, 
with foci at F and F’. By varying the distance between 
the two lenses, the symmetrically refracted rays A, A‘, 
Az A's, As A’s, or A, A’, may be made to fall oppo- 
site the centres of the pupils of the two eyes, which will 
then be compelled to assume positions varying from 
parallelism of the visual axes to a considerable degree of 
convergence. * In the case of the transposed halves of 


* The arrangement of transposed halves of a convex lens, as shown 
in Fig. 3577, is that usually adopted, after Brewster, %* in the construction 


509 


Spectacles, 
Spectacles. 


a concave lens (Fig. 3578) the conditions are exactly the 
reverse of those shown in Fig. 3577. 

Instead of cutting out two spectacle lenses from a 
peripheral zone of a very large convex or concave lens, 
it is found to be quite as convenient, and much less 
costly, to grind the required convex or concave surface 
upon one side of a prism; upon the other side of the 
prism a cylin- 
drical surface 
may be ground 
if required for 
the correction 
of astigma- 
tism, Such 
glasses are of 
not infrequent 
use in ametro- 
pia, when com- 
plicated by in- 
sufficiency of the recti-interni or 
of the recti-externi muscles, and 
are thus available in many cases of 
muscular asthenopia, and of diplo- 
pia of moderate grade even when 
dependent on paresis of one of 
the recti muscles ; in strabismus, 
they are seldom of much utility. 

It is, of course, possible to de- 
centrate one of the lenses of a pair 
of spectacles, either upward or 
downward, or to decentrate one | 
glass upward and the other down- 
ward ; this expedient is occasionally utilized in cases of 
slight upward or downward deviation of one of the visual 
axes," 

The decentration of a spherical lens, whether convex or 
concave, necessarily gives rise to some distortion of the 
retinal image, and the greater the decentration the more 
pronounced will be the distortion. This is shown in 
Fig. 3578, 6, and c, in which the small squares at the 
sides and at the angles of the larger square are drawn as 
they are seen through peripheral portions of a convex or 
a concave lens. 

Moreover, the ZA 

several pencils = 
of rays, after = 
refraction by —— 
a decentrated : = 
lens, are no 
longer homo- 
centric, 7.€., 
they no longer 
converge to- 
ward or di- 
verge from a focal point, but pass 
through two so-called focal lines. 
In other words, a decentrated 
spherical lens always gives rise to 
some degree of astigmatism, which | 
may, in certain cases, be so great as 
to require correction ; this may be 
effected by using lenses of the 
plano-convex or plano-concave 
form, and grinding a cylindrical 
surface upon the plane side.* 

Prismatic glasses with plane sur- 
faces (Fig. 3568) may be mounted 
with their bases turned toward the nose, in which case 
they relieve the recti-interni muscles of a part of their 
work in convergence, and may also restore binocular 


JAM 


—— 


of stereoscopes ; its effect is to permit the two (slightly different) pictures, 
mounted upon the stereoscopic slide, to be viewed, at one and the same 
time, by the two eyes, under moderate convergence of the visual axes, or, 
as is more commonly the case, to permit two pictures whose correspond- 
ing points are more widely separated than are the centres of the two 
pupils to be viewed by the two eyes with parallel visual axes, 

* For a mathematical discussion of these and other examples of the 
effects of spherical aberration, the reader is referred to special works on 
optics—e.g., Parkinson’s Optics, Chapter IV., ‘‘on focal lines of small 
oblique pencils, and caustics; ” also Chapter VII., ‘‘on spherical aberra- 
tion of lenses.” 


510 


ES W. QUEEN & CO, Baia 


Fie. 3583. 


JAMES W. QUEEN & CO, 


Fig. 3584. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


vision at a distance in cases of crossed diplopia, depend: 
ent on very slight divergence of the visual axes. 
Mounted with their bases turned toward the temples, 
they are applicable in certain cases of insufficiency of 
the recti-externi, or of preponderance of the recti-interni, 
as in the homonymous diplopia which is sometimes ob- 


served in low grades of convergent strabismus. <A pris- 
matic glass, 

= mounted with 

: the base up- 


ward or down- 
ward, before 
one eye only, 
may be used 
to neutralize 
the effect of a 
slight upward 
or downward 
deviation of the eye before which 
it is worn, or the correction may 
be divided between the two eyes 
by making use of two prisms, the 
one mounted with its base up- 
ward and the other with its base 
downward. The deviation which 
may be thus overcome by a prism 
is equal to about one-half of the 
angle included between its two 
sides—7.e., about 4° with a sin- 
gle prism of 8° angle, or 8° with 
a prism of 8° angle worn before 
each eye. Prisms of more than 
8° angle are ordinarily rejected on account of the con- 
spicuous colored fringes due to chromatic dispersion. 
The normal effect of any spectacle lens is, as already 
shown, obtained only when the lens is accurately centred 
in front of the pupil ; another important condition is that 
the plane in which the lens is set be perpendicular to the 
direction of the visual axis. The distance between the 
centres of the two lenses of a pair of spectacles intended 
to be worn in distant vision should, therefore, be exactly 
equal to the interpupillary distance, but in the case of 
reading glass- 
es, the distance 
between the 
centres of the 
two lenses 
should be 
somewhat less 
than the lesser 
inter-pupillary 
distance when 
the visual axes 
are made to 
converge upon the printed page. 
Furthermore, the two lenses 
should be set in one and the same 
plane, perpendicular to the direc- 
tion of the (parallel) visual axes— 
¢.é., vertical, in the case of glasses 
to be worn in distant vision—but 
they should be tipped forward in 
spectacles which are to be used in 
reading. In strictness, the lenses 
of reading spectacles should be 
also inclined a little toward each 
other, so as to face the point of 
intersection of the visual axes upon the printed page. 
Whenever a (convex or concave) spherical lens is set 
obliquely to the direction of the visual axis, its refractive. 
power is increased, though in very different degree, in all 
its meridians, the increase being greatest in the meridian 
corresponding to the plane of the arc through which the 
lens is rotated, and least in the meridian of the axis 
about which the rotation takes place. In the case of a 
(convex or concave) cylindrical lens, rotated about its 
axis, the increase in refractive power varies from a max- 
imum, in the meridian at right angles to the axis, to zero, 
in the meridian of the axis. When rotated about the 


+ PHILA, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Spectacles, 
Spectacles, 


meridian at right angles to its axis, a (convex or concave) 
cylindrical lens shows also a positive increase in refrac- 
tive power, though in a lesser degree than when it is 


from his (convex spherical) 
through them to one side. 
A myope, wearing concave glasses of a power insuf- 
ficient fully to correct his myo- 
pia, is very apt to look obliquely 


glasses by looking obliquely 


to one side, in order to improve 


his vision for the vertical lines 


Fie. 3585. 44 


~ 
Ne 


rotated about its axis. It follows that a tipped spherical 
lens becomes practically equivalent to a (somewhat 
stronger) spherical lens with a cylindrical lens added to 
it, and that, in the case of a spherico-cylindrical lens, 
the special effect of the cylindri- 


cal surface may be either in- 


-, of a distant object, and he may, 
“~at the same time, contract the 
opening of the eyelids, in order 
to improve his vision for hori- 
zontal lines. In hypermetropia, 
this habit is but rarely acquired, 
for the reason that here the 
accommodation is generally 
brought into exercise to supple- 
ment the effect of the glasses, 
but in aphakia, owing to the 


total loss of accommodative 
power, it is not infrequently ob- 
served. 


Spectacle lenses are usually 
mounted in oval rings of metal 
(rims—cercles), or, in the case of 
eye- glasses, of tortoise - shell, 
horn, hard rubber, celluloid, 
etc. The rims used in mounting 
convex glasses are almost always grooved, so as to grasp 
the sharp edge of the lens; concave glasses, too, are 
ground, as a rule,.to a sharp edge, and mounted in 
grooved rims, but it is a not infrequent practice to groove 


creased or diminished, according 


as the (compound) lens is rotated 


about one or the other of its prin- 
cipal meridians. <A. tipped con-§ 
cave spherical lens may be oc- 
casionally utilized, in distant 
vision, in myopia, with astigma- 
tism of relatively low grade, 
when the ocular meridian of 
greatest refraction happens to be 
vertical (or very nearly vertical), 
“and a vertically mounted convex 
spherical lens may be given, for 
reading, when the ocular meridi- 
an of greatest refraction happens 
to be (exactly or approximately) 
horizontal.* Again, in myopia 
with astigmatism, when the ocu- 
lar meridian of greatest refrac- 
tion happens to be approximately 
horizontal, the wearer of con- 
cave spherical glasses may learn 
the trick of looking obliquely through his glasses, either 
to the right or to the left, and may thus add materially to 
his acuteness of vision, though at the cost of acquiring an 
awkward carriage of the head. So, also, a hypermetrope 


Fia. 3586. 44 SF 


§ 


the lens itself, and to sink the rim, which is then made of 
thin (steel or gold) wire, in the groove. Convex lenses, 
also, are occasionally mounted with the rims sunken, 
but at the cost of making the lens needlessly thick and 


FIG. 


with some measure of astigmatism, when the ocular 
meridian of greatest refraction happens to be approxi- 
mately vertical, may, similarly, get a better correction 


* A familiar instance of such a correction, in myopia, is seen in the 
not infrequent preference given to a tipped (concave spherical) eye-glass 
over glasses mounted in a vertical position, ina spectacle frame. So, also, 
after an operation for cataract, a spherico-cylindrical lens, with axis 
horizontal, may be required to raise distant vision to its maximum, al- 
though, for reading, a spherical glass may be preferred, by reason of the 
augmented refraction, in the vertical meridian, incident to the oblique 
(downward) direction of the visual axes. 


3587. 44 


heavy. So-called frameless or rimless glasses have the 
nose and side pieces attached by means of screws passing 
through holes drilled in the lenses at their nasal and tem- 
poral sides; concave lenses, with their thick margins, 
lend themselves better to this construction than do con- 
vex lenses. : 
Caprice has sometimes dictated the wearing of a single 
eye-glass, carried at the end of a riding-whip, a fan, etc., 
or worn suspended by a cord ; in the latter case the glass 
is held in front of the eye by contracting the orbicularis 


511 


Spectacles. 
Spectacles, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


muscle upon its rim in a singularly awkward and incon- 
Binocular glasses may be divided, ac- 


venient fashion. 


cording to the way in which they are held before the 
eyes, into three groups—namely, eye-glasses held in the 
hand (lorgnette—face a@ main; Figs. 


3579, 8580, and 3581 4°), those held in 
place by means of a spring which 
pinches the nose (pince-nez—Nasen- 
zwicker, Nasenklemmer), and spectacles 
proper, which are held in place by 
means of side-pieces passing above and 
behind the ears (Junettes ad branches). 
To these three principal types may be 
added a fourth, now disused except in 
the case of protective goggles, in which 
the glasses are held in place by means 
of tapes or an elastic band passing 
around the head above the ears. 

The several parts of a pair of spec- 


tacles are (1) the rims (cercles), in which the glasses are | 
mounted, (2) the bridge, or nose-piece (arcade centrale), 
by which the rims are connected and supported upon the 


in 
i 
i 


| 
| 


| 


ne 
il 
a a A 


iM 


bridge of the nose, and (8) the side-pieces (temples— 
branches laterales), by which the spectacles are held in 
place upon the head. The size of. the rims and the length 


of the bridge 
should be so pro- 


Fia@. 3588. 


Fia. 3590. 4¢ 


greater or a little less than the interpupillary distance, 
but in such a case care should be taken, in setting the 
glasses, to preserve the proper 
distance between their centres. 

The bridge should be shaped 
to fit the nose, and partially to 
encircle it; noses, however, 
ax differ very greatly in promi- 
=? nence and in thickness, so that 
SJ no single type of bridge is suit- 
ed to all cases. The ‘‘ hoop” 
bridge (Fig. 3582, 5 and 6) is 
one of the older forms, and is 
suited to noses of considerable 
thickness and prominence ; the hoop may lie in the same 
plane with the glasses, or it may be turned forward at 


Fie. 3589. 


any required angle. The slightly modified form shown 
in Fig. 3582, 1, 2, 3, and 4 is now more commonly used 
than the plain hoop, and, like it, may be set at any re- 


mm 2225 


glasses. These forms are well 
"al 
Hi, 


fail to support the glasses at the 
proper height, or at a sufficient 
distance from the eyes to avoid 
contact with the eyelashes. To 
obviate this serious defect in the 
hoop bridge two very useful 
modifications have been recently 
introduced, namely, the twisted 
or ‘‘ snake” bridge (Fig. 3583 4°), 
and the ‘‘saddle” bridge (Fig. 
3084 4%), The so-called X bridge 
(Fig. 35854), and the K bridge 
(Fig. 3586 “*), are extensively used in frames of very light 
weight ; they are, however, of less general applicability 
than the other forms. A perfect bridge should present a 
rather broad sur- 


suited to noses of some promi- 
nence, but in other cases they 
{| i | 


face of contact 


portioned as to 


with the nose, 


conform both to 


and special care 


the interpupil- 


should be taken 


lary distance, in 


to secure an ac- 


order that the 


curate and easy 


wearer may look 


through the cen- 
tres of the glass- 
es, and to the 
width of the face, so that the 
side-pieces may touch, but not 
press too tightly against, the 
sides of the head. In the case 
of great width of face, larger 
rims are generally required than 
when the face is narrow (see 
Fig. 358244); any variation from 
the usual proportion between 
the interpupillary distance and 
the width of the face may gen- 
erally be met by varying the 
length of the bridge. 


512 


In order properly to fit the face, 
it may sometimes be necessary to select a frame in which 
the distance between the centres of the rims is a little 


fit; in rare in- 
stances it may 
even be worth 
while to make a 
cast of the nose upon which to 
mould the bridge. Bridges of 
the X and K patterns, as usually 
made from very thin wire, are 
apt to cut the nose. A gold 
bridge is often to be preferred, 
even when the other parts of the 
frame are made of steel, as being 
more easily moulded to the nose 
and free from liability to rust ; 
a recent improvement consists in 
the application to the hoop or 
saddle bridge of a lining of fine cork. Spectacle-frames 
of tortoise-shell were once in common use, and are on 
many accounts to be commended ; frames are still made 


‘JAMES W- QUEEN & CO., PHILA 


Fie, 3591. 


REFERENCE HANDBOOK OF 


Spectacles. 
Spectacles. 


THE MEDICAL SCIENCES. 


in limited quantities with the rims and bridge formed 
from a single piece of shell or of celluloid. Hither mate- 
rial may be softened by the application of a gentle heat, 
so that the bridge 

may be bent to al- 
most any desired 
shape. 

The side-pieces 
(temples — dr-anch- 
és)should beslight- 
ly bowed to fit the sides of the head ; they should be of 
at least sufficient length to reach a little behind the ears 
(single temples, Fig. 3587 *4), or they may be made a couple 
of inches longer by jointing them on a pivot at about the 


Fie, 3592.43 


point where they rest upon the ears (turn-pin temples, 
Fig. 3588 4°), or by the use of a sliding mechanism (slid- 
ing temples, Fig. 35894). Best of ali are the hooked or 
“‘riding” temples (Figs. 3583 to 3586, and 3590“), which 


Fie. 3593.44 


called, have the upper part of the rims flattened (Fig. 
3093 44), in order to permit the wearer of reading glasses 
to see over them in looking at distant objects ; the glasses 
are also set, as a rule, obliquely to the direction of the 
side-pieces, but perpendicular to the direction of the vis- 
ual axesinreading. In ametropia, with defective accom- 
modation, it is often convenient to mount two half-lenses 
in each rim (Fig. 3594), the upper half (convex or con- 
cave) of a focal length suited to the correction of the 
actual hypermetropia or myopia, the lower half, of the 
focus needed for reading ;* a similar effect is obtained, 
though somewhat less perfectly, by grinding the upper 
and lower halves of the same lens to different radii of 
curvature (bi-focal glasses—verres d double foyer, Fig. 


Se 


| 3595 **), Another useful arrangement consists in mount- 


ing areading correction in a separate frame, to be hooked 
upon the front of the spectacles habitually worn in dis- 
tant vision (Fig. 3596 “**). 


Fie. 3594.44 


are made of thin and very elastic wire bent downward in 
an easy curve behind the ears. By a recent invention, 
consisting in the introduction of a delicate, spirally 
wound wire in the side-pieces, near their proximal ends, 


the flexibility of hooked temples has been materially in- 
creased (Fig. 3591 4°). 

The several parés of a spectacle-frame should be nicely 
proportioned to each other. In the case of spectacles 
with single temples the 
bridge should be of sufficient 
stiffness to maintain its shape 
unaffected by the lateral 


Fia@. 3595.44 


spring of the _ side-pieces. 


Only when hooked temples 
are used is it admissible to 
make all parts of the frame 
of very light weight. 
Fashion has played its part 
in prescribing the form of spectacle-glasses ; the original 
shape was doubtless circular, a form still occasionally 
adopted for spectacles, but more frequently for eye- 
glasses. The shape now generally preferred is a nearly 
regular oval, but with considerable variation in the pro- 
portion of the two principal diameters. Another and per- 
haps preferable form is oblong, with rounded angles (Fig. 
3587). A parallelogram with the four corners cut off by 
straight lines (octagon glasses, Fig. 3592) was a favorite 
shape not many years ago, and, though rather ungrace- 
ful, is still occasionally used. Pantoscopic glasses, so 


VoL. VI.—33 


Eye-glasses of the pince-nez+ pattern have been made 
since an early period in the history of spectacles, but 
their construction has been greatly improved within the 
past ten or twenty years. 


In the older forms (Figs, 3597 ** 


and 3598 44) the centres of the glasses stand much too near 
together, and the glasses themselves are very apt to tip 
forward in a way that is sometimes very detrimental to 
the optical effect intended to be obtained from them. In 


F1a@, 3596.44 


many cases, also, they stand so near to the eyes as to allow 
insufficient room for the play of the eyelashes, and when- 


commonly called by his name. 

+ In a fresco by Dom®. Ghirlandajo (1449-1494), in the Church of Sta. 
Trinita at Florence, an elderly bishop is represented as reading through 
a pince-nez set very low upon the nose; the rims of the glasses are cir- 
cular, and the connecting arc is apparently rigid, This construction and 
manner of wearing the pince-nez explains the objection formerly made to 
it, as liable to compress the nostrils and impart a nasal quality to the 
voice. A fac-simile of the portion of the fresco containing this head has 
been reproduced, in color, in one of the publications of the Arundel Soci- 
ety, London, 1860. 


513 


Spectacles. 
Spectacles, 


ever the nose is unsymmetrical one glass is pretty sure to 
stand noticeably higher than the other. In eye-glasses 
of improved construction these defects are to a consider- 
able extent obviated. Thus most of the modern eye- 
glasses have some form of projecting nose-clips, which 
may be set either in the same plane with the glasses, or In 
a plane behind that of the glasses and inclined to it at any 
required angle to secure the best possible bearing upon 
the sides of the nose; some eye-glasses have also 
a provision for adjusting the clips, upon the two 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Myopia, Presbyopia, and Optometry. The points to be 
particularly investigated in all cases are (1) the state of 
the refraction, (2) the acuteness of vision, and (8) the 

state of the accom- 
modation. Only 
after these three de- 
terminations have 
been made, with at 


SS 


sides, so as to fit noses of almost any shape and 


= ————— 


thickness, and of very considerable degrees of 


asymmetry. <A cork-lining to the clips greatly 


increases their adhesiveness, and thus does away 


with the necessity of strong pressure in order to 


hold the’ glasses firmly in position (Figs. 35994, 


3600 #, 3601 *, 


and 3608 4°). The 


tilting of the 


glasses, in cases 
of exceptional 
prominence of 


Fig. 3597, 4 


least approximate accuracy, can 
the selection of glasses for any 
particular kind of work be intel- 


ligently made. In the present 


state of diffusion of knowledge in the domain 


of physiological optics these tests can be 


safely entrusted only to the ophthalmic spe- 


cialist—physicians and spectacle-dealers be- 


ing alike incompetent, as a rule, to decide 


Fie. 3598. 44 


the forehead, has been in a great measure obviated by 
giving to the connecting spring a decided forward slant 
(Fig. 3602*). All that has been said regarding the posi- 
tion of the glasses when mounted in spectacle-frames ap- 
plies equally to eye-glasses, and it is often possible, by 
taking sufficient pains, to fit up a pince-nez which shall 
prove a very tolerable substitute for a pair of spectacles. 
For mounting cylindrical 
and prismatic glasses they 
are especially unsuitable, 
by reason of the difficulty 
which is apt to be experi- 
enced in keeping them 
straight before the two 
eyes. The especial con- 
venience of eye-glasses 
lies in the fact that they 
are easily put on and off ; 
they are not well suited 
for reading, except for a 
few minutes at a time, 
nor for continuous wearing in distant vision. In most 
cases of asthenopia, and especially in progressive myo- 
pia, the wearing of a pince-nez should be prohibited. 
The different methods used in testing eyes for the cor- 


Fie. 3599. 


Fie. 3601. 
rection of the several refractive and accommodative de- 


fects, whether simple or complicated, have been already 
described under the titles Astigmatism, Hypermetropia, 


514 


‘any but the simplest questions. A person 

who hasarrived at the age of forty-five years 
& without having experienced any trouble in 

\ the continuous use of his eyes in near and 
distant work, may not be likely to commit 
any great error in buying weak convex 
glasses when he becomes conscious that he is 
beginning to suffer from the disabilities of presbyopia ; 
but even in such a case an examination of the eyes by a 
competent observer may bring to light some measure of © 


astigmatism which it may be well worth while to correct, 
or, possibly, some pathological condition which it may 
be of vital consequence to detect in its incipiency. The 
indiscriminate selling of concave spectacles and eye- 
glasses to young myopes, or to young 
persons hastily assumed to be myopic, is 
a most reprehensible, as it is, unfortu- 
nately, an almost universal practice. 

The power of convex and concave 
glasses, whether spherical or cylindrical, 
is expressed by numbers, with the plus 
(+) or the minus (—) sign prefixed. 
Two systems of numbering are in com- 
mon use, the older (inch) system, based 
on a unit-lens with two curved 
surfaces of equal radii of 1 
Paris inch; the other or new 
(metric) system, in which a lens 
of a focal length of 1. metre (di- 
optric ; D) is taken as the unit. 
In the older system it so happens, through an accidental 
relation of the Paris to the English inch, that the focal 
length of a bi-convex or bi-concave lens, of equal radii, in 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


English inches is almost exactly equal to the radius of 
curvature in Paris inches. The two systems may, there- 


Spectacles, 
Spectacles. 


Cylindrical lenses are numbered according to their 
power (in dioptrics) or focal length (in English inches) 
in the meridian at right angles to 
‘the axis. Lenses of unequal re- 


fraction in their two principal 


meridians are almost always made 


by grinding a spherical and a cy- 


lindrical surface upon the two 


sides of the same glass, and the 


Fre. 8602. 44 


fore, be regarded as based respectively upon unit-lenses 
of 1 English inch and 1, metre focal length. The differ- 
ence between the two systems consists essentially in the 
fact that in the case of the smaller unit, of 1. metre fo- 
cal length, the power of any lens of a power greater than 
this unit is expressed by a whole number or by a whole 
number and a decimal fraction, whereas in the case of 
the larger unit, of 1 English inch focal length, the power 
of every lens is expressed in the form of a vulgar frac- 
tion, with unity for its numerator, and the focal length 
of the lens, in English inches, for its de- 
nominator. Each system has practical 
advantages of its own, and neither is of 
such pre-eminent merit as to justify the 
total rejection of the other. Fortunately, 
the relation of the metre to the English 
inch is such as to admit of the use of the 
two systems interchangeably, by taking 
the metre-lens (dioptric) as practically 
equivalent to the lens numbered 7g in the 
inch system—an assumption which in- 
volves an insignificant error, and less than 
that which arises from the use, at different times and by 
different makers, of glass whose index of refraction is 
not always exactly the same. Tables I. and II. give the 
two series of numbers according to the two systems, as 
they are generally kept in stock by opticians, and for 
which grinding tools are ordinarily available. 


TABLE I, TABLE II, 
, F Inch Equiva- 
fete ee a ea ie quiva- || Metric System. lent. 
ractional ex- p : : ae ; 
_pression. ) (Dioptrics.) (Dioptrics. ) Seen: o 
1-144 0.277 0.25 1-160 
1-120 0.333 0.5 1-80 
1-96 0.416 0.75 1-53% 
1-84 0.476 1.0 1-40 
1-72 0.555 1.25 1-32 
1-60 0.666 ike 1-26% 
1-48 0,838 15 1-225/, 
1-42 0.952 2.0 1-20 
1-86 a te 2.25 1-177}, 
1-30 1.333 2.5 1-16 
1-24 1.666 male 1-14/,, 
1-20 2.0 3.0 1-13% 
1-18 2.222 3.5 1-113/, 
1-16 2.5 4.0 1-10 
1-15 2.666 4.5 1-88/, 
1-14 2.857 5.0 1-8 
1-13 3.07% 5.5 1-73/,, 
1-12 3.383 6.0 1-6% 
1-11 3.686 7.0 1-55/, 
1-10 4.0 8.0 1-5 
1-9 4,444 9.0 1-44/, 
1-8 5.0 10.0 1-4 
1-7 5.714 ial) 1-387/,, 
1-616 6.154 12.0 1-314 
1-6 6.666 13.0 1-3'/;5 
1-536 202 14.0 1-2°/, 
1-5 8.0 15.0 1-2% 
1-444 8.888 16.0 1-246 
1-4 10.0 18.0 1-22/, 
1-314 11.428 20.0 1-2 
1-34 12.307 Be 
1-3 13.333 : 
1-23 14.545 
1-21g 16.0 
1-24 17.777 
1-2 0 


formula for such a lens is written, 
for each surface, exactly as if the 
lens were made up of a plano- 
spherical and a plano-cylindrical 
lens with their plane surfaces in 
contact. The direction of the axis 
of a cylindrical lens or surface is defined by giving its 
inclination (in degrees of arc) to either the horizontal or 
the vertical plane of the eyeball. If the two surfaces of 
any lens, where they are cut by the axis of the eye, are 
nat parallel, the deviation from parallelism is expressed 
Za by the magnitude of 

Lows W. QUEEN 4 C0, py the angle which the two 

. , tangent-planes make to 

4 cach other, as if the 
two refracting surfaces 


Fie. 3603. 


were ground upon the.two surfaces of a prism ; 
the direction of the refracting angle of this 
prism is defined in the same manner as the di- 
rection of the axis of a cylindrical lens. 

In prescribing spectacles it is convenient and useful 
to lay off these angles on a printed diagram. Such dia- 
grams have been in common use in this country since 
1876, and are furnished, in a variety of forms, by most 
opticians. A spectacle frame (Fig. 3604) is shown in the 
position in which the wearer is supposed to look through 
it, and the angles are marked, in degrees, with the plus 
(+) sign to the right, and the minus (—) sign to the left 
of zero, which is taken at the upper end of the vertical 
meridian. A more usual, but less natural, system of 
marking the angle of inclination is by beginning with 
zero on the horizontal line, at the left side, and number- 
ing around the upper half of the circle to 180°. A half- 
circle is sufficient to designate the direction of the axis 
of any cylindrical Jens, but the whole circle of 860° is re- 
quired to indicate the different directions in which it may 
be necessary to turn the refracting, edge of a prismatic 
glass. 

The power of any (convex or concave) lens is most 
easily measured by placing over it an equivalent (con- 
cave or convex) lens, of known value, and looking 
through the two lenses at a straight line, such as a sash- 
bar of the window ; the equivalence of the two lenses is 
shown by the absence of any enlargement or diminution 
of the virtual image, as indicated by the immobility of 
the image of the (vertical) bar when the mutually neu- 
tralizing glasses are moved from side to side. In apply- 
ing this test to a cylindrical lens the axis of the lens must 
be so turned as to coincide in direction with the line used 
as a test-object ; in the case of a spherico-cylindrical lens 
the refraction may be measured in the two principal 
meridians in succession, the lesser of the two measure- 
ments representing the spherical, and their difference 
representing the cylindrical refraction when both sur- 
faces are of the same kind (7.e., convex or concave). The 
direction of the two principal meridians of a cylindrical 
or spherico-cylindrical lens is readily determined by hold- 
ing the lens in a plane perpendicular to the axis of the 


515 


Spectacles. 
Spectroscopy. 


eye, and looking, through its centre, at the sash-bar ; 
the lens is then rotated, in its own plane, until the direc- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


35 Vide Desmarres: Traité théorique et pratique des Maladies des 
Yeux. tome iii.. p. 706, 2me edition. Paris, 1858. 
36 fH, Jackson: Transactions of the American Ophthalmological Soci- 


tion of the image coincides exactly with the direction of | ety, Twenty-second Annual Meeting, pp. 268-77. G. Hay: Ibid., pp. 


a 
—. a 


& ere er ee 


! 
| 
1 
| 
i 
1 
i 
I 
i 
' 
1 
1 
| 
| 
| 
I 
‘ 
' 


— = ee. 


384-90. 1886. 
37 Donders; Op. cit., chap. iv., 
erste es 

38 Pierer’s Universal-Lexicon, ar- 
ticle Bernstein, neunte Auflage. 
Altenburg, 1867. 

39 J. Green: Transactions of the 
American Ophthalmological Soci- 
ety, Tenth Annual Meeting, p. 182. 
1874. 

40C. O. Curtman: American 
Journal of Ophthalmology, iii., 4, 
p. 106, April, 1886. 

41Cohn: Berliner klinische 
Wochenschrift, No. 8, 1868. Klin- 
ische Monatsblatter fur Augenheil- 
kunde, vi., S. 298, 1868. 

42 Giraud-Teulon: Physiologie et 
Pathologie Functionelle de la Vi- 
sion Binoculaire, ch. x., § 245. 
Paris, 1861. Scheffler: Die Physi- 
ologische Optik. Braunschweig, 
1865. Die Theorie der Augenfehler 
und der Brille. Wien, 1868. 

43 From the trade catalogue of 
James W. Queen & Co. Sixty-fifth 
edition, Philadelphia, 1886. 

44 From the trade catalogue of 
Meyrowitz Brothers. Second edi- 
tion, New York,. 1885. 


SPECTROSCOPY, MEDICAL. The 
spectroscope is an instrument for ex- 
amining the spectrum. <A spectrum is, 


4 

tay Poe 
Aepce ae las Le 24 ie ,u----~~. primarily, the series of colors produced 
> s when a ray of white light is transmitted 
the bar. This condition =e through any transparent body, the sur- 
is ‘fulfilled in two>posi. wait oh a ee eee faces of which are not parallel. The general form 
tions of the lens, at right which this transparent body takes is that of an 
angles to each other, in L equilateral prism of glass, the sides forming an 
which positions the di- ron, : : ; . angle of sixty degrees. Hollow prisms with sides 
rectionof one or the other *""*** a a ne Low Hoop at the same angle are also used, being filled with 

I@. . 


principal meridian coin- 
cides with the direction of the bar. The middle point of 
any spherical or spherico-cylindrical lens is readily found 
by noting the point at which the crossing of two sash- 
bars coincides in the image and in the object. 

John Green. 


1 Chaucer: The Wif of Bathes Tale. Canterbury Tales, v., 6785. 

2cheler: Dictionnaire d’Etymologie Frangaise, Nouvelle Edition, 
Bruxelles, 1873. 

3 Encyclopedia Britannica, ninth edition, article Beryl. 

4 Guy de Chauliac: Chirurgia Magna. Venetiis, 1546. 

5 Skeat: Etymological Dictionary of the English Language, Oxford, 
1882. 

6 Klein: HEulenburg’s Real-Encyclopiidie der gesammten Heilkunde, 
article Brillen. 

T Encyclopedia Britannica, ninth edition, article Microscope, 

®8 Paulus Aegineta: Lib. iii., sect. xxii. 

® Pliny: Naturalis Historia, lib. xi., cap. liv. 

10 Thid., lib. xxxvii., cap. xvi. 

11 Seneca: Naturales Questiones, lib. i., cap. vi. 

12 Pliny : Naturalis Historia, lib. xxxvii., cap. x. 

13 Thid., lib. xxxvi., cap. 1xvii. \4 Thid., lib. xxxiii., cap. xlv. 

15 Alhazen: Opticee Thesaurus (Latin version). Basilise, 1572. 

16 Klein: Eulenburg’s Real-Encyclopidie, article Brillen. 

17 Ceesemacker: Annales d’Oculistique, xvii., 1846. 

18 Klein: EKulenburg’s Real-Encyclopadie, article Brillen. 

19 Salvino degli Armati—inscription on his tombstone in the Church 
of Sta. Maria Maggiore at Florence, 

20 Bartisch: "OPOadmovdoAreia. Dresden, 1583. 

22 Mackenzie: A Practical Treatise on the Diseases of the Hye, p. 914. 
Fourth edition, London, 1554, 

22 De Sauvages: Nosologia Methodica, cl. vi. ord.i., iii, 3 and 4. 
Edo. Ultima. Amstelodami, 1768. 

23 Rosas: Handbuch der theoretischen und practischen Augenheil- 
kunde, Bd. i., § 648. Wien, 1850. 

24 Wollaston : Nicholson’s Journal of Natural Philosophy, vol. vii., 
pp. 143, 192, 242, 291; vol. viii., p. 88. London, 1804. Cited from Mac- 
kenzie, op. cit., p. 917, note. 25 Rosas: Op. cit., Bd. i., § 657. 

26 Airy: Transactions of the Cambridge Philosophical Society, vol. Lig 
p. 267. Cambridge, 1827. Cited from Mackenzie, op. cit., p. 928, note. 

27 Donders: Astigmatisme en cylindrische glazen. Utrecht, 1862. On 
the Anomalies of Accommodation and Refraction of the Eye, chap. viii. 
The New Sydenham Society, London, 1864. 

28 G. C. Harlan: Transactions of the American Ophthalmological So- 
ciety, Twenty-first Annual Meeting, p. 96. 1885. 

29 J, Green: American Journal of Ophthalmology, March, 1886. 

30 Donders: On the Anomalies of Accommodation and Refraction of 
the Eye, chap. iv., pp. 152-135. 31 Ibid., chap. iv., pp. 166-168. 

82 Bracke: Archiv fir Ophthalmologie, v., ii., S. 180. 1859. 

83 Brewster: Edinburgh Philosophical Transactions, xv., 1844. 

34 Donders: Op. cit., chap. iv., pp. 128-182. 


516 


transparent liquids. 

Sir Isaac Newton first made the observation that when 
aray of white light is transmitted through a prism the 
ray is not only bent out of its course, but is spread into 
an array of colors, the order of which is nearly invari- 
able, no matter what the source of light or the material 
of which the prism is composed. Since the facility of 
differentiating colors varies in different persons, the ex- 
act tints of the spectrum so formed are not easy to ex- 
press, but they are generally assumed to be seven in 
number, and arranged as follows: violet, indigo, blue, 
green, yellow, orange, red. If the ray of light be, as in 
Newton’s original experiment, admitted through an open- 
ing of appreciable dimensions, the colors will be somewhat 
confused and will appear unbroken, but when the open- 
ing is very narrow a more distinct effect is produced, 
and, as will be seen below, the spectrum is crossed by 
numerous dark lines. It is a law of the propagation of 
light that when a ray passes from one transparent sub- 
stance to another of different density it undergoes a de- 
flection, known technically as refraction. The direction 
and extent of this refraction depend on the nature of the 
materials and on the difference of the densities. When 
the ray passes from a rarer to a denser substance, for in- 
stance, from air to water, or from water to glass, the ray 
is bent (refracted) so as to be more nearly parallel toa 
line perpendicular to the surface of contact, while if the 
ray passes in the reverse direction, that is, from a denser 
to ararer body, as from glass to water, the refraction is 
away from the perpendicular. It is upon this principle 
that the image-forming and magnifying properties of all 
lenses depend. 

The accepted theories in regard to light refer it to very 
rapid vibration, and the difference between the various 
colors is supposed to be due to difference in the rate of 
vibration. White light is supposed to contain all the 
rates of vibration, and when such a ray undergoes re- 
fraction the different vibrations are refracted to different 
degrees, and hence are separated. If we view a ray 
through a plate of glass or other transparent body with 
parallel sides, the refraction produced in one direction on 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Spectacles, 
Spectroscopy. 


entering the glass is corrected by the refraction in the 
opposite direction on emerging, so that, with the excep- 
tion of a slight displacement of the line of light, no strik- 
ing optical change is manifest. If, however, the equi- 
lateral prism is used, the refraction on emergence is in the 
same direction as on entering, and the optical action is 
exaggerated. The separation of the different vibrations 
that compose aray of white light is called déspersion, and 
is not coextensive with refraction, that is, bodies of 
equal refractive power do not necessarily separate the 
colors to the same extent. This law is a very important 
one in practical optics, for all lenses are forms with more 
or less prismatic outlines, and hence produce a disper- 
sive effect. If it were only possible to prevent produc- 
tion of color by neutralizing the refraction, it would be 
impossible to construct any convenient optical apparatus 
free from colored images, but by combining different va- 
rieties of glass in such forms as to have equal and oppo- 
site dispersive powers with difference of refraction, large 
lenses entirely free from color defects (achromatic) may 
be constructed. 

In the spectroscope the object is to secure as complete 
and extended a dispersion as possible ; that is, to separate 
the colors thoroughly. For these purposes prisms of 
dense glass, or hollow prisms filled with carbon disul- 
phide, CSz, are used. 

The simplest method of examining the spectrum is to 
allow aray of light to enter a dark room or dark box 
through a small opening and fall upon a prism. Upon 
the side of the room opposite the opening will be seen 
a more or less confused spectrum, in which all the colors 
will be found diverted from the path which the original 
ray would pursue if it did not enter the prism, the violet 
being most diverted and the red the least. Such a method 
of observation, however, is unsuitable for scientific pur- 
poses. The most serious defect in it is that if the ray has 
an appreciable thickness the vibrations on one part inter- 
fere and overlap those of the other, so that the series of 
colors obtained is really a combination of a number of 
spectra not coincident with each other. To obtain a 
pure spectrum the ray must be reduced to an exceedingly 
tine line of light, in which there will be but few sets of 
vibrations. This is accomplished by using a very narrow 
slit, and shutting off all light from the prism except that 
which passes through this slit. The observation is also 
much facilitated by viewing the spectrum through a 
telescope of low magnifying power. 

About the beginning of this century Dr. Wollaston, an 
English chemist, discovered, by using such aslit, that the 
spectrum of sunlight is not continuous, but is interrupted 
by numerous fine, dark lines. He did not develop this 
observation, and it was not until 1814 that Fraunhofer, a 
German optician, rediscovered these lines and mapped 
the positions of a considerable number of them. Some 
of the most prominent he distinguished by letters of the 
alphabet. They have in consequence generally been 
known as the Fraunhofer lines. They are all at right 
angles to the direction of the spectrum, and their distance 
from each other depends on the dispersive power of the 
prism. Since each particular line is always seen in the 
same color, and is more easy to define than the limits of 
the color itself, these lines are preferred for purposes of 
comparison. 

Various improvements and advances in the construc- 
tion of apparatus for observing spectra have been made 
from time to time, until the spectroscope in its usual form 
consists essentially as follows: A straight tube terminates 
at one end by anarrow, upright, adjustable slit, and at the 
other a convex lens, the focal length of which is the dis- 
tance between it and the slit, so that the rays of light as 
they pass through the latter are rendered parallel by the 
lens. In the course of these rays is placed a dense glass 
prism, or series of prisms, greater dispersion being at- 
tained by acombination of prisms. A-movable telescope 
of low magnifying power, arranged so that it can be 
brought in the course of the rays emerging from the prism, 
enables one to view conveniently the spectrum formed. 
Such an arrangement constitutes a refraction spectroscope. 
In the cut there is shown a third tube, illuminated by a 


candle. This contains a graduated scale, an image of 
which is projected in the field of view above the spec- 
trum, for the purpose of measurement, as given below. 

Another form of the instrument depends on a some- 
what different principle, and as it is now in frequent use 
and possesses advantages over the older form it will be 
necessary to describe it. 

When the surface of a polished flat plate is ruled with 
a considerable number of fine lines in very close prox- 
imity, on viewing the plate obliquely, series of spectra 
are seen which are due to interferences in the different 
light waves as they are reflected from the angular sur- 
faces produced by theruling. This effect is called diffrac- 
tion, and a plate so arranged is called a diffraction grating. 
The superiority of such an instrument rests principally 
on the fact that in all parts of the spectra the colors are 
proportionately distributed. In the ordinary spectrum, 
as seen by the prism, the dispersion is proportionately 
greater toward the violet end, and consequently this por- 


Zn ci 


Fie. 3605. 


tion is abnormally spread out and the distances between 
the dark lines are exaggerated. 

Spectra, by whatever method observed, may be divided 
into three groups: 

1. Continuous spectra: Those in which a more or less 
continuous sheet of color is seen, usually beginning with 
violet and ending with red. Such spectra are produced 
by the light which is emitted from solid objects in a 
highly heated state. 

2. Interrupted, or bright-line spectra : Those in which 
the colors are seen in the form of narrow lines or bands, 
separated by proportionately wide, dark spaces. Such 
spectra are derived from light emitted by gaseous bodies 
in a highly heated condition. 

3. Absorption spectra: Those in which a nearly contin- 
uous series of colors is present, but interrupted by dark 
lines or bands. Such spectra are produced by various 
conditions, principally, however, by the transmission of 
white light, or light which would give a continuous 
spectrum, through substances which have the power of 
absorbing or annihilating special vibrations. In the ap- 
plications of the spectroscope to medicine and organic 
chemistry these absorption spectra are the most impor- 
tant. 

It is obvious from the above considerations that we 
have in the spectroscope, whether of the refraction or 
diffraction form, a“very valuable means of studying 
structure. In the first place, we can determine with 
great exactness the character of the source of light, 7.e., 
whether it is composed of gaseous matter intensely heated 
or of solid particles. Further, taking a source of known 


517 


Spectroscopy. 
Spectroscopy. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


character, we can, by interposing various substances in 
the path of the light, determine the effect which those 
substances produce upon the different forms of light 
vibrations present in the ray, and as particular effects 
are often peculiar to particular bodies, we have here a 
means of identification. Thirdly, using a source of heat 
practically non-luminous, such as the flame of the Bun- 
sen burner, we can detect different substances by the 
color they impart to this flame, and when several such 
substances are present the eye alone is unable to separate 
and distinguish the colors, but by the spectroscope each 
tint is distinctly indicated. 

As stated above, it is the absorption spectra that are 
most important in reference to the medical applications 
of the spectroscope. Except in the comparatively rare 
cases of the study of the character of light emitted by 
luminous organic bodies, living or dead, and in the detec- 
tion of certain metals present in minute amount in the 
tissues and secretions, é.g., lithium, the direct study of 
normal spectra is not much resorted to in biological work. 

The arrangement of the spectroscope for observation of 
absorption spectra is simple. An oil- or gas-flame is ad- 
justed so as to throw a beam of light through the slit 
of the instrument, by which a continuous spectrum not 
broken at any point by dark lines is obtained. Sunlight 
does not answer so well for the purpose, because, owing 
to certain interfering conditions occurring at the surface 
of the sun, and also during the passage of the sunlight 
through our atmosphere, there are numerous absorption 
bands (Fraunhofer’s lines) always present in its spectrum. 
The material to be examined is placed in a cell with flat 
sides.in the path of the light before it enters the slit. It 
is scarcely necessary to observe that to secure a satisfac- 
tory result the body must be sufficiently transparent to 
permit some light to pass through, otherwise no compar- 
ison as to the effect on different parts of the spectrum 
can be made. Such a condition is easily obtained by 
using solutions of the substance in the usual colorless sol- 
vents—water, alcohol, ether, glycerine, etc., and diluting 
until a satisfactory result is obtained. The character of 
the absorption spectra sometimes differs, according to the 
solvent used and the presence of free acid or alkali. 
Working spectroscopes are generally arranged so that 
two spectra can be compared, one being a. standard ob- 
tained under known conditions, the other being that of 
the body to be tested. 

To understand the functions of the spectroscope it is 
necessary to bear in mind that the colors seen are practi- 
cally images of the slit through which the light passes, 
and that when the ray contains all the colors, that is, 
every vibration from violet to red, the prism, in setting 
out the vibrations according to dispersive-power, gives, 
of course, a continuous series of images, that is to say, 
a continuous spectrum. When, however, in the ray of 
light that enters the slit any vibrations are missing, as 
in sunlight, or when by some interposed condition cer- 
tain colors are struck out of the ray, the images which 
would otherwise be formed by those rays are missing, 
and hence the spectrum appears interrupted. When the 
interposed substance strikes out many rays, eg., deep- 
colored glasses, the great bulk of the spectrum is miss- 
ing. The red glasses, for instance, used in photographic 
dark-rooms strike out all rays but the red. The spectro- 
scope as ordinarily constructed is, unfortunately, subject 
to serious defects, which can be avoided only by instru- 
ments of very expensive form. It has been found that 
all the forms of glass possess marked absorption powers 
for certain rays of light. If, instead of employing glass 
lenses and prisms, we use those made of quartz, and em- 
ploy as a source of light the electric arc, or burning mag- 
nesium wire, a spectrum is obtained which is very much 
extended at the violet end. This portion of the spec- 
trum exists to a greater or less extent in white light from 
any source, but 1s absorbed to such an extent by glass 
that it is not seen in the ordinary spectroscope. There 
are also color waves beyond the red, which are only de- 
monstrable by special apparatus. In the usual applica- 
tions of the spectroscope we cannot, therefore, utilize the 
so-called ultra-red and ultra-violet rays. 


518 


A very important advance has been made recently in 
practical spectroscopy in the application of photography. 
A sensitive plate is capable of responding to and record- 
ing conditions which the eye is unable to recognize, and 
we have, therefore, not only a method of extending our 
knowledge of spectra, but we may obtain permanent 
records of absolute accuracy, and independent of any 
general or special defects in vision. This method is yet 
incompletely developed, but it promises well. The pho- 
tographic plate is especially capable of receiving impres- 
sions from the violet and ultra-violet portions of the 
spectrum, which are especially those which the eye ap- 
preciates with the greatest difficulty, while the yellow 
and red rays are practically inactive. . 

Many substances are known which have the power to 
retard the rate of vibration of light rays, so that they 
change the color of the light falling on them. Now, the 
ultra-violet rays, which are inappreciable to the human 
eye, are caused by extremely rapid vibrations ; any sub- 
stance which will reduce this rate will bring the rays 
within the range of vision. This property is known as 
fluorescence. It does not come within the scope of this 
article to more than refer to it, but it may be men- 
tioned that one of the most recent advances in the prep- 
aration of photographic plates is to incorporate into 
the sensitive material some fluorescent body by which 
the rays of light are modified and effects produced with 
colors that would otherwise be inactive. It is not un- 
likely that we have in this method a line for still further 


‘extension of the application of photography to the spec- 


troscope. 

The only way of acquiring familiarity with spectro- 
scopic appearances is by actual use of the instrument. 
No drawing, colored or otherwise, can convey perfectly 
the appearances, Nevertheless, a method of indicating 
the character and position of the lines is useful, and sev- 
eral plans have been adopted. The use of colored plates 
is, of course, the most vivid, but too costly for most pur- 
poses. The usual methods are either by recording the 
position of any line, or the centre of a band, by its posi- 
tion on an arbitrary and fixed scale, or by angular posi- 
tion. A form of spectroscope made by Browning, of 
London, has this latter arrangement. The view telescope 
moves in a graduated arc, and cross lines in the field en- 
able it to be brought to exact position with any line. 
By such method or by the scale the lines may be mapped 
in their relative positions as seen in that particular in- 
strument. 

Another method is to indicate the positions of lines 
by their calculated wave-lengths ; that is, the length of 
one complete movement constituting the ray which pro- 
duces a line at the given point. Such a method has the 
advantage of being an absolute indication, and not de- 
pendent on any particular instrument. Wave-lengths are 
determined by mathematical calculation by means of the 
phenomena observed in diffraction, and the calculation 
may be easily applied to ordinary cases by plotting off on 
a chart certain lines of which the wave-lengths are known, 
and interpolating those of which it is desired to deter- 
mine the wave-length. ‘These lengths are very minute, 
and are usually expressed in millionths of a millimetre. 

DESCRIPTION OF SPECIAL SPECTRA. DBright-line Spec- 
tra.—Each of the known elements gives a special and 
distinct spectrum when heated sufficiently to become a 
luminous gas. It has been pointed out at the beginning 
of the article that solid substances give continuous spec- 
tra, and hence there is no appreciable difference between 
the spectroscopic appearances of the different elements as 
long as they remain solid bodies. When the temperature 
rises sufficiently to convert them into gases, and render 
them at the same time luminous, the characteristic bright- 
line spectra are obtained. This temperature can be at- 
tained with most elements only by the use of the electric 
spark. A few bodies, among which are potassium, so- 
dium, lithium, barium, calcium, strontium, and boron, 
yield at the temperature of the non-luminous gas-flame— 
Bunsen-burner flame—a limited number of rays which 
are early observed by the spectroscope as bright lines. 
Thus sodium imparts to flame a deep yellow color which 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Spectroscopy. 
Spectroscopy. 


consists of two tints, and is seen in the spectroscope as 
a narrow double line. Potassium gives red and violet 
lines. By increasing the temperature some of these spec- 
tra are modified. When the electric spark is employed 
the spectra obtained are usually more complex, the bright 
lines being numerous. The detection of the different 
elements by this means is not so widely applicable as 
might at first be supposed, for the method is extremely 
delicate, and it is difficult to distinguish between the mi- 
nute traces which often have no significance and the pres- 
ence of an appreciable amount. Nevertheless, the method 
has been of great usefulness in special cases in showing 
the occurrence of some elements in unexpected relations, 
and the wide distribution of others in minute quantities. 
Several elements have been discovered by the spectro- 
scope, occurring in such minute quantities that ordinary 
chemical analysis would have failed to indicate them. 

There are a few rare metals which give a limited bright- 
line spectrum before reaching the temperature at which 
they became gaseous. | 

Absorption Spectra.—These are of several kinds. The 
absorption may affect a considerable part of one or both 
ends of the spectrum, by which a whole block of color 
may be cut out, or it may take place in broad bands or in 
fine lines. The spectrum of the sun and of many of the 
fixed stars is an example of this latter class. The lines of 
absorption are numerous, but they are narrow and repre- 
sent but a small portion of the entire field, which appears 
to the unassisted eye to be a uniform sheet of color. 
Band absorption, that is, the cutting out of a considera- 
ble number of rays at some point on an otherwise con- 
tinuous spectrum, is brought about very easily by means 
of many organic bodies. 

Extended absorption, by which a considerable portion 
of the spectrum is absorbed, is seen in many substances 
possessing deep color, and the absorption may include all 
but a single color. Various colored glasses may be used. 
To test the effect of a graduated increase of color, wedge- 
shaped glasses may be employed. Hollow wedge-shaped 
cells are often used for the examination of colored liquids. 

The method of observing absorption spectra has been 
given above. It has been also already pointed out that 
no description, nor even drawing, can give an adequate 
idea of the actual appearances of spectra, but for the 
purpose of completing the article and indicating some of 
the practical applications of the methods a few absorp- 
tion spectra will be described. 

Line-absorption Spectra.—Some of the rarer elements 
possess the peculiar property, when in solution, of ab- 
sorbing special rays of light. Among the best known of 
these is the metal didymium, which occurs only in some 
moderately rare minerals. Its compounds have a delicate 
but distinct rose-red tint, but even when so far diluted as 
to make the tint not perceptible, they give several ab- 
sorption-bands about the middle of the spectrum, The 
vapors of bromine and of nitrogen dioxide, NO, which 
to the eye have much the same color, give each a pecul- 
jar series of numerous fine absorption-lines in the central 
part of the spectrum. The absorption-lines that normally 
occur in the spectra of the sun and stars are an impor- 
tant clue to the chemical composition and physical con- 
dition of those bodies, but a consideration of this topic 
does not belong here. 

Band-absorption.—One of the most familiar and strik- 
ing instances of this form of absorption is seen in chloro- 
phyll, which is the general term under which the green 
coloring matter of plants is designated. <A solution of 
this substance is easily obtained by macerating leaves 
with ether or alcohol. The filtered liquid being diluted 
so as to be fairly transparent has a beautiful green color 
by transmitted light, and when viewed through the spec- 
troscope transmits all the colors except a band in the ex- 
treme red, at which point there appears a well-marked 
broad dark band. The position of this band is highly 
characteristic of this substance, and can be detected by 
careful observation, even when the solution is too dilute 
to exhibit the color to the eye. In this way the adulter- 
ation of animal oils by vegetable oils—for instance, of 
lard-oil by cotton-seed oil—may often be detected, for cot- 


ton-seed oil exhibits the absorption-band of chlorophyll 
derived from the vegetable tissue. f 

Valuable use is made of absorption spectra in detecting 
the nature of various natural and artificial coloring mat- 
ters. Fuchsine, for instance, not infrequently employed 
as an artificial coloring matter in wine, gives a broad but 
not very sharply marked band about the junction of the 
green and yellow of the spectrum. 

It is, however, with reference to the absorption-bands 
produced by the fluids of the animal body that the clini- 
cal applications of the spectroscope are seen. The most 
important of these are the appearances seen in blood 
under various conditions. These appearances are due to 
the hemoglobin. As ordinarily seen by examining blood 
much diluted with water, the spectrum is that of oxidized 
hemoglobin, oxyhemoglobin. The dilution must be suffi- 
cient to allow considerable light to pass, and a modification 
of the absorption spectrum is obtained by continually add- 
ing water until no absorption at all occurs. The same ef- 
fect may be produced by examining the solution through a 
wedge-shaped cell, gradually diminishing the thickness of 
the solution through which the light passes. The effects 
are briefly as follows: In rather strong solution, all the 
light is cut off except a portion of the orange and red ; 
when the solution is diluted somewhat, green rays are 
transmitted, and the dark interval between these and the 
orange constitutes a broad absorption-band ; still further 
dilution produces a yellowish-green mass of light divid- 
ing the dark space into two nearly equal portions, develop- 
ing, therefore, two well-marked absorption-bands. On 
still further diluting, the absorption becomes reduced to 
a single band in the yellow. When to a solution of blood 
of sufficient density to give the two bands we add some 
reducing agent, 7.e., some body having an affinity for 
oxygen, the hemoglobin is reduced, and a new spectrum 
is obtained. For this reduction ammonium sulphide is 
preferred. The spectrum of reduced hemoglobin is a 
single band, broader than, and not exactly coincident 
with, either of the bands obtained from oxyhemoglobin, 
the darkest portion corresponding to the mass of light 
dividing the two bands in that spectrum. ‘The chemical 
condition of the blood in the vessels may in this way be 
tested. Another important result is in determining the 
effect of various gases and chemical substances in blood, 
either by direct action or by poisoning animals and quick- 
ly subjecting the blood to examination. If we examine 
blood charged with nitrous oxide (N.O), we find the 
spectrum of reduced hemoglobin, but agitating the blood 
with air will reproduce the oxyhemoglobin. When, 
however, carbon monoxide (CO), carbonic oxide, is in- 
troduced into blood, we get a new condition which gives 
a spectrum resembling, but not identical with, that of 
oxyhemoglobin, there being two bands, but their posi- 
tion being slightly nearer the violet. 

Furthermore, we cannot so easily restore the original 
condition by agitating the blood with air, nor will the 
ordinary reducing agents produce the spectrum of re- 
duced hemoglobin. Carbon monoxide is known to be 
one of the most active of the gaseous narcotic poisons, 
and the above observations show, in part, at least, the pe- 
culiar action it has on the essential breathing constituent 
of the blood. The carbon-monoxide-hemoglobin—caro- 
oxyhemoglobin—spectrum is seen in the blood of persons 
poisoned by coal-gas or fumes of burning charcoal, and 
an examination of the blood by the spectroscope in cases 
of this character may be animportant medico-legal point. 
Another important modification of the hemoglobin is 
produced by the action of sulphides, especially by hydro- 
gen sulphide (H.S), sulphuretted hydrogen. This gas is 
often present in sewer air, cesspool exhalations, and other 
foul places, but not invariably, nor in so great quantity 
as is generally supposed. When its action upon blood 
is examined we find a spectrum which presents the broad 
single absorption-band of reduced hemoglobin (see above), 
but in addition a band in the red just at the junction with 
the orange. This band does not disappear on shaking 
the blood with air, although the two bands of oxyhemo- 
globin appear. The body produced by the action of hy- 
drogen sulphide on blood, and to which the properties 


519 


Spectroscopy. 
Spermatozoa. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


above described are due, has been called sulphamoglobin. 
It has been noticed that this substance cannot be formed 
by the action of hydrogen sulphide on reduced hemo- 
yglobin, which is the form which exists in the veins ; hence, 
hydrogen sulphide may be introduced into the venous 
circulation without marked effect, but taken into the 
arterial system it is very dangerous. The difference be- 
tween inhalations of this gas, by which it would get di- 
rectly into arterialized blood, and its introduction into 
the system through the veins, has been shown strikingly 
in the recently employed method of treating phthisis by 
injections of hydrogen sulphide and carbon dioxide. In 
this case the gas is taken up by the veins of the portal 
system and excreted before it comes in contact with the 
arterial blood. 

If a solution of blood be exposed to the air for some 
time it undergoes various changes, accompanied by an 
alteration in the absorption spectrum. This alteration 
can be brought about by the action of weak acids, and 
also of potassium permanganate, on blood. <A substance 
called methemoglobin isformed. Its absorption-bands are 
three, nearly coincident with those seen when sulphzmo- 
globin is shaken with air, but one band is more com- 
pletely within the limits of the red. Methemoglobin is 
believed to be a highly oxidized hemoglobin, but its con- 
stitution is in some doubt. 

Many other changes in the absorption spectra of blood 
are known, but while the investigation of them has much 
to do with physiological chemistry, the matter is too tech- 
nical for discussion here. It is obvious, from what has 
been said, that very important medico-legal, toxicologi- 
cal, and even clinical questions can be determined by 
means of the spectroscopic appearances. The different ef- 
fects produced on blood by different poisonous gases and 
vapors, the general symptomatology of what may be the 
same, offers a means of determining even post-mortem the 
character of the gas, and as an aid in the study of the 
so-called sewer-gas poisoning the spectroscope will be 
valuable. 

Clinically, the spectroscopic appearances may be util- 
ized for examining the fluids of the body either in their 
normal or abnormal condition. The spectrum of bile, for 
instance, may be utilized for the detection of it in the 
urine, for when the color reaction is too faint to be per- 
ceived by the unassisted eye, the spectroscope will show 
it. Normal urine contains a coloring matter believed 
to be derived from a constituent of bile, which gives a 
broad absorption-band on the green. In certain febrile 
affections another band appears, also in the green, toward 
the border of the yellow. Blood in urine may also be 
detected by the spectroscopic tests. If in solution in the 
urine, the absorption spectrum is seen without difficulty. 
If the blood be present in the form of methemoglobin, 
as is sometimes the case, it will give the three bands 
peculiar to that body, but it is necessary to distinguish 
these bands from those produced by a decomposition 
product of hemoglobin known as acid hematin. This dis- 
tinction can be made by the use of ammonium sulphide, 
when, if methemoglobin is present, the band of reduced 
hemoglobin, as described above, will appear. If the 
blood is in the insoluble form no absorption-bands may 
be shown. In this case the blood is filtered and the filter 
paper treated with alcohol and ammonia, and then with 
ammonium sulphide; bands appear which are due to re- 
duced hematin formed by decomposition. 

In the accompanying map are shown some of the im- 
portant absorption-spectra as seen in a refraction spectro- 
scope of moderate power. Over the plate has been placed 
indications of the limits of the various colors, but these 
must be regarded as a mere approximation, as it is not 
possible to determine precisely at what point one color 
ceases and another begins. The dotted lines at each 
end of the plates represent the limits of the visible spec- 
trum in each case, and it will be noticed that:there is 
considerable extinction of color, especially toward the 
violet end. A represents the spectrum of sunlight, with 
some of the principal absorption-bands, and the letters 
which distinguish them. All these bands, as has been 
remarked above, are absent in the light of ordinary 


520 


flames and electric lights. The observation of absorp- 
tion-spectra being made with artificial light does not 
therefore show any such bands. B shows the absorption- 
bands of oxyhzemoglobin. The visible spectrum, it will 
be seen, extends only from green to a short distance on 
the red. C shows the spectrum of reduced hemoglobin. 
The limits of the visible spectrum are extended slightly 
toward the violet. D is the spectrum of carboxyhemo- 
globin, that is, of blood impregnated with carbon mon- 


oxide. E is the spectrum of methemoglobin, F is the 
red orange yellow green blue indigo 
ADDI D Eb F G 
A 
* 
t 1 B 
{ | 
5 I 


Y i 
t 
i Y 
1 ‘6 
I 1 
I | 
I E 
| | 
: 
a ! 
e ! 
Fre. 3606. 
spectrum seen commonly in normal urine. The broad 


band is at about the junction of the blue and green and 
is somewhat faint. 

Very little practical clinical application, however, is 
yet made of these spectroscopic appearances. The in- 
struments required are expensive and unfamiliar, and 
hence unsuited to the general uses of the practitioner. 
The use of the spectroscope in the detection of various 
natural and artificial colors, and in the recognition of 
blood-stains, belongs to special treatises. 

Z Henry Leffmann. 

SPERMACETI (Cetaceum, U. S. Ph., Br. Ph., Ph. G.;. 
Blane de Baleine ou Cétine, Codex Med., Sperma-Cet?). 
A solid, paraffine-like substance obtained in connection 
with oil, in cavities or cells in the head of the sperm- 
whale, Physeter macrocephalus Linn., order Cetacea. 

This enormous mammal, the largest living animal, 
measuring from forty to sixty, or even eighty feet in 
length, has the general structure and shape of other 
whales, but is distinguished by its enormous head, one- 
third or more as long as the entire body, a single nostril, 
a very large upper jaw, which is toothless, and a much 
shorter and smaller lower one, bearing twenty or more 
pairs of conical simple teeth. Eyes small, near the base 
of the head ; ears inconspicuous. The body tapers back- 
ward from the head, bears a small dorsal fin, and a hori- 
zontally bifurcated tail. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Spectroscopy. 
Spermatozoa, 


This whale is gregarious in its habits and is found in 
the ocean waters of both hemispheres, from the extreme 
north to the tropics. It is hunted for its oil, which is 
one of the most valuable of its class. 

Spermaceti, or rather the crude fat, is a semi-solid, yel- 
low substance as it is scooped out from its reservoirs, 
but becomes hard and brittle upon exposure to cold ; for 
purification it is then pressed in bags, when the oil 
Hinge through, and the solid cetaceum is left behind. 
This can be further purified by melting in water, skim- 
ming, and recrystallization. Purified spermaceti is a 
pearly white, glistening, crystalline, translucent, odorless, 
and tasteless solid, insoluble in water ; soluble in ether, 
chloroform, and boiling alcohol. Melting-point 111° to 
112° F. It is mostly composed of palmitic acid combined 
with cetyl (instead of glycerine); there are also small 
quantities of compounds of stearic, myristic, and lauric 
acids. It is pretty permanent in the atmosphere, in this 
respect excelling most fats. 

Usre.—Spermaceti has no active medicinal qualities. 
It is sometimes used in sore throats, etc., where its value 
is mostly as a protective. Its principal employment in 
medicine is as an ingredient of cerates and ointments, to 
which it gives consistency, blandness, and permanence. 
The following are officinal : Cerate of Spermaceti (Cera- 
tum Cetacet, U. 8. Ph.), spermaceti, ten parts ; white 
wax, thirty-five parts; olive-oil, fifty-five parts; an 
elegant, white, nearly odorless salve; and Cold Cream 
(Unguentum Aque hose, U. 8. Ph.), of the following 
composition : 


Expressed oil of almond....... fifty parts 
PPeLgcell Ce eh cee it cess ten tie 
IVY EIU CES We AY othe err teen eoree . oh tem sf 
Byosee Water tt ite cee amet. 4 ga dev pts 


ALLIED ANIMALS.—Several species of whales, besides 
numerous other Cetacea, are hunted for their valuable, 
and generally very permanent, oils. ° 

ALLIED SuBsTaANcES.—The ordinary solid fats and 
tallows, wax, and paraffine. Ambergris is a peculiar, 
odorous concretion found in the intestines of the sperm 
whale. W. P. Bolles. 


SPERMATOZOA. In this article there is: 1, a brief 
summary of the structure 4nd development of spermato- 
zoa; 2, a fuller account of the mature spermatozoa ; 8, 
a detailed history of spermatogenesis in mammals; 4, a 
few historical notes. 

1. Summary.—The spermatozoa of mammals are fila- 
ments, consisting of a short thicker end called the head, 
and a very long and delicate thread called the tail. The 
head varies greatly in shape, according to the species ; in 
man it is broad and thin (Fig. 3609), and is widest at 
a little distance from the tail. The head contains chroma- 
tine, and may be colored by the usual nuclear dyes. The 
tail consists of three parts: 1, the meddle piece, next 
the head, and which is the thickest of the three ; it con- 
tains an axial thread, and probably always has a very fine 
spiral thread running round it; 2, the main piece, and, 
3, the end piece, which is not more than a line, even as 
seen with very high magnifying powers. The human 
spermatozoon is 0.055 mm. long—the head being 0.005 
mm., the tail 0.050, and the middle piece 0.009. 

The development of the mammalian spermatozoa be- 
gins with a so-called parent- or mother-cell, which lies 
near the outer wall of the seminiferous tubule. The 
mother-cell produces a number of daughter-cells, which 
also multiply by division ; the daughter-cells break down, 
forming a column of matter (protoplasm), in which lie 
their nuclei, and at the base of which lies the nucleus of 
the mother-cell; the nucleus of the mother-cell and the 
column of matter both ultimately disappear, but exactly 
how is not determined ; the nuclei of the daughter-cells 
produce each a spermatozoon. The head and tail of the 
future spermatozoon become visible within the nuclear 
membrane ; the head is formed chiefly by the chromatine 
of the nucleus; the nuclear membrane finally ruptures, 
and it, as well as the contents of the nucleus, which have 
not taken part in the formation of the spermatozoon, are 


4 


lost; among the lost parts is a special round body of 
small size, which appears in the nucleus while the sper- 
matozoon is developing ; this body may be stained by 
chloride of gold, but not by hematoxyline; its signifi- 
cance is unknown. The long column holding the sper- 


‘matozoa together has usually been regarded as a cell, 


and is the supporting-cell duct. 

2. SPERMATOZOA are the essential fertilizing elements 
secreted by the male gland. They are minute bodies 
capable of active locomotion, and present always a form 
characteristic of the species. In a few instances (certain 
snails, etc.) there are two distinct forms of spermatozoon 
for a single species, but usually there is only one form, 
and that little variable. In a small number of animals 
the spermatozoa, as in the nematods, are distinctly cell- 
like, but in the great majority of animals, and so far as I 
know, in all vertebrates, they are long and thread-like ; 
hence their common German name, Samenfdden, first 
proposed, I think, by Kolliker. 

The mammalian spermatozoa are long, slender bodies, 
varying considerably in configuration (cf. Fig. 3607), but 
all presenting at least the following feat- 
ures in common: One end is thickened 
and is called the head; it has a strong 
affinity for nuclear staining fluids ; this 
affinity must be attributed to the chro- 
matine which the head contains, as is 
shown by the history of its develop- 
ment; the remainder of the spermato- » 
zoon is long and slender, and constitutes 
the tail; the tail consists of, 1, a middle 
part (Mittelstiick), a little thicker than 
the rest, and situated next to the head; 
the middle part is traversed by a very 
fine axial thread, and ends abruptly ; 
and, 2, a hind piece, which, according 
to some writers, may be subdivided 
naturally into two segments, the main 
piece (Hauptstiick) and end piece. 

The spermatozoa of the various spe- 
cies differ in size in the proportions of 
the parts, and often very strikingly in 
the shape and structure of the head ; 
those of the opossuin are especially re- 
markable for being double: two appa- 
rently complete spermatozoa being unit- 
ed to a common plate by their heads 
(Selenka: ‘‘ Studien tiber Entwickel- 
ungsgeschichte,” Heftiv., p. 106). Twin 
spermatozoa have also been observed in 
the rat by Neumann (p. 313, Taf. xvii., 
Fig. 16, 5).3° Compare also Max von 


Brunn and Brock.® The largest ¥1¢, 3607.—Sperma- 

known mammalian spermatozoon is 4 common mouse: 
. 2 

perhaps that of a marsupial, phascogale ;__ ¢, bat. 


the spermatozoon of this animal is 0.263 

mm. long, the head, however, being only 0.0138 mm. 
(Fiirst, p. 354).2° The spermatozoon of the rat is 0.144 
mm. long—the head 0.009, the tail 0.185, and the ‘‘ mid- 
dle” piece 0.045 mm. 

La Vallette ® gives a synopsis concerning the forms of 
vertebrate spermatozoa nearly as follows: Mish: The 
spermatozoa of amphioxus are threads with round heads. 
In petromyzon the head is rod-like or egg-shaped. The 
teleosts generally have pin-like spermatozoa ; but in the 
salmonidee (Owsjannikow) the head is pointed and 
shaped like a heart pip. The spermatozoa of selachians 
are much larger, with the head end spindle-shaped and 
often spirally twisted. Amphibia: The head is long, 
generally pointed, the middle piece short, and the tail is 
often provided with an undulatory membrane (Retzius**). 
Reptiles and birds: The head is usually long, often twisted. 
Mammals: The head is more or less elongated, and gen- 
erally, in ungulates, the head is flattened and usually 
more or less egg-shaped in outline, the pointed end to- 
ward the tail. Among rodents there is considerable va- 
riety of form. In the dog the head is pear-shaped ; in 
the hedge-hog the head is truncated inferiorly and the 
tail is inserted laterally. No comprehensive summary of 


521 


Spermatozoa. 
Spermatozoa. 


the observed forms of spermatozoa has been made since 
the publication of Wagner and Leuckart’s®! article in 
‘“Todd’s Cyclopedia.” 

The most minutely studied mammalian spermatozoon 
is that of the rat, thanks especially to the patience of O. 
S. Jensen, whose posthumous paper *® furnishes the ba- 
sis of the ensuing description. The rat’s spermatozoon 
measures 144 »; its head (Fig. 3608, B) is a broad hook, 
pointed at one end and obliquely 
truncated at the other; from one 
corner of the truncated end starts the 
very long, slender tail, which is di- 
visible into the thicker middle piece 
(Mittelstiick, or Jensen’s Verbindungs- 
stick) and the thinner main piece 
(Haupistiick) (Fig. 3608, C), which 
terminates in a short and still finer 
thread, called the end piece (Hnd- 
stick). The appearance of the sper- 
matozoon varies according to its de- 
gree of development, it not attaining 
full maturity until it has left the sem- 
iniferous tubule. The changes re- 
ferred to affect principally the head 
and the middle piece. The head is 
covered, while the spermatozoon re- 
mains in the seminiferous tubules, by 
a membranous cap (Fig. 3608, C), 
which subsequently disappears. The 
middle piece has a spiral thread run- 
ning round its outside (Fig. 3608, A). 
The spiral thread appears soon after 
the rupture of the nuclear membrane, 
by which the developing spermato- 
zoon is set free (cf. ¢nfra). The 
thread is at first indistinct and makes 
only a few turns; it rapidly becomes 
more distinct, and the number of 
turns increases, until they become so 
numerous that in a spermatozoon 
taken from the vas deferens only a 
series of thick-set cross-lines can be 
distinguished ; these lines have been 
seen by several observers, and vari- 
ously interpreted; the spiral ma 
run to the right or to the left. The 
; thread becomes loosened off by the 
Fre. 3608.—Structure of 2Ction of glycerine (1 part) and -water 

Rat’s Spermatozoon, (4 parts), and is destroyed in one to 

(After Jensen.) A, two hours by 0.6 per cent. salt solu- 

Young spermatozoon, tion, leaving then the axis uncov- 

end ofthe middle piece | < : 

and beginning of the Cred. The thread can be stained by 

main piece, to show Chloride of gold, though the axis 

the spiral thread cannot. The axis, when the sperma- 

head, with part of the t0Z0a are treated with acetic acid, 

axial thread; C,.im- Often breaks up into threads (cf. 

mature spermatozoon, Ballowitz'); it shows a lighter line 

anterior half only. —_ in its centre. These observations lead 
Jensen to the conclusion that the axis is formed by a 
wall of fibrille surrounding a central core or cavity. 
The axis does not reach quite to the head, but ends with 
a little knob, leaving a small, perfectly transparent space 
between the knob and the head (Fig. 3608, B). In some 
spermatozoa—e.g., horse and ox—though not in those of 
the rat, there is a minute opening in the head, called the 
microporus, and situated just opposite the knob of the 
axis. When the spermatozoa are stained with nuclear 
dyes, most of the head is colored, but the tip of the hook, 
which contains no chromatine, and is probably formed 
out of a scrap of the nuclear membrane, remains uncol- 
ored ; on the concave side of the tip a fine line can be 
distinguished, due, apparently, to a rod of substance. 
Sometimes a minute fragment of the nuclear membrane 
is left adherent to the lower end of the middle piece; 
for the explanation of this possibility, compare the sec- 
tion below on development. 

The human spermatozoa are described by Retzius, 
p. 85,* as follows: 

The head, seen from the flat side, appears oval (Fig. 


522 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


3609, A), with the front end generally tapering a little, but 
never pointed; the anterior half or two-thirds has a 
brighter and more transparent part. Seen on edge (Fig. 
3609, B), the head has a pointed form, with 
a posterior, thicker, round, dark part. By 
adjustment of the focus it can be ascer- 
tained that the sides near the point are de- 
pressed, somewhat like those of red blood- 
corpuscles. Retzius could nowise succeed 
in demonstrating a special tip (Spiess) cor- 
responding to that in the salamander. The 
following piece (Schweigger-Seidel’s Mit- 
telstiick) is directly united with the head 
by a transverse joint ; there is no neck in 
Eimer’s sense ; the middle piece is cylin- 
drical and relatively small, about as long, 
or a little longer, than the head ; its sur- 
face is often granular or rough, and there 
cling to it a few shreds of protoplasm, as 
has been described by several investiga- 
tors ; the spiral thread could not be distin- 
guished. The main piece of the tail is 
about half as thick as the Mittelstiick, 
gradually tapers, and ends abruptly at the 
beginning of the still finer and very short 
end piece. ‘There is, according to Retzius, 
no membrane such as has been described 
by Gibbes,?? whose account has received 
Krause’s *” #! confirmation. It seems to me 
probable that there is a spiral thread, which 
may be loosened by maceration, as is the 
Fre. 3609.—Hu- case with the rat, and that such altered 

man Spermato- spermatozoa were seen by Gibbes, and led 

zoa. (After him to assume the existence of an undula- 

etzius.) A, 3 

Complete sper. tory membrane in the human spermatozoa. 

matozoon; B, 98. SPERMATOGENESIS.— The seminifer- 

mii sip ios ous tubules are cylindrical, ¢.¢., in cross-sec- 

extremity’ of tions they appear round ; a large partof the 

the tail. All tubule is filled with spermatozoa in various 

highly magni- stages of development. The outer boun- 

fon dary is marked by a distinct line corre- 
sponding to the tunica propria, a layer of endothelial 
cells, with flat oval nuclei (Neumann,*® p. 306). Next 
to the tunica comes a layey which, as far as known, 
presents pretty much the same appearances, whatever 
may be the stage of development of the spermatozoa 
within. This layer contains two kinds of cells’: Hirst, the 
large Sertoli’s cells, as they may be called after their dis- 
coverer.* These cells are identical with Merkel’s Stutz- 
zellen, La Vallette’s spermatogonien, Swaen and Masque- 
lin’s cellules folliculaires. Second, smaller granular cells. 


Fie. 3610,—Peripheral Layer of the Seminiferous Tubule of a Rat. Two 
views from a teased preparation. (After Neumann.) 


Examined in surface views (Fig. 3610) (compare also 
Figs. 5, 6, and 41 of Furst’s paper’), the large cells are 
seen to be mostly hexagonal in outline, to touch one an- 
other, and to pass below, ?.¢., outside, the small cells ; 
they have large, clear, oval nuclei, with sharp outlines, 
and usually a single, well-marked nucleolus. The nu- 
clei lie quite near the tunica propria, but in man lie far- 
ther inward, and are in this case not so near the tunica 


* First described by Sertoli in H. Morgagni (cf. Henle’s Jahresbericht 
for 1864, p. 120). Compare Sertoli, Arch. Sci, mediche, ii., 107 (1877). 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Spermatozoa. 
Spermatozoa, 


as are the small cells. Around the nucleus there lie a 
few highly refractile granules, which may be stained by 
osmic acid, and are probably fat. The small cells lie in 
depressions or cups of the large cells (Fig. 3610, 8), and 
when the small cells are knocked out—as sometimes hap- 
pens in teasing—the partitions between the cups appear 
more distinctly and create a network figure, which has 
misled von Ebner and others into describing a real net- 
work as constituting the layer. The large cells also have 
long columnar prolongations, as can be best seen in trans- 
verse sections of the tubules (compare Fig. 3616); the 
prolongations are united with bundles of developing 
spermatoblasts. The small cells are very different ; they 
lie over the outlines of the large cells, and between their 
centripetal prolongations (compare Fig. 3616); they are 
granular, have comparatively little protoplasm, and nu- 
clei more or less nearly spherical in shape. The nuclei 
vary considerably in appearance, as these cells multiply 
by indirect division ; usually they contain a chromatine 
network or a coiled chromatine cord ; sometimes the net- 
work is concentrated at one side of the nucleus, leaving 
the other side comparatively clear. At certain periods 
the nuclei are found in various stages of karyokinesis. 
The cells resulting from the division of the small cells 
form the packing between the inward columns of the 
large cells, hence in cross-sections we get alternating 
columns (Fig. 3616). The descendants of the small cells 
produce the spermatoblasts, and the spermatoblasts are 
converted into the spermatozoa. The small cells are then 
the parents of the spermatozoa, and may be called the 
parent-cells ; a great variety of names have been em- 
ployed to designate them, such as mother-cells, spore- 
cells, germinative cells, Samenstammzellen, etc. 
Formation of the Spermatoblasts.—The parent-cells di- 
vide and produce probably two daughter-cells, although 
the number has never been accurate- 
ly ascertained. According to Bion- 
di,® the nucleus of the parent-cell re- 
mains and becomes like the nucleus 
of the large cells (Sertoli’s or sup- 
porting cells). The daughter-cells 
divide, and their descendants also di- 
vide, until there is produced a column 
of cells (Fig. 3611), which stretches 
in a radial line from the mother-cell 
toward the centre of the tubule, and 
is packed in between the columnar 
centripetal prolongations of Sertoli 
cells (cf. Figs. 3611 and 3616). Prob- 
ably, then, although investigators are 
not agreed in regard to this point, the 
mother-cells divide in such a way 
that the cells resulting from the di- 
vision are unlike—one of them pre- 
serving the character of the mother- 
cell, and the other differing from it 
in having a relatively larger nucleus 
and a finer chromatine network ; the 
appearance of the nuclei varies, of 
course, according as they are in the 
resting or divisional (kinetic) phase. * 
The cell most like the original one, 
and which we may call still the 
mother-cell, lies at the outer edge of py. 3611 
the tubule, while the other, or first . ; 
daughter-cell, lies toward the centre theRat. x 600. (Af- 
(Fig. 3611). The mother- or parent- *F Biondi.) 
cell, as already stated, produces at least a second, and 
perhaps more daughter-cells, so that the column grows 
centripetally. The column also grows by multiplication 
of the daughter-cells, but the cells thus formed lie in the 
innermost part of the column ; they are smaller (Fig. 
3611) than the first generation of daughter-cells ; they 
have relatively large nuclei, with the chromatine gath- 
ered into two or three spots—nucleoli. We thus have a 
column of cellsin which we can distinguish three zones : 


Column of 
Spermatocytes from 


* For figures of the karyokinetic division of the daughter-cells, see 
Furst, Figs. 10-13.2° 


1, The outer zone of the mother-cell; 2, the middle zone 
of the daughter-cells ; 3, the inner zone of the second 
generation of daughter-cells. These zones remain more 
or less marked for a considerable period, for, as the cells 
of the inner zone change into spermatoblasts, those of 
the middle zone change into second daughter-cells, and 
as the inner spermatoblasts change into spermatozoa, the 
cells of the second zone change into spermatoblasts ; the 
innermost zone long continues one stage ahead. The tri- 
zonal arrangement is very conspicuous in cross-sections. 
The division of the daughter-cells presents many pecu- 
liarities, and does not conform exactly to Flemming’s 
well-known scheme of phases for indirect division. At- 
tention was first directed to these peculiarities by Carnoy, 
in an important memoir.!? Flemming !§ has since con- 
firmed these discoveries, in large part, by observations on 


Fie. 3612.—Developing Spermatoblasts of the Rat. a, b,c, d,e, 9, ”, 
Successive stages, >< about 75V diameters. (After H. H. Brown.) 


the salamander, and gives a plate of diagrams which is 
instructive as a facile means of comparison. 

The spermatoblasts arise from the nuclei of the second 
daughter-cells (spermatocytes), and not as Brown’? and 
many others have, I think, erroneously believed, each out 
of a whole cell. Biondi® seems to me right in his state- 
ment that the bodies of the cells break down, or at any 
rate lose their boundaries, thus creating a granular pro- 
toplasmatic column in which the nuclei lie. The mother- 
cell participates in these changes, hence its nucleus comes 
to lie at the base of the column. This nucleus has mean- 
while altered its character, and become large, clear, and 
nucleolated. Now, these columns are the same as the 
large Sertoli’s, or supporting cells above described. By 
no means all writers agree with this account of the ori- 
gin of Sertoli’s cells, but all other explanations that I 


523 


Spermatozoa. 
Sphygmograph. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


have found appear to me vague and confused, and the 
history of the changes here advocated is clear, and ac- 
counts for the well-established grouping of the spermato- 
blasts in the substance of Sertoli’s column ; this essential 
phase is explained satisfactorily by no other theory. 

The nuclei congregate at the inner end of the column, 
and there change their character and become recogniz- 
able spermatoblasts (Figs. 3612 and 3616). 

Development of the Spermatoblasts into Spermatozoa.— 
The nuclei change into spermatozoa as follows: The 
chromatine is at first une- 
qually distributed through- 
out the nucleus; it then in 
great part accumulates at the 
end of the nucleus toward 
the outer wall of the tubule; 
particles of the chromatine 
are said to remain in other 
regions of the nucleus, and 
finally to gather together to 
form the small accessory cor- 
puscle mentioned below. 
The main mass of the chro- 
matine is concerned in the 
formation of the head of the 
spermatozoon ; it is at first 
quite round (Fig. 3612, a and 
b), but soon begins to alter 
its shape, gradually assuming 
the form of the spermatozoon 
head (Fig. 3612, c, d, e, f). 
The tail appears very early 
as a delicate filament, lying 
entirely within the nucleus 
(Fig. 3612, a), but shortly 
after is found to project be- 
yond the nuclear membrane 
b, and lengthens rapidly, é, Quica. A, B, C, different stages. 
t, g. The nuclear membrane Se 
is very distinct ; it elongates into an oval bag, 0, ¢, one 
end of which lies close against the chromatine, while the 
other surrounds part of the tail and is wide; the length- 
ening continues, é, f, g, with accompanying changes of 
form, best indicated by the figures; the part of the tail 
within the nuclear membrane becomes the middle piece 
(Fig. 3613), but the spiral thread is not developed until 
later. The accessory body may be readily seen in the 
rat; unlike the chromatine of the head it can be stained 
by chloride of gold, hence if it is formed of chromatine 
at all, the chromatine must have undergone alteration. 
Finally, the nuclear membrane ruptures (Fig. 3614), a 
portion of the membrane remains 
upon the head, and the caudal bag 
sometimes endures longer (Fig. 
3612, g), but at last also disappears, 
except that in certain cases a trace 
of it remains visible as a fine cross- 
line at the end of the middle piece. » 
First and _ others 
think that the axis 
of the tail is formed 
from the chromatine, 
and that the sheath of 
the axis arises from 
the achromatic sub- 
stance of the nucleus 
(caryoplasma). 

After the rupture 
of the nuclear mem- 
brane, the young 
spermatozoa still develop a little further. The sperma- 
tozoa are ultimately liberated, and, falling into the lumen 
of the tubule, pass off. 

From their mode of development, it is evident that the 
spermatozoa necessarily lie in bundles, each bundle be- 
ing held together by a Sertoli’s column (Fig. 3615) ; at 
first they lie at the inner end of the column, at a consid- 
erable distance from the basal nucleus (Fig. 3615), but as 
the nuclei (spermatoblasts) lengthen, the heads push their 


Fra. 3613.—Developing Spermato- 
zoa of a Marsupial, Metachirus 


Fie. 3614.—Human Spermatoblasts, to Il- 
lustrate the Rupture of the Membrane, 
(After Wiedersperg. ) 


524 


way toward the base of the column (Fig. 3616). Now, as 
the development of the daughter-cells (spermatocytes) is 
continually progressing between 
Sertoli’s columns, we obtain in 
sections the long-known remark- 
able appearances shown in Fig. 
3616, of bundles of spermatozoa 
alternating with columns of pro- 
liferating cells. : 
4. Hisrorican. — The seminal 
animalcules were, it is stated, first 
discovered by Ludwig Hamm, 
then a student at Leyden, in Aug- 
ust, 1677. Loewenhoeck claimed 
the merit of having made the dis- 
covery in November of the same 
year, and in 1678 Hartsoeker pub- 
lished an account of them, pro- 
fessing to have seen them as early 
as 1674. They were long consid- 
ered to be probably parasites, and 
it was not until Prevost and Du- 
mas’s researches that it was defi- 
nitely ascertained that the “‘ ani- 
malcules” were the essential 
fertilizing element. Thus Richard 
Owen, in his article on ‘‘ Entozoa” 
(1836), in ‘‘ Todd’s Cyclopedia,” 
includes the spermatozoa under 
that head, although he writes— 
‘it is still undetermined whether 
they are to be regarded as analo- 
gous to the moving filaments of 
the pollen of plants or as indepen- 
dent organisms ” (vol. ii., p. 412). 
But just after he adds: ‘‘ Although 
no distinct organs of generation 
have been detected, there is reason 
to suspect that the 
spermatozoa are 
oviparous; they 
are also stated 
to propagate 
by spontaneous fission, the separa- 
tion taking place between the disk 
of the body and the caudal ap- 
pendage; each of which de- 
velop the part required to 
form a perfect whole.” 
Meanwhile the investi- 
gations of Spallanzani, 
Wagner, Czermak, and 
many others, grad- 
ually increased the 
knowledge of the ¢, 
forms of the 
spermatozoa. 
Dujardin’® 
was the gp 
first to con- 


Fre. 8615.—Sertoli’s Col- 
umn, with a Basal Nucle- 
ated Nucleus and a Clus- 
ter of Developing Sperma- 
toblasts. (After H. H. 
Brown.) 


sider the 
sperma - 
tozoa as 
generat - 
ed from the inner “* 
layer of the seminif- 
erous tubules, and, 
therefore, not as 
parasites. The dis- 
covery of the sper- 
matoblasts, or im- 
mature spermatozoa, by von Siebold (Miiller’s Archiv, 
1836 and 1843), soon confirmed by Kélliker and Reichert, 


Fia. 8616.—Part of a Cross-section of a Sem- 
iniferous Tubule of a Rat. >< about 750 di- 
ameters. (After H. H. Brown.) 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


marks an important step. Now followed a series of pub- 
lications by which one detail after another was added to 
our knowledge. During the past twenty years there has 
been rapid progress, which may be said to have begun 
with Schweigger-Seidel’s important memoir,* and to have 
made us acquainted with the minute structure of the 
spermatozoa, and their development. Another line of 
investigation was opened by O. Hertwig (1875), in follow- 
ing up the history of the spermatozoon within the ovum 
after impregnation. For further historical data see 
Waldeyer’s address *? (1887). 


LITERATURE. 


The literature is enormous. The following references include most of 
those which have been consulted for the preparation of this article: 


1 Ballowitz: Anat. Anzeiger, i., 363. 

2 Beauregard, C. R.: Société de Biologie, Paris, viiie Série, t, iv. 

3 Benda: Arch. mikrosk. Anat., xxx., 49. 

4 Beneden et Julin: Bulletin de l’Acad. des Sci. Belge (3), vii., 312. 

§ Biondi: Arch. f. mikrosk. Anat., xxv., 594. 

6 Blomfield, J. E.: Quarterly Journal of Microscopic Science, xx., 79. 

7 Blomfield : Quarterly Journal of Microscopic Science, xxi., 415. 

8 Blomfield: Review of Recent Researches on Spermatogenesis, Quar- 
terly Journal of Microscopic Science, xxiii., 320. 

9 Brock, J.: Zool. Jahrb., ii., 615. 

10 Brown, H. H.: On Spermatogenesis in the Rat, Quarterly Journal 
of Microscopic Science, xxv., 343. 

11 Von Brunn, A.: Arch. mikrosk. Anat., xii., 528, and xxiii., 108. 

12 Von Brunn, Max: Arch. mikrosk. Anat., xxiii., 413. 

13 Carnoy: La Cellule, i., 191-440. 

14 Czermak: Uebersicht-Arbeiten Schles. Ges. Vaterland. Cultur, 1848. 

15 Dujardin: Annales des Sciences Naturelles, viii., 291. 

16 Ebner: In Rollett’s Untersuchungen, 1871. 

17 Kimer : Verh. phys.-med. Ges., Wurzburg, N. F., Bd. vi., 1874. 

18 Flemming, W.: Arch. mikrosk. Anat., xviii., 233. 

79 Flemming (Karyokinesis of Spermatocytes in Salamandra): Arch. 
mikrosk. Anat., xxix., 889. 2° Furst: Arch. mikrosk, Anat., xxx., 336. 

21 Geddes and Thompson: Procecdings Royal Society, Edinturgh, 
1885-86. 

22 Gibbes: Quarterly Journal of Microscopic Science, xix., 487. 

23 Helman: Inaug. Diss., Dorpat, 1879. 

24 Hermann: Robin’s Journ., 1882, 373. 

25 Jensen, O. S.: Die Struktur der Samenfdden, Bergen, 1879, 1 Taf. 

26 Jensen, O. S.: Archives de Biologie, iv., 1883, pp. 1-94 and 669- 
TAT. 27 Jensen: Anat. Anzeiger, i., 251. 

28 Jensen: Arch. mikrosk. Anat., xxx., 3 

29 K6lliker: Zeitschr. wiss. Zool., vii., 201. 

30 Krause: Biol. Centralblatt, i., 25. 

31 Krause: Internat. Monatschr. Anat. Histol., ii. 

32 Ta Vallette St. George: Der Hoden (Cap. xxiv.), in Stricker’s Hand- 
buch der Gewebelehre. 

33 Leydig: Untersuchungen zur Anat. und Histologie der Thiere, Bonn, 
1883. 34 Merkel: In Unters. Anat. Inst., Rostock, 1874. 

35 Merkel: Miller’s Archiy, 1571. 

‘38 Miescher: Verh. Naturforsch. Ges., Basel, vi., 138. 

37 Mihalkowics: Ber. K. Ges. Sachs. Ges., Wiss., Juli 26, 1878, p. 217. 

38 Neumann, H.: Arch. mikrosk. Anat., xi,, 292. 

39 Nussbaum, Moritz: Arch. mikrosk. Anat., xviii., 1. 

40 Platner, G,: Arch. mikrosk. Anat., xxv., 564 (Spermatogenesis in 
Pulmonata). 41 Platner, G.: Arch. f. mikrosk. Anat., xxvi., 343. 

42 Renson, G.: Arch. Biol., iii., 291. 

43 Retzius, Gustav (Best Description of Human Spermatozoa) : Biolo- 
gische Untersuchungen, i., 77-88, Taf. x. 

44 Romiti: In his Notizie Anatomiche, No, ix., p. 23; Abstract in Biol. 
Centralbl., 1855, 505. 

45 Schweigger-Seidel: Ueber die Samenkor- fs 
per und ihre Entwickelung, Arch. mikrosk, 

Anat,, i., 309-835, Taf. xix. 

46 Semper: Das Urogenital-System der Pla- 
giostomen, etc., Arbeiten Zool.-zoot. Inst., 
Wurzburg, ii., 195. 

47 Sertoli: Arch. Sci. Mediche, ii., 107. 

48 Sertoli, E.: Arch. Ital. Biol., vii., 369. ¢ 

49 Spengel: Arbeiten Zool.-zoot. Inst., Wurz- 
burg, iii., 114. 

50 Swaen et Masquelin: iv., 749. } 

51 Wagner and Leuckart: Article Semen in Todd’s Cyclopedia, vol, 
iv., Part I.. p. 472 (an invaluable summary). } _ 

52 Waldeyer (Summary of Recent Investigations): Anat. Anzeiger, U., 
345. 

58 Weissmann: Zeitschr. wiss. Zool., xxxiii., 55. 

54 Wiedersperg: Arch. mikrosk. Anat., xxv., 113. 

55 Zacharias: Arch. mikrosk. Anat., xxx., 111. 


Charles Sedgwick Minot. 


ba) 


ON} UTIL 


SPHYGMOGRAPH AND CARDIOGRAPH. _ Instru- 
ments for ubtaining graphic representations of the pulse- 
movements of the arterial wall, or of the movements 
imparted to the chest-wall by the impulse of the heart. 
They cause a lever or style, which follows and magnifies 
the movements, to write upon a surface passing at a con- 
stant speed, and thus trace a record of the rhythmical 
movements in a series of curves. In order to fulfil the 
fundamental requirements, such instruments should ac- 
curately follow the pulse-movements, without modifying 


Spermatozoa. 
Sphygmograph, 


them by their own inertia; they should magnify the 
movements sufficiently to permit convenient study of 
their record ; and the rate at which the recording surface 
moves should be reasonably constant, so that the time 
occupied by the various phases of the movement can be 
calculated. 

A great number of instruments have been devised, 
which meet these conditions more or less successfully. 
The first-named requirement offers the only problem dif- 
ficult of solution. The first useful sphygmograph, the 
curves of which have been shown to represent the actual 
movements of a pulsating artery, was introduced by 
Marey, the great master of the graphic method, in 1860, 
Before him the most important apparatus designed for 
the same end was the sphygmograph of Vierordt (1855), 
who failed to register the real movements of the pulse 
only from his anxiety to produce curves like those of the 
kymographion—an instrument which indicates the varia- 
tions of mean blood-pressure with great exactness, but 
does not follow the quick and delicate variations of the 
pulse. The sphygmograph of Marey (originally con- 
structed for the radial artery alone) was at once em- 
ployed not only by physiologists, but by clinicians, and 
added sphygmography to the methods of clinical investi- 
gation. It has since been variously modified and im- 
proved, and the principle of its construction—‘‘ sphygmo- 
graphe a pression élastique’’—is the basis of most of the 
instruments now in common use. Moreover, it has been 
critically tested by other competent observers, and -has 
been found to answer the requirements of an instrument 
of precision, in spite of certain limitations.! 

ELASTIC SPRING SPHYGMOGRAPHS.—WMarey’s sphygmo- 
graph. A rather strong elastic steel spring, a, Fig. 3617, 
is fixed by one end, 0, to a frame of brass to be applied 
to the forearm, while its other (free) end is provided with 
a thin ivory button, c, intended to press upon the radial 
artery at the wrist. The pulse-movements communica- 
ted to this button are transmitted to the lever by means 
of an upright toothed rod, d, which presses against a 
small similarly toothed wheel, e, turning on an axis to 
which the light wooden lever, f, is fastened. Every 
movement of the upright turns the wheel and elevates or 
depresses the lever. he axis of the lever revolves in a 
bearing in the end of the frame which rests 7 
upon the wrist. The other end of the 
brass frame, to which the spring 
is fastened, sup- \ 


DO ciated pes 
L 
a 


clockwork, 


Fie. 3617.— 
Scheme of 
Marey’s 
S phygmo- 
graph, 
with Mach 
and Bé- 
hier’s modification. 
Breguet’s manufacture. 
1g natural size. 


g, that drives a light brass sled, /, in the direction toward 
the wrist, as indicated by the arrow. This sled carries 
the recording surface of smoked paper or glass upon 
which the end of the lever—a fine-pointed style, 7— 
scratches its record. 

The described connection between the spring and the 
lever, by means of the toothed rod and cog-wheel, is a 
modification by Mach? (1863) and by Béhier? (1868), and 
is now used in all the instruments made by Breguet. 
The rod is movable on an axis in a brass plate on the free 
end of the spring, so that it can be laid flat upon the lat- 
ter while the sphygmograph is being adjusted to the arm, 
and lifted up against the toothed wheel of the lever when 
the instrument is set in action. The spring itself keeps 
it closely applied to the cogs of the wheel. : 

The pressure of the spring upon the artery 1s modified 
by means of the screw s, which presses the spring down- 
ward with greater or less force. While by this means the 
pressure can be varied, it cannot be measured. To obviate 
this defect Burdon-Sanderson (1867) introduced a modi- 


525 


Sphygmograph. 
Sphygmograph. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


fication, by which the instrument is at the same time 
more securely fixed to the wrist. Removing the wings 
by which Marey binds the frame upon the forearm, he 


i RATT 
Cc 
ie 


ina 
JUST I i} 
aaa 


Fia. 3618.—JZ, Marey’s Sphygmograph, Applied; ZZ shows the manner in 
which the upright toothed rod of Béhier is joined to the end of the 
spring, (Rollett, in Hermann’s Hdb. d. Physiologie, Bd. iv.) 


adjusts to the end of the instrument (between the letters 
a and 6 in Fig. 3618) ‘‘a rectangular block of brass, by 
the under surface of which [covered with ebonite] it rests 
on the tendon of the flexor longus pollicis, and on the __ 
space between that tendon and the spine of the ra- fig 
dius ; the block being kept closely applied to the sur- |i 
face by means of a strong elastic band 
which encircles the wrist.” 4 By means 
of a screw the distance between the 
ebonite surface and the frame is varied 
at will and the pressure modified ; the 
amount of the pressure is measured by the deflexion 
of the spring (the distance between the spring and 
the lever) as determined by experimental test. Ma- 
homed® (1872) substituted for the screw s, which in 
Marey’s sphygmograph varies the pressure of the spring, 
an excentric wheel m (Fig. 3619), graduated in accord- 
ance with the degree of pressure, so that the 
latter may be read off at once. 


Fie. 3619.—Mahomed’s Sphygmograph, Applied. 


Marey’s instrument is fixed to the forearm by means of 
japanned wings hinged to the frame, which are provided 
with hooks, and a silken cord passed under the arm from 
hook to hook. This mode of adjustment is defective. 
Mahomed’s sphygmograph is more securely attached, by 


Fia, 3620.—Scheme of Landois’s Angiograph. 


(Rollett.) 


means of two straps, one at each end of the frame, toa 
supporting pad placed under the arm, as seen in Fig. 3619. 

INSTRUMENTS IN WHICH THE PRESSURE IS EXERTED 
BY WerIGHTSs.—Instead of the elastic spring pressure, 


526 : 


(Bramwell. ) 


methods have been devised for applying the pressure by 

weights, which afford the advantage of numerical accu- 

racy. Such are the modification of Marey’s sphygmo- 
graph by Baker ° (1867), the angiograph 
of Landois* (1872), the sphygmograph of 
Sommerbrodt ® (1876), and the sphygmo- 
graphe passif of Brondel® (1878). Baker 
and Brondel replace the steel spring of 
Marey’s instrument by sliding weights ; 

‘ the most important contrivance for car- 
rying out the principle of pressure by 
direct weight, however, was invented by 
Landois. 

Landois’s Angtograph.—On the proxi- 
mal end of a plate, g, g, (Fig. 8620), that 
serves as the base of the instrument, is 
balanced on an axis the solid rod d, z, 
which takes the place of the spring in 
Marey’s sphygmograph; to its longer 

arm, near d, are attached, below, a stem carrying the 
button c, which explores the artery, and above, a stem 
carrying a dish or scale, @, for holding the weights, and 


.a toothed rod which, as in Béhier’s modification, moves 


the toothed wheel /, attached to the spindle of the writ- 
ing lever. This lever bears upon its extremity a light | 
needle, k, hung from the joint Zin such manner that it 
falls by its own weight upon the smoked plate ¢; this 
plate—the recording surface—is moved by clock-work at 
right angles to the plane of the lever (and to the forearm). 


Fig. 3621.—Marey’s Tambour with Registering Lever. 
(Gscheidlen.) One-half natural size. 


This arrangement secures vertical movement of the nee- 
dle instead of the curved movement of the style of Marey’s 
sphygmograph, as well as the least possible friction in 
the tracing apparatus, but at the same time involves a 
clumsiness which detracts from the convenience of the 
instrument. The lever itself, as well as the 
rod d z, with all its attachments, being bal- 
anced by counterpoises, é and z, the pressure 
upon the artery is exerted only by the 
weights placed in the scale. ; 
Sommerbrodt made use of a like accurate 
method of pressure by weights in his some- 
what complicated modification of 
Marey’s sphygmograph. 
TRANSMISSION #SPHYGMOGRAPHS, 
io POLYGRAPHS, PANTOGRAPHS, —A new 
j } principle in the construction of pulse- 
« / writers wasintroduced by Marey (1868), 
‘ following the methods of Upham and 
Buisson, in his instruments ‘‘@ trans- 
mission.” With the help of a suitable 
mechanism the pulsatory movements 
are conveyed to a Marey’s tambour or 
tympanum, which is put in communi- 
cation, by a flexible tube, with asecond tympanum. The 
second tympanum carries the writing lever. 
The tympanum is a shallow capsule of metal covered 
by a caoutchouc membrane, the centre of which bears a 


Fia. 8622,—Marey’s Registering Tambour ; new construction. (Gscheid- 
len.) Natural size. 


very light round metal (aluminium) plate. In the second 
(or registering) tambour this plate is provided with a 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sphygmograph. 
Sphygmograph. 


wooden bridge or knife-edge upon which the writing 
lever rests. Figs. 8621 and 3622 show the details of con- 
struction of this apparatus, now well known in the physi- 
ological laboratory. The expanding movement of the 
artery compresses the air in the first (or receiving) tam- 
bour and forces a part of the contained air into the sec- 
ond tympanum, whose membrane is thereby raised and 
lifts up the lever placed upon 
it. The lever magnifies the 
movements. 

The recording surface may 
be so large and so constructed 


ul NN 
zi Uh sh 


SSS —— 


Fia. 3623.—Receiving Tympanum of Brondgeest’s Pansphygmograph, 
(Gscheidlen.) One-half natural size. 


that a number of levers can register upon it at the same 
time, one exactly under the other, and the pulse-move- 
ments from two or more sources can be inscribed upon it 
synchronously ; such instruments have been called poly- 
graphs, 

Sphygmographs of this construction differ mainly in 
the mode of application of the receiving tambour to the 
pulsating surface ; many of them can be applied to any 
pulsating artery, as well as to the chest-wall over the 
impulse of the heart, and are known collectively as 


a 


3623), whose elastic membrane, C, is provided with a 
button, D, is held over the vessel by means of a metal 
bow in which its short metal tube, B, is fastened by a 
screw, F, in such manner that the button bears upon 
the artery with the necessary degree of pressure. The 
tube B is connected by a caoutchouc tube with the reg- 
istering tambour. Two systems of tambours, or three, 


hele 


Fic. 38625.—Marey’s Sphygmographe @ transmission. (Ozanam.) 


can be employed to register movements upon a revolving 
cylinder simultaneously. 
Meurisse and Mathieu (1875) made use of a more com- 
plicated receiving apparatus, adding spring-pressure ; 
they also placed the recording apparatus, for greater 
clinical convenience, in a portable box which contains 
the clock-work that propels a strip of paper on which the 
tracing is inscribed. This sphygmograph has been 
modified by Grunmach (1876) and by v. Knoll (1879). 
Fig. 8624 shows its modern form. The exploring but- 
ton -D is detached from the cap- 
sule ; it is carried on the end of 
a curved steel spring, B C, ris- 
ing from a_horse-shoe plate, 
which serves as the base; the 
degree of pressure of the spring 
is regulated by the screw E. 
The capsule is held over the 
button by two vertical rods fixed 
upon the base-plate, so that the 
stem of the button touches the 
centre of the membrane of the tam- 
bour. The latter is set higher or 
lower by a ratchet mechanism. The 
use of the spring-pressure in connection 
with the transmission-apparatus seems to 
have been suggested by Burdon-Sanderson’s 


Fig. 8624.—Grunmach’s Modification of Meurisse and Mathieu’s Poly- 
graph. (Gscheidlen.) One-fcurth natural size. 


j 
pantographs. Many cardiographs (see below) are con- 
structed on this principle, which was, indeed, first used 
for demonstrating the movements of the heart by Up- 
ham, Buisson, and Marey. Brondgeest (1878), in his 
pansphygmograph, devised a mechanism for applying the 
tambour to all pulsating surfaces; the capsule A (Fig. 


cardiograph (see below). 

In Marey’s sphyymographe & transmission (1878) 
(Fig. 3625), spring-pressure is also used, the mode 
of application being the same as in his elastic-spring 
sphygmograph ; the same frame, without the clock-work, 
carries a steel spring and a Béhier-Mach grooved stem, 
which rests against one end of an angular lever; the 
other end of this lever touches the centre-plate of the re- 
ceiving tambour, which is set upright facing the wrist. 
Dilatation of the artery raises the spring, presses the lever 
against the membrane of the tambour, and, by com- 
pression of the air within, raises the membrane of the 
recording tambour and lifts the writing lever. i 

‘Keyt,'° of Cincinnati, starting with a ‘‘ sphygmometer 

of his own invention, similar to the old sphygmometer 
of Hérisson and the sphygmoscope of Naumann, evolved 
the ‘compound sphygmograph,” which Fig. 3627 shows 
in its most complete form—a transmission sphygmograph, 
in which water is used as the medium, instead of air. 
His sphygmometer was a graduated glass tube, cight or 


527 


Sphygmograph. 
Sphygmograph. 


ten inches long, with an exploring ‘‘ base” of brass (Fig. 
3626), ‘‘ semicircular in form, with an oblong free edge 
below, and a shallow neck into which is inserted, air- 
tight, the glass tube.” The free edge of the base, one 
and three-eighths by three-eighths inch, is closed by a 
rubber membrane. This base is used in the perfected 
instrument for receiving the pulse movements. When 
the base is pressed upon the artery, the water in the tube 
follows the movements of the arterial wall. He then 
closed the top of the tube (filled with water) 
by a rubber membrane, and placing on 
this a pin and lever, was ready to register 
the enlarged movements on a passing plate. 
In the complete instrument (Fig. 3627) 
there are supplied two exploring bases, each 
with its tube and lever, one of which regis- 
ters exactly below the other. The 
communicating tubes are made of 
stiff rubber, or of glass with rub- 
ber joints, so that the bases can be 
freely moved. The upper end of 
Fic. 3626.--Base of Keyt’s the tube is now a metal cylinder 
Sphygmometerand closed by a rubber membrane. 
sa rete (After Bach base can also be put in com- 
munication with a manometer tube 
indicating the degree of pressure applied. The register- 
ing plate is driven by a clock-work, and receives, besides 
the tracings of the lever, the simultaneous markings of a 
chronograph. The instrument thus becomes one of the 
best polygraphs, and lends itself especially to the study of 
the synchronism or succession of events in the circulation. 
Keyt asserts that in his manner of employing water as 
the medium for the transmission of movements, the in- 
ertia of the water does not become obnoxious, and its 
power of transmission is greater than that of air. His 
tracings seem to bear out this claim. But when Ozanam, 
in his sphygmograph,'! resorts 
to the much heavier medium 
mercury, the resulting curves 
are scarcely more than the rec- 
ords of rhythmical oscillations 
of the mercury. — 


fl 


Fia. 3627.—Keyt’s Compound Sphygmograph, 


and clinical convenience have been consulted in two in- 
struments, which have been used more extensively by 
physicians, perhaps, and which have bred more amateur 
sphygmographers than any others, in America as well as 
in England and Germany—those of Pond (Vermont, 
1877) and of Dudgeon (England, 1878-80). 


528 


Facility of application ° 


(Keyt.) 


| 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Pond’s sphygmograph, in its present form, when in use, 
is held in the fingers by the hollow cylindrical body a, 
(Fig. 8628) and the necessary pressure is thus exerted on 
the artery more readily, and quite as steadily, as by use 
of the arm-rest furnished with the instrument in its 
earlier phases. The foot of 
this body is an oval metal 
capsule, 6, closed by a pure- 
rubber cap; the base is thus 
made of a slightly stretched 
elastic membrane, which is 
made more or less tense ac- 
cording to the pressure used. 
Upon this membrane rests a 
small metal plate bearing an 
upright rod, which moves 
loosely within the body and 
terminates in the button ec. 
From the upper part of the 
body spring two metal arms, 
one of which supports the 
clock-work d, and a stage, e, 
for the card-board or mica 
slide on which the trace is 
written (the slide moves, in 

the figure, at right angles 

B to the plane of the paper, 
and toward the specta- 
a tor). The 
other metal 


arm bears 
the system of 
levers and 
ie bi Oe Wir Lb 

Fic. 3628.—Scheme of Pond’s Sphygmograph. B,Side ; dl 
view of the base; C, shape of rubber membrane clos- in g- needle, 
ing the bottom of the base, One-half natural size. When the 


instrument 
is pressed upon the artery the rod concealed in the cy- 
lindrical body rises and touches the screw 7, which can 
be set to conform to the pressure, 7.¢., to the height to 
which the rod is lifted; any further upward movement 
now imparted to the rod by the pulse raises the screw 
and turns the lower lever about the pivotal point g, so 
that its upper end moves outward toward the 
letter A. This end, by a loop, embraces the 
short arm of the second lever, and, pushing it 
to the right (in the figure), moves its long arm 
to the left. From the end of this lever is sus- 
Wg pended, by the loose joint 7, the needle n, whose 
f point rests upon the slide and traces the pulse- 
curve. The short arm of the upper lever ends 
in a counterpoise, which by its weight 
secures the return of the lever when the 
" upward pressure is withdrawn. In this 
instrument, the pressure made over the 
artery is that of the more or less tense 
rubber membrane at the base. 

The defects of this instrument are 
obvious. The weight of the levers and 
their counterpoise is so great, as com- 
pared with that of the rod, which lies 
loosely upon the membrane of the base, 
that the inherent vibrations of the appa- 
ratus make themselves felt in the curve. 
, The excursions of the needle are limited 
= to the distance of the upper lever (at 
rest) from the stage on which the slide 
travels, which is not much over half an 
inch ; the tracing cannot be higher than 
this ; if the lever strikes at either ex- 
tremity of its course, the curve is viti- 
ated. This imperfection could be easily 
removed; the former defect pertains to 
the plan of the instrument, and is more difficult to rem- 
edy. 

Better workmanship and some modifications in detail 
have been introduced in the construction of this instru- 
ment by Edwards (Buffalo, 1880), but without apparent 
improvement in the results, as Hopkins’ curves testify.” 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sphygmograph, 
Sphygmograph. 


Dudgeon’s sphygmograph combines in an ingenious 
manner the steel spring of Marey with the registering 
mechanism of Pond. A rather short steel spring, A, 
Fig. 3629, whose pressure is regulated by a Mahomed’s 
eccentric, N, indicating ounces, is provided at its free end 
with a movable exploring button, B, and transmits its 
movements to the writing-needle L, by asystem of levers 
on the plan of Pond, as seen in the illustrations (Figs. 
3629 and 8630). The whole instru- 
ment is given a more compact form, 
and is fastened to the wrist by a sin- 
gle strap, the tightening of which 
can be usefully controlled by the 
fingers of the experimenter. This 
mode of application has some advan- 
tages. The use of the steel spring 
is a decided improvement upon the 
rubber membrane of Pond’s sphyg- 
mograph ; the system of levers is, 
however, as in Pond’s, subject to vi- 
brations of its own which are apt to 
mar the curve. 

CARDIO- 
GRAPHS.—The 
principle of 
transmission 
was first car- ad A 
ried out in the 
older form of 
Marey’s cardi- 
ograph (1865) (Fig. 3631). The receiving mechanism of 
this instrument was, however, defective and has been re- 
_ placed by a later device in 1875. The transmission instru- 
ments intended for the heart are now constructed with a 
receiving tambour, whose earliest and simplest form was 
embodied in Brondgeest’s pansphygmograph (1878), al- 
ready described. Burdon-Sanderson, in the same year, 
added the elastic curved spring, and supported the 
exploring tambour on an adjustable tripod which was 
fastened over the heart by straps passing round the 
chest. The receiving apparatus of Meurisse and Ma- 
thieu (1875), and its modifications by Grunmach and v, 


B 
Fic. 3629.—Scheme of Dudgeon’s Sphygmograph, 
(Dudgeon.) Natural size. 


(Dudgeon.) Natural size. 


Fie. 8630.—Dudgeon’s Sphygmograph. 


Knoll (1876, 1879), which also presses the exploring 
button upon the pulsating surface by means of a curved 
spring, has been described before. Marey (1875) im- 
proved his instrument by inclosing the receiving tam- 
bour, furnished with a central button, in a cylindrical 
capsule, in which a spiral spring exerts the necessary 
pressure (Fig. 3633). In all these transmission instru- 
ments the registering apparatus is constructed on similar 
principles. 

Keyt’s compound sphygmograph, transmitting move- 
ments through water, as before described, is as well 


Vou. VI.—34 


adapted for recording the apex beat as the arterial pulsa- 
tions. 

Marey’s sphygmograph in its ordinary forms has also 
been extensively used for the exploration of the heart’s 
impulse, and with excellent results, e.g., by Landois. It 


f 


t) 


sli 


i 
iM 


| 
4} 
ll 


i 
| 


Fig. 3631.—Marey’s Cardiograph, original form. (Ozanam.) 


has also been specially adapted to use as a cardiograph 
by Galabin '? (1872). He suspends a Marey’s sphygmo- 
graph, of the Mahomed pattern (so modified that the 
magnifying power of the lever can be varied at will from 
ten to about a hundred), from two transverse rods held 


Fia. 36382.—Burdon-Sanderson’s Cardiograph, Receiving Apparatus, 
(Gscheidlen.) Natural size. 


up by four vertical rods inserted into two bars of wood 
covered with leather, which rest upon the chest. The 
attachment of the transverse rods to the vertical supports 
permits their being raised or lowered at either end, so 
that the instrument can be levelled, and the bars can be 


Fic. 3633.—Marey’s Cardiograph, Receiving Apparatus of later form, 
18%5. (Gscheidlen.) Natural size. 


separated to a width of nearly five inches, and adapted to 


a chest of any size or shape. The whole is fixed upon 
the chest by straps passed round the body. 


529 


Sphygmograph. 
Sphygmograph. 


Pond’s and Dudgeon’s sphygmographs have but a 
limited use as cardiographs, and give curves which are 
imperfect in some details. 

For specimens of tracings obtained by various cardi- 
ographs, see article Pulse, Arterial, section Cardiogram. 

HypROsPHYGMOGRAPHS, — The pulsating movement 
constituted by the increase and decrease of volume of an 
entire extremity, caused by the arterial diastole and sys- 
tole, can be recorded by instruments combining the re- 
ceiving apparatus of a plethysmograph with the register- 
ing mechanism of a transmission sphygmograph. Such 
are the hydrosphygmographs of Frangois-Franck '4 (1876) 
and of Mosso!® (1879). The latter, especially, affords 
curves very similar to those of the ordinary sphyg- 
mograph. The receiving apparatus of Mosso’s instru- 
ment consists of a large glass cylinder filled with water, 
into which the forearm can be inserted, air-tight, through 
an opening closed by a rubber sleeve. The cylinder is 
suspended from above by a chain; it communicates by 
its smaller end with a reservoir of water which regulates 
the hydrostatic pressure ; by another opening on top it is 
connected, by means of a flexible tube, with a Marey’s 
tambour and lever. The curves thus obtained record the 
pulsatory changes in volume of the forearm. It is not 
to be expected that they agree perfectly with those ob- 
tained with the sphygmograph ; the latter registers the 
changes taking place in the short piece of artery touched 
by the exploring button—practically one cross-section of 
the arterial system; the hydrosphygmograph registers 
the increments of volume of all sections of the arterial 
system of the forearm and hand at once, and since these 
increments do not take place at exactly the same time, a 
certain amount of fusing of details in the curve must re- 
sult; that this fusion is, under ordinary circumstances, 
small, is explained by the high rate of transmission of the 
pulse-wave. 

The instrument lends itself especially to investigations 
requiring continuous registration for hours, uniform ex- 
ternal pressure upon the blood-vessels uninfluenced by 
their own changes of calibre, and immutable local con- 
ditions during changes in position and action of the body ; 
and it permits the synchronous registration of curves of 
the heart’s impulse, the carotids, the respiration, etc., by 
other instruments. It has yielded valuable results in the 
hands of its author. 

THE RECORDING SURFACE.—Some of the transmission 
instruments register upon a revolving drum, such as is 
used in the graphic instruments of the physiological 
laboratory (see Fig. 8631). Other sphygmographs are con- 
structed for registering upon strips of smooth paper or 
glazed card-board, or upon slides of glass, smoked. Pond, 
I think, was the first to recommend slides of mica, useful 
by virtue of their lightness, and because, being very thin, 
they can be used as negatives for direct photographic 
reproduction.* Mica slides must be selected with care ; 
those which are warped must be rejected, especially for 
Marey’s instruments ; in Pond’s and Dudgeon’s they are 
excellent substitutes for card-board. Paper and card- 
board answer well in the instruments which write with 
a loosely suspended needle ; but the tracings cannot be 
multiplied as readily as when taken on transparent slides. 
Thin plate-glass is the best material for use in Marey’s 
and in Keyt’s sphygmographs, because of its smooth and 
level surface. 

Glass and mica are best smoked ina large gas flame, 
which yields a very even coat of soot of any desired 
density. Paper must be smoked over a flame emitting 
less heat and more smoke, as an open petroleum flame, 
and this requires greater skill to obtain an even coating. 
In either case the coating of smoke should be as thin as 
is compatible with the purpose. 

The curves are fixed by dipping the slides, of whatever 
material, into a thin, quickly drying varnish. Perhaps 
the most useful varnish is a concentrated solution of the 
best white shel-lac in alcohol. 
in use by photographers. 


* Most of the tracings illustrating this article, and the article Pulse, 
were taken on mica; some on glass, 


530 


Some prefer the varnishes . 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


The method of writing with ink upon a glazed paper 
surface, by means of a pen or marker at the end of the 
lever, aS in the older Marey instruments, has been aban- 
doned, mainly because the friction involved in this 
method is far too great to give delicate traces, 


In the foregoing account of instruments, no attempt 
at completeness has been made. Many other instruments 
have been invented ; some have been confined to the 
physiological laboratory, or employed only by the in- 
ventors; others have been quickly abandoned. The 
sphygmographs in present use in medical practice, hos- ° 
pital or private, are chiefly the spring sphygmograph of 
Marey and its modifications by Burdon-Sanderson and by 
Mahomed, Grunmach’s modification of the transmission 
sphygmograph of Meurisse and. Mathieu, Pond’s, and 
Dudgeon’s. 

TAKING THE TRACING.—To give in this place detailed 
directions for the application of each instrument were 
fruitless. The use of the sphygmograph is not easily 
learned, and skill in its application can be acquired only 
in conjunction with knowledge of the tracing and the 
pulse. The serious study of sphygmography is best be- 
gun with a Marey, Mahomed, or Burdon-Sanderson ; al- 
though these are difficult to operate, they sooner teach 
the much more difficult art of recognizing whether or 
no the trace taken is a correct and adequate representa- 
tion of the pulse explored. 

In order to write a correct sphygmogram it is neces- 
sary (1) to explore the artery at the best possible point ; 
(2) to exert just the requisite pressure upon it, neither 
too much nor too little ; and (8) to let the lever write 
with the least possible friction. 

1. The radial artery is best reached just before it 
crosses the end of the radius. Beginners often err, es- 
pecially when using spring sphygmographs, in applying 
the exploring button higher up. At the point indicated 
the artery is most superficial, and rests upon a firm sup- 
port ; above this point it lies upon the pronator quadra- 
tus muscle and is embedded in abundant adipose tissue. 
In all sphygmographs the exploring mechanism and the 
means of fixing the instrument are constructed with spe- 
cial regard to this artery, but they do not all adjust them- 
selves equally well even to this locality. In Marey’s 
instrument, notably, the correct adjustment of the press- 
ure upon thevartery is sometimes impossible with the 
mechanical means provided ; the best tracings are often 
obtained by hoiding the lower end of the instrument in 
the fingers. With Dudgeon’s sphygmograph the exact 
spot and the proper pressure are more easily found, 
most easily with Pond’s, and with the movable bases of 
transmission sphygmographs. Care must be taken to 
place the button or explorer exactly over the artery ; if the — 
button les to one side of it, the curve is stunted in its 
details ; if it slips off and lies alongside the artery, there 
often results a so-called negative curve. 

The arm should be slightly tlexed at the elbow, the 
hand supinated and fully, but not forcibly, extended at 
the wrist. A rest for the hand, as the wedge-shaped 
cushion of Mahomed, is often useful in connection with 
the spring sphygmographs, but not indispensable. The 
rest provided for the original Pond’s was a useless encum- 
brance, and has been abandoned. 

2. Next to the most available locality, the degree of 
pressure is of greatest importance. The exploring but- 
ton or base should come into such (mediate) contact with 
the arterial walls that it must follow their movements 
closely. If too far removed (too lightly applied), it re- 
ceives the impulse of the artery too feebly or too late, 
and fails to record them in proper extent or time ; if 
pressed too forcibly upon the artery, the expansion of the 
latter is diminished and delayed ; in either case the curve 
is too small and otherwise deformed. Figs. 3634 to 3636 
afford examples; also Fig. 3637, e and f. 

With insufficient pressure, the curve is small and inex- 
pressive, and the secondary waves are ill developed (Figs. 
3634, a ; 3636, a.) As the pressure is increased the second- 
ary events become more pronounced and characteristic, 
and the curve grows higher. With a pressure exactly 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, 


Sphygmograph,. 
Sphygmograph.,. 


suited to the pulse, the details of the curve are most per- 
fect, and the secondary waves, especially the dicrotic, 
most distinctly delineated (Figs. 3634, ) ; 3635, b,; 3636, 
6). Still increasing the pressure, we see the curve di- 
minish in amplitude, the up-stroke being shortened (ex- 
pressing a celerity greater than the actual) ; but the apex 
is still sharp, and the predicrotic wave well expressed, 
while the dicrotic elevation becomes smaller (Fig. 3635, c, 


vA 


ze 
ee a 


aed 
Cc 


Fie. 3684.—Radial Pulse of Healthy Man, aged fifty. Dudgeon’s. a, 
Pressure, 1 0z.; b,8 02.3 ¢, 4 0z,; d, 5 oz., the instrument meanwhile 
remaining i7 situ. : 


d). With still increasing pressure the curve becomes 
much smaller, the upstroke short, the first secondary 
wave is much enlarged, and the dicrotic wave disappears 
(Fig. 3634, c, d). The resulting trace is that of a very 
hard, even anacrotic curve-(Figs. 3634, d ; 3636, c), such 
as only highly atheromatous arteries could truly give. 
Still stronger pressure finally suppresses the pulse alto- 
gether. 

The evident importance of this point, and the desire, 
by means of the pressure found necessary, upon trial, to 


MARIA AR 
NINISINIIAY 
: oe 


Fic. 8635.—Healthy Boy, aged six. -Dudgeon’s. 
3 OZ: 4)-€, 4.07.5, dy 5 02, 


a, Pressure, 2 0z.: , 
evoke the most perfect curve, to estimate the blood-press- 
ure within the living artery, has led sphygmographers 
to devise means not only for varying, but for expressing 
the pressure of the instrument in numbers. This object 
has been accomplished only in those pulse-writers which 
exert their pressure by weights instead of springs, as in 
Landois’s angiograph—an instrument of great scientific 
accuracy—and in Keyt’s sphygmograph.by means of the 
manometric tube. But even in this case the weights in- 
dicate only the pressure upon the skin, not that upon the 


a ce A ee 


Fre. 3636.—Woman, aged forty-eight. Dudgeon’s. a, Pressure, 1}¢ 0z.; 


b, 214 02.3 ¢, 3 OZ. 


artery, which must be less than the former, by the vari- 
able amounts of elastic resistance of the intervening skin, 
fascia, and neighboring tendons. This source of error, 
and the impossibility of estimating the force exerted in 
fastening the sphygmograph upon the wrist, has made 
all attempts at measuring the pressure with other instru- 
ments illusory. The devices to this end of Burdon-San- 
derson and of Mahomed furnish numbers of only ap- 


proximate value, useful when the pressure is varied 
while the instrument remains 77 sétw, but not comparable 
with observations at different times or on different arte- 
ries—not at all comparable with the numbers expressing 
the pressure in other instruments. 

Sphygmographs in which the pressure is controlled by 
the hand alone, as in Pond’s, are most easily adjusted, 
and the pressure can be more evenly applied in this way 
than would seem possible. 

Even if the degree of pressure could be accurately 
known, it would still give no correct information as to 
the blood-pressure ; the form of the pulse-curve assists 
in judging of the comparative degree of tension of the 
artery ; but accuracy in determining the compressibility 
of the pulse must be sought by aid of other instruments, 
such as Waldenburg’s Pulsuhr or Basch’s sphygmoma- 
nometer. 

3. When the lever of the instrument meets with too 
much friction the curve is altered in the same direction 
as when excessive pressure is used ; it loses in delicacy, 
the minor events are obliterated, and the apex is apt to 
be blunted or flattened. Hence it is essential that the 
recording surface be very smooth, and smoked only just 
enough to make the trace distinct. For the same rea- 
son, the method of writing with an inked style upon a 
glazed paper has been almost discarded. Moreover, the 
lever should not bear too firmly upon the surface. 

In judging of the adequacy of a curve, two points are 
of special importance: the apex should be sharp, and 
there should be no evidence of vibrations due to inertia 
of the instrument itself. A curve witha rounded, blunt, 
or truncated apex is to.be suspected until all source of 
error is eliminated. This defect is common in the trac- 
ings by the spring sphygmographs, and is owing either 
to excessive pressure (too hard a spring, as in many of 
Marey’s instruments) or to undue friction in the writing 
apparatus. Vibrations by inertia, exaggerated excur- 
sions of the needle, are apt to deform the curves by 
Pond’s and Dudgeon’s instruments. Not only may evi- 
dent and avoidable monstrosities of curves * result in 
this manner, but there is a genera] tendency to exaggera- 
tions of certain events in the curve.+ The fall of the 
lever is apt to be too rapid and too sudden, deepening the 
depressions preceding the secondary waves, and hence 
also increasing the size of the latter. (Compare Fig. 3637, 
b, c). These sphygmographs produce dicrotism too 
easily, with lower fever-temperatures, than the spring 
sphygmographs do, and generally their curves have the 
look of low tension. On the other hand, the frequently 
exaggerated predicrotic wave sometimes gives the appear- 
ance of higher tension than is found with other instru- 
ments.{ This error in interpretation is in a measure 
guarded against by comparing the relative height and 
position of the predicrotic with the dicrotic wave. 

It is evident, therefore, that the instruments described 
differ greatly in the two practically important respects 
of (1) facility of application and (2) accuracy of results. 
Unfortunately, those which excel in the one are most 
apt to fail in the other. In ease of handling, Pond’s and 
Dudgeon’s sphygmographs take the first rank, and the 
transmission instruments with movable bases, especially 
Keyt’s, are likewise easy of adjustment. Among the 
spring sphygmographs, Mahomed’s and Burdon-Sander- 
son’s are more readily applied than Marey’s own. For 


* Broadbent (British Medical Journal, March 26, 1887, i., p. €57) gives 
a curve to illustrate the vagaries of Dud geon’s sphygmograph, but which 
shows, rather, the inexperience of the operator who would seriously pre- 
sent it as the curve expressing the movements ofthe artery. Bad curves 
can be taken with a Marey as well, erring mostly in an opposite direc- 
tion, as the student can best learn from the excellent article ** Ueber 
fehlerhaftes Pulszeichnen,” by Wolff, in the Prager Vierteljahrsschrift f. 
prakt. Heilk., 1871. : 

+ A glance at the curves taken with an Edwards sphygmograph (modi- 
fication of Pond’s), and published by Dr. H. R. Hopkins (Medical Press 
of Western New York, November, 1885, pp. 7. 9, 10, 12), will illustrate 
this point ; some of these curves reproduce only the vibrations of the in- 
strument itself, e.g., Fig. 5 (M. S.), 4(B.), and 6 (KE. H.). i 

t In Guy’s Hospital Reports, 1881, p. 337, Mahomed reproduces a trac- 
ing by Pond’s to show ‘ very high tension,” which by no means shows 
it. He was evidently led into error by comparing Pond’s curves with 
those of his own sphygmograph, without due allowance for inherent dif- 
ferences in the action of the two instruments. 


531 


Sphygmograph. 
Spinal Abscess, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


his angiograph Landois himself does not claim clinical 
convenience. In accuracy of results, however, the 
sphygmographs named rank in nearly inverse, order. 
Jurves obtained with different instruments in different 
cases cannot be directly compared, no matter how per- 
fect of their kind they may be. Those written with 
Marey’s spring sphygmograph are universally accepted 
as reproducing most exactly the movements of the arte- 
rial wall, and to them all others must be referred. ‘The 
use of Pond’s and Dudgeon’s sphygmographs, so thor- 
oughly convenient for every-day practice, can be recom- 
mended only to those who are familiar with the working 
of the spring sphygmographs ; their convenience is off- 
set by the danger of misinterpretation from neglecting 
to allow for the inherent defects of the instruments. 

For illustrations of the tracings afforded by a number 
of sphygmographs and cardiographs the reader is re- 


AS redhat pelea 
BY illo 
avanraWuberoi ao 


heh wrhhahahchathh, 


e 
! 
Fia. 3637.—Man, aged fifty-three to fifty-four. Moderate Hypertrophy 
of the Heart. Subject to infrequent attacks of angina pectoris. a, 
May, 1886, Pond’s; 6, June, 1886, Pond’s; c, August, 1886, Pond’s; d, 


October, 1886, Marey’s ; e and 7, March, 1887, Dudgeon’s. Pressure, 214 
oz. and 44g oz., respectively. (The latter pressure is too great.) 


ferred to the article Pulse, Arterial, and to the series of 
Fig. 3637, which reproduces the pulse-curves in the case 
of one individual, in fair general health, taken at different 
times under varying conditions, by Pond’s, Marey’s, and 
Dudgeon’s sphygmographs. G. Baumgarten. 


1 Landois: Lehre vom Arterienpuls, Berlin, 1872, p. 49, where the 
reader will find a résumé of Mach’s experimental criticism, with refer- 
ences. 

2 Mach: Sitzungsberichte d. k. k. Akademie der Wissensch. zu Wien, 
1863. 3 Béhier: Bulletin de Acad. de Médecine, Paris, 1868. 

4 Burdon-Sanderson : Handbook of the Sphygmograph, p.'%. London, 
1867. Handbook of the Physiological Laboratory, pp. 229, 230. Philad., 
1873. 5 Mahomed: Med. Times and Gazette, 1872. 

-§ Baker: Brit. Med. Journal, 1867, p. 604. 

7 Landois: loc. cit.,1 p. 70. 

§ Sommerbrodt: Ein neuer Sphygmograph. Breslau, 1876. 

® Figured in Ozanam ; La Circulation et le Pouls, p. 41%. Paris, 1886. 
10 Keyt : Sphygmography and Cardiography. New York and London, 
1887. 11 Ozanam : loc. cit.,® p. 432 et seq. 

12 Hopkins : Medical Press of Western New York, November, 1885, p. 5. 

13 Galabin ; Medico-Chirurgical Transactions, vol. lviii., p.:359. Fig- 
ured and described, also, in Bramwell: Diseases of the Heart, p. 7538. 
New York, 1884. ; 

‘4 Frangois-Franck : Travaux du Laboratoire de M. Marey. Paris, 
1876. 195 Mosso: Die Diagnostik des Pulses. Leipzig, 1879. 


SPINAL ABSCESS. Usually in the course of caries 
of the spine, or Pott’s disease, suppuration takes place. 
To the collections of pus which result may be givea the 
generic term ‘‘ spinal abscess.” Surgeons, however, have 
been long in the habit of naming these collections after 
. the regions in or near which they first make their appear- 
ance on the surface. Hence the terms cervical or post- 
pharyngeal (retro-pharyngeal), dorsal, lumbar, iliac, psoas 
abscess, etc., depending on the locality diseased or in- 
vaded. 

FORMATION OF SPINAL ABSCESS.-—As in caries or ulcer- 
ation of bone elsewhere, granulations rapidly spring up 


532 


in the affected vertebra, raising the periosteum, which in 
turn becomes much thickened and vascular, and is itself 
often penetrated by the same granulations. Thus not 
only is pus formed, but at the same time the soft parts 
outside the periosteum become gradually inflamed, infil- 
trated, and thickened, and ultimately constitute the chief 
boundary wall of the purulent collection. Where the 
caries originates in the centre of one of the vertebral bod- 
ies these changes progress very slowly, and adjoining 
vertebree may become invaded before pus appears exter- 
nal to the bone. Indeed, the abscess may never become 
visible (caries sicca), remaining within the limits of the 
bone. To this variety the term ‘‘ vertebral abscess” has 
been given. The tendency, however, is to the formation 
of large collections, which usually take a downward 
course, limited only by the resistance of the soft parts. 
The pus resulting is at first usually curdy, but later be- 
comes more homogeneous, though seldom laudable. 
Bone-dust and fragments of necrosed bone are also occa- 
sionally present. 

The occurrence of spinal abscess is always a serious 
complication of Pott’s disease, and is probably the most 
common cause of death. It has been noticed also that 
the more circuitous the route taken by the pus, the more 


serious are the consequences likely to be. 


The variety of spinal abscess will depend on the region 
affected with caries, on the resistance offered to the pus 
as it leaves the diseased bone, a on the route subse- 
quently taken to reach the surface of the body. 

While caries of the vertebre is by far the most fre- 
quent cause of spinal abscess, it is well to mention that 
collections of pus due to other causes are occasionally 
found in the immediate vicinity of the spinal column, 
and may receive the same name. Thus we occasionally 
find abscesses in the cervical region due to tubercular 
and syphilitic ulcerations about the pharynx, while a 
more acute form is now and then met with as a compli- 
cation of acute pharyngitis and quinsy. So psoas ab- 
scess may occur quite independently of disease of the 
vertebre. 

CERVICAL ABSCESS, termed also post-pharyngeal and 
retro-pharyngeal abscess.—This usually results from dis- 
ease of one or more of the cervical vertebra, and is often 
the first indication of caries. It is, however, not in- 
variably due to this cause. The writer has seen retro-pha- 
ryngeal abscess, evidently following tonsillitis or pharyn- 
gitis, in children, where there were restrained movement 
of the neck, retraction of the head, and other signs of ca- 
ries. The abscesses were evacuated behind the sterno- 
mastoid muscle, when all symptoms suddenly disap- 
peared and complete. recovery followed. Usually when 
the disease is confined to the anterior or lateral surface 
of the bodies of the vertebra, a soft, fluctuating, and 
somewhat cedematous swelling is to be seen and felt 
bulging forward on the posterior wall of the pharynx. 
This may increase to such an extent as to interfere with 
deglutition, and even to cause troublesome and alarming 
dyspnea, Purulent collections from cervical disease, 
however, more frequently proceed in a lateral or postero- 
lateral direction, between the longus colli and scaleni 
muscles, first appearing in the posterior triangle of the 
neck, behind the sterno-cleido-mastoid muscle. In very 
exceptional cases cervical abscess points posteriorly near 
the ligamentum nuche, and still more rarely the pus 
gravitates downward into the posterior mediastinum, 
whence it may enter the pleura or pericardium. Cer- 
vical abscess has likewise been known to penetrate the 
cesophagus and trachea, and in one case reported, first 
appeared in the axilla. 

The diagnosis of abscess from cervical disease is sel- 
dom difficult, if due attention be paid to the signs and 
symptoms of bone disease invariably present, namely, 
stiffness of the neck, with limited movement of the head, 
deformity, and increased pain on pressure over the cer- 
vical spine. 

The dangers of cervical abscess are chiefly dyspncea 
and suffocation, the latter from sudden bursting of the 
collection, especially during sleep, and the entry of pus 
into the air-passages. Gautier collected 97 cases, of which 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


41 proved fatal, but this is an exceptionally large mortal- 
ity, and it is probable that not more than from fifteen to 
twenty per cent. terminate in death. 

The treatment of all the forms of spinal abscess will be 
described further on in this article. 

DorsaL ApBscEss.—By this is meant usually a collec- 
tion of pus, the result of caries of the dorsal vertebre, 
which has passed backward between, or external to, the 
transverse processes, and opened on the back. The col- 
lection in this case may be part only of a large psoas 
abscess, some of the pus gravitating backward in con- 
sequence of long confinement of the patient in the recum- 
bent position. Dorsal abscess usually first appears on 
one side of the spine, its inner margin being often not 
more than an inch or two from the vertebral column. 
The pus occasionally passes outward along the intercos- 
tal muscles, and points in the lateral region of the thorax 
or abdomen, or near the middle line in front. 

Dorsal abscess is frequently mistaken for fatty tumor, 
chiefly on account of its smooth outline and the absence 
of inflammatory symptoms. Besides, this is a favorite 
situation for lipoma. The aspirating needle should be 
resorted to in all cases of doubt. From abscess, the re- 
sult of a necrosed rib, and from a pointing empyema the 
diagnosis should be made with ease by due attention to 
the symptoms. 

It is remarkable, considering the proximity of the 
pleural cavity, how seldom abscess, the result of caries of 
the thoracic vertebree, encroaches on that cavity. Cases 
are reported, however, in which this cavity has become 
the receptacle for a dorsal abscess, and fatal pleurisy has 
resulted from this cause. Agnew! refers to a case in 
which, through inflammatory adhesion, the two layers of 
the pleura, with the lung, united to the sac of the ab- 
scess, and through ulceration the purulent accumulation 
opened into one of the bronchial tubes and was discharged 
by the mouth. 

Psoas ABscEss.—This is the commonest variety of ab- 
scess, resulting from vertebral disease. It may follow dis- 
ease in any part of the dorsal or lumbar portions of the 
spine, but is most frequently met with in cases where the 
lower dorsal or upper lumbar regions are affected. The 
pus, guided by the thickened periosteum and soft parts, 
reaches the diaphragm, where it arches over the lumbar 
muscles, and forcing a passage beneath the internal arcu- 
ate ligament, enters the substance of the psoas magnus 
muscle, along which it passes to its insertion beneath 
Poupart’s ligament, and presents in Scarpa’s space. Thus 
the entire psoas sheath may become converted into a bag 
of pus, the muscle being removed by a process of absorp- 
tion. Bifurcation of the abscess sac has been known to 
take place high up, the pus descending in both psoas 
muscles forming adouble psoas abscess ; or two abscesses 
may form independently at the source of the disease. 
The latter variety, however, is very rare. 

The pus may leave the psoas sheath at any part in the 
course of the abscess, proceeding sometimes in odd di- 
rections, Thus it may pass forward and find its way 
along any of the planes of areolar tissue in the abdominal 
wall, travelling between the transversalis muscle and 
fascia, or, perforating the fascia, may get between the 
latter and the peritoneum. Again, taking a more super- 
ficial course it may point in front, perhaps in the position 
of the external abdominal ring, closely simulating in- 
guinal hernia. Or a portion of the abscess may pass 
along the sacrum by the side of the rectum and present 
in the perineum, like an ischio-rectal abscess. Or, finally, 
leaving the pelvis by the great sacro-sciatic notch, either 
above or below the pyriformis muscle, it may appear in 
the gluteal region (gluteal abscess), and thence pass down 
the thigh in the course of the sciatic nerve. The small 
intestine, colon, rectum, and bladder have all been pene- 
trated by the pus from psoas abscess. Broca? reports 
a rare form of psoas abscess where the pus entered the 
hip-joint, penetrating the anterior part of the capsule. 
In its passage through the iliac fossa it is not uncommon 
for a psoas abscess to be arrested in its progress and 
form a prominent swelling. It is then termed “iliac ab- 
scess,” 


Sphygmograph, 
Spinal Abscess, 


Below Poupart’s ligament a psoas abscess generally 
takes an independent course, either spreading over the 
front of the thigh, or, guided by the sartorius muscle and 
the fascia, passes down the inner aspect and back of the 
limb, until, as in a case reported by Erichsen,’ it may 
reach even to the heel. 

Diagnosis.—This is usually an easy task, providing 
always that a rigid investigation has been made regard- 
ing the condition of the spine. It is true, psoas abscess 
may make its appearance before any noticeable change 
has taken place in the contour of the spine, but there 
will be present, almost invariably, a feeling of stiffness of 
the back, and a persistent pain in one locality. As before 
intimated, it is possible to have suppuration within the 
sheath of the psoas muscle as the result of sprain or in- 
flammation of the muscle itself (psoitis), quite indeper- 
dently of disease of the vertebrae. Here there will be 
an absence of all the ordinary signs of Pott’s disease, and 
thorough evacuation of the abscess should be followed 
by speedy cure. The simple form is found most fre- 
quently in adults. 

Among the conditions met with in the vicinity of Pou- 
part’s ligament, with which psoas abscess might be con- 
founded, are the following : Large buboes or glandular ab- 
scesses, Suppuration from hip-joint disease (in those cases 
where the bursa of the conjoined tendon of the psoas 
and iliacus muscles communicates directly with the hip- 
joint), hernia, serous cysts, fatty tumors, pus from an 
empyema which has found its way into the psoas sheath, 
aneurism, and phantom tumors in hysterical females. 
While the abscess is still in the iliac fossa there may be 
some difficulty in diagnosing it from peri-cecal abscess 
(on the right side only), perinephritic abscess, fluctuating 
renal tumors, and iliac abscess, the result of disease of 
the sacro-iliac joint or of the pelvic bones. There is, be- 
sides, the possibility of an abdominal or iliac aneurism, 
communicating with the sheath of the psoas muscle and 
forming a diffuse, non-pulsating extravasation. The 
pain from erosion of the vertebre in such a case may 
easily be mistaken for the pain of Pott’s disease. 

It would be impossible within the limits of this article 
to give the diagnostic differences between psoas abscess 
and all the conditions above enumerated. It is simply 
necessary to state that in the latter, almost without ex- 
ception, there will be an absence of stiffness and pain in 
the dorsal and lumbar spine ; whereas in none but ab- 
scess accompanying Pott’s disease will there be any ex- 
curvation. 

LuMBAR AxsscEss.—This usually results from disease 
of the lumbar spine, although it is possible to have this 
variety of spinal abscess from disease in the dorsal re- 
gion. Here the pus, whether it comes from a psoas ab- 
scess, or directly from caries of the lumbar vertebre, 
passes to the outer edge of the quadratus lumborum 
muscle, and projects posteriorly in the space between 
the last rib and the crest of the ilium. Like all cold ab- 
scesses in the back, this may readily be mistaken for fatty 
tumor, but attention to the points referred to in connec- 
tion with dorsal abscess should obviate the possibility of 
such a mistake. 

GENERAL OBSERVATIONS. —Spinal abscess seldom 
makes its appearance for many months after the disease 
in the vertebree has begun. In fact, many years have 
been known to elapse before suppuration was noticed. 
Such cases are probably examples of what Paget‘ terms 
‘‘residual abscess,” meaning an old abscess cavity, in 
which from some cause, as ill-health or injury, a fresh in- 
flammation, and suppuration, have been suddenly lighted 
up. On the other hand, abscess may be the first indica- 
tion of.the presence of caries. As might be imagined, 
the more acute the disease in the bone, and the greater 
the constitutional disturbance, the more rapidly does ab-. 
scess form and make its appearance on the surface. 
Again, we meet with cases where great excurvation has 
occurred without any evidence of suppuration. 

ProGnosis oF SprnaL ABscess.—The larger the ab- 
scess, and the more extensive the ground traversed by the 
pus, the more serious will be the prognosis. The most 
favorable cases are those in which the abscess opens close 


533 


Spinal Abscess. 
Spinal Cord. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


to the seat of disease. The greatest of the primary dan- 
gers in connection with suppuration are exhaustion and 
septicemia. Secondary dangers are inflammation of 
serous membranes, due to the invasion of cavities by the 
pus ; hemorrhage from ulceration into a large artery or 
vein ; suffocation (in cervical abscess only), and amyloid 
disease of the liver and kidneys. Many of the deaths 
from Pott’s disease occur soon after the abscess is opened. 
Thus Michel records a series of 28 cases where, in ten 
instances, death followed the evacuation of the abscess 
within twenty days. The presence or absence of hered- 
itary predisposition to struma, the social conditions and 
hygienic surroundings of the patient, and the quality of 
surgical skill employed in the case, will be found to in- 
fluence the prognosis in a marked degree. 

TREATMENT OF SPINAL ABSCESS.—Up to a very recent 
date there was a general consensus of opinion among sur- 
geons that spinal abscess should not be opened hastily. 
This advice should still be followed in cases where sup- 
puration appears to be arrested, and absorption or casea- 
tion is likely to supervene. As arule, however, where 
the collection is large, and evidently increasing, early in- 
terference is in order. Since Lister began to teach sur- 
geons how to take care of these abscesses the old dread 
of interfering with them has ceased to exist. 

Cervical Abscess.— Here, perhaps, more than in any other 
form, should the practice of early opening prevail, lest, 
bursting unexpectedly, the pus might be drawn into the 
larynx and produce suffocation. 

Opening through the Mouth.—Should the abscess point 
in the pharynx more markedly than elsewhere, one often 
has no alternative but to evacuate it through the mouth, by 
means of a trocar or of a guarded bistoury. The patient 
should be placed in the sitting position, with the head 
thrown well forward. An anesthetic is not usually re- 
quired, excepting perhaps in the case of a very rebellious 
child. The mouth should be held open by means of some 
simple gag, which can be withdrawn simultaneously with 
the bistoury, so as not to interfere with the action of the 
palatal and pharyngeal muscles in their endeavor to pro- 
ject the pus forward. The forefinger of the left hand 
may be used to depress the tongue and push it backward, 
thus forcing the epiglottis to close. The incision should 
be made as nearly as possible in the middle line, and di- 
rectly upward. When the abscess is pointing, the sharp- 
ened finger-nail of the surgeon may be employed to open 
it, instead of the bistoury. Some antiseptic mouth-wash, 
containing carbolic acid, iodine, or Condy’s fluid, should 
be used freely as a gargle, as well as for injecting the 
abscess-cavity. 

Opening in the Neck.—When the collection tends to 
point laterally it will usually first be detected behind the 
sterno-mastoid muscle, on a level with the angle of the 
jaw. Here, when practicable, cervical abscess should al- 
ways be opened, chiefly because of the comparative ease 
with which it may be kept aseptic. Professor Chiene, of 
Edinburgh, was one of the first surgeons to advocate 
this method of treating post-pharyngeal abscess. He 
recommends a free incision through skin, superficial fas- 
cia, and platysma muscle, carried along the posterior bor- 
der of the sterno-mastoid. Then asmall opening is made 
through the deep fascia, into whieh a director is pushed 
onward until pus is reached. The deeper parts of the 
incision are opened up by means of dressing-forceps, after 
Hilton’s method. A drainage-tube is then introduced, 
and throughout the strictest antiseptic precautions are 
taken. There can be no objection to the use of the aspi- 
rator here, as in any variety of spinal abscess, providing 
the purulent collection can be accurately located in the 
neck. When the abscess is undoubtedly due to caries, 
the head and neck should meanwhile be well supported, 
either by means of sand-bags or by a leather collar. The 
writer employed plaster-of-Paris in a memorable case® of 
caries of the upper cervical vertebre, with post-pharyn- 
geal abscess, in which the weight of the plaster caused 
partial dislocation of one of the diseased vertebrae and 
alarming asphyxia, with almost complete paralysis of 
sensation and motion. The patient died of exhaustion 
in about four weeks. 


534 


In all varieties of spinal abscess the bag of pus acts as 
a sort of splint to the crumbling vertebree ; hence, before 
removing the purulent collection by operation, means 
should be taken to provide a substitute of some kind for 
the support about to be withdrawn. Sayre’s plaster 
dressing (with the jury-mast in cases of cervical and 
upper dorsal disease) will be found one of the most con- 
venient methods for carrying out this indication. 

Dorsal and Lumbar Abscess.—These need not be inter- 
fered with until they show signs of rapid enlargement. 
The aspirator should first be brought into requisition. 
The needle should not be thrust into the summit of the 
abscess, but introduced at a considerable distance from 
the border, so as to traverse an inch or two of healthy 
tissue before entering the abscess-cavity.' In this way 
leakage and the admission of air are effectually pre- 
vented. <A firm compress and bandage should afterward 
be applied over the situation of the empty abscess. As- 
piration may be repeated three or four times, after which, 
if ineffectual, or if the needle becomes blocked with 
curdy matter, a free, dependent opening should be made 
and a large drain introduced. Every means should be 
adopted to keep the cavity aseptic. The late Mr. Cal- 
lender’s method of hyperdistention with weak carbolic 
or boracic solution may be practised with benefit here. _ 

Psoas Abscess.—There can be no objection to one or 
two aspirations in this variety of abscess, although it is 
well not to evacuate the contents completely at one time, 
as alarming syncope has been known to follow the sud- 
den removal of large collections of this kind, doubtless 
from disturbance of the circulation. Some pains should 
be taken to make the valvular puncture above referred 
to. 

There are few surgical conditions in which Lister’s an- 
tiseptic precautions are so urgently called for as in the 
treatment of psoas abscess by incision. It is a well- 
known fact that, by the older methods, death from ex- 
haustion or septic troubles almost invariably followed 
the opening of this variety of abscess. Paget has de- 
clared that he could not recall to mind a single case 
of extensive psoas abscess in which recovery followed 
the older plans of treatment. Should the abscess have, 
unfortunately, opened before surgical aid has been sought, 
much may still be done by injecting a solution of chlo- 
ride of zinc (one per cént.), or of bichloride of mercury (1 
to 5,000), followed by injections of warm water. 

Opening below Poupart’s Ligament.—When the ab- 
scess points below Poupart’s ligament, the incision may 
be made at the most dependent point, and simply large 
enough to admit a good-sized drainage-tube, every pre- 
caution being taken to prevent sepsis. The part should 
be thoroughly washed and shaved, and the spray or con- 
tinuous irrigation employed while the wound remains 
uncovered. To encourage free drainage, the patient 
should be kept in a sitting position, or, where the condi- 
tion will justify it, he may be allowed to move about for. 
a short time each day. 

Opening above Poupart’s Ligament.— Where the abscess 
is still intra-abdominal it may with advantage be opened 
above the ligament. An incision is made as if for liga- 
ture of the external iliac artery. The abscess-sac being 
reached, it is opened by scratching through it with a di- 
rector, followed by dressing-forceps. Lister, who was 
probably the first to practise this method, claims for it 
that the abscess-cavity is by so much shortened, while 
the risks of putrefaction are considerably lessened. In 
fact, in cases where the abscess has already extended be- 
low Poupart’s ligament the method of incision above de- 
scribed may with advantage be employed. 

Operation in the Loin.—Professor Chiene, of Edin- 
burgh ; Mr. Frederick Treves, of London ; and Dr. Nor- 
man Chavasse, of Birmingham, recorded almost simul- 
taneously the successful treatment of psoas abscess by 
incision in the loin. Dr. Chavasse® describes the opera- 
tion as performed by him, briefly, as follows: ‘‘ An inci- 
sion is made immediately above the crest of the ilium, 
commencing at the edge of the erector spinee muscle, and 
carried three or four inches transversely outward toward 
the anterior superior spine. The various structures are 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, 


divided, as in colotomy, till the quadratus lumborum mus- 
cle isreached. The forefinger should then be passed down- 
ward and forward on the iliacus muscle till the tense 
and distended psoas sheath is detected. A scalpel should 
then be carried along the finger and the abscess incised, 
the opening being enlarged by dressing-forceps. A drain- 
age-tube should be introduced and the wound treated 
antiseptically.” In this way the anterior surfaces of the 
bodies of all the lumbar and of the last dorsal vertebre 
can be reached from the loin and thoroughly examined, 
while at the same time any particles of necrosed bone 
can be removed. The most dependent drainage possible 
is thus procured. ‘Treves reports three cases treated in 
this way. In one he removed forty ounces of pus and a 
large sequestrum from the first lumbar vertebra. In an- 
other, where the abscess had pointed in the thigh, he 
passed a tube from the origin of the psoas muscle to its 
insertion, thus draining the entire abscess-cavity. The 
third case succumbed to amyloid disease soon after the 
operation. 

Mr. Edmund Owen strongly advocates the early open- 
ing of psoas abscess. He recommends a free anterior as 

well as posterior opening, and a thorough washing out of 
the cavity. He says:* ‘‘ The first opening I make close 
above the outer end of Poupart’s ligament, using the 
scalpel until about an inch of the length of the fibres of 
the aponeurosis of the external oblique has been exposed. 
I then scratch through the fleshy attachment of the inter- 
nal oblique and transversalis, and, keeping well below the 
level of the peritoneum, thrust the director into the swell- 
ing. Pus escapes, and the opening is enlarged by the 
dressing-forceps and the finger. A stiff probe is then 
passed through the abscess-cavity, and made to project 
beneath the skin on the outer side of the erector spine. 
With this as a guide, a counter-opening is made in the 
loin. The large cavity is then flushed perfectly clean 
with a warm antiseptic solution, and a drainage-tube of 
the size of a penholder is laid through the chasm for a 
few days, being afterward replaced by a silk thread.” 
For a dressing Owen prefers pads of wood-wool and 
picked oakum inclosed in gauze bags. He irrigates with 
warm iodine-water decolorized by carbolic acid. He con- 
siders the sublimate solution highly dangerous, having 
had a sad experience in one case, where the use of a 1 to 
1,000 solution caused the death, within four hours, of a 
child six years of age. 

In conclusion, the writer would be disposed to urge the 
early and careful aspiration of psoas abscess, repeating 
this at least twice. Then, should a subsequent operation 
become necessary, he would be disposed to recommend 
Owen’s method, above described, as being both safe and 
easy of execution. For purposes of irrigation the warm 
solution of boracic acid is preferred, being sufficiently 
antiseptic and free from toxic properties. As a dressing, 
a powder composed of equal parts of boracic acid and 
naphthalin or hydronaphthol may be dusted freely over 
the wounds and into the drainage-tube, the whole being 
enveloped in a large pad of sublimated jute. 

T. G. Roddick. 
1 Agnew’s Surgery, p. 882. 


2 Bull. de la Soc. Anat., tome xxvi., p. 406. 

3 Science and Art of Surgery, vol. ii., p. 242. 

4 Lectures and Essays, p. 310. 

5 Montreal General Hospital Reports, vol. i., p. 141. 
6 Lancet, December 29, 1883, p. 1119. 

7 Brit. Med. Journal, April 23, 1887, p. 869. 


SPINAL CORD, DIAGNOSIS OF LOCAL LESIONS 
IN THE. In diseases of the spinal cord it is usual for 
the lesion to involve a portion only of the organ. It is 
true that in general myelitis the entire spinal cord may 
finally become affected, but even in this disease it is the 
rule for the lesion to invade one part after another rather 
than for it to begin at once in the entire length of the 
cord. And it is well known that in infantile paralysis, 
in progressive muscular atrophy, in locomotor ataxia, in 
spastic paraplegia, and in ataxic paraplegia, the lesion is 
strictly defined in its extent, being limited so exactly to 
a set of nerve-cells, or of nerve-tracts of a single function, 
that for these affections the term ‘‘ system-diseases”’ has 


Spinal Abscess. 
Spinal Cord, 


been coined. Furthermore, from its peculiar form—that 
of a long but small organ—and from its location—within 
the spinal column—the spinal cord is liable to become 
the seat of disease at some particular level rather than in 
its entire length. Thus pressure from injuries of the 
vertebre, or from the effects of Pott’s disease, or by tu- 
mors ; or destruction by wounds, or by intraspinal hem- 
orrhage, will affect only a small segment of the entire 
cylinder. 

It is evident, therefore, that in diseases of the spinal 
cord local lesions are the rule, and that the symptoms 
will vary greatly, and will depend entirely upon the par- 
ticular portion of the organ which is involved. 

Hence, in the diagnosis of diseases of the spinal cord 
it is necessary to determine the situation of the lesion 


Fig. 8638.—Diagrammatic Representation of the Spinal Segment as a 
Spinal Centre and as a Conducting Medium. (Bramwell.) B, Right, 
B/, left, hemispheres of the brain; M O, medulla oblongata; 1, motor 
tract from right hemisphere; at MO it divides; the larger subdivi- 
sion decussates, passes down the lateral column of the opposite side of 
the cord, and supplies the muscular fibres M and M/ on the left side 
of the body; at 1/ the supply to Mis given off; the smaller subdivi- 
sion does not decussate, but passes down the anterior column, and sup- 
plies the muscles m and m/ on the same (right) side of the body ; 2. 
motor tract from left hemisphere ; it supplies muscles M? and M3 on 
the right side of the body, and muscles m? and m? on the left side of 
the body ; S, 8’, sensitive areas on the left side of the body ; 3/, 3, the 
main sensory tract from the left side of the body; it passes into the 
gray matter of the segment, then decussates, and passes up the right 
half of the spinal eord in the posterior columns, and thence to the 
right hemisphere of the brain; S?, S3, sensitive areas on the right side 
of the. body; 4’, 4, the main sensory tract from the right side of the 
body, up the left half of the cord to the left hemisphere of the brain ; 
5, 6, tract of muscular sense from the legs, passing up upon the same 
side of the spinal cord in which it enters, in the column of Goll, de- 
cussating at the medulla, above the motor decussation, that from the 
left side of the body (5) going to the right hemisphere, that from the 
right side (6) to the left hemisphere ; the arrows indicate the direction 
of the nerve-currents. 


producing the symptoms. And this is by no means as 
simple a matter as might be supposed. For the spinal 
cord is along, cylindrical organ, made up of numerous 
segments, each of which not only has a function of its 
own, but also bears an important part in relation to the 
functions of other segments. Each segment of the cord 
consists of a mass of gray matter, surrounded by a series 
of white tracts, from which passes out a pair of spinal 
nerves. In some of the lowest order of vertebrata the 
comparative independence of each segment is indicated 
by the fact that the spinal cord consists of a series of 
bulbous enlargements joined together by only a few con- 
necting fibres. And even in man there are some eVvl- 


535 


Spinal Cord. 
Spinal Cord. 


dences that the functions of each segment of the cord 
are independent of all others. But in the higher verte- 
brata the various segments are closely united to one an- 
other, and are also connected with the brain, which con- 
trols them all, by means of the white tracts surrounding 
the gray matter. Hence, in addition to its own special 
function as a nervous centre, each segment has functions 
of transmission of impulses to adjacent segments and to 
distant parts of the 
nervous system. 
Therefore, in dealing 
with local lesions in 
the spinal cord, the 
first point to deter- 
mine is whether the 
lesion involves the 
nerve-centres of a sin- 
gle segment, or the 
tracts which pass 
through that segment 
to other centres. In 
the first case, when 
the gray matter of a 
single segment is af- 
fected, the symptoms 
are limited in extent 
and in number, con- 
sisting of localized 
paralysis, limited an- 
sesthesia, loss of cer- 
tain reflexes, disturb- 
ance of certain auto- 
matic actions, and 
local vaso-motor and 
trophic disturbances. 
In the second case, 
when the white mat- 
ter of asingle segment 
is affected, the symp- 
toms are widespread 
and numerous, con- 
sisting of partial or 
complete paraplegia, 
anesthesia of the low- 
er half, or even of the 
entire body, loss of 
control overreflex and 
automatic activity, 
and extensive vascular 
and trophic changes. 
And when both gray 
and white matter of 
a single segment are 
totally involved, there 
will be a combination 
of local and general 
symptoms, the distri- 
bution and extent of 
which will depend 
wholly upon the par- 
ticular level of the 
segment of the cord 


which is affected. It F1 3639.—Diagrams of Transverse Sections of the Spinal Cord at Different Levels; the 
level at each section is indicated by the number opposite to it. 
the anterior horns: 1, inner; 2, antero-lateral ; 3, postero-lateral ; 4, anterior ; 5, median; through several seg- 
2 central. I to IX, Columns of the cord: I, Direct or anterior pyramidal tract, or column ments, 
of Tiirck; II, anterior, and III, lateral ground-fibres, separated by exit of anterior nerve- gy 

roots ; IV. crossed or lateral pyramidal tract; V, lateral limiting layer; VI, postero-ex- ee eT SL of the 
ternal tract, or column of Burdach; YII, postero-internal tract, or column of Goll; VIII, anterior 
antero-lateral ascending tract; IX, direct cerebellar column. \ 


is therefore evident 
that the first step in 
the diagnosis of local 
lesions of the spinal 
cord is the determina- 
tion of the functions 
of the various segments, and of the various tracts which 
pass through them. 

I]. THe FUNCTIONS OF THE SEGMENTS OF THE SPI- 
NAL Corp.—Each segment of the spinal cord consists 
of that portion of the entire organ giving origin to one 
pair of spinal nerves (see Fig. 38688). There are, there- 
fore, thirty-one segments in the human cord. There is 
no natural division between adjacent segments, but if a 
cord with its nerves be carefully removed, there will be 
no difficulty in cutting it up into segments, each of which 


536 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


will receive two afferent and give off two efferent nerves. 
Each segment is made up of two symmetrical halves, 
naturally separated by the anterior fissure and posterior 
septum, but joined by a commissure. 

The afferent or sensory nerves enter the posterior sur- 
face of the segment, and, passing through the white mat- 
ter, end in the gray. The efferent or motor nerves pass 
out from the anterior surface of the segment, having 

their origin in the an- 

terior gray horn, and 
traversing the white 
matter bordering 
these horns. 
A. The Gray Mat- 
- ter. — The size and 
shape of the area of 
gray matter, seen in 
horizontal section of 
the cord, differ in al- 
most every segment, 
the difference  be- 
tween adjacent seg- 
ments being more 
marked in the cervi- 
cal and lumbar en- 
largements than in 
the dorsal region. 
The shape of the area 
of gray matter in the 
dorsal region resem- 
bles that of the letter 
H, and, accordingly, 
anatomists describe 
two lateral halves 
with a central gray 
commissure between 
them, and in each 
half an anterior and 
a posterior horn. In 
the enlargements of 
the cord the mass of 
the horns is much 
larger than in the dor- 
sal region, and the 
shape varies in each 
segment. The amount 
of gray matter in any 
segment depends 
upon the number of 
cells in the anterior 
and posterior horns. 
These cells are not 
scattered irregularly 
through the gray mat- 
ter, but are collected 
into groups. These 
groups are quite dis- 
tinct in the anterior 
horns, in some cases 
being small, and only 
found in a single seg- 
ment ; in others being 
1 to 6, Groups of cells in long, and extending 


This varying 


groups at 
different levels is seen 
in the figure (Fig. 
3639, 1 to 6). The function of the cells in the anterior 
horn is to govern the motion and nutrition of the motor 
mechanisms of the body. 

The more exact localization of motor functions in the 
groups of cells in the cervical and lumbar enlargements 
has been attempted by Ross and Spitzka. There are 
some of these groups, viz., the inner antero-lateral and 
postero-lateral groups (Fig. 3639, 1, 2, and 3), which de- 
velop early in feetal life, and are common to man and the 
less highly developed vertebrates. These are thought to 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Spinal Cord. 
Spinal Cord, 


govern the fundamental movements common to man and 
animals, and earliest acquired in children, viz., flexion and 
extension, abduction and adduction of the limbs. Other 
groups, viz., anterior and median groups (Fig. 3639, 4 
and 5), are found only in monkeys and man, and the cen- 
tral groups (Fig. 3639, 6) in man alone. These are also 
found to develop later than the others. They are there- 
fore thought to govern the accessory movements, which 
are more specialized and depend on finer adjustment, such 
as the act of walking upright, pronation and supination, 
and the finer motions of the hands and fingers, actions 
which are learned some months later than those of a 
fundamental kind. In some cases of disease, limited to 
these groups of cells, poliomyelitis anterior, the symp- 
toms have been found to justify this distinction, loss of 
power and atrophy of certain muscles being produced 
by a lesion in certain groups of cells. The connection 
of the different groups, in various segments, with indi- 
vidual muscles, as far as at present known, is shown in 


ferent from that in the anterior horns. There is a col- 
umn of cells extending through the lower dorsal region, 
known as’ the vesicular column of Clarke, and situated 
in the median and inner part of the horn. The column 
begins in the third lumbar segment, and extends upward 
to the seventh dorsal segment. Its probable function is 
to regulate the vaso-motor and sympathetic nervous mech- 
anisms.? There is a continuous column of cells in the 
middle of the posterior horn, not collected together into 
groups, but scattered through the neuroglia and gelatin- 
ous substance of the posterior horn. These cells are very 
small in size, and thus contrast markedly with those al- 
ready described. It is probable that the gelatinous mass 
in the posterior horn has something to do with the sen- 
sory function, for it is present in the nervous system 
wherever a sensory nerve ends. The sensations of touch, 
temperature, and pain are carried into the posterior horns 
by the posterior nerve-roots, which terminate in these 
cells and the gelatinous substance. 


the table accompanying this article.! 


The arrangement of cells in the posterior horns is dif-- 


All the cells of the gray matter give off branching pro- 
cesses which anastomose, forming a dense net-work of 


LOCALIZATION OF THE FUNCTIONS OF THE SEGMENTS OF THE SPINAL CoRD. 


Segment. Muscles. 


Reflex. 


Second and third cervical..| Sterno-mastoid, trapezius. 
Scaleni and neck, 
Diaphragm, 

Fourth Cervical. ....4..-... Diaphragm. 

Deltoid. 
Biceps, coraco-brachialis. 
Supinator longus. 

Rhoniboid. 

Supra- and infra-spinatus. 
Deltoid. 

Biceps, coraco-brachialis. 
Brachialis anticus. 

Supinator longus, 

Supinator brevis. 

Deep muscles of shoulder-blade, 
Rhomboid, teres minor. 
Pectoralis (clavicular part), 
Serratus magnus. 

Biceps, brachialis anticus. 
Pectoralis (clavicular part). 
Serratus magnus, 

Triceps. 

Extensors of wrist and fingers. 
Pronators. 


WrEGh: Gervicaliincsass eek cee 


Sixt COrvViCAl ssis sieia cose athe 


Seventh cervical...........| Triceps (long head). 

Extensors of wrist and fingers. 
2 Pronators of wrist. 

Flexors of wrist. 

Subscapular. 

Pectoralis (costal part). 
Latissimus dorsi. 

Teres major. 

Flexors of wrist and fingers. 
Intrinsic muscles of hand. 
Extensors of thumb. 

Intrinsic hand muscles. 
Thenar and hypothenar eminences. 
Muscles of back and abdomen. 
Erectores spine. 


Aghth Cervical yoctas cece a 6 


Mirah) DOPrsallis. kaa sewsle so < 


Second and twelfth dorsal. . 


Tlio-psoas, 
Sartorius. 


Lio-psoas, sartorius. 
Flexors of knee (Remak). 
Quadriceps femoris. 
Quadriceps femoris. 
Inner rotators of thigh. 
Abductors of thigh. 
Abductors of thigh. 
Adductors of thigh. 
Flexors of knee (Ferrier). 
Tibialis anticus. 
Peroneus longus. 

DAEGU UMD AE << os so ane as 5 « Outward rotators of thigh. 
Flexors of knee (Ferrier). 
Flexors of ankle, peronei. 
Extensors of toes, 

Flexors of ankle. 

Long flexor of toes. 
Intrinsic muscles of foot, 


First and second sacral..... 


Sensation, 


Hypochondrium (?). 

Sudden inspiration, produced by sudden 
pressure beneath the lower border of 
ribs. 

Pup'l, fourth to seventh cervical. 

Dilatation of the pupil produced by irri- 
tation of neck. 


Scapular, 

Fifth cervical to first dorsal. 

Irritation of skin over the scapula pro- 
duces contraction of the scapular mus- 
cles. 

Supinator longus. 

Tapping its tendon in wrist produces 
flexion of forearm. 


Triceps. 

Fifth to sixth cervical. 

Tapping eibow tendon produces exten- 
sion of forearm. 

Posterior wrist. 

Sixth to eighth cervical. 

Tapping tendons causes extension of 
hand. 

Anterior wrist. 

Seventh to eighth cervical. 

Tapping anterior tendon causes flexion 
of wrist. 

Palmar, seventh cervical to first dorsal. 

Stroking palm causes closure of fingers. 


Epigastric, fourth to seventh dorsal. 

Tickling mammary region causes retrac- 
tion of the epigastrium, 

Abdominal, seventh to eleventh dorsal. 

Stroking side of abdomen causes retrac- 
tion of belly. 

Cremasteric, first to third lumbar. 

Stroking inner thigh causes retraction 
of scrotum. 

Patella tendon. 

Striking tendon causes extension of leg. 


Bladder centre. 
Sevond to fourth lumbar. 


Rectal centre. 

Fourth lumbar to second sacral. 

Gluteal. 

Fourth to fifth Jumbar, 

Stroking buttock causes dimpling in fold 
of buttock. 

Achilles tendon, 

Over-extension causes rapid flexion of 
ankle, called ankle clonos. 


Plantar. 
Tickling sole of foot causes flexion of 
toes and retraction of leg. 


Back of head to vertex. 
Neck. 


Neck. 
Upper shoulder. 
Outer arm. 


Back of shoulder and arm. 
Outer side of arm and forearm. 
Anterior upper two-thirds of arm. 


Outer side of arm and forearm. 
Inside and front of forearm. 


Inner and back of arm and forearm. 
Radial distribution in the hand. 


Forearm and hand; median and ulnar 
areas. 
Ulnar distribution to hand. 


Skin of chest and abdomen, in bands 
running around and downward, corre- 
sponding to spinal nerves. 

Upper giuteal region. 


Skin over nee and front of scrotum. 
Outer side of thigh. 

Front of thigh. 

Inner side of thigh and leg to ankle. 
Inner aide of foot. 

Lower gluteal region back of thigh. Leg 


and foot outer part. 


Leg and foot except inner side. 


Perineum and back of scrotum. Anus. 


537 


Spinal Cord. 
Spinal Cord. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


nerve-fibrillz around the groups of cells. ‘This net-work 
is supported by a trellis of neuroglia, and through it im- 
pulses pass in all directions, uniting the functions of the 
various cell-groups, and of the sensory and motor areas 
of the cord. It is probable that impulses coming to the 
segment, either from the periphery or from the brain, are 
not conveyed directly to the cells of the segment, but are 
distributed through the medium of this net-work of fibres 
to several groups of cells. 

Furthermore, each segment controls in some degree 
the processes of nutrition in the part of the body with 
which its sensory nerves are connected. It regulates the 
vaso-motor tone in the organs and limbs, and it influ- 
ences processes of growth and repair in the skin and mu- 
cous membranes. But the existence of trophic cells in 
the cord has not been proven. Nor can the automatic 
mechanisms of the cord be assigned to definite cells. 
They can only be referred to the gray matter of certain 
segments. 

The function of the gray matter of the individual seg- 
ments is shown in the preceding table. ‘The facts upon 
which this table has been prepared are gathered* from 
comparative anatomy, from physiological experiment, 
and from pathological observation. The level of the 
segment is given; the muscles governed by the groups 
of cells in it are mentioned so far as they are at present 
known; the reflex and automatic mechanisms governed 
by each segment are recorded, and the manner of pro- 
ducing the reflex acts; and the 
area of skin which sends its sen- 
sory nerves to the individual 
segments is described. 

B. The White Tracts.— 
(Figs. 8639 and 3640.) 
The gray matter of 
the spinal segment 
is surrounded by 
white nerve- 
tracts, whose 
function is the { 
transmission of 
impulses between 
adjacent and dis- 
tant segments, and 
between the various 
segments and the 
brain. These tracts are 
quite numerous, and al- 
though in the normal adult 
cord they cannot be distinguished 
from one another, there are several 
means by which their limits are de- 
termined. Thus in fetal cords of 
various ages different tracts can be 
distinguished, by the fact that they 
develop at different times. And in 
diseased cords pathological processes are often strictly 
confined to certain tracts. This is especially true of the 
processes known as secondary degenerations, by means 
of which the exact boundaries, the length, and the func- 
tion of the various tracts have been ascertained. The 
older division of the columns of the cord into anterior, 
lateral, and posterior, must be set aside in favor of the 
later divisions founded on these facts, 

In a cross-section of the cord at the cervical region the 
following tracts are seen in each half of the segment : 

1. The motor tracts, two in number, which come 
through the anterior pyramids of the medulla, from the 
motor region of the cerebral cortex on either side of the 
fissure of Rolando. It will be remembered that the 
pyramids of the medulla decussate partially just at the 
upper limit of the spinal cord.* The majority of the 
fibres of each pyramid cross the median line to the lateral 
column of the spinal cord. The remainder pass directly 
onward into the anterior column. Those that cross over 
are called the crossed pyramidal tract. Those that do 
not cross are called the direct or anterior pyramidal tract, 
or column of Tiirck. The latter les along the side of 
the anterior fissure of the cord, and is called the anterior 


538 


' the anterior one. 


Fie. 3640.—(From Gowers.) Diagram of a Section of 
the Spinal Cord in the Cervical Region. 
rior commissure ; P.C., posterior commissure; I.g.s., 
intermediate gray substance ; P.Cor., posterior cornu ; 
c.c.p., caput cornu, post.; L.L.L., lateral limiting 
layer; A.=L.A.T., antero-lateral ascending tract. 


median column (Fig. 3639, I). The former lies in a tri- 
angular space in the posterior part of lateral column, 
bounded by other tracts on all sides (Fig. 3689, IV). 
These motor tracts differ somewhat in size in different 
cords. When only a few fibres from the medulla cross 
over, the anterior median column is large and the oppo- 
site lateral pyramidal tract is small ; but this is the excep- 
tion. Asarule the lateral tract is three times the size of 
They differ also in length ; for the 
anterior median column only extends to the mid-dorsal 
region, but the crossed pyramidal tract extends to the 
very lowest segment of the cord. They both send in 
their fibres to the anterior gray horns of the cord at all 
levels, and therefore decrease in size as they pass down- 
ward. ‘They both transmit voluntary impulses from the 
brain to the anterior motor cells of the cord, a single 
nerve-fibre in the motor tract carrying an impulse which 
reaches several groups of cells through the fine net-work 
of fibres within the gray horn, in which it terminates. 
They both degenerate downward after any lesion which 
cuts them off from their nutrient cells in the cerebral 
cortex. If that lesion is in the brain on one side, the an- 
terior median column on that side, and the crossed pyra- 
midal tract on the opposite side, will be degenerated in 
the cord. If the lesion is in the cord on one side, both 
motor tracts on that side will degenerate downward. If 
the lesion divides the entire cord, the degeneration will be 
bilateral in both columns. These motor tracts transmit 
not only voluntary impulses, but 
also inhibitory impulses, which 
hold in check the reflex ac- 
tivity of the spinal cen- 
tres. Hence a lesion 
in their course pro- 
duces not only pa- 
ralysis, but also 
a loss of control 
over the bladder 
and rectum, and 
an increase in the 
spinal reflex ac- 
tivity. 
2. The Associa- 
tion Tracts. Each 
spinal segment has 
been shown to have 
functions of its own. 
But the different segments 
DNS always act in harmony, and 
Te” in hardly any act, either motor 
or sensory, is any segment inde- 
pendent of the rest. Hence a 
large part of the white matter of 
the cord is composed of tracts, 
shorter or longer, joining the vari- 
ous segments with one another, 
and associating their actions. These association tracts 
lie about the anterior horns of the cord, on their differ- 
ent sides, making up together a large antero-lateral col- 
umn which has been divided artificially into an anterior 
column (Fig. 3639, II), anda general lateral column (Fig. 
3639, III), the latter having a portion between the crossed 
pyramidal tract and the outer surface of the gray matter 
which has been called the lateral limiting layer (Fig. 
3639, V). All these tracts are about the same size at all 
levels of the cord, thus differing from the motor tracts, 
which decrease in size from above downward, and from 
the sensory tracts, which increase in size from below up- 
ward. They degenerate but a short distance in any 
transverse lesion of the cord. It should not be forgotten 
that the anterior nerve-roots pass out of the cord through 
the anterior column, and that many of these roots pass 
upward or downward for some distance before making 
their exit. Hence this column is not wholly made up of 
association tracts. There is no form of disease limited 
to the association tracts exclusively, hence it is impossi- 
ble to bring any known symptoms into connection with 
the lesion when they are affected in a general myelitis. 
3. Lhe Sensory Tracts. These occupy the posterior 


oe: adds 


A.C., Ante- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


columns of the cord, of which there are two on each side 
of the posterior median septum, viz., the postero-external 
column, or column of Burdach (Fig. 3689, VI), and the 
postero-median column, or column of Goll (Fig. 3639, 


Spinal Cord, 
Spinal Cord, 


cauda equina, including both sacral and lumbar nerves, 
are compressed and destroyed, the ascending degenera- 
tion occupies a somewhat larger area than in the first 
case, involving both posterior columns as high as the 


Fia. 3641,—Area of Ascending Degeneration after Compression of Cauda Equina, involving the Sciatic Nerve-roots only. 


VII). The column of Burdach is made up very largely 
of the posterior nerve-roots which enter it and pass up- 
ward or downward for some distance before leaving it, to 
end in the posterior gray horn, or to enter the column of 
Goll. The column of Goll is made up wholly of long 


fibres extending from the posterior nerve-roots to the 


VC 


medulla. The exact areas taken 
up respectively by the short pos- 
terior roots and the long fibres 
differ greatly at different levels, 
and they have only recently been 
determined by a study of the 
tracts degenerated after trans- 
verse lesions at different levels. 
These recent investigations de- 
serve a moment’s notice. 

If the posterior nerve-roots 
are divided between the poste- 
rior spinal ganglia and their en- 
trance into the cord, an ascending degeneration occurs 
in the cord. It is by observing the course of this ascend- 
ing degeneration that the upward continuation of the 
sensory nerves has been determined.4 The area of the 
posterior columns of the cord which degenerates upward 
differs in different cases. When the sciatic nerve-roots 


Fre@. 8642.—Area of Ascending Degeneration after Compression of 
Cauda Equina, involving all the Sacral and Lumbar Nerves. 


middle of the dorsal region and a large part of the column 
of Goll in the cervical region (see Fig. 3642). When a 
transverse lesion of the cord in the dorsal region cuts off 
all sensory conduction from below the level of the mid- 
dorsal region, the area of ascending degeneration is still 
larger than in the first two cases, and in the cervical re- 


gion involves the entire column 
of Goll (see Fig. 36438). When 
the cord is divided in the lower 
part of the cervical enlargement, 
the ascending degeneration in- 
volves a very large area, includ- 
ing both the entire column of 
Goll and a part of the column 
STATA of Burdach in the upper cervical 
Oe Via a region (see Fig. 3644). 

From these facts it becomes 
evident that the posterior nerve- 
roots contain a number of fibres 
which, after entering the cord, turn upward and pass on 
to the medulla oblongata, each successive set from below 
upward lying a little in front of, and outside of, the pre- 
ceding set, and gradually filling out the entire column of 
Goll and a portion of the column of Burdach. In a cross- 
section in the upper cervical region (Fig. 3640) it can, 


i Fie. 3643.—Area of Ascending Degeneration after a Transverse Lesion of the Mid-dorsal Region. 


alone are divided, or the sacral portion of the spinal cord 
is destroyed, the ascending degeneration occupies a large 
area of the posterior columns in the lumbar region, a 
smaller area in the dorsal region lying wholly in the col- 
umn of Goll, and the posterior median portion only of 
the column of Goll in the upper dorsal and cervical re- 
gions (see Fig, 3641). When all the nerve-roots of the 


therefore, be affirmed that the fibres in the posterior me- 
dian part of the column of Goll transmit sensory impulses 
from the legs; that the fibres in the median and lateral 
portion of the column of Goll transmit sensations from 
the thighs and pelvis ; that the fibres in the anterior por- 
tion of the column of Goll transmit sensations from the 
body exclusive of the arms; and that the median part of 


539 


Spinal Cord. 
Spinal Cord. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, 


the column of Burdach transmits sensations from the 
arms. Experimentation on animals has proven that the 
nerve-fibres entering the cord in the posterior nerve-roots, 

and passing upward in this manner to the medulla, de- 


medulla. It is not improbable that these fibres transmit 
sensations of touch, Even in the most extreme cases of 
secondary ascending degeneration in the posterior col- 
umns, after division of the nerve-roots, many fibres inthose 


Fie. 3644.—Area of Ascending Degeneration when the Lower Cervical Region of the Cord is involved by a Transverse Lesion. 


generate upward upon the side on which they enter. 
There is no reason, therefore, to believe that in man 
there is any decussation in the spinal cord of the fibres 
thus far described. But since all sensations, except those 
of muscular sense, are known to cross over to. and ascend 
in, the opposite side of the cord in man, immediately after 
their entrance, it follows that the fibres thus far consid- 
ered have for their function to transmit the sensations of 
muscular sense. And this conclusion is further estab- 
lished from the facts gathered from the pathology. of loco- 
motor ataxia. For in this disease, in which the muscular 
sense is the one most seriously impaired, the same areas 
of degeneration are found. ‘There is, first, the primary 
sclerosis in the column of Burdach, involving the nerve- 
roots in it, and secondly, the secondary degeneration in 
the column of Goll, whose extent is determined by the 
extent of the primary lesion. The higher the primary 
lesion advances, the greater the area of the column of 
Goll involved. Since cases have been observed in which 
the sensations of touch, of pain, and temperature, and of 
the muscular sense, have been affected singly, it follows 
that the tracts conveying these sensations must be separate 
from one another. The fibres so far described terminate 
in the nuclei of Goll and Burdach. But from these nu- 
clei the fibres of the interolivary tract and lemniscus 
arise, which are known to decussate in the sensory de- 
cussation of the medulla, and are known to transmit sen- 
sations of muscular sense exclusively. Hence the conclu- 
sion seems warranted that the sensory tract for muscular 
sense lies in the column of Goll for all parts below the 
arms, and in the median part of the column of Burdach 
for the arms. 

With regard to the sensory tracts for touch, pain, and 
temperature, our knowledge is much more indefinite. 
These sensations enter the cord by the posterior nerve- 
roots. But these roots do not send all of their fibres up- 
ward in the path already described. And if the area of 
the cord occupied by the column of Goll in the cervical 
region be compared with the entire area of the posterior 
nerve-roots, it will be seen that a mere fraction of the 
fibres entering the cord by these roots ascends to the me- 
dulla. The large remainder terminate in the cord. Anat- 
omists describe various manners of termination. Some 
fibres end directly in the posterior gray horn; others 
pass through it to reach the anterior gray horn; others 
still, cross over through the posterior gray decussation to 
the other side of the cord. Many fibres enter the column 
of Burdach and pass directly through it to enter the gray 
matter in the vicinity of the vesicular column of Clarke ; 
others ascend some distance in the column of Burdach 
before they enter the gray matter, and a few turn down- 
ward in the column of Burdach before ending in the 
gray matter. From the fact that general myelitis involv- 
ing the posterior gray matter is always attended by sen- 
sory symptoms, it is concluded that many sensations are 
sent to the cells of the posterior horns. From the poste- 
rior gray matter nerve-fibres pass backward into the col- 
umns of Goll and Burdach, and mingle with the fibres of 
those columns, presumably ascending with them to the 


540 


columnsescape. It is therefore possible that some of the 
fibres making them up have their origin and nutrient 
cells in the gray matter of the posterior horns, rather than 
in the posterior spinal ganglia. Hence the facts do not 
exclude the possibility of the transmission upward of sen- 
sations of touch in the posterior columns of the cord after 
such sensations have crossed the median line in the gray 
matter. And that they are transmitted in this region the 
older physiological experiments established. Other phys- 
iological experiments point to a transmission of sensa- 
tions of touch in the lateral columns of the cord. And 
Gowers has established the existence of a tract in the 
periphery of the antero-lateral column (Fig. 8639, VIII), 
lying anterior to the direct cerebellar tract, which degen- 
erates upward after transverse lesions. This is called 
the antero-lateral ascending tract. Positive facts, how- 
ever, do not yet warrant the statement that a sensory tract 
is to be found in man in the lateral columns. And the fact 
that in lateral sclerosis, and in amyotrophic lateral scle- 
rosis, aS well as in ataxic paraplegia and in Friedrich’s 
form of locomotor ataxia, in all of which the lateral col- 
umns are extensively involved and the fibres passing to 
the antero-lateral column from the gray matter must be 
implicated, but in none of which sensory symptoms are 
present or severe, would seem to prove that in man sensa- 
tions of touch are not transmitted in the lateral columns. 
It is evident, therefore, that sensations of touch are prob- 
ably transmitted upward through the posterior columns 
of the cord, after crossing over at the level at which they 
enter, but that a definite limitation of the tract through 
which they pass is impossible. 

The sensations of temperature and pain are uniformly 
preserved or lost together, hence it is concluded that they 
pass in the same tract. No definite position can be as- 
signed as yet to that tract. In syringo-myelitis, in which 
the lesion is limited to the central gray matter of the spi- 
nal cord between the anterior and posterior horns, a loss 
of temperature and pain sensations in all parts below the 
level of the lesion has been observed, and it has been 
concluded that these sensations are transmitted by the 
gray matter. Gowers believes that they pass in his an- 
tero-lateral tract, but the conclusion rests upon too small 
a number of observations to be hastily adopted. Spitzka, 
from a single case, concludes that sensations of pain pass 
in a triangular area on the periphery of the posterior col- 
umns, at the junction of the columns of Goll and Burdach. 
But each of these views is open to objections, and facts 
are wanting to determine between them. 

4, The Direct Cerebellar Column. The last column of 
the cord to be described is one lying upon the outer sur- 
face of the lateral column, and extending from the lower 
dorsal region to the corpus restiforme of the medulla, 
and thence to the cerebellum. Its termination in that 
organ has led to its name—the direct cerebellar tract. It 
is made up of fibres whose origin is in that column of cells 
lying in the median part of the posterior horn known as 
the vesicular column of Clarke. The cells are only found 
in the dorsal region, hence all the fibres in this tract 
come from the dorsal segments of the cord. They reach 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the lateral periphery of the cord by passing diagonally 
through the lateral column. They are supposed to 
transmit sensations upward from the Clarke column of 
cells to the cerebellum, because they degenerate upward 
after a transverse lesion of the cord. The function of 
both the cells and the tract is uncertain. From recent 
investigations by Gaskell, however, it seems probable 
that the vesicular column of Clarke is connected with 
the vaso-motor and sympathetic nervous systems by 
means of very small nerve-fibres extending from the 
sympathetic ganglia into the cord. If so, the function 
of the direct cerebellar tract is to transmit those rather 
indefinite sensations from the viscera, or to act as a tract 
for unconscious sensations or motor impulses necessary 
in a central regulation of visceral and vascular action. 
The hypothesis that they convey muscular-sense sensa- 
tions from the trunk is hardly warranted, since these 
must be of little importance in lower animals, who do not 
walk erect—in which animals, however, this column is 
well developed. 

II. Symptoms LEADING TO THE DraGNosis oF LocaL 
Lesrons.—Such being the functions of the various parts 
of the spinal cord, it remains to discuss the symptoms 
arising when various parts are diseased. And it will be 
as well to approach this subject from the side of the 
symptoms rather than of the lesion, since it is the object 
to determine the lesion in any case. 

1. Spinal Paralysis.—The motor tract conveying vol- 
untary impulses from the brain to the muscles consists 
of two elements: first, the cerebro-spinal element, and 
secondly, the spino-muscular element. Each element 
consists of a set of nerve-cells and their outgoing fibres, 
which not only transmit impulses from the cells but are 
nourished by them. The cells of the cerebro-spinal ele- 
ment lie in the cerebral cortex. Their fibres make up 
the motor tract through the brain and through the direct 
and crossed pyramidal tracts of the spinal cord.> These 
fibres terminate in the net-work of the anterior horns of 
the cord at various levels, some of them reaching its very 
lowest part. Any lesion in the cells of the cortex, or in 
the course of the fibres which cuts them off from those 
cells, results in the degeneration downward of the 
cerebro-spinal element to its termination in the motor 
cells of the spinal cord. The first form of spinal paral- 
ysis is due to a lesion at the spinal part of this cerebro- 
spinal element of the motor tract. Ifthe cord is divided 
by a transverse lesion at any point, the function of this 
element of the motor tract is thereby suspended. Asare- 
sult, voluntary motion is arrested in the parts below the 
lesion. If the lesion involves but one-half of the cord, it 
is the limbs on the side of the lesion which are paralyzed. 
If it involves the entire cord, both sides are paralyzed. 
The extent of the paralysis. depends upon the level of 
the lesion ; the higher the lesion the more extensive the 
paralysis. The degree of the paralysis will depend on 
the character. of the lesion, slight compression of the 
cord at one point by a tumor, or a pachymeningitis, or a 
projecting vertebra being followed by some stiffness of 
movement and rigidity of the muscles, with weakness, 
rather than by absolute loss of power in the parts below 
the level of the pressure. The cerebro-spinal element of 
the motor tract also transmits the inhibitory impulses 
which continually keep the spinal reflex and automatic 
mechanisms in check. A lesion of this tract, therefore, 
produces not only weakness and paralysis, but also in- 
crease of the deep reflexes, and impairment of control 
over the bladder and rectum. The muscular action of 
the limbs being no longer controlled by the brain, is gov- 
erned wholly by the centres in the spinal cord. These 
act in response to sensory impulses, or spontaneously, 
without check, and hence the preponderating strength of 
flexor over extensor muscles tends to produce a position 
of adduction and flexion of the limbs which are para- 
lyzed, and a heightened muscular tone, with tendency 
to rigidity. The nutrition of the paralyzed muscles may 
suffer somewhat from disuse, and from the attendant 
vaso-motor paresis, but no rapid atrophy is noted when 
the cerebro-spinal element of the motor tract is alone in- 
volved. And it is also to be noted that the paralysis 


Spinal Cord. 
Spinal Cord. 


affects the entire limb or limbs, and not any special group 
of muscles. In these cases the electric contractility re- 
mains normal in the paralyzed limbs. 

A typical example of this form of spinal paralysis is 
seen in compression of the spinal cord, below the lesion, 
and in lateral sclerosis or spastic paraplegia (q.0.). 

The second form of spinal paralysis is due to a lesion 
in the spinal part of the second element of the motor 
tract, viz., the spino-muscular element. This consists of 
the cells of the anterior gray horns of the cord, and the 
anterior nerve-roots which pass out through the anterior 
columns of the cord. Destruction of the cells suspends 
both voluntary and refiex motor impulses to the muscles. 
The cells not only control the motion, but also the nu- 
trition, of the nerves to which they give origin, and of the 
muscles to which these nerves go. Therefore destruc- 
tion of the cells produces atrophy of the muscles with 
which they are connected. If the destruction is grad- 
ual, the atrophy is gradual, as in progressive muscular 
atrophy. If the destruction is rapid, the atrophy is 
rapid, as in infantile paralysis. The degree of the 
atrophy depends upon the degree of destruction of the 
group of cells which govern the particular muscle af- 
fected. If the group is wholly destroyed, the muscle be- 
comes totally atrophied. In addition to paralysis with 
atrophy there is in the second form of spinal paralysis a 
change in the electric reaction of the paralyzed muscles. 
They lose their contractility to the faradic current, and 
alter their contractility to the galvanic current, respond- 
ing in asluggish manner, and to the positive more readily 
than to the negative pole. This is called the Reaction 
of Degeneration (¢.2.). 

The extent of the paralysis depends upon the extent of 
gray matter affected, and a reference to the table of the 
localization of functions already given will enable one 
to determine the effect of a lesion at any particular seg- 
ment, or through a group of segments, of the spinal cord. 
A typical example of the second form of spinal paralysis 
is found in infantile paralysis or poliomyelitis anterior. 
The muscles in this disease are paralyzed, atrophied, ex- 
hibit the reaction of degeneration, and lose their reflex 
excitability. An entire limb is rarely affected, certain 
groups of muscles being usually paralyzed together, e.., 
the deltoid, biceps, brachialis anticus, and supinator 
longus (upper arm group) ; or the extensors of the wrist 
and hand muscles (lower arm group); or the glutei and 
thigh muscles, with the tibialis anticus (thigh group) ; or 
the posterior tibial and peroneal groups of the leg (leg 
group). The muscles affected are not those which are 
supplied by a single peripheral nerve—a fact which en- 
ables a diagnosis between a lesion in the spinal cord and 
a lesion in a peripheral nerve to be easily made—but 
those which act together to produce a definite physio- 
logical act. 

The contrast between these two forms of spinal paral- 
ysis can be seen at a glance in the following table: 


First TyPE OF SPINAL PARALY- SECOND TYPE OF SPINAL PARAL- 


SIS. 


Lesion in pyramidal tracts. 

Paralysis usually on both sides 
equally, in legs, or in legs and 
arms, never in arms alone. 

All muscles are about equally af- 
fected. No muscles are entirely 
normal. 

Muscular tone is heightened. 

Tendency to rigidity appears. 

Reflex excitability is increased. 

Atrophy is absent, or is slight; and 
merely due to disuse, hence is 
gradual in progress. It affects 
the entire limb. 

Electric contractility is unchanged. 


Vascular tone is diminished; cy- 
anosis and cedema may occur. 

Paralyzed limb is cold, and sweat 
may be increased. 

Trophic disturbances in the skin 
are not infrequent. 

The control over the bladder and 
rectum may be diminished or lost, 

Example: Spastic paraplegia. 


YSIS. 


Lesion in anterior gray horns. ‘ 

Paralysis may be limited to any 
single limb, and rarely affects 
both limbs equally. 

Certain groups of muscles only are 
affected. Others escape wholly. 


Muscular tone is diminished. 

Muscles are relaxed. 

Reflex excitability is lost. 

Atrophy is always present in the 
paralyzed muscles. It advances 
rapidly, and may become ex- 
treme, 

Electric contractility is changed. 
Reaction of degeneration is pres- 
ent within two weeks of the onset. 

Vascular tone is diminished, but 
cedema does not occur. 

Paralyzed limb is cool, but sweat is 
not increased. 

Trophic disturbances in the skin 
do not occur. 

The control over the bladder and 
rectum is not impaired. 

Example: Infantile paralysis. 


541 


Spinal Cord. 
Spinal Cord. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


The third type of spinal paralysis is a combination of 
the first and second types. When a transverse lesion of 
the spinal cord entirely destroys a single segment, it pro- 
duces paralysis of the first type in the parts below the 
level of the lesion by cutting off the tracts to those parts, 
and paralysis of the second type at the level of the lesion 
by destroying the gray motor cells at that level. The 
general effect of such a lesion depends entirely upon the 
level at which it occurs ; the higher the lesion, the greater 
the extent of the first type of paralysis. The distribu- 
tion of the second type will depend on the level of the 
segment involved. The greater the extent of the lesion 
at the level affected, the greater the extent of the second 
type of paralysis. An example of this is also found in 
amyotrophic lateral sclerosis. When a longitudinal le- 
sion of great extent occurs—such as the general destruc- 
tion of the cord in general myelitis—the second type of 
paralysis is the form which is found, but all the muscles 
are affected, not merely a few groups. The bladder and 
rectum are also affected, and bed-sores are frequent. 

In any case of spinal paralysis, if the electric condition 
of the muscles paralyzed be ascertained by the aid of a 
faradic battery, and the diagnostic points here brought 
together be applied, reference to the table of the locali- 
zation of functions will enable the exact level of the le- 
sion to be determined. 

SPINAL AN#STHESIA.—The course of the sensory tract 
in the spinal cord is still somewhat imperfectly under- 
stood. It is known that all sensory impulses reach the 
spinal cord through the posterior nerve-roots, which 
partly enter the apex of the posterior horn, and partly 
enter the column of Burdach, and pass upward as al- 
ready described. The sensations of muscular sense as- 


cend on the same side as that on which they enter. . 


Those of touch, temperature, and pain cross. over as soon 
as they enter to the opposite side and ascend init. The 
various views regarding the tracts transmitting these sen- 
sations have been already stated. 

In transverse lesions of the spinal cord the area of an- 
vesthesia present in the skin depends upon the level of the 
lesion. Ansesthesia of the feet, legs, and thighs, except- 
ing their inner surfaces, indicates a lesion in the sacral 
and lower lumbar enlargement. Anesthesia of the en- 
tire surface of the legs, thighs, and buttocks, including 
the genitals, indicates a lesion involving the entire lum- 
bar enlargement. Aneesthesia around the body, attended 
by the so-called ‘‘ girdle sensation,” as if a band were 
drawn around the trunk, indicates a lesion in the dorsal 
region of the cord, and its level is indicated by observing 
the exact nerve above which sensation is normal. An- 
esthesia of the trunk, and of the inner surface of the 
arms and one-half the hands, indicates a lesion of the 
lower portion of the cervical enlargement, not higher 
than the seventh cervical segment. Anesthesia of the 
trunk and entire hand, forearm, and arm—the neck, upper 
chest, and outer surface of the shoulder only escaping— 
indicates a lesion as high as the fifth cervical segment. 
Transverse lesions higher than this cause sudden death 
from paralysis of the phrenic nerves. Limited areas of 
anesthesia in the skin, at any part of the body, are to be 
ascribed rather to lesions in the peripheral nerves or 
nerve-roots (as in tumors of the cord) than to any local 
lesions in the cord itself; for posterior poliomyelitis as 
a distinct lesion is unknown. The areas of the skin 
which are connected with the various segments have 
been described already in the table. When a transverse 
lesion involves but one-half of the spinal cord, the anes- 
thesia is found upon the side opposite to the lesion, below 
the level of the lesion, and extends around the trunk in 
a band at the level of the lesion, the width of the anes- 
thetic band depending upon the longitudinal extent of 
the lesion. On the side of the lesion below the level of 
the anesthetic band the skin is hypersensitive to touch. 
Such unilateral lesions produce a loss of muscular sense 
on the hyperesthetic and paralyzed side, not upon the 
side of the aneesthesia—a fact which proves that the sen- 
sations of muscular sense do not decussate within the 
cord. 

Hyperesthesia sometimes occurs from spinal lesions, 


542 


but is quite rare. It indicates an irritation of the sen- 
sory tracts in the cord by hypersemia, or by pressure, 
rather than destruction of those tracts. Gowers sug- 
gests that this hypereesthesia may be due to an increased 
irritability of the part of the cerebral cortex to which 
the injured tracts pass, as well as to an intensification of 
the impression passing in them. Pain is arare symptom 
in spinal-cord disease, excepting in locomotor ataxia. 
And here it is to be ascribed to irritation of the posterior 
nerve-roots within the cord, similar in character to their 
irritation without the cord, as occurs in meningitis and 
in diseases of the vertebral column. Numbness is a fre- 
quently mentioned symptom of spinal-cord disease, and 
has some value in local diagnosis, as the area of the skin 
in which the numbness is felt depends upon the level of 
the cord affected. Hence, when the numbness is limited 
to certain parts, especially to the extremities, a reference 
to the table will indicate the segment of the cord which 
is diseased. Thus in locomotor ataxia the beginning of 
numbness or pain in the little fingers indicates that the 
disease has advanced up the spinal cord and has reached 
the first dorsal and lowest cervical segments. 

SprnaAL ATAXxIA.—This symptom always indicates an 
affection of the posterior nerve-roots in their passage 
through the column of Burdach. Inco-ordination is due 
to an interference with the reception of sensations of 
muscular sense which are sent in from the skin, joints, 
and muscles, These sensations may be intercepted as 
they pass through the nerves, for ataxia is a symptom of 
toxic multiple neuritis; they may be intercepted as 
they pass through the column of Burdach, as is the case 
in locomotor ataxia; they may be intercepted in the 
brain by lesions in the lemniscus (see Pons) or in the 
cerebellum (see Cerebellum). It is probable that a por- 
tion of the muscular sensations are sent to the gray mat- 
ter of the cord, producing reflex action of balancing, and 
unconscious co-ordination, and that the remainder are 
sent upward to the brain. For the inco-ordination in 
cerebral disease, when the latter only are disturbed, is 
less severe and intense than in spinal-cord disease, where 
all are implicated. Ataxia from neuritis is usually ac- 
companied by tenderness in the nerves and muscles. 
Ataxia from cerebellar disease is only present in the act 
of walking, and is attended by vertigo. Ataxia from 
spinal disease is not attended by these two symptoms, 
but is usually accompanied by severe lightning pains 
and by loss of deep reflexes, together with other charac- 
teristic symptoms of locomotor ataxia (¢.2.). 

It must be stated here that in lesions of the spinal 
cord, as in those of the nerves, the motor symptoms are 
usually more pronounced than the sensory symptoms ; 
and even when the spinal cord is greatly compressed, or 
disintegrated, sensory impulses may continue to pass 
after motor impulses are entirely arrested. 

DISTURBANCES OF THE SPINAL REFLEX AND AUTO- 
MATIC AcTION.—Whatever view may be held regarding 
the nature of spinal reflex action, it is well established 
that certain structures are necessary to its production. 
It is necessary that a sensory nerve from the surface of 
the body be capable of transmitting impulses to the spinal 
cord. Itis known that the fibres transmitting the cen- 
tripetal impulses from the skin enter the apex of the pos- 
terior horn, while those transmitting impulses from the 
tendons enter the median surface of the posterior gray 
matter after traversing the lateral part of the column of 
Burdach called the root zone. Itis also necessary that 
the net-work of nerve-fibres through which impulses pass 
from the posterior gray matter to the cells of the anterior 
horn be intact. It is also necessary that the groups of 
cells in the anterior horn, and the motor nerves from them 
to the muscles, be in a normal state, or capable of exercis- 
ing theirfunctions. These structures, together, make up 
a reflex arc, and a lesion in any part of this are will ar- 
rest the reflex activity. Thus neuritis, outside the cord 
or due to meningitis, may interfere with the conduction 
of impulses to and from the cord; posterior sclerosis 
may arrest centripetal impulses as they reach the root 
zone ; general myelitis may destroy the net-work of fibres 
within the gray matter; and anterior poliomyelitis may 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Spinal Cord. 
Spinal Cord. 


destroy the motor cells in the anterior horn, Al these 
diseases, therefore, may cause a loss of tendon reflex. 
There are reflex activities governed by almost every seg- 
ment of the cord, as may be seen in the table ; and the 
particular reflex which is suspended in disease will de- 
pend wholly on the location of the lesion. Hence the 
loss of any one or more reflexes gives important informa- 
tion as to the seat of the lesion. And this can be ascer- 
tained after examination of the patient by a reference to 
the table. It has been already stated that an inhibitory 
influence is exerted by the brain upon spinal activity, and 
that this influence is conducted to the spinal motor cells 
through the motor tracts in the lateral column. Any- 
thing which impairs the conduction of impulses through 
this tract will result in removing restraint from the spinal 
reflexes and allowing them fullsway. Hence an increase 
in deep spinal reflexes indicates a suspension of function 
in the lateral pyramidal tracts. A transverse myelitis, 
therefore, will cause an increase of the reflexes below the 
level of the lesion, and a loss of the spinal reflex governed 
at the level of the lesion. This has been already men- 
tioned in connection with spinal paralysis. The skin 
reflexes are, however, not increased by lesions in the py- 
ramidal tract. 

The automatic activity of the cord includes the mech- 
anisms of micturition and defecation. These mechan- 
isms are complex reflexes, several sensory impulses 
combining to produce a compound motor effect, a part 
of which is inhibitory and a part of which is active. 
Thus in micturition, the sensations of pressure on the 
sensitive neck of the bladder, and of distention of the en- 
tire organ, produce an inhibition of the motor impulses 
which normally hold the sphincter tight, and set in ac- 
tivity the motor impulses which contract the detrusor 
urine, thus emptying the bladder. The same is true, 
mutatis mutandis, of the other automatic acts. The struct- 
ures necessary for any one of these acts are similar to 
those underlying the simple spinal reflex, and the same 
lesions arresting it may arrest these acts. But the result 
of such arrest is more serious, for, in the case of the 
bladder or rectum, retention or passive incontinence of 
urine or feeces may follow. And if the inhibitory impulses 
from the brain to these centres are cut off, the voluntary 
control over these mechanisms is impaired, and the acts 
cannot be initiated voluntarily, and active incontinence 
may result. The location of the rectal mechanism is in 
the lower sacral region. That of the bladder and sexual 
mechanisms is in the mid-lumbar region. Hence, when 
these parts are the seat of a lesion, or are cut off from the 
brain by a lesion at a higher level in the motor tract, in- 
continence, either active or passive, or retention, may 
result. 

A part of the automatic mechanism of respiration is 
governed by the cervical and dorsal regions of the cord, 
and is interfered with in disease in those regions. Lesions 
of the upper cervical region paralyze the diaphragm and 
thus cause death. 

DISTURBANCE OF VASO-MOTOR AND TROPHIC FUNC- 
TIONS of the cord may occur from various forms of 
lesion. Anterior poliomyelitis produces atrophy of the 
muscles paralyzed, and a sufficient affection of the 
vaso-motor system to cause objective, as well as sub- 
jective, coldness in the limb ; and when the lesion hes 
deep in the anterior horn, an arrest of development of 
the bones of the limb affected. General myelitis is usu- 
ally associated with a tendency to bed-sores upon the 
parts exposed to pressure, which cannot be avoided by 
the most scrupulous cleanliness, and to cystitis, and 
these are ascribed to a disturbance of trophic impulses 
to the skin and bladder. Posterior sclerosis is some- 
times associated with trophic changes, such as perfo- 
rating ulcers, joint affections (Charcot’s arthropathies), 
and eruptions on the skin. In a few cases of leprosy 
serious lesions of the posterior gray horns have been ob- 
served. In general myelitis there is a partial vaso-motor 
paralysis, indicated by cyanosis, sluggish circulation, 
cdema, and coldness, with abnormal sweating in the 
paralyzed parts. But any definite statement regarding 
the exact localization of vaso-motor or trophic functions 


in the spinal cord cannot be made as yet. And recently 
many vaso-motor and trophic symptoms, formerly sup- 
posed to be due to spinal 
lesions, have been found 
to be produced by disease 
in the peripheral nerves. 
It is, however, established 
that trophic lesions are 
most frequently observed 
when the gray matter of 
the spinal cord in the 
vicinity of the central 
canal, including the ve- 
sicular column of Clarke, 
is the part diseased ; or 
when all sensation is cut 
off from the paralyzed 
limbs by a transverse le- 
sion. 

The regulation of uri- 
nary excretion is presided 
over by a centre in the 
medulla, and the nerve- 
tract thence to the liver 
and kidneys is traced 
through the cervical re- 
gion of the spinal cord to 
the first dorsal segment, 
where it enters the sym- 
pathetic chain of ganglia. 
A lesion in the lateral 
column of the cervical 
cord, by involving this 
tract, may cause a vaso- 
motor paralysis of either 
the liver or the kidneys. 
In the former case diabe- 
tes mellitus is produced ; 
in the latter, diabetes in- L4 
sipidus results. It is 
therefore necessary, in le- 
sions of the spinal cord, 
to examine the amount 
and constituents of the 
urine. 

In any case of spinal 
disease where it is desir- 
able to localize accurately 
the lesion, it is suggested 
that a written summary 
of the symptoms be com- 
pared with the table of 
localization of the func- 
tions of the cord, when 
it will become evident, 
by contrasting the nor- 
mal with the abnormal 
conditions, what part of 
the cord is affected. As 
Bramwell justly ob- 
serves, ‘‘the essence of 
the clinical examination of the spinal cord consists in the 
systematic and separate examination of each spinal seg- 
ment, by observing the motor, sensory, reflex, vaso-motor, 
and trophic conditions of its body area.”” Such an exami- 
nation will lead to accurate diagnosis of local lesions. 

But one point remains to be mentioned, that is, the re- 
lation of the various segments of the cord to the bodies 
and spines of the various vertebre. As the cord extends 
only to the level of the second lumbar vertebra, its various 
segments do not lie opposite to the vertebrae from which 
they are named. The accompanying diagram of Gowers 
displays the mutual relation between the segments and 
their nerves, and the bodies of the vertebra, and no 
further description is needed. 


— 
he, 


SSE 
ia 


USS talons 


eS ad 


Fia. 3645. 


AUTHORITIES. 


Gowers: Diseases of the Spinal Cord. 
Luderitz: Ueber das Ruckenmark Segment, Arch. f. Anat. u.. Phys., 
1881, 


543 


Spinal Cord. 
Spinal Cord. 


Spitzka: Jour. Ment. and Nerv. Dis., 1880. 

Ferrier: Brain, vol. iv., p. 223. 

Beevor: Med. Chirurg. Transactions, vol. 1xxvili. 

Ross: Brain, April, 1884. 

Starr: Localization of the Functions of the Spinal Cord, Amer. Jour. 
Neurol. and Psych., August and November, 1884. 


M. Allen Starr. 


1 For a full account of the grouping of these cells, see Localization of 
the Functions of the Spinal Cord, by M. A. Starr, American Journal of 
Neurology and Psychiatry, vol. iii., p. 443 et seq. Ross: Diseases of the 
Nervous System, vol. i., p. 829. 

2 Gaskell: Journal of Physiology, 1886, 

3 See Brain and Pons, Diagnosis of Local Lesions in the. 
Tract, vols. i. and v. 

4 Schultze, F.: Ueber Secondare Degeneration im Rickenmarke, Arch, 
f. Psych., xiv., from which article the figures are taken. 

5 For the anatomy of this motor tract, see Diagnosis of Local Lesions in 
the Brain, vol. i. 


The Motor 


SPINAL CORD DISEASES. GENERAL SyMPTOMA- 
TOLOGY AND DrAGNnosis.—The spinal cord is a conductor 
of outgoing impulses, which are: 1, motor, to muscles ; 
2, secretory, to glands ; 3, vaso-motor, to blood-vessels ; 
4, trophic, to skin, muscles, bones. 

It conducts ingoing impulses, causing: 1, general sen- 
sations—cutaneous, articular, muscular, and visceral ; 2, 
special sensations—tactile, thermic, and muscular; 3, 
exciting reflex actions, simple and complex, and arous- 
ing automatic centres. 

The cord contains arrangements of cells forming reflex 
and automatic centres. 

These are the vesical centre, the anal, sexual, uterine, 
subordinate sweat and vaso-motor centres, cilio-spinal 
centres, and centres which regulate in a measure the 
functions of the abdominal viscera and the development 
of heat. 

The symptoms produced by disease of the spinal cord 
are due to interference with these various functions, and 
a thorough knowledge of the anatomy and physiology 
of this organ is the best means of guiding one to their 
interpretation. Those which may be called the dominant, 
and, in a measure, characteristic symptoms of spinal cord 
disease are the following, it being remembered that we 
have not only the individual symptoms to study, but 
their distribution and clinical history, in order to learn 
that they are peculiar to an organ or a disease. 

I. Of the motor class we have, in diseases of the spinal 
cord peculiar paralyses and spasms. These are either 
bilateral and paraplegic, as is usually the case in adults, 
or monoplegic and unequally distributed, as is often the 
case in children. Spinal paralyses are very rarely indeed 
hemiplegic, and they, of course, never involve the face. 
They are accompanied with wasting and sensory disor- 
ders, and involvement of the organic spinal centres. By 
these signs we can thus readily distinguish spinal from 
cerebral paralyses in almost all cases. Paralysis that oc- 
curs from involvement of the nerves is usually more cir- 
cumscribed, and if widespread, as in multiple neuritis, is 
painful, with the sphincters, vesical and rectal, only very 
exceptionally involved. Spasm is rare in the paralysis 
from neuritis, but frequent in that from spinal and cere- 
bral disease. 

In general, a paralysis with atrophy and without pain, 
or one with spasm and pains, means an involvement of 
the cord; a paralysis with pain and wasting means in- 
volvement of the nerves; a paralysis with spasm, but 
without wasting or much sensory disturbance, means in- 
volvement of the brain. 

Excessive motor action (hyperkinesis) without paraly- 
sis is a somewhat rare condition in spinal cord disease. 
Spinal convulsions, however, occur in tetanus and as the 
result of some poisons ; while in the spasmodic disorders 
known as writers’ cramp and chorea, the cord is in part 
involved. 

The peculiar electrical reactions in different forms of 
paralysis are of great help in determining the seat of the 
disease (see special articles). 

II. The pains due to spinal cord disease are somewhat 
characteristic. They are usually darting in character, 
and radiate through a number of branches of outgoing 
nerves ; or they are cinctural, causing a feeling as if 
the trunk were squeezed in a vise. Band-like feelings 


544 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


also occur about the head and lower limbs. Pain and 
tenderness along the spine occur in spinal irritation, in 
meningitis, and acute myelitis, but are rare in chronic 
diseases of the cord. The tissue of the spinal cord is 
probably somewhat sensitive to painful irritations in the 
posterior and antero-lateral parts, but practically most 
spinal pains come from irritation of the posterior roots, 
or root zones. Ansesthesia rarely follows organic cere- 
bral disease, and it is then unilateral ; therefore, when 
present in any other form of distribution, it is usually a 
symptom of involvement of the medulla, cord, or nerves. 
If the lesion is in the cord, the anesthetic region is most 
likely to be diffuse and bilateral, and to be limited at a 
certain level of the limb or trunk. Delayed sensation 
and allocheiria, or transferred sensation, are usually evi- 
dence of cord disease. Parasthesige, and in particular 
burning sensations, are, as arule, due to neuritis, while a 
peculiar sense of heaviness, often complained of, is of 
spinal origin. Ataxia due to disturbance of muscular 
and articular sensibility used to be thought a sign of dis- 
ease of the spinal cord, and such is usually the case. 
But ataxia may occur in neuritis. 

It will be seen that the extent and location of sensory 
symptoms determine the question of spinal or peripheral 
origin more than the character. 

III. In certain spinal affections involving the central 
gray, such as syringomyelia and progressive muscular 
atrophy, there are decided disturbances of the vaso-motor 
system and of the sweat-glands. The involvement is 
usually widespread and includes a whole limb, or nearly 
all of the bodily surface. idema, hyperidrosis, vaso- 
motor spasm, and paralysis, occur in a more localized 
and limited manner, from disease of nerves. 

IV. It is quite impossible in many cases to say posi- 
tively what neuro-trophic changes are due to spinal, and 
what to peripheral, neural influence. 

However, the rule is that the profounder trophic dis- 
turbances, such as decubitus, symmetrical gangrene, os- 
seous and articular lesions (arthropathies), scleroderma, 
and the severe forms of muscular atrophy, are of spinal 
origin. The more superficial lesions of the skin, such 
as herpes, glossy skin, etc., and minor degrees of mus- 
cular atrophy, are more likely to be peripheral. Mus- 
cular atrophies result from degenerative myositis, from 
neuritis, and from myelitis. For the special characters 
of the different forms the reader is referred to the arti- 
cles on these subjects. 

V. Among the common symptoms of cord disease are 
disturbances of the superficial, the deep, and the organic 
reflexes. The presence or absence of the superficial skin 
reflexes gives us very little practical information, as they 
are not abolished or exaggerated without other symptoms. 
In some cases a study of them may furnish a guide to the 
height of the cord lesion. 

The deep, or tendon, reflexes are always present in 
healthy persons (the exceptions are not one per cent.). 
When exggerated, they indicate a great degree of cere- 
bro-spinal irritability (hysteria, neurasthenia), or some 
cerebro-spinal lesion. Organic disease of the peripheral 
nerve may usually be excluded. 

A loss of tendon reflexes, on the other hand, may be 
due either to peripheral nerve or spinal cord disease, but 
not to cerebral disease unless there is also paralysis. If 
the loss is not due simply to motor paralysis, the trouble 
may, in the majority of cases, be referred to the cord. 

Disturbance of organic reflexes and centres of visceral 
control is a common, early, and almost pathognomonic 
sign of disease of the spinal cord. Some vesical weakness, 
or sexual weakness, may be for years the only sign of ap- 
proaching degenerative changes. It is only in certain 
rare cases that the bladder and rectum become involved 
through inflammation of the nerves (multiple neuritis). 
In profound cerebral and mental disturbance, control 
over the organic centres may also be lost. 

In diseases affecting the central gray of the cervico- 
dorsal segments of the cord, pupillary disturbances, retrac- 
tion or bulging of the eyeball, and facial flushing, pallor, 
or sweating may occur. 

The spinal cord contains thermogenetic centres in its 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


central gray, and an increase or lowering of bodily tem- 
perature from disease of these parts is sometimes ob- 
served. A lowering of temperature is especially notice- 
able in poliomyelitis anterior. 

GENERAL PatHoLocy.—The spinal cord is subject to 
nearly all the diseases which affect other tissues of the 
body. Owing, however, to its peculiarly guarded posi- 
tion, the nature of its tissue, and its vascular supply, it is 
much less often affected with fatal disease than most or- 
gans, and is practically exempt from all but a few types 
of pathological processes. (Among 2,456 deaths from 
nervous disease, not more than 50 can be attributed to 
the spinal cord, leaving out the acute meningitis of chil- 
dren.—‘‘ Rept. New York City Health Board.”) These 
are acute and chronic inflammations and degenerations. 
But though organic disease is rare, the cord, being a 
highly organized tissue, is often subject to functional or 
nutritional disorders, and to secondary degeneration from 
brain disorder. 

Blood-vessels.—The arteries of the cord are numerous, 
but are of small calibre, smaller considerably than the 
veins, and carry blood at a low pressure. 

Embolism and thrombosis are very rare, so far as is 
known, owing to the tortuous course of the arteries, and 
the capaciousness of the veins. Endarteritis and athe- 
roma are not rare as compared with other organs, but are 
much less frequent than in the brain. ‘The arterial 
branches, after penetrating the cord, anastomose with 
each other but slightly ; hence the plugging of a single 
branch tends to produce softening, asin the brain. But 
softening may, perhaps, be produced in another way. 
The small blood-vessels of the cord are richly supplied 
with vaso-motor nerves, which have a powerful influ- 
ence over the calibre of the arteries. The result is that 
by reflex influence, or direct irritation, these arteries may 
be so tightly closed as to produce complete anzmia, with 
consequent softening, or they may be so completely par- 
alyzed as to produce minute hemorrhages and incipient 
inflammatory conditions. Such, at least, seemsto be the 
mechanism of many cases of acute white softening, of 
transverse myelitis, and of acute poliomyelitis. 

The anterior horns of the cord, which are particularly 
liable to this latter affection, are supplied each by a 
branch of the anterior median artery, and occlusion of 
‘this would cause suppression of nearly all motor func- 
tion in one segment of the cord (Ziegler). 

According to Stenon’s experiments, a stoppage of ar- 
terial supply to the spinal cord affects first the gray mat- 
ter, then the white, and lastly the nerves and muscles. 
It is evident, from both anatomical and physiological con- 
siderations, that the gray matter is most richly and sensi- 
tively supplied with blood. 

The veins are also numerous, are larger in calibre than 
the arteries, and communicate with the very rich plexus 
lying outside the dura mater, which also receives return- 
ing blood from the vertebre, bones, and tissues posterior 
to these. The spinal cord veins cannot be injected from 
these large spinal plexus, and passive congestion of the 
cordes, from obstruction to the general circulation, rarely 
occurs to such an extent as to cause symptoms. 

The circulation of the cord and its functions as a cen- 
tre are, so to speak, ‘‘segmental.”” The blood flows in, 
horizontally, through Jateral branches of the intercostal, 
lumbar, or sacral arteries, and flows out through veins at 
about the same level. Hence it is that acute disorders, 
which depend so much upon the vascular disturbance, are 
focal or transverse. — 

Fibre Systems.—The conducting portions of the cord 
necessarily embrace long stretches of nerve-fibres, and 
these must exist in their whole continuity, if at all. If 
disease attacks one point, cutting off a strand, it extends 
slowly till it involves a large part of the fibres. Hence 
chronic diseases of the cord, involving the white matter, 
always eventually extend up or down the cord. 

Regions of Least Resistance to Disease.—For some rea- 
son, Which is not at present well understood, the upper 
part of the dorsal cord is particularly liable to be affected 
in subacute or acute diffuse inflammation. The poste- 
rior columns in their lower part are most susceptible to 


Vou. VI.—85 


chronic degenerations. 


Spinal Cord, 
Spinal Cord. 


The cervical and lumbar en- 
largements are especially often attacked by the ischemic 
softening known as acute anterior poliomyelitis. Of the 
gray matter, the anterior cornual cells are especially sus- 
ceptible to slow degenerative atrophy. Hemorrhages, tu- 
mors, syphilitic and tubercular growths, rarely attack the 
substance of the cord, but take their start in the meninges. 

Infections.—The cord enjoys considerable immunity 
against infections, that of cerebro-spinal meningitis be- 
ing the only one frequently attacking it. The virus of 
tetanus, rabies, and of leprosy also especially involve the 
cord. Syphilis rarely affects it with peculiar growths, but 
often predisposes it to chronic degenerative and inflam- 
matory disorder. Tuberculosis of the cord is also very 
rare, and tumors of all kinds, occurring primarily, may 
be considered pathological curiosities. 

Meningeal Disease.—The spinal meninges are subject 
somewhat frequently to chronic or subacute inflamma- 
tion ; but primary acute spinal meningitis is not very 
often seen, except as part of the infective cerebro-spinal 
disorder. 

Trauma.—Traumatism causes heemorrhages, inflam- 
mation, and softening, and may start up degenerative 
processes. 

The list of general pathological disturbances of the 
spinal cord is as follows: 

I, Malformations. — Myelocele, meningo-myelocele 
(spina bifida), meningocele, heteratopia, micromyelia, 
macromyelia, and duplication of cord. 

II. Vascular Disorders.—Congestion and ansemia, en- 
darteritis, hemorrhage, aneurism, embolism and throm- 
bosis, oedema. 

IIL. Syringomyelia. 

IV. Inflammatory Disorders.—Acute, subacute, and 
chronic myelitis, ischemic and hemorrhagic softening, 
acute and chronic meningitis, abscess of cord. 

V. Degenerative Processes of Cells.—Simple atrophy, 
fatty degeneration. 

Degenerative Processes of Fibres and Neuroglia.—(1) 
Gelatinous degeneration. (2) Gray degeneration, or 
sclerosis, primary and secondary. 

VI. Tuberculosis.—(1) Miliary, without or with men- 
ingo-myelitis. (2) Solitary tubercle. 

VII. Syphilis.—(1) Gummatous. (2) Meningo-myelitis. 

VIII. Zumors.—Chiefly sarcomata, gliomata, and gum- 
mata. 

IX. Diseases of the Meninges.—External meningitis, 
internal meningitis of dura, internal meningitis of pia, 
hemorrhages, malformations, tumors. 

I. Under the head of malformations, or agenetic dis- 
orders, should be mentioned a bioplasmic tendency which 
leads, under slight causes, or simply in the course of de- 
velopment, to degenerative changes of the proper tissue 
of the cord. An illustration of this is the cord in heredi- 
tary ataxia, which is often micro-myelic or deformed, as 
well'as degenerated. 

Syringomyelia is also usually associated with, or caused 
by, some congenital malformation. 

Of other malformations meningo-myelocele is the one 
oftenest observed. 

II. Hyperzemia of the cord, so great as to cause symp- 
toms, occurs occasionally as the result of sexual excesses, 
over-exertion, the stoppage of fluxes, and possibly in 
the caisson disease. An hyperemia, affecting especially 
the meninges, seems sometimes to remain after attacks of 
meningitis. Spinal hyperemia, however, of a chronic 
character, is a doubtful pathological entity, and though 
the spinal circulation is believed to be sluggish, its course 
is not easily interfered with. 

III. Spinal anzemia is a more real thing. Profuse he- 
morrhages, and mechanical obstructions, such as thora- 
cic and abdominal aneurisms, may cause an anemic 
paraplegia. Reflex paralysis from intestinal or other 
visceral injuries is probably due to a spinal ischemia. 
Injuries such as gunshot wounds have produced reflex 
paralyses of presumably similar origin. In general ane- 
mia, when very pronounced, the spinal cord shows some 
evidence of depression or irritation, but hardly more 
than do other organs. 


545 


Spinal Cord. 
Spinal Cord. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


After exhausting fevers and depressing traumatisms 
a paraplegic condition sometimes occurs ; it is attributed 
to spinal anzemia, but probably the condition is more 
often due to nutritive disturbance. Chronic spinal ane- 
mia can hardly be placed as yet in the category of distinct 
spinal affections. 

Embolism of the spinal cord has been known to occur, 
but only very rarely. Thrombosis is still more infre- 
quent. Miliary aneurisms, such as develop in the cere- 
bral vessels, are sometimes found in the cord, but they 
do not, as in the brain, lead to spontaneous apoplexy. 

IV. Inflammation is a peculiarly damaging process to 
the spinal cord ; its nervous tissue, once destroyed, has 
no power of regeneration. Acute inflammation is usually 
accompanied at first with such exudation and congestion 
that function is completely and widely suspended. Later, 
when absorption takes place, the focus of disease becomes 
more circumscribed and the symptoms lessen. Hence, in 
acute and subacute myelitis, not ending fatally, the paral- 
ysis is usually retrogressive. This is especially the case 
in myelitis of the gray matter. Chronic inflammation 
has a tendency, on the other hand, to extend, either by a 
progress in the inflammation or by setting up secondary 
degenerations. Hence chronic myelitis causes usually a 
progressive paralysis. Acute myelitis, after improving, 
may develop into a chronic form, when we have first 
retrogressive, then progressive, paralysis. The character- 
istic changes in acute myelitis and meningitis will be de- 
scribed under the special headings. Inflammation of the 
spinal cord has this peculiarity, that it is usually necrotic 
and rarely leads to suppuration or abscess. The initial 
stage of acute myelitis is often an ischemic or hemor- 
rhagic softening. In chronic myelitis the process affects 
the interstitial connective tissue primarily. As this in- 
creases in nutritive activity and anatomical extent, the 
nerve-fibres and cells atrophy. 

V. In degenerative processes, however, the nerve-tis- 
sue suffers first, and then the interstitial proliferates. 
There is thus an inverse ratio in the activities of the two 
(Gowers). Primary degenerative processes attack, first, 
the long-fibre systems of the cord and the anterior cornua, 
throughout more or less of their extent. The primary 
degenerative process travels both up and down the strand, 
while secondary degencrations only travel in the direction 
in which the impulses are carried (Striimpell). Forel 
shows that in certain pathological conditions which cut 
the fibre off near its trophic cell, the degeneration ex- 
tends up to this cell as well as along the peripheral part. 
After a degeneration is established in one strand, there is 
a tendency for it to extend to neighboring parts, through 
proliferation of the connective tissue. The term sclerosis 
has been used to indicate the condition in chronic mye- 
litis, and also in primary and secondary degeneration. It 
is used as an equivalent also to gray degeneration. @elat- 
inous degeneration is a term applied to the earlier stages 
of the latter process. 

VI. For details regarding the rarer conditions of tuber- 
culosis and tumors of the cord, the reader is referred to 
the special articles. Syphilis appears powerfully to pre- 
dispose the cord to chronic myelitis and degenerative dis- 
orders. The peculiar products of syphilitic development, 
such as gummata and diffuse gummatous inflammation, 
are rare. When present they attack, first, the meninges. 

GENERAL ETioLocy.—The remarks made upon this 
head must bear chiefly upon the more common cord af- 
fections, viz., inflammations and degenerations. Acute 
inflammation of the anterior cornual gray matter (anterior 
poliomyelitis) is mainly confined to children, while acute 
transverse myelitis belongs to adults. Males suffer more 
from both forms. Exposure, over-exertion, injuries, and 
infective fevers furnish the prominent exciting causes. 
It is not unlikely that a specific infection is the active 
agent in the acute poliomyelitis or acute ischemic soft- 
ening of children. In chronic myelitis there is some- 
times, though rarely, a hereditary tendency. Early and 
middle life, the male sex, syphilis, sexual excess, chronic 
alcoholism, occupations calling for exposure and over- 
exertion, are among the chief predisposing causes. 

The causes which lead to chronic myelitis are much 


546 


the same as those that lead to the typical degeneration 
disease, locomotor ataxia. In ataxia, however, the in- 
fluence of a hereditary taint and of syphilis is more 
marked. 

Syphilis and lead-poisoning seem to favor the develop- 
ment of chronic degenerations of the anterior horns (pro- 
gressive muscular atrophy). Alcohol has less influence, 
pathologically, on the cord than on the peripheral nerves 
and brain, and it is a minor factor in causing its degen- 
erations. Malariararely affects the cord, and then chiefly 
to produce vascular disturbances of the gray matter. 
Like alcohol, arsenic causes paralysis, if at all, by produc- 
ing inflammations of the nerves. Chronic poisoning by 
ergot may lead to a sclerosis of the posterior columns. 
In lathyrismus the lateral columns are especially at- 
tacked. In certain forms of podagra both lateral and 
posterior columns degenerate (Tuczec). Hence certain 
poisons seem to pick out definite physiological tracts. 
Chronic disorders of the brain, particularly general pa- 
ralysis, lead often to degenerative changes in the cord ; 
and the brain undoubtedly holds a certain amount of 
trophic influence over the cord. 

Traumatism is an important element in spinal pathol- 
ogy. Severe shocks and blows to the trunk may lead to 
heemorrhage (usually meningeal), or excite a chronic my- 
elitis, or lead to the development of degenerative pro- 
cesses. Still more often do traumatism and mental 
shock, combined, lead to nutritive or functional disor- 
ders. It is usually the case, however, in these instances, 
that the patient has some neuropathic predisposition. It 
is doubtful if purely mental shock can cause a spinal dis- 
order, though it may lead to a neurasthenic or hysterical 
condition in which spinal symptoms predominate. 

In conclusion, among the remaining causes of spinal 
cord disease are sudden disturbances of the circulation, 
such as hemorrhoidal discharges, suppressed menses, in- 
fectious fevers, irritation and disease of peripheral or- 
gans, 

GENERAL THERAPEUTICS.—In the functional diseases 
of the spinal cord, such as spinal irritation, spinal ex- 
haustion, and the various disturbances associated with 
hysteria or the morbid diatheses, treatment must always 
be more of a general than of a special character. 

In the scleroses and degenerations specific attempts to 
affect the nutrition of the cord are attempted. Drugs, 
diet, rest, counter-irritants, electricity, and mechanical 
appliances are here used. 

The posterior spinal nerves supply directly the skin of 
the back with sensation. They contain excito-reflex 
fibres, and by acting on them through the counter-irritants 
the circulation in the cord is profoundly affected. 

The veins carrying blood from the cord join with those 
supplying the postérior spinal region, and unite with the 
intercostal, lumbar, etc., veins. By drawing blood from 
the tissues of the back, therefore, we presumably draw 
some away from the cord. Hence cupping the back is a 
favorite therapeutical measure. Slight changes in the 
spinal circulation are produced by posture, and this is of 
some importance. Faradic currents act on the cord by 
counter-irritation ; galvanic currents, in addition, reach, 
and to some extent affect, the cord. 

It may be considered certain that strychnia causes a 
hyperemia of the cord in large doses ; probably phos- 
phorus does the same. Ergot can very probably cause 
some spinal aneemia, the bromides have a direct sedative 
power, and iodide of potassium has some resolvent prop- 
erties here as in other organs. There is ground for be- 
lieving that mercury has some antiphlogistic powers in 
acute spinal inflammatory disorders. It would not be 
worth while to discuss other drugs or remedies here. 
It will be seen that the spinal cord can be affected by the 
therapeutist, 1, through the posterior spinal and other 
excito-reflex nerves; 2, through the efferent blood-ves- 
sels; 38, through drugs that directly affect the circula- 
tion, the tissue irritability, and the nutrition. 

The history of lathyrism, ergot-poisoning, and podagra 
leads one to hope that we may yet find that certain 
drugs especially affect certain parts of the cord. 

7 Charles Loomis Dana, 


REFERENCE HANDBOOK OF 


SPINAL CORD DISEASES: ACUTE ANTERIOR 
POLIOMYELITIS. Synonyms: Acute inflammation of 
the gray anterior horns; acute atrophic spinal paralysis ; 
infantile spinal paralysis ; acute spinal paralysis of adults. 

DEFINITION.—The disease is characterized by a rapidly 
setting-in paralysis of various parts of the body, most 
commonly the lower extremities, preceded, especially in 
children, by a fever of short duration, sometimes by con- 
vulsions, coma, or other nervous symptoms. ‘The paraly- 
sis, attended by flaccidity of the muscles, reaches its great- 
est intensity very quickly, and at the end of a few days 
begins to decrease. The permanently paralyzed muscles 
undergo rapid atrophy. In children, when the disease 
is extensive, there is arrest of development of the bones, 
and various deformities are produced. 

The pathological basis appears to be an acute myelitis, 
affecting chiefly the anterior cornua. 

The clinical appearances of the disease in children were 
pointed out by Heine in 1840, though its anatomical char- 
acter was not recognized until a much later period. Since 
the report of cases by Meyer in 1868, it has been known 
that the disease occurs also in adults. 

Errotocy.—The disease occurs chiefly in childhood. 
According to some observers three-fourths of all cases 
occur between the ages of six months and two years. It 
is possible that the liability to disease in early life is due 
to the yet incompletely developed condition of the spinal 
cord, especially its motor portions. It oceurs chiefly dur- 
ing the summer months. According to Sinkler, 77 of 149 
cases appeared in July and August. Sex, heredity, and 
previous condition of health, seem to exert no influence. 
External injury, dentition, and exposure are often as- 
signed as exciting causes, but their influence is, at least, 
doubtful. — 

The paralysis often appears after an attack of measles, 
scarlatina, or the like, so that in these cases—possibly 
this is true of other instances—the disease appears to be 
produced by a poison circulating in the blood. 

Symproms.—The disease presents a somewhat different 
appearance in children and in adults, so that it is well to 
describe each separately. 

(a) Acute Anterior Poliomyelitis of Childhood.—The pa- 
ralysis sometimes sets in suddenly, without any prior man- 
ifestations of disease ; but, more commonly, it is preceded 
by high fever of a few hours’ or days’ duration, which 
may be complicated by various nervous symptoms, as 
somnolency, or even complete coma. In a large number 
of cases the disease is ushered in by convulsive seizures. 
_ These are like eclamptic attacks, and are of short duration. 
They may occur in large number, or there may be but a 
single seizure. The fever in these cases is, possibly, due 
to the acute inflammatory changes in the cord, but it is 
singular that such severe cerebral symptoms should usher 
in what appears to be a purely spinal disease. 

The paralysis sets in very rapidly and soon reaches its 
greatest intensity. When the children are removed from 
bed, after subsidence of the fever, it is observed that the 
paralyzed parts hang lifeless, a condition which may at 
first be attributed to mere weakness. In older children, 
in whom such observations can more easily be made, the 
paralysis is usually observed to have come on overnight, 
or to have reached its height in a few hours, very rarely 
in several days, while every part affected is paralyzed at 
the same time. 

The distribution of the paralysis is variable. Frequent- 
ly a single limb, or only a group of muscles, is affected, 
but more commonly several members are attacked. The 
paralysis occurs most frequently in a paraplegic form, in 
the lower extremities, but it may attack the four extrem- 
ities, and even the trunk, at the same time, or the upper 
extremities alone. More rarely it occurs in hemiplegic 
form, affecting a leg and arm of the same side, or even 
a leg on one side and an arm on the other. The para- 
lyzed muscles are quite flaccid, so that the limbs can eas- 
ily be moved in a passive manner; the reflexes, both 
superficial and deep, are abolished. 

The paralysis reaches its height very quickly, and from 
that time the changes are only toward improvement, 
which takes place, to a greater or less extent, in all cases. 


Spinal Cord. 


THE MEDICAL SCIENCES. Spinal Cord. 


The improvement is usually manifest within one or two 
weeks, and, for a time, progresses rapidly. In rare cases 
there is complete recovery (temporary spinal paralysis). 
But in the great majority of cases a greater or less degree 
of paralysis remains permanently. Of the paralyzed ex- 
tremities some may entirely recover, while in others, 
especially the lower, groups of muscles remain perma- 
nently paralyzed. The improvement is most rapid during 
the first six or eight weeks, and then continues very 
slowly for six or eight months, and, with proper treat- 
ment, possibly without it in some instances, the muscles 
may gain in strength for a year or two. 

The profoundly paralyzed muscles soon undergo atro- 
phy. This is usually observed within a week or two. 
When their power is restored the muscles regain their 
volume, but in those permanently paralyzed the atrophy 
may be so complete that no muscular tissue can be felt 
beneath the skin. The atrophy is sometimes concealed 
by the accumulation of adipose tissue. 

Along with the muscular atrophy are observed changes 
in the electrical reactions. These are very important, 
both as diagnostic and prognostic indications. When 
the paralysis is profound, the faradic irritability of the 
nerves and muscles is diminished in from three to five 
days, and entirely abolished in a week. When, on the 
other hand, at the end of the second week the faradic 
contractility of the muscles, though diminished, is not 
abolished, the muscles will not remain paralyzed perma- 
nently. The changes in the galvanic reactions are those 
characteristic of the reaction of degeneration—first, in- 
creased gaivanic irritability, then anodal closure contrac- 
tion stronger than cathodal closure—the reverse of the 
normal formula; finally, the galvanic reactions become 
weaker and may be abolished. In muscles not so pro- 
foundly paralyzed there is usually only a quantitative 
change in the electrical reactions, a diminution of the fa- 
radic and galvanic irritability, but no qualitative change, 
no reversal of the normal formula of contractions. 

The bones and joints are often greatly altered. The 
bones may be arrested in their development, be much 
shorter and narrower than the corresponding ones on the 
other side, and also be more yielding or friable. In this 
way the whole limb remains smaller than its fellow. 
This is especially true of the lower extremity, which 
may be from two to six inches shorter than the sound 
one ; but the arm is also frequently reduced in size, and 
even the bones of the pelvis are sometimes arrested in 
their development. The changes in the bone need not 
correspond to those in the muscles. There may be con- 
siderable atrophy of muscles and but little change in the 
bones, or vice versa. 

The joints may become deformed and abnormally mov- 
able, due partly to atrophy of the cartilages and the epiph- 
yses of the bones, partly to a weakness of the ligaments 
of the joints. The skin is usually cold and cyanotic, and 
sometimes becomes dry, liable to indolent sores, etc. 

The most characteristic features of the long-standing 
disease are the various deformities which occur. Vari- 
ous factors play a part in their production. One is the 
weight of the limb, as when the child lies on its back 
the paralyzed foot naturally falls into a state of exten- 
sion, and talipes equinus results. A more important fac- 
tor is the state of the muscles. The deformity is greater 
when not all of the muscles of a joint are paralyzed. The 
limb is then drawn and maintained in its new position by 
the unantagonized sound muscles, which may subsequent- 
ly become shortened to adapt themselves to their changed 
relations. Some other factors may come into play, as re- 
traction of the connective tissue related to the atrophied 
muscles. In fact, the explanation of the production of 
deformities is still largely a controversial point. 

The most common deformities are the different kinds 
of club-foot, especially equino-varus. Among others are 
various contractures of the knees and hips, lateral and 
antero-posterior curvature of the spine, and contractures 
of the hands, wrists, and arms. 

Apart from those mentioned there are, as a rule, no 
nervous symptoms. In the very beginning there may be 
some pain and hyperesthesia, and weakness of the blad- 


547 


Spinal Cord. 
Spinal Cord. 


der. But these soon disappear, and then there are no 
sensory symptoms, and the functions of the bladder and 
rectum are normal. The mind isclear, the general health 
unaffected, and the patient may live to old age. 

(b) Acute Anterior Poliomyelitis of Adults.—The dis- 
ease is ushered in by fever and nervous symptoms, as in 
children, though convulsions have not been observed. 
The paralysis sets in rapidly, the paralyzed muscles are 
flaccid, the permanently paralyzed muscles undergo rapid 
atrophy, and there are changes in the electrical reactions, 
just as we found them in children. Less frequently than 
in children is a single limb affected. Often the four ex- 
tremities, at least the lower, are paralyzed, though the 
upper may be alone affected. Improvement soon begins, 
and, as in children, rare cases of recovery occur. As a 
rule, more or less paralysis remains permanently. The 
deformities, which appear at a later period, are not so 
great as in children, for the bones have attained their 
full size, and the joints are firmer. 

Morzsip ANATOMY.—The great majority of post-mor- 
tem examinations have been made in cases where the 
disease had existed many years. In these extensive 
changes have been found in both the white and gray 
matter of the cord, as well as in the nerves and muscles. 
But most of these are to be considered secondary changes. 
In the few cases where an examination could be made at 
a comparatively early period (after the disease had ex- 
isted four weeks or longer), evidences of myelitis were 
found, affecting chiefly the anterior cornua, and, to the 
largest extent, the cervical and lumbar enlargements. 
The large ganglion cells were always affected, and their 
destruction appeared to correspond to the extent of per- 
manent paralysis. It is now generally believed that the 
paralysis, as well as the trophic changes in the muscles, 
bones, etc., is due to the destruction of these cells— 
which have both motor and trophic functions—or to the 
severance of their relations with the peripheral nerves. 
The acuity of the inflammatory process accounts for the 
rapid onset of the paralysis, and the considerable resolu- 
tion of the pathological process which takes place ex- 
plains the improvement which is always observed. 

The naked eye appearances in recent cases are some- 
times negative ; sometimes there is indistinctness of out- 
line on section, and discoloration and diminution of size 
of the anterior cornua. In several instances distinct foci 
of red softening were found. The seat and extent of the 
pathological changes are more accurately seen in the mi- 
croscopical appearances. Foci of disease may be found 
in various parts of the cord, especially the anterior gray 
matter, while those of greatest intensity are usually in 
the cervical or lumbar regions. They may reach for 
some distance up and down the cord, occupying, at the 
same time, but a part of the anterior cornua. These are, 
usually, foci of red softening, in which the blood-vessels 
are much dilated, and granular cells appear in more or 
less abundance, and where the nervous elements, large 
ganglion cells and nerve-fibres, have mostly disappeared. 
The areas of disease may be distinctly circumscribed, and 
the neighboring tissues be entirely normal, or a slight 
and more diffuse inflammation may be observed to ex- 
tend beyond this in various directions. 

Occasionally there is found slight sclerosis of the an- 
tero-lateral columns, and diminution of their size, while 
the anterior roots, those corresponding to the diseased 
areas, are usually more or less atrophied. 

In old cases, where the disease has been extensive, 
changes are readily seen by the naked eye. The anterior 
cornua, and often the antero-lateral columns, are much 
shrunken, and the anterior roots greatly atrophied. On 
microscopical examination quite circumscribed lesions 
are usually found in the anterior cornua of the cervical 
or lumbar enlargements, which are composed mainly of 
fine wavy connective tissue, with corpora amylacea and 
pigment granules, and in which the nervous elements have 
mostly disappeared. If ganglion cells are present they 
are usually in various stages of degeneration. At the 
same time the ganglion cells are often reduced in num- 
ber in other parts of the cord, which may present other 
slight pathological changes. 


548 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


In the antero-lateral columns, either in the immediate 
neighborhood of the greatest changes in the anterior cor- 
nua or involving a greater part of those tracts, are evi- 
dences of sclerosis, increase of the neuroglia, and atrophy 
of nerve-fibres. ‘ 

The muscles present pathological changes correspond- 
ing to the intensity of the disease. Sometimes a few 
normal muscular fibres are found among others which 
are to a greater or less degree degenerated. In other in- 
stances the muscular fibre has altogether disappeared 
and been replaced by connective or adipose tissue. 

More or less degeneration and atrophy are also found 
in the peripheral nerves, tendons, bones, and joints. 

Draenosis.—Usually a diagnosis is easily made, on ac- 
count of the striking and characteristic features of the 
disease. These are flaccidity of the paralyzed muscles, 
altered electrical reactions, rapidly developing atrophy, 
and loss of the reflexes, together with absence of sensory 
or other nervous symptoms. 

In young children pseudo-paralysis from disease of 
bone or other surgical affection might be mistaken for in- 
fantile paralysis, but a careful examination, or the lapse 
of a short period of time, would clear up the diagnosis, 

Cerebral infantile paralysis can be distinguished by the 
absence of pathological atrophy, the normal electrical re- 
actions, presence of the reflexes, the frequent involve- 
ment of the intellect, and the hemiplegic form of the 
paralysis. 

The differentiation of hematomyelitis, or hemorrhage 
into the substance of the cord, will often be impossible. 
The same is true of some cases of neuritis, though ten- 
derness over the nerve and presence of anesthesia or 
other sensory symptoms will usually point to the true 
disease. 

In transverse myelitis there are usually indications of 
disease of the posterior as well as the anterior part of the 
cord. 

Compression myelitis from Pott’s disease presents, usu- 
ally, the appearance of spastic paralysis, exaggerated ten- 
don reflexes, etc. 

Proenosis.—It is possible that some of the fatal cases 

of convulsions in children were in the initial stage of this 
disease ; otherwise it is not attended by serious danger to 
life. The prospect is less favorable as regards the pa- 
ralysis, more or less remaining permanently in most cases. 
The electrical current is of great value in informing us 
at an early period as to the probability of permanent 
paralysis. The information to be gained from it has al- 
ready been mentioned. The greatest amount of improve- 
ment will take place in the first two months. It may be 
much furthered by proper treatment, and may even con- 
tinue after a year or more has elapsed. 
_ TREATMENT.—The early symptoms—fever, etc.—re- 
quire chiefly rest in bed. Ergot and belladonna have 
been recommended, on the theory that they limit the in- 
flammation through their influence on the circulation. 
Applications of ice to the spine, and revulsive applica- 
tions, have been made for the same purpose. The ad- 
ministration of iodide of potash to promote the absorption 
of inflammatory products seems appropriate treatment. 
Electrical applications are often made at an early period. 
The object of making them, at this time, is to directly 
influence the spinal cord.. For this purpose a large elec- 
trode should be selected and applied over the spine, while 
the other is applied to a distant part, for in this manner 
the largest quantity of the current may be expected to 
reach the cord. The positive pole is usually applied to 
the spine, and as near as possible to the seat of the dis- 
ease—for instance, to the cervical spine if the upper, to 
the lower dorsal and lumbar spine if the lower, extrem- 
ity is paralyzed. 

Ata later period the current should be applied to the 
paralyzed nerves and muscles. It must now be looked 
upon as one of the most valuable agents in treatment. 
The faradic current is appropriate if it can produce mus- 
cular contractions ; otherwise the galvanic current should 
be selected. Duchenne, who was an enthusiast on the 
subject, believed he could create entire muscles out of a 
few fibres by means of faradization. At the same time 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Spinal Cord. 
Spinal Cord. 


massage of the muscles, and other gymnastic exercises, 
should be instituted. 

Arsenic and strychnine have been extolled for their 
power over the paralyzed muscles. Cod-liver oil, tonics, 
open air, and all else that can invigorate the system are 
indicated. 

During this time efforts must also be made to counter- 
act the tendency to deformity. In this effort the meas- 
ures already mentioned—electricity, gymnastic exercise, 
especially the frequent stretching of the retracted mus- 
cles—accomplish much. Avoiding positions in which 
the weight of the limb may cause deformity, sometimes 
easy walking, holding the joints in proper positions, but 
not too firmly fixed, may all assist in preventing deformi- 
ties When the latter are well marked, suitable appa- 
ratus, sometimes tenotomy, etc., are called for. 

Philip Zenner. 


SPINAL CORD DISEASES: ACUTE ASCENDING 
PARALYSIS. Synonym, Landry’s Paralysis. 

DEFINITION.—A rapidly progressing paralysis, usually 
beginning at the lower extremities, extending to the up- 
per extremities, the muscles of the trunk, and finally 
to those supplied by the cranial nerves, death often re- 
sulting from paralysis of respiration. The paralyzed 
muscles are flaccid, but there is no special atrophy, 
and no alteration in the electrical reactions. There are 
slight, if any, symptoms on the part of sensibility, blad- 
der, or rectum, no bed-sores, and usually little fever. 
There are no anatomical changes to account for the symp- 
toms. 

In 1859 Landry gave an accurate description of this 
disease, noting, at the same time, the absence of appre- 
ciable anatomical changes, and since that time many 
similar cases have been reported. In 1875 Westphal, in 
connection with a report of four cases, gave a critical re- 
view of the subject. He excluded a number of reported 
cases in which some anatomical changes were found post 
mortem, and made an absence of the latter an essential 
feature of the disease. His views have been very largely 
accepted. 

The absence of anatomical changes in the nervous 
system has been pronounced by most competent patholo- 
gists, such as Vulpian, Cornil and Ranvier, Bernhardt, 
-Westphal, and Kahler and Pick, so that the accuracy of 
their observations cannot be questioned. But, especially 
since Westphal’s report, a number of cases have been 
recorded, whose histories are almost or altogether in full 
accord with those of acute ascending paralysis, in which 
lesions in the nervous system were found. We must 
leave it to the future to decide whether the latter do not 
belong to the same class of diseases, or whether the nega- 
tive results in earlier cases merely indicate that the path- 
ological changes had not yet progressed far enough, or 
were not sufficiently intense to be recognized by our pres- 
ent methods of examination. 

EtroLtogy.—The disease occurs chiefly in men, and in 
adult life. It does not seem to occur specially in those 
predisposed to nervous diseases. Exposure to cold, sup- 
pressed menses, etc., have been assigned as causes. It 
sometimes occurs in syphilitic subjects, and some have 
believed, especially on account of the apparent results of 
treatment, that the disease is sometimes of syphilitic ori- 
gin, but post-mortem examinations find nothing to up- 
hold this view. It has occurred in the course of, or dur- 
ing convalescence from, acute diseases, as typhoid fever 
and diphtheria. Westphal believes that some toxic agent 
causes the disease. In a case of Baumgarten’s, where 
the disease complicated splenic fever, bacilli anthracis 
were found in the blood and in the cord. 

SymptToms.—The disease is sometimes ushered in by 
shooting pains in the back and legs, sometimes by slight 
fever, or there may be a general sense of debility and dis- 
comfort for some days preceding the paralysis. Numb- 
ness and tingling in fingers and toes are not infre- 
quently felt, and this is often the only sensory symptom. 
The paralysis begins generally in the lower extremities. 
From a degree of weakness which the patient first com- 
plains of, it increases rapidly to complete paralysis. 


Either at the same time, or shortly afterward, the arms 
become affected, the paralysis rapidly increasing in in- 
tensity. Then the muscles of the abdomen are affected, 
making defecation, etc., difficult ; next, the muscles of the 
chest, causing respiratory difficulties. Lastly, the cranial 
nerves are involved, chiefly the hypoglossal and pneu- 
mogastric, causing difficult deglutition, indistinct speech, 
and difficult breathing, the latter oftenin paroxysms, but 
occasionally the seventh and other motor cranial nerves 
are also paralyzed. 

The paralysis does not always follow this course. It 
occasionally begins in the upper extremities, occasionally 
in the cranial nerves. In the latter case there is usually 
a very rapidly fatal issue. 

The further characteristics of this disease are negative 
symptoms. The muscles are quite flaccid, but they do 
not undergo atrophy, at least to any considerable extent, 
and the electrical reactions remain normal. In a num- 
ber of instances the patellar tendon reflex was abol- 
ished. There are no bed-sores, and no, or at least very 
slight, disturbance of the. bladder and rectum. Sensory 
symptoms are slight, or altogether absent. Anesthesia 
of the soles of the feet, or other parts, has been observed. 
Usually the general health is but little disturbed, and the 
mind is unaffected. 

The duration of the disease is from a very few days to 
several weeks, the average being from ten to twelve 
days. A fatal issue is usually brought on by paralysis of 
respiration. 

But the disease does not always terminate fatally. Of 
ten cases mentioned by Landry, eight recovered. But 
there is often room for doubt whether cases that recover 
really belong to this disease. In favorable cases the dis- 
ease is usually arrested before it reaches the cranial 
nerves, though cases of recovery are reported even after 
the latter have been affected. The progress toward im- 
provement is usually in an inverse order to that of attack, 
the part affected last being the first to improve. The 
patient usually remains weak for a long time after the 
more pronounced paralysis has disappeared. The prog- 
ress of convalescence is liable to interruptions from re- 
lapses, which may even take a serious course. 

Morgpip ANATOMy.—It has already been stated that, 
so far as the central nervous system is concerned, the re- 
sults, in cases generally accepted as those of this disease, 
were negative. Enlarged spleen, lymphatic glands, etc., 
as in cases of infectious diseases, were found in a number 
of instances. This gives some basis to Westphal’s view, 
that the disease is due to a kind of intoxication. 

Eisenlohr reported a case (Virchow’s Archiv, Ixiii., 
page 73), with almost typical history, of acute ascending 
paralysis, in which there were slight evidences of myeli- 
tis and small capillary hemorrhages in the medulla ob- 
longata. Ina case of Kiimmell (Zeitsch. f. klin. Med., 
ii., page 272), coming on during the convalescence from 
typhoid, and with a typical history of ascending paraly- 
sis, small hemorrhages in the medulla oblongata were 
found. Schulz and Schultze reported a case (Archiv f. 
Psychiatrie, xii., page 457) with the usual symptoms of 
ascending paralysis, only that the course was a slow one, 
its whole duration being nearly two months, in which 
the electrical responses of most of the paralyzed muscles 
were those of the reaction of degeneration. But the 
electrical test was not made until about the sixth week 
of the disease, and, as pointed out by the authors, it is 
not improbable, if tested in the first or second week, as in 
other cases, the electrical reactions might have been nor- 
mal. The post-mortem revealed a fresh myelitis, chiefly 
of the motor tracts of the cord, of the anterior gray 
matter, and of part of the medulla oblongata. Lastly, 
Hoffman (Archiv f. Psychiatrie, xv., page 140) reported 
a typical case of ascending paralysis, only that there was 
double facial paralysis, with some diminution of the elec- 
trical irritability of the right facial nerve and muscles, 
though the electrical reactions were elsewhere quite nor- 
mal. On post-mortem examination a moderately intense 
meningitis, and slight myclitis, chiefly of the antero- 
lateral columns in the cervical and dorsal regions, were 
found. In none of these cases did the extent of morbid 


549 


Spinal Cord. 
Spinal Cord, 


changes appear to correspond to the intensity of the 
symptoms manifested during life, but they, nevertheless, 
indicate that those symptoms were dependent on a pal- 
pable lesion. 

Draanosis.—The rapidly progressive course, the pres- 
ence of mostly motor symptoms and normal electrical 
reactions, will usually distinguish these cases. 

Acute multiple neuritis can usually be distinguished 
by the sensory symptoms, pain, tenderness, anesthesia, 
etc., and by the atrophy of muscles and altered electrical 
reactions. Some cases of subacute anterior poliomyeli- 
tis run a very rapid course, so that they closely simulate 
this disease. But there is greater likelihood of muscular 
atrophy and altered electrical reactions, bulbar symptoms 
usually appear at a much later period, and the disease 
runs a less rapid course. 

Acute central myelitis, also, often causes an ascending 
‘paralysis, and runs a rapid course. But in this disease 
the sensory symptoms, anesthesia, etc., are prominent ; 
there are paralyses of the bladder and rectum, acute de- 
cubitus, fever, etc. 

ProGnosis.—The disease must always be looked upon 
as a serious one, It is true, cases, apparently of this 
affection, recover, but in most of these the disease is ar- 
rested at an early period. The more rapid the progress 
of the disease, and the earlier bulbar symptoms appear, 
the more unfavorable the prognosis. 

TREATMENT.—Cold to the spine, cupping, and blisters 
have been tried at an early period. ILodide of potash 
should be administered, especially where there is a 
syphilitic history. In the latter case inunctions of mer- 
cury should also be tried. In Schulz’s case hot baths 
seemed to do much harm, while the constant current to 
the spine was followed by considerable improvement. 

In cases running a favorable course, the use of electric- 
ity, hydrotherapy, tonics, change of air, etc., are indi- 
cated. Philip Zenner. 


SPINAL CORD DISEASES: ACUTE SPINAL MEN- 
INGITIS. Synonyms: Acute inflammation of the spinal 
pia mater and arachnoid ; lepto-meningitis spinalis acuta ; 
perinmyelitis and arachnitis. 

This disease, which is the most frequent and impor- 
tant of the affections of the spinal meninges, is an acute 
inflammation of the spinal pia mater, with implication 
to a greater or less extent of the arachnoid, the sub-pia 
connective tissue, the connective tissue between the pia 
mater and arachnoid, and the internal surface of the dura 
mater. As a sporadic affection it is rare, but it is often 
found associated with lepto-meningitis of the brain, con- 
stituting the affection known as epidemic cerebro-spinal 
fever. 

PATHOLOGICAL ANATOMY.—This affection may be di- 
vided pathologically into three stages: First, the stage 
of hyperemia, or commencing exudation; second, the 
stage of purulent or fibrinous exudation ; and third, the 
stage in which chronic changes are established. 

In the first stage, which is seldom observed post mor- 
tem, the pia mater appears thickened, opaque, rosy, or 
dark red in color, and dotted with hemorrhagic extrava- 
sations; the tissues around are swollen from infiltra- 
tion of serum ; the spinal fluid is increased in quantity, 
and turbid. The sub-pia connective tissue, the arach- 
noid, the connective tissue between the pia mater and 
arachnoid, and the internal surface of the dura mater 
are also congested, the hyperemia frequently extending 
to the cord and nerve-roots arising from the affected re- 
gion. 

In the second stage the spinal fluid becomes more and 
more turbid, and assumes a sero-purulent appearance, 
containing numerous flakes of fibrin. The pia mater, 
and the connective tissue underneath the pia, and between 
that membrane and the arachnoid, become more and 
more opaque and softened, and are converted into a gelat- 
inous mass by a more or less infiltrated, dense, whitish, 
fibrinous, or purulent exudation, composed of leucocytes 
and fibrin. This exudation is more or less resisting, and 
may appear in lamelle. Small miliary nodules are 
found, in some cases, distributed along the course of the 


550 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


vessels of the pia mater, constituting tubercular spinal 
meningitis. The arachnoid is opaque, and sometimes 
adherent to the dura mater. The dura mater is hyper- 
eemic, reddened, and opaque, and fibrinous flakes and 
plates are found adherent to its internal surface. Peri- 
pachymeningitic hemorrhages occasionally occur. The 
nerve-roots are always involved ; they are enveloped in 
thick masses of exudation, and are swollen and soft- 
ened. The cord itself is pale, edematous, or congested, 
and finally softened in spots or diffusely. Microscopical 
examination shows in the soft membranes of the cord all 
the signs of an exudative inflammation—abundant cell- 
infiltration, especially along the vessels; fulness of the 
capillaries; swelling and spreading of the bundles of 
connective tissue, and infiltration of cells in the nerve- 
roots. The nerve-fibres are swollen, granular, and be- 
ginning to break down; the axis-cylinders are swollen 
and granular, and the bundles of root-fibres entering the 
cord are similarly affected. In the cord the neuroglia is 
infiltrated with small celis and nuclei, or actual paren- 
chymatous myelitis is found; the axis-cylinders are 
enormously swollen and breaking down ; the medullary 
sheaths are cloudy and undergoing granular decay ; in the 
gray substance swelling and cedema of the ganglion-cells 
occur; the central canal is closely packed with round 
exudation-cells. 

The distribution of the exudation in the membranes 
varies greatly, both as regards its consistency and thick- 
ness and the longitudinal extent it occupies. Asa rule, 
it is circular, covering the whole periphery of the cord, 
being thicker, however, at the posterior surface of that 
organ, and it extends the whole length of the spinal 
canal. The greater thickness of the exudate on the pos- 
terior surface has been attributed by some to the fact 
that the patients lie more on the back. This explanation 
would not hold good in one of my cases, here reported, 
where the same thing was observed in a patient who 
almost constantly lay on his side or face. Others have 
thought this difference in the thickness to be due to 
the richer supply of nerves in the posterior region. 
When the meningitis is limited in longitudinal extent 
to the length of one or two vertebree, the inflammation 
is, as arule, due to disease of the bone. It is very sel- 
dom that the exudation extends upward from the spinal 
canal to the membranes of the brain, though this has 
occasionally been seen, as in one of Ollivier’s cases and 
in the second case reported by me. 

The third stage, or that in which chronic changes are 
established, is, of course, only seen in those cases in which 
acute inflammation gives place to a chronic one. The 
most common of these changes are opacity and thick- 
ening of the spinal membranes, with the formation of 
adhesions ; accumulation of fluid in the arachnoid space 
(hydrorrhachis); and sclerosis or atrophy, either diffused 
through the cord or affecting isolated portions or sys- 
tems. When absorption has taken place, there is, of 
course, no third stage. 

Errotocy.—The causes of acute spinal meningitis are 
still very obscure. It occurs more frequently in the 
young and aged than in those in middle life, but is not 
altogether limited to these extremes, a number of cases 
having been observed in adults. Men seem to be more 
often affected by the disease than women; but this depends, 
probably, rather on the fact that they are more exposed to 
traumatism by the nature of their occupations, and that 
they are more given to excesses and dissipation, than it 
does upon any special susceptibility inherent in the sex. 

Of the known predisposing causes, the most important 
are a scrofulous or tuberculous constitution ; insufficient. 
food ; damp dwellings; sexual, alcoholic, and other ex- 
cesses, and syphilis. 

Omitting the epidemic and infectious influences which. 
affect the occurrence of cerebro-spinal meningitis, with 
which we are not here concerned, and not considering 
those cases of extension of the affection from the cerebral 
meninges to the spinal membranes, as in the tubercular 
and other forms, the following are credited with having 
been the exciting causes of this affection in some in- 
stances : Injuries to the spinal column from blows, falls, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Spinal Cord. 
Spinal Cord. 


or railroad accidents, causing either fracture, disloca- 
tion, or concussion of the spine; gunshot wounds of 
the spine, or punctured wounds of the membranes, as 
in the operation for spina bifida ; violent bodily efforts, 
as in lifting a heavy weight; sacral eschars perforating 
the dura mater ; a sudden fall into cold water; a cold- 
air current striking the back when the person is sweat- 
ing ; exposure to wet and cold, as from sleeping on damp 
ground, or standing long in water while working; the 
suppression of the menstrual and hemorrhoidal fluxes ; 
suppressed perspiration of the feet ; communication of a 
peripheric neuritis to the spinal meninges, observed in 
a case of tetanus ; dentition; the puerperal state; the 
opening of an abscess from neighboring parts into the 
spinal canal; and the extension of inflammation from 
parts around into the vertebral canal. The following 
constitutional diseases are known to have been occasion- 
ally complicated with acute spinal meningitis: Acute 
rheumatism ; pneumonia; scarlet fever, and the other 
exanthemata ; and pyemia. 

Of these causes the following are rather doubtful : Den- 
tition; the disappearance of acute exanthemata; the 
suppression of the menstrual and hemorrhoidal fluxes ; 
suppressed perspiration of the feet. 

SYMPTOMS AND CLINICAL History.—In the study of 
the clinical history of this disease it will be best to di- 
vide it into two stages: First, that of congestion and be- 
ginning exudation, the irritative stage ; and second, that 
of complete exudation, or compression. 

First Stage. —Acute spinal meningitis is only in excep- 
tional cases preceded by the usual symptoms denoting 
inflammatory action, such as chilly sensations, restless- 
ness, headache, etc. Its onset is generally sudden, a 
sharp rigor being the first indication of the disease in 
most cases. This is followed by an irregular fever, and 
a quick, hard, full pulse. Pain in the back, either con- 
fined to a limited region or extending along the whole 
spine, makes its appearance. This pain, at first dull, 
soon becomes acute, boring or shooting in character, and 
is greatly increased by movements of the trunk and limbs ; 
but, as a rule, it is not affected by pressure on the spinal 
processes of the vertebrae. The pain soon extends around 
the body, in the form of a girdle, and down the limbs; 
the alternate passage of a hot and cold sponge along the 
Spine increases it ; it is greatest at the site of the princi- 
pal lesions. In a very short time contraction of the back 
and limbs is observed, and when the cervical region is 
involved the head is drawn backward and arched in a 
condition of more or less complete opisthotonos. Hy- 
peresthesia and various pareesthesiz of the skin are 
well marked. The muscles of the trunk and extremities 
are also hypersensitive, and the patient remains motion- 
less in bed, with the limbs rigid, not from paralysis, but 
from fear of the acute pain which accompanies the 
slightest motion ; the muscles are in a state of tension or 
spasm, which is increased by motion, but not by reflex 
irritation ; there are also spontaneous muscular twitch- 
ings, giving rise to severe pain. Dyspncea, amounting 
in some cascs to asphyxia, is sometimes seen, owing to 
implication of the respiratory muscles. The pupils are 
irregular ; sometimes they are normal, at other times 
they may be contracted or dilated, or one of them only 
may depart from the normal. Violent headaches, verti- 
go, vomiting, irritation or paralysis of the oculo-motor 
nerves, together with delirium and coma, are due to inva- 
sion of the cerebral meninges. The reflexes, skin and 
tendinous, are, as a rule, exaggerated in this stage, and 
there is also exaggerated electrical reaction. Functional 
derangements of the bladder and rectum appear early in 
the disease; there is at first costiveness, with retention of 
urine from spasms of the sphincters of the anus and 
bladder, then afterward dribbling of urine from overdis- 
tention, and later on paralysis of the sphincters. The 
urine is at first dark, scanty, and cloudy from the urates, 
but later on it becomes abundant, light, and clear; in 
some cases an excess has been observed, due probably to 
direct nervous stimulation of the secretory centres in the 
cord ; in rare cases mellituria has occurred. The abdo- 
men is sunken and tense, and free from meteorisms and 


swelling ; diarrhcea is rare. Eruptions on the skin have 
occasionally been observed, but not so frequently as in 
the epidemic form of the disease. 

The duration of this stage is variable, lasting from two 
or three days to a week or more, the disease being oc- 
casionally, though very rarely, arrested at this period. 
At times deceitful signs of temporary improvement will 
show themselves, but are soon followed by symptoms 
denoting invasion of the cord or of the meninges of the 
brain. Death occasionally closes the scene at this period ; 
but this is rare, unless the affection is a sequel to some 
exhausting disease, or unless the membranes of the brain 
and medulla are severely affected. Asa rule, the symp- 
toms of irritation belonging to the first stage gradually 
give way to symptoms of paralysis of motion and sensa- 
tion, denoting compression of the cord and nerve-roots. 

Second Stage.—The pains in the back and limbs still 
persist, but have lost their acuteness ; the patient feels 
dull and heavy ; cutaneous and muscular hypereesthesia 
are replaced by aneesthesia and muscular paralysis, with 
contracture and atrophy ; the reflexes and electrical reac- 
tion become diminished, and sometimes altogether lost ; 
the sphincters of the anus and bladder become paralyzed, 
and there is incontinence of urine and feces ; more or less 
paresis, or paralysis, of the extremities exists, the exten- 
sor muscles being generally more affected than the flex- 
ors; bed-sores and cystitis supervene as dangerous com- 
plications. Paralysis of the muscles of deglutition and 
of the tongue, usually a fatal complication, denotes inva- 
sion of the medulla oblongata. Rapidity and irregularity 
of the pulse and respiration, occasionally observed at this 
stage, are due to compression of the vagus. The tem- 
perature at times rises to 106° or 108° F., denoting exten- 
sion of the disease to the cerebral meninges; delirium 
and coma ensue, and speedily lead to a fatal termina- 
tion, but more often death is brought on by exhaustion 
and marasmus, 

The location of the disease at different levels of the 
cord naturally causes variations in the symptomatology ; 
as we have said before, it is more common to see the 
meningitis extending along the whole spinal canal, but 
at times, in traumatic cases especially, it is more local- 
ized. 

When the lumbar and sacral regions are alone affected, 
the pain is felt in the sacrum and loins; the stiffness is 
limited to the lower part of the spine ; the pain radiates 
to the hypogastrium, perineum, and lower extremities, 
and the spasms and paralysis are limited to those parts ; 
the urinary troubles are very severe. 

When the dorsal region is also involved, the pain and 
stiffness extend higher up in the back, as far up as the 
shoulders; there are disturbances of respiration, etc., 
added to the symptoms manifest in the lower extrem- 
ities. 

When the cervical region is also implicated, there are, 
in addition, stiffness and pain in the back and neck ; ex- 
centric pain, extending to the upper extremities ; difficulty 
in breathing and swallowing ; derangement of the heart’s 
action, pupillary symptoms, etc. 

When the inflammation extends to the medulla ob- 
longata and base of the brain, in addition to the spinal 
symptoms those of a cerebral nature are observed, such 
as violent headache, vomiting, vertigo, delirium, trismus, 
oculo-motor paralysis, disturbances of speech and respi- 
ration, and coma. 

Some of the symptoms above enumerated are due to 
the inflammation of the meninges, but the physiological 
explanation of by far the greater number of these is to 
be found in the implication of the nerve-roots or periph- 
ery of the cord itself, almost invariable accompaniments 
of spinal meningitis. For instance, the pain in the back, 
according to Hallopeau, is not due to irritation of the 
posterior nerve-roots, but is caused by irritation of the 
meningeal nerves ; the spinal meninges have been demon- 
strated, he says, not to be sensitive in their normal con- 
dition, but become extremely so when in a state of in- 
flammation, and he bases his argument on the fact that 
the pain is almost always absent in myelitis. That irri- 
tation of the nerves of the pia and dura mater 1s account- 


551 


Spinal Cord. 
Spinal Cord. 


able for a certain amount of this pain admits of no doubt, 
but the very character of the pains—their excentric nat- 
ure, occurring in portions of the body which derive their 
nerve-supply from the affected regions of the cord—prove 
beyond contradiction that irritation of the posterior nerve- 
roots acts as an important factor in their production. 
The same explanation must be given for the hyperes- 
thesia and paresthesia found in different portions of the 
body. 

The stiffness of the back and extremities, the muscu- 
lar tension, the contractures and spasms, are due chiefly 
to direct irritation of the motor apparatus—that is, in part 
to inflammatory irritation of the anterior roots, in part to 
irritation of the motor paths in the lateral columns of the 
cord by secondary points of myelitis. That these motor 
disturbances are in some cases caused in a reflex manner, 
by the abnormal irritation of the posterior roots, must 
be also admitted, as well as the fact that this muscular 
tension is half voluntary in character, or is increased by 
a voluntary act which has for its object the prevention 
of movement when all movements are so painful. 

The motor and sensory paralyses, neuralgia, and anees- 
thesia of the extremities which occur in the later stages 
of this disease are due to affection of the anterior and pos- 
terior nerve-roots, but it is not impossible that myelitic 
points in the white columns of the cord contribute, in 
some cases, to the production of this paralysis. 

The retention of urine occurring early in the disease 
is explained by the direct or reflex spasms of the sphinc- 
ter of the bladder. The later paralysis of this viscus is 
due to the same causes that produce the paraplegia. 

The disturbances of the digestive apparatus and the cos- 
tiveness which accompany this affection are referred by 
Koehler to spasm of the intestinal muscles and consequent 
interference with peristaltic action, and to the spasmodic 
tension of the abdominal muscles. But to this must be 
added the sluggishness and weakness which are so char- 
acteristic of intestinal movements in spinal diseases. 

The disturbances of respiration which occur, from sim- 
ple accelerated and difficult breathing up to extreme 
dyspnoea and asphyxia, are due to implication of the 
cervical roots, causing tension and spasms or paralysis of 
the respiratory muscles, or to implication of the white 
matter of the cervical cord, in which are situated the 
respiratory paths, or to an extension of the disease to the 
respiratory centre in the medulla oblongata. 

The pupillary changes may be due either to irritation 
of special fibres in the cervical cord or to disturbances of 
the oculo-motor nerves by extension of the disease to the 
brain. 

The symptoms denoting invasion of the brain have 
been referred to. 

CouRskE, DURATION, AND TERMINATION.—In the most 
acute forms of the disease death may occur in a few 
hours, but more generally it occurs in three or four days, 
from asphyxia. In less violent cases the duration of the 
disease is two or three weeks, recovery ensuing at the 
end of that time in exceptional cases. In other cases 
the violence of the symptoms is abated, but the patient 
remains an invalid for a number of weeks or months, 
improvement in the paralyzed muscles being very slow ; 
and at times contractures and paralysis of certain groups 
of muscles remain permanent. In other cases, again, 
the acute symptoms subside and the disease assumes a 
chronic form, which is usually associated with myelitis, 
the patient dying, later on, of cystitis and bed-sores. 

The following two cases give a clear clinical illustra- 
tion of spinal meningitis ; hence their insertion here. 

Case of Acute Meningitis ending in Recovery.—John 
G—,, aged thirty-five, born in England ; a machinist by 
occupation ; has been a hard whiskey-drinker for years ; 
smokes and chews to excess ; has never contracted syph- 
ilis ; gives no history of hereditary predisposition. About 
June 16, 1888, he went on a spree, and slept all night on 
the ground in one of our public squares, where he was 
picked up by the police next morning. The day pre- 
vious had been a very rainy one, and the ground, on 
which he must have lain for hours, was quite wet. When 
aroused he felt stiff in the legs, but was able to accom- 


552 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. . 


pany the officers to the jail, and on that same day he was 
discharged by the police-court and. was admitted into 
Charity Hospital, in the ward for nervous diseases, com- 
plaining of great pain of a shooting character in the lum- 
bar and dorsal regions of the spine. The pain extended 
all around his body at the level of the nipples, and shot 
down the legs ; these felt numb and stiff, but he was still 
able to stand; his pulse was hard, full, and fast, about 
104 per minute; his respiration somewhat accelerated, 
and his temperature 1014° F. I saw him on the next day, 
and made the following notes of his case: Patient is well 
nourished ; general appearance good ; complains of sharp, 
shooting pains along the spine, from the neck down, ex- 
tending around the body and around the arms and down 
the legs; this pain is not increased by pressure on the 
spinous processes, but the slightest movement of the body 
or extremities brings on an exacerbation ; the back is stiff 
and arched, and the legs flexed on the thighs, and the 
thighs on the pelvis; he is unable to extend the extrem- 
ities, not that any paralysis exists, but from the fact that 
the attempts at motion give rise to severe paroxysms of 


_ pain ; the muscles in the trunk and extremities are tense 


and contracted, and the patient complains at times of in- 
voluntary twitching, giving rise to exquisite pain ; his 
bowels are constipated, and he has passed no urine since 
admission. With asoft catheter over a pint of highly 
colored urine was drawn from his bladder. The pulse 
is 112, full and hard, and the temperature has reached 
102° F. The patient’s mind is clear, and, aside from some 
frontal headache, he complains of no disorder about the 
head. <A brisk purgative of calomel and bicarbonate of 
soda, each fifteen grains, was prescribed, and cold appli- 
cations were made to the back, the patient being ordered 
to lie on the side, which position he had, however, already 
assumed of his own accord. Quinine sulphate, in five- 
grain doses, was also given every four hours, and a table- 
spoonful of the following mixture after each dose of 
quinine: Fluid extract of ergot, 3iv.; potassium bro- 
mide, 3iv.; syrup of orange-peel and water, each % iij. 

On the 18th the patient was found very restless ; the 
pains still continued to be intense in the back and lower 
extremities, which were found still more stiff, the hands 
and arms felt numb, and he complained of shooting pains 
also in these. The bowels had acted several times, but 
his urine had to be drawn, the slightest effort to pass 
water being accompanied by excruciating pain; the pa- 
tient’s position was that of opisthotonos. The tempera- 
ture was 102° F., pulse 110. The mind was clear ; there 
was no vomiting ; respiration hurried, but otherwise nor- 
mal. The same medication was continued, with five drops 
of Batley’s sedative added to each dose of bromide of 
potassium. 

During the next week the patient rested somewhat bet- 
ter, but there was no improvement in his symptoms ; the 
urine was still retained ; the disease, however, seemed to 
have made no noticeable progress. A considerable quan- 
tity of milk and several eggs were taken, and retained, 
every day ; the temperature oscillated between 101° and 
103° F., with no uniform remission. On the seventh day 
the quinine and Batley’s sedative were stopped, the bro- 
mide and ergot continued ; a saline purgative—Glauber’s 
and Epsom salts, each % ss.—was given, and the cold ap- 
plications to the back were replaced by applications of 
tincture of iodine along the spine. 

The patient’s condition was now as follows: Pain some- 
what diminished, but back and extremities feel stiff, 
numb, and heavy ; sensation to touch and pain, tested in 
hands and feet, is blunted and retarded ; patient finds con- 
siderable difficulty in moving his legs and arms, but when 
these are moved the pain in the back is not so greatly 
increased as on the previous days. The urine is still re- 
tained, and dribbles from him unawares ; his bowels have 
not acted since the second day. On July 8th, the twen- 
tieth day of the disease, the temperature has for the first 
time fallen to normal; the pulse is weaker and faster, 
120 to the minute ; the urine still dribbles, and has to be 
withdrawn ; the bowels have acted several times since 
last account ; the pain and stiffness in the back are still 
present, but bearable as long as the patient remains at 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Spinal Cord. 
Spinal Cord. 


rest ; the paresis and anesthesia of the lower extremities 
are almost complete, and the patient complains of burn- 
ing and creeping sensations in these parts; there is a 
slight wasting of the muscles; the skin over the sacrum 
is reddened, and a bed-sore is feared. The upper extremi- 
ties are numb and weak, but the patient is able to move 
them slowly. Counter-irritation, by means of tincture-of- 
iodine applications to the spine, is still kept up, and all 
medicine, except the following, discontinued : Potassium 
el gr. V.; potassium bromide, gr. x. ; four times a 
ay. 

On August 12th the patient is able to sit up in a chair; 
the dribbling of urine has stopped, and the bladder is 
slowly evacuated by natural means; the bowels, though 
sluggish, act without assistance ; the back and lower ex- 
tremities are as yet stiff and a little painful, but the pa- 
tient has obtained some control over the latter and is able 
to move them slowly; the wasting has not progressed ; 
sensation is evidently better than at last report; the up- 
per extremities have improved ; there is a superficial sore 
over the sacrum, which, however, shows healthy granu- 
lations. The potassium iodide, in ten-grain doses, three 
times a day, is still continued ; daily mild galvanic cur- 
rents, alternately ascending and descending, are applied 
to the spine, and the muscles of the lower extremities are 
ee the faradic irritability is somewhat dimin- 
ished. 

At the end of September the patient was able to go 
about unassisted, and was discharged, cured, on October 
10th, nearly four months after admission, nothing but a 
slight stiffness of the back and lower limbs remaining. 

Case of Acute Spinal Meningitis, with Cerebral Compli- 
cations, ending fatally on the Ninth Day. Autopsy.— 
A, P——, white, male, aged twenty-three, was admitted 
in the ward for nervous diseases in Charity Hospital, 
under my care, complaining of acute pain in the spine, 
extending from the head to the sacrum. The back was 
considerably stiffened, and the lower extremities were 
drawn up; the pain also extended to the trunk and all 
four extremities, and, though continuous, would be con- 
siderably increased at times ; pressure over the vertebre 
seemed to give rise to no exacerbation of the pain, but 
the slightest motion of the spine, either backward or for- 
ward, would cause the patient to scream with agony ; 
there was considerable hypereesthesia of the legs and 
arms, and pressure on the same gave rise to immediate 
complaint; the muscles of the extremities were con- 
tracted; the urine dribbled away, and the bladder was 
full; the bowels were costive; temperature 103° F. ; 

_pulse hard, full, and 116 a minute; respiration jerky, 24 
to the minute. The patient said that he had been taken 
with uneasy feelings and weakness in his back and head 
three days ago ; that this had so increased the following 
day that he was forced to keep his bed, when a chill, 
followed by fever, came on. He was occupying a bed 
on the fourth floor of a boarding-house, and on the third 
day, as the symptoms seemed to be aggravated, he re- 
quested to be taken to the hospital. 

After admission a saline purgative was administered, 
cold applications to the back were immediately begun, 
and quinine was given to reduce the temperature, and 
sedatives, such as opium, bromide, and chloral, used to 
soothe the pain. On the two following days the patient’s 
symptoms were found more severe ; the pains in the back 
and limbs were excessive; the opisthotonos was com- 
plete; the urine was passed involuntarily, and the pa- 
tient had had two unconscious motions from the bowels 
in bed; the temperature was 1043° F.; the pulse very 
rapid, soft, and irregular, 124 to the minute; and at times 
there was considerable delirium of a most violent kind. 
On the next day—the sixth of the disease—the patient’s 
condition was found considerably aggravated ; the delir- 
ium, though milder,:was almost continuous ; and other 
troubles, such as vomiting and eructations, were frequent; 
the respiration was rapid and labored, 32 to the minute, 
and deglutition was difficult ; the pulse was scarcely per- 
ceptible ; paralysis in the extremities had supervened, and 
the skin reflexes were almost entirely abolished. The pa- 
tient’s condition continued to grow worse, the delirium 


passing into coma, which ended in death on the ninth day 


of the disease, and the sixth day after his admission to the 
hospital. 

Autopsy, held five hours after death, revealed a con- 
gested and cedematous condition of the lungs; heart full 
of fluid, dark-colored blood; other organs normal. Spi- 
nal marrow: Along the whole spine the internal surface 
of the dura mater was rosy ; blood-vessels very much en- 
larged ; opposite the lumbar enlargement, particularly, 
there was a slight fibrinous deposit on the internal sur- 
face of that membrane ; the arachnoid was opaque, but 
showed no other evidence of disease; the spinal fluid 
was very abundant and sero-purulent ; on the surface of 
the cord and in the meshes of the pia mater was a thick 
fibrinous deposit, which enveloped the whole cord and 
the nerve-roots; this deposit was thicker posteriorly, and 
diminished in density from below upward to the medulla, 
where it was very thin; the marrow was pale, and in 
some localities (at the lumbar and cervical enlargements) 
a little softened. At the base of the brain, and over the 
Sylvian fissure on both sides of the convexity, a thin exu- 
date of fibrin was found ; the cerebral fluid was increased, 
and the blood-vessels of the brain were much congested. 
The cord was preserved, by hardening, for microscopical 
examination, but, unhappily, the Pathological Depart- 
ment of the hospital was being rebuilt at the time and 
the specimen was lost. 

This case, if we are to judge by the amount of post- 
mortem changes and the development of symptoms, was 
undoubtedly one of inflammation of the spinal meninges, 
progressing upward and implicating, secondarily, the 
cerebral meninges. As to its cause nothing could be 
ascertained, the patient being a laborer who had been 


-out of work for some time; he was of temperate and 


regular habits, and had never had syphilis; he had re- 
ceived no blow and suffered no fall; he gave no history 
of hereditary predisposition to tuberculosis, and showed 
no evidence of this disease in any of the organs examined. 

Draenosis.—The diagnosis of acute spinal meningitis 
must be based on its sudden onset and the severity of its 
symptoms. The distinguishing signs, aside from fever 
and other general symptoms, are sudden, acute pain in 
the back, extending to the trunk and limbs, increased by 
motion, but not affected by pressure over the spine; ri- 
gidity of the back and extremities; hyperesthesia and 
pareesthesia of the skin and muscles; retraction of the 
head ; difficulty of breathing and swallowing ; retention 
of urine’and constipation; normal or exaggerated re- 
exes: 

Dorsal muscular rheumatism is distinguished from 
spinal meningitis by the character of the pain, which is 
confined to the back, the absence of general and spinal 
symptoms, and its usually favorable termination. 

Tetanus may be differentiated by the fact that the tris- 
mus appears first in that disease, by the absence of fever 
in the beginning, by the absence of hyperesthesia, and 
by the fact that the exacerbations of pain and the spasms 
are brought about by peripheric irritation. 

Myelitis can be recognized by the early and deep motor 
and sensory paralyses, and by the absence of stiffness in 
the back and neck, of the excentric pains in the limbs, 
and of hyperzesthesia of the muscles or skin, which char- 
acterize, especially, meningitis. 

The diagnosis of tubercular meningitis must rest on 
general considerations, and on the association with basal 
cerebral meningitis. 

Proenosis.—Acute spinal meningitis is always a grave 
affection ; hence our opinion should always be guarded. 
When the symptoms are in general mild, the fever not 
very high, and when there is no extension to the upper 
portion of the cervical cord, in an otherwise strong and 
healthy individual, the outlook is more encouraging, but 
we should not be too hurried in prognosticating favorably. 

Hyperacute and tubercular cases, or those caused by 
deep bed-sores, are nearly always fatal. Rheumatic and 
traumatic cases, when the lesions are moderate, are more 
favorable. Symptoms which show that there is early 
compression or implication of the cord itself, such as 
paresis or paralysis, twitching of the limbs, muscular 


553 


Spinal Cord. 
Spinal Cord. 


contractures, and anzesthesia of the skin, are generally 
unfavorable, as are also a high fever, progressive rise of 
temperature, extreme frequency and irregularity of the 
pulse, great difficulty of breathing, early signs of ex- 
haustion, severe cerebral symptoms, and signs of impli- 
cation of the medulla oblongata. The disease is also 
much more liable to terminate unfavorably in the very 
young and in the aged. 

TREATMENT.— We know at present of no remedy that 
will act as a prophylactic in spinal meningitis; the 
avoidance of such of the causes as are known to have 
brought on the disease are, however, here to be recom- 
mended. 

In the first stage of the affection our attempts should 
be directed to the reduction of the hyperemia in the 
parts, and the moderation of the general symptoms; for 
this purpose the local abstraction of blood by cupping 
along the spine, the application of leeches to the neck, 
back, and perineum, cold applications to the back by 
means of ice-bags, the internal administration of large 
doses of fluid extract of ergot or ergotine and tincture of 
belladonna, are to be recommended, and have been found 
occasionally of benefit. The patient should be put in a 
quiet, airy room, and should rest on the side or face ; anti- 
pyretics, such as quinine, salicylate of sodium, antipyrine, 
and antifebrine, should be used, if indicated, to lower the 
temperature ; a brisk mercurial purgative, followed by 
salines, is also of use to cause derivation to the intestines. 
If the disease is of rheumatic origin, free, energetic dia- 
phoresis will be of benefit. If the pains are very severe, 
sedatives, such as bromide of potassium, chloral hydrate, 
the preparations of opium and of hyoscyamus, or the 
moist pack, are indicated. To limit the amount of effu- 
sion, mercurial inunctions are considered of benefit. To 
relieve the retention of urine, the catheter should be regu- 
larly used. 

When the disease has passed into the second stage all 
depressing medication must be stopped ; the patient is to 
be well nourished, and tonics and stimulants are to be 
freely given. Absorbents, such as iodine, or the iodide 
of potassium, and ergot, in full doses; mercury, in small 
doses, internally and externally, in the form of an oint- 
ment ; and counter-irritation along the spine, by means 
of tincture of iodine or otherwise, are to be used. Warm 
baths and moist packs are of marked utility. The use 
of sedatives is to be continued if required. The urine is 
to be attended to. The sequele, such as paresthesia, 
anesthesia, and the various motor disturbances, are to be 
treated by means of baths and the judicious use of the 
galvanic and faradic currents to the spine and affected 
parts. Care must be taken during convalescence to avoid 
all fatigue and bodily exertion. 


AUTHORITIES CONSULTED. 


Charcot : Lecgons sur les Maladies du Systéme Nerveux. 

Bramwell, Byrom: Diseases of the Spinal Cord. 

Grasset, J.: Maladies du Systeme Nerveux, 3d edition. 

Haase, K. E.: Krankheiten des Nervensystems (being vol. iv., part i., 
of Virchow’s Handbuch der speciellen Pathologie und Therapie). 

Ross: Diseases of the Nervous System, vol. ii. 

Rosenthal: Diseases of the Nervous System. 

Erb: Article in Ziemssen’s Cyclopedia of Medicine, vol. xiii, 

Ollivier: Maladies dela Moélle Epiniére. 

Radcliffe, C. B., in Reynolds’s System of Medicine, vol. i. 


P. EH. Archinard. 


SPINAL CORD DISEASES: CHRONIC SPINAL MEN- 
INGITIS. DeErrnrrion.—Chronic lepto-meningitis is an 
inflammation of the soft membranes of the spinal cord, 
unaccompanied by fever, slow and gradual in its evolu- 
tion and course, which either develops spontaneously or 
follows acute inflammation of those parts. The symp- 
toms, which are generally at first trifling, may gradually 
assume a more severe character as the inflammation ex- 
tends from.the membranes to the cord itself. 

PATHOLOGICAL ANATOMY.—The lesions of chronic 
spinal meningitis are constant as regards their nature, 
though differing widely in intensity and extent in differ- 
ent cases, the changes being often only microscopic. On 
opening the spinal canal the spinal blood-vessels—the 
veins and capillaries mainly—are found congested, full 


554 


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of a dark-colored blood ; the membranes, especially the 
arachnoid and pia mater, are hyperemic, opaque, and 
more or less thickened and adherent ; there are often ad- 
hesions between the pia mater and the cord, and between 
the former and the dura mater ; the spinal fluid is abun- 
dant. The thickening of the soft membranes may be so 
great as to appear cartilaginous, and they may be pig- 
mented in spots and present small points of extravasation 
of blood. Numerous small plates of calcareous matter 
are generally found upon the arachnoid, especially in the 
lumbar region. The dura mater is, asa rule, involved 
in the inflammatory process, and shows more or less 
marked congestion, opacity, and thickening. The extra- 
dural connective tissue also frequently participates in the 
process. Sometimes small granular growths of connec- 
tive tissue may be found on the internal or external sur- 
face of the dura mater. 

As a rule, the cord and nerve-roots are implicated to a 
varying degree and extent. Besides the degenerative 
changes occasionally induced by compression from the 
thickened membranes on that delicate organ, the pro- 
cesses which penetrate the spinal marrow from the pia ma- 
ter are also thickened and swollen; at other times this 
inflammatory process spreads to the neuroglia of the 
cord, and we have then atrue sclerosis in different re- 
gions and varying in extent, sometimes affecting the 
whole periphery of the cord and causing the usual sec- 
ondary degenerative changes in the nervous elements in 
the posterior and antero-lateral columns ; the changes oc- 
casionally extend to the gray substance and nerve-cells, 
whence results an atrophy of the cord. 

The nerve-roots arising from the affected region are 
usually compressed, atrophied, and degenerated, and this 
atrophy and degeneration, as a rule, extend to the pe- 
ripheral nerves and muscles. As sequele bed-sores and 
cystitis develop. 2 

ErroLtocy.—Chronic spinal meningitis very often fol- 
lows the acute form, in which case its causes are the same 
as those of the latter. 

As predisposing causes must be mentioned all debili- 
tating influences ; the abuse of alcoholics and tobacco ; 
syphilis ; chronic diseases of the heart, lungs, liver, and 
all conditions that give rise to impeded circulation in 
the vertebral and spinal veins; also sexual or other ex- 
cesses. 

Among the exciting causes must be mentioned fre- 
quent exposure to cold; the inhabiting of damp dwell- 
ings ; constant exposure to bad weather ; sleeping on damp 
ground ; the abuse of alcoholics ; the suppression of cer- 
tain discharges of long standing, such as the menses, 
hemorrhoids, sweating of the feet; and finally, trauma- 
tisms of moderate intensity, such as shocks, falls upon 
the buttocks or back, railway accidents, excessive bodily 
exercise, the lifting of heavy weights when the body is 
in an unfavorable position, etc. The disease may also 
be excited by the presence of chronic inflammatory pro- 
cesses or neoplastic growths of neighboring parts, which 
may pass to the meninges or excite a constant irritative 
action upon them; among these causes may be men- 
tioned periosteitis, or caries of the vertebre, chronic in- 
flammation or sclerosis of the cord itself; tumors of 
every nature in or around the spinal cord, syphilis, and 
leprosy. 

SYMPTOMS AND CLINICAL History.—The semeiology 
of chronic spinal meningitis has not been sufficiently stud- 
ied, by reason of the fact that the disease is complicated 
with other affections which more or less effectually mask 
its symptoms. Its symptoms are, however, very similar 
to those of the acute form, but slower in development. In 
some cases the disease follows directly upon the acute 
form, in other cases several successive attacks of sub- 
acute meningitis develop gradually into the chronic form 
from want of proper precautions being taken during con- 
valescence, but more often the disease is chronic from 
the very beginning, and insidious in its development. 
The first symptoms are usually abnormal sensations, as 
of weight in the lower limbs, with pain and stiffness in 
the back gradually increasing. This pain is at first not 
severe, it is never increased on pressure, but is aggra- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


vated by motion of the vertebral column or by the alter- 
nate passage of a hot and a cold sponge along the spine ; 
this is accompanied by excentric sensations, such as the 
feeling of a girdle round the trunk and boring or shoot- 
ing pains down the extremities along the nerves arising 
from the affected region. The extremities feel heavy 
and weak, and a number of abnormal sensations, such as 
prickling, tingling, formication, numbness, etc., are pres- 
ent, varying in degree during changes in the barometric 
and thermometric conditions. These sensations are al- 
ways more marked in the lower extremities. Along with 
these sensory disturbances symptoms of motor irritation 
also develop, but they are, as arule, of subordinate im- 
portance; stiffness of the back and neck when the dis- 
ease is situated high up; trembling of the extremities, 
sudden startings, muscular twitchings, jerking and in- 
voluntary drawing up or extension of the limbs, and 
gradual weakness, going on to paralysis, with loss of con- 
trol over the extremities. The tendon and skin reflexes 
are sometimes normal, more often diminished or absent, 
rarely exaggerated. From the beginning there is always 
some disturbance of the functions of the rectum and 
_ bladder; the patient complains of costiveness, which 
only gives way to purgatives, and of difficulty in empty- 
ing the bladder, with some dribbling of the urine. The 
electrical irritability is at first diminished, and afterward 
altogether lost. 

These symptoms fluctuate greatly, being worse in 
some cases one day than another, and in others being 
aggravated by the standing position ; in the latter cases 
the accumulation of spinal fluid is probably excessive. 
In other cases, again, lying down on the back aggravates 
the symptoms; this is probably due to increase of the 
passive congestion occasioned by that position. 

As time rolls on, the disease progresses ; the pains and 
stiffness of the back become aggravated ; the pareesthe- 
sia slowly gives way to anesthesia, more or less com- 
plete ; paralysis and atrophy succeed to the weakness of 
the limbs, so that the patient is bedridden. The bladder 
and rectum become completely paralyzed ; cystitis and 
bed-sores are developed, and the patient dies of exhaus- 
tion or marasmus, unless he is sooner taken off by some 
acute complication. 

Exceptionally an acute attack supervenes upon a 
chronic one, which has lasted for years, and rapidly puts 
an end to the case ; but more frequently the disease drags 
on for years, with occasional temporary improvement 
and retrogression in the patient’s condition, as described 
above. Occasionally, after a long lapse of time, the pa- 
tients recover, with or without treatment; but, as a rule, 
this recovery is seldom altogether complete, and more or 
less impairment of function remains, in the form of atro- 
phy or contracture of certain muscles or groups of mus- 
cles, etc. In very rare cases a complete and lasting cure 
is obtained. 

The following cases will serve to illustrate the symp- 
toms and course of the disease : 

C. D——, white, male, aged thirty-seven, applied for 
treatment at the out-clinic department of Charity Hospi- 
tal, in September, 1883, and was referred to my service. 
He gave the following history: By occupation he is a 
painter, but he has done no work for a year, on account 
of ill health. He is married, and of late years has been 
very temperate in his habits, not drinking at all, and 
using tobacco moderately ; for ten years of his life, from 
the age of twenty-one to thirty-one, he drank rather 
freely, mostly whiskey of an inferior quality ; he has 
never had syphilis; his family history shows no ten- 
dency to nervous or tubercular disease; he shows no 
sign of inherited syphilis, and, up to the beginning of his 
present ailment, he has been all his life in fair health. 
He has never had any symptoms of saturnine poisoning, 
either acute or chronic, and examination fails to reveal 
any of the signs of the toxic effect of this metal. About 
eighteen months previous to his admission to the hos- 
pital he felt, on getting up in the. morning, a peculiar 
numbness and tingling feeling in both his lower extremi- 
ties, and especially in his feet; this he attributed, how- 
ever, to. some abnormal position assumed during sleep, 


f 


Spinal Cord. 
Spinal Cord. 


and went out to his work, as usual, returning only in the 
evening, when he felt altogether himself again. This 
feeling, however, returned on the following two or three 
mornings, accompanied by a dull, stiff sensation in the 
back, about the lumbar region ; it became more and more 
persistent, so that by the end of a week it did not leave 
him during the whole day, and interfered with him in his 
work. He went to consult his physician, who told him 
he had taken cold, and gave him a plaster to apply to his 
back, a liniment to rub his extremities with, and a tonic 
to take internally, and said everything would be right in 
a few days. Not finding any relief after two weeks’ 
treatment under his family physician, he was prevailed 
upon to consult another physician, under whose care he 
remained for several weeks, the symptoms becoming 
all the time aggravated, but not being of suflicient im- 
portance to force him to relinquish work as yet. About 
two months after he was first attacked he noticed that 
something was wrong with his urine, which he passed 
only ina small stream, and while at work a few drops 
would occasionally dribble from him. About that time 
also his bowels, which, had always been very regular, 
became somewhat costive, and he was forced to make 
use of aperients frequently. Alarmed at this, he again 
changed medical advisers, and upon the advice of his 
newly chosen attendant refrained from work and re- 
mained at home, a great deal of his time in bed, for 
several weeks. Under this treatment he gradually im- 
proved, and at the end of that time was again able to return 
to his occupation. He remained better, however, only 
a short time, for the pains soon returned, but sufficiently 
severe this time to force him to rest of his }wn accord ; 
the dribbling of urine became worse, and the numbness 
and tingling were continuous, even when he was in bed. 
After several weeks of rest he attempted to resume work, 
but could not. His legs felt heavy, he was unable to 
stand on them long, and the pain and stiffness in the 
back were worse, and had also invaded the legs; his 
urine continued to dribble, and he had to empty his blad- 
der every hour or two during the day and night. This 
condition grew slowly worse up to the time of his admis- 
sion into the hospital. 

Upon my advice he remained as a patient in the hos- 
pital for two months, undergoing treatment, which con- 
sisted of mild galvanic applications to the spine, faradi- 
zation of the extremities, and ten grains of potassium 
iodide, internally, four times a day, besides which he 
took, morning and evening, thirty drops of fluid extract 
of ergot and ten drops of tincture of belladonna. At the 
end of that time the following notes of his case were 
taken : Lancinating pains in back, extending from the mid- 
dle dorsal region to the sacrum ; pains extend around the 
abdomen and down the anterior and posterior aspects of 
the legs and thighs ; stiffness of these regions ; the pain 
and stiffness are increased by active motion of the spine 
and limbs, but there is no tenderness of the back, and no 
change in the symptoms is caused by motion of the body ; 
his legs feel numb and heavy, and he occasionally suffers 
from formication ; his gait is uncertain and tottering ; 
tactile sensation is diminished in the lower extremities, 
but sensation to pain is about normal; the patellar reflex 
is a little exaggerated ; electrical sensibility and irrita- 
bility are diminished, but there is no reaction of degener- 
ation. The muscles of the limbs are well developed and 
in a state of constant tension ; the patient’s general health 
is good, his appetite is good, body well nourished, and the 
cerebral functions are well performed. His upper ex- 
tremities feel somewhat numb, but are otherwise nor- 
mal ; he suffers still from dribbling of the urine, and has 
frequent calls for micturition ; he has occasionally passed 
his urine unconsciously in bed during sleep ; the bowels 
are costive, requiring the frequent administration of pur- 
gatives and enemata; his abdomen is tense; the other 
inorganic functions are well performed. 

At his own request the patient was discharged in this 
unimproved condition, and since then nothing has been 
heard of him. 

A Case of Chronic Spinal Meningitis, of Six Months’ du- 
ration, following an Acute Attack, resulting favorably after 


555 


Spinal Cord. 
Spinal Cord. 


Six Months’ Treatment.—A. M——, white, male, aged 
twenty, a clerk by occupation, is well nourished, of tem- 
perate habits, never drinks, but smokes occasionally ; he 
has indulged in sexual excesses for the past year. There 
is no hereditary history of disease ; the patient has never 
had syphilis, but has had malarial intermittent fever fre- 
quently, lasting weeks at a time, during the last few 
years. Six months ago he fell from a horse and struck 
his back in the lumbar region ; he was stunned, and re- 
mained unconscious for some time, and had to be carried 
home. He felt very sore in the back after the accident, 
but could move his legs and body, and had no difficulty 
with the bladder or rectum. After being taken home he 
was examined by his physician, who pronounced the in- 
jury trivial, no bone being broken or out of place, but 
advised his remaining in bed for some days. 

The next day the patient, feeling better, got up and 
went about the house ; two days after this he was taken 
with severe pain in the back, in the region where he had 
received the injury ; the pain, he says, spread around the 
body like a belt, and shot down the thighs and legs; it 
was so severe that he had to go to bed. The next day 
a high fever developed, and the pain continued to in- 
crease, his back and lower limbs being also very much 
stiffened, so that he could not be moved without experi- 
encing excruciating pains, and his urine had to be drawn. 
He was immediately put under treatment, and in a fort- 
night the fever had subsided, and the pains had dimin- 
ished, but he had strange feelings, as of ants crawling, and 
numbness down ‘the legs, which latter were almost com- 
pletely paralyzed ; he had lost control over his water, 
and his bowels were very much constipated. He re- 
mained pretty much in this condition until his admission 
into the ward for nervous diseases, of Charity Hospital, 
in December, 1885. He was immediately placed under 
treatment, large doses of bromide of potassium and 
chloral being given at first to relieve the pain, which 
had again become more acute in the back and lower 
limbs. In two or three weeks electricity was applied, 
when the reaction to the galvanic current was found 
diminished, but in the normal formula; the tendon re- 
flexes were found subnormal; regular electrical applica- 
tions were begun at that time, potassium iodide in five- 
grain doses, three times a day, was ordered, and the pa- 
tient’s bladder and bowels were attended to. Improve- 
ment was perceptible in a very short space of time, and 
six months after admission, in July, 1886, he was dis- 
charged, thoroughly cured, no untoward symptoms re- 
maining. The patient was seen a few weeks ago, and 
it was ascertained that he had remained completely well 
since his discharge from the hospital. 

DraGcnosis.—Chronic spinal meningitis is, as already 
mentioned, at times difficult to recognize, on account of 
the insidiousness of its beginning, and masked as it is by 
important complications ; for its diagnosis we must rely 
on the pain and stiffness in the back, the paresthesia of 
the extremities, and on the mildness and uniformity in 
distribution of the paresis, and the general absence of 
increased reflex action, of obstinate contractures, of atro- 
phy, and of painful muscular jerkings, and on the modifi- 
cation of the symptoms generally caused by change in 
the position ; all of these are characteristics of this dis- 
ease and serve to differentiate it from myelitis, in which 
the paralysis and anesthesia are severe, the contractures 
well marked and lasting, the muscular atrophy of para- 
lyzed limbs noticeable, and the reflexes exaggerated, and 
in which the pains in the back and extremities, with stiff- 
ness of the spinal muscles, are absent. 

From anterior poliomyelitis the characteristics of this 
disease, paralysis and atrophy, with no disturbance of 
sensibility, and absence of pain, are sufficient diagnostic 
signs. 

Tabes dorsalis may be recognized by its accompanying 
fulgurating pains, ataxia, and disturbances of muscular 
sensibility. We must remember, however, that both af- 
fections are often combined. 

Spinal irritation occurs in young women, as a rule, 
and is accompanied by symptoms of hysteria ; its onset 
is sudden, and not always free from fever; there is hy- 


5d6 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


peresthesia of the spine, but no stiffness ; there is tender- 
ness over the spine rather than real. pain, and the fluctu- 
ations in the intensity and character of the symptoms are 
marked. The severity of the subjective symptoms is 
also in striking contrast with the mildness of the objec- 
tive appearances ; there are no signs of organic disease 
of the cord ; other signs of hysteria and of ovarian and 
uterine diseases are common. 

Proenosis.—The prognosis of chronic spinal menin- 
gitis is always serious ; a cure is hard to obtain, and is 
generally exceptional in old and tedious cases; but im- 
provement and cure have occurred even in what seemed 
at first hopeless cases, so that the prognosis must be 
guarded, and treatment should be persevered in for a 
long time, even in severe cases. 

Sometimes, without apparent cause, the inflammation 
will become limited and the work of repair begin. The 
amount of improvement to be expected, then, depends 
essentially on the extent of the organization, calcification, 
or retraction of the effused material, and on its absorption. 
But even after the changes in the inflammatory products 
seem to be at an end, and the case has remained station- 
ary for a long while, further improvement in the func- 
tions may occasionally be obtained in the course of time 
by means of judicious treatment. 

Before making a prognosis the following conditions 
must be taken into account: The patient’s age, constitu- 
tion, and powers of resistance ; the state of bodily nutri- 
tion ; the causes which have brought on the disease, and 
the possibility of their removal; the amount of structu- 
ral changes which have taken place in the spinal canal ; 
the amount of myelitis and other complications, as shown 
by the intensity of the symptoms; and finally, the im- 
provement brought about by previous treatment. 

We must not, however, be too sanguine in our prog- 
nosis and lead the patient to expect too much. 

TREATMENT.—In order to prevent the occurrence of 
this affection, great care should be exercised during con- 
valescence from the acute form of the disease; all pre- 
disposing causes should be carefully looked after, and 
the exciting causes removed when possible. 

As to the treatment proper, our attempts should be 
directed to the limitation of the disease, the relief of an- 
noying symptoms, and the prevention of avoidable com- 
plications. For the first purpose, counter-irritation to 
the skin, especially along the spine, is useful ; this is best 
accomplished by blistering, the application of tincture 
of iodine, turpentine, croton-oil, or other epispastics, and 
the use of dry cups. Antiphlogistics are rarely required, 
except in plethoric individuals with unusually severe 
symptoms, pointing to an invasion of the cerebral menin- 
ges; the same may be said of the wet cups and of pro- 
fuse purgation for the purpose of bringing on intestinal 
derivation ; at most, mild laxatives will be of use. In- 
wardly, iodine and the iodides in moderate doses, con- 
tinued for a long while, with mercury in syphilitic cases ; 
ergot and belladonna are often employed, but have been 
found of little or no benefit. Diuretics are of some util- 
ity in cases of abundant serous exudation. Warmth, ex- 
ternally, with stimulating frictions and massage to the 
affected limbs, has occasionally been serviceable. 

To fulfil the second indication, an abundance of good, 
nourishing food, with an occasional stimulant, is re- 
quired; tonics, such as quinine, iron, and the compound 
hypophosphites are necessary to combat the anzemia and 
debility which generally coexist with the disease. 

For the relief of distressing symptoms, sedatives, such 
as opium and hyoscyamus, chloral, and the bromides are 
used for the quieting of the pain; for the same purpose, 
in obstinate cases, warm baths and baths of all sorts, wet 
packs, and alternate cold and warm water douches are 
also of service. A stay at one of various mineral springs 
will be of benefit in some cases to relieve the paresis and 
paresthesia ; stabile ascending and descending galvanic 
currents, of moderate intensity, and faradism to the af- 
fected muscles will also be of use in the same direction. 
For the rectal and bladder troubles, aperients, regularly 
administered, ergot, nux vomica, and electricity are of 
service. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


AUTHORITIES CONSULTED. 


Grasset, J.: Maladies du Systeme nerveux, 8d edition. 

Haase, K, E,: Krankheiten des Nervensystems (being vol. iv., part i., of 
Virchow’s Handbuch der speciellen Pathologie und Therapie). 

Erb: Article in Ziemssen’s Cyclopzdia of Medicine, vol. xiii. 

Radcliffe, C. B., in Reynolds’s System of Medicine, vol. i. 

Oliivier : Maladies de la Moélle épiniére. 

Ross: Diseases of the Nervous System, vol. ii. 

Rosenthal: Diseases of the Nervous System. 

Charcot: Lecons sur les Maladies du Systéme nerveux, 

Bramwell, Byrom; Diseases of the Spinal Cord, 


P. EH. Archinard. 


SPINAL CORD DISEASES: CONGESTION OF THE 
CORD. Our actual knowledge regarding spinal conges- 
tion is very limited, and hypothetical statements that it 
is the basis of many nervous symptoms are unwarranted. 
The diseases in which it is uniformly found after death 
are those in which the patient has died in convulsions 
complicated by asphyxia, or in the early stages of mye- 
litis. The only positive evidence that a spinal conges- 
tion has existed during life is the discovery of distended 
capillaries, accompanied by small capillary hemorrhages. 
Without the latter the congestion found may have been 
a post-mortem occurrence, due to the position of the 
body on the back. 

The causes of active congestion are excessive muscular 
exertion, violent sexual excesses, poisoning by strychnia, 
alcohol, and carbonic oxide, the sudden arrest of men- 
struation or the stoppage of hemorrhage from piles, and 
possibly exposure to cold. Traumatism of the vertebre, 
especially-general concussion of the spine, such as occurs 
in railway injuries, probably causes active spinal hyper- 
gemia, in a few cases examined capillary hemorrhages 
having been found after death in the cord. It is proba- 
ble that spinal congestion is usually localized in the 
lower half of the cord, though the entire organ may be 
affected. An active hyperemia of the anterior cornua 
is the first occurrence in poliomyelitis anterior, and this 
is usually quite extensive, while the actual process of 
inflammatory degeneration is subsequently limited to a 
small area. The latter produces the permanent atrophic 
paralysis of infants ; to the former must be ascribed the 
temporary paresis of the first stage of the disease, which 
is always more extensive than the permanent paralysis. 

The causes of passive congestion are the same as those 
producing this effect in the brain or other organs (¢.?.). 

The symptoms of spinal congestion are a sensation of 
weight and fatigue in the legs and back, increased by 
any effort, so that continued exertion is impossible ; 
pains, numbness, formication, and sensations of heat and 
cold, with increased susceptibility to changes of temper- 
ature and to pain and touch in the extremities ; weak- 
ness, but not paralysis, in the entire muscular system, 
attended by an increase of reflex excitability ; a diminu- 
tion of sexual power; and a diminution of control over 
the bladder and rectum not sufficient to be termed in- 
continence. Any symptoms more serious than these, 
such. as severe tearing pains in the back and general hy- 
peresthesia ; or such as girdle sensations, incontinence, 
and actual paralysis, must be ascribed to congestion of 
the spinal meninges as well*’as of the cord, or to disturb- 
ances of a grave nutritive kind initial to an actual mye- 
litis. These symptoms are always bilateral, and usually 
more marked in the lower half of the body, although 
the arms may become involved. ‘They usually come on 
suddenly after some known cause ; but occasionally a 
chronic congestion is suspected, which lasts for months, 
and is attended by symptoms of neurasthenia. 

The diagnosis of spinal congestion is an uncertain one. 
When symptoms such as those described appear, and do 
not go on to more serious conditions, but gradually pass 
off, and an adequate cause can be found, the diagnosis 
can be made. If, however, serious symptoms of myeli- 
tis ensue, it must be admitted that the disease was mye- 
litis from the outset, and not a simple hyperemia. A 
long duration of symptoms of spinal congestion points 
rather to the existence of capillary hemorrhages, at- 
tended by small foci of inflammatory degeneration, or 
to nutritive changes in the spinal cord. 

The prognosis should always be reserved, in view of 


Spinal Cord. 
Spinal Cord, 


a uncertainty of diagnosis and the possibility of mye- 
itis. 

The treatment should consist of absolute rest in bed, 
in a prone position ; the application of cool cloths, wet 
with an evaporating lotion, to the spine, or an ice-bag or 
the ether spray ; saline purgatives ; and full doses of 
ergot with small doses of belladonna. 

M. Alien Starr. 


SPINAL CORD DISEASES: HA-MORRHAGE IN THE 
CORD. Synonyms: Hematomyelia; spinal apoplexy. 

Heemorrhage in the spinal cord is very rare in compari- 
son with hemorrhage in the brain. When it occurs it is 
usually of small extent. This is not extraordinary when 
the size of the organ and the firmness of its connective- 
tissue sheath, and the low pressure in the spinal arteries, are 
considered. As arule, the clot in the spinal cord is long 
and narrow. It destroys a considerable part of the cord 
at one segment, and extends into the segments above and 
below, injuring these to a less extent. The clot is usually 
found in the gray matter of the cord, most frequently in 
the anterior horns, then in the posterior horns, and most 
rarely in the white columns. Sometimes the surface of 
the cord is broken and the blood infiltrates the pia mater. 
As the patient rarely dies at once of hemorrhage the 
clot is usually found in a state of decomposition, and the 
cord around it is infiltrated with blood-cells, pigment- 
granules, and hematin crystals. If the hemorrhage is 
capillary—as sometimes occurs—it is detected by the.pres- 
ence of pigment and crystals among the degenerated 
spinal elements. Around the clot the spinal cord is usu- 
ally found in a state of softening, which is red in recent 
cases, and white when the process has been a long one. 
At a post-mortem the question sometimes arises whether . 
the condition found is a myelitis with secondary hemor- 
rhage, or a hemorrhage with secondary myelitis. In 
the former case the microscopic examination shows a 
greater preponderance of granular corpuscles, a greater 
degree of degeneration in the nerve-cells, and a greater 
extent of connective-tissue growth. Secondary degenera- 
tions upward and downward from the segment destroyed, 
and secondary degenerations in the motor nerves from 
the segment affected to the muscles, are observed after 
spinal heemorrhage as after myelitis. The meninges are 
rarely involved. 

ErroLtogy.—Spinal hemorrhage is met with in males 
more frequently than in females, and in youth and mid- 
dle age most often. The predisposing causes are chronic 
changes in the general arterial system, and inflammatory 
congestion or myelitis of the spinal cord. The exciting 
causes are the same as those of spinal congestion (g.2.), 
to which must be added the sudden exposure to a marked 
change of atmospheric pressure, to which workers in 
caissons and divers are exposed. The so-called caisson- 
disease is a congestion of the spinal cord (and brain 7) at- 
tended by minute hemorrhages and secondary subacute 
myelitis. 

Symproms.—Very rarely the symptoms of spinal con- 
gestion precede those of hemorrhage. As a rule, the 
symptoms begin very suddenly, and the patient is seized 
in a moment with complete paraplegia and intense pain 
in the back at the level of the hemiorrhage. When pre- 
monitory symptoms have existed for a few days it is 
probable that the case is one of acute myelitis. A spinal 
apoplexy usually comes without any warning, after a 
sudden effort. The extent of the paralysis depends upon 
the level of the lesion. (See Local Lesions.) If in the lum- 
bar or dorsal region, the lower half of the body only is 
involved ; if in the cervical region, the arms are affected 
as well. The hemorrhage is rarely so very limited as to 
affect one extremity only, but itis not infrequently the 
case that the symptoms are more marked on one side. 
The paralysis is total, no voluntary motion is possible, the 
limbs are relaxed and never rigid. The muscles do not 
atrophy or present any change in the electric reactions, 
excepting those which are supplied with nerves from the 
segment which is destroyed by the hemorrhage. The 
condition of the reflex action depends upon the seat of 
the lesion, it is suspended at the level of the hemorrhage, 


557 


Spinal Cord. 
Spinal Cord. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, 


and increased in the segments below it. The bladder and 
rectum are uniformly paralyzed, and various forms of in- 
continence of urine and feces result, dependent upon the 
seat of the lesion. If this is high up in the cord, the vis- 
cus may empty itself occasionally, as the need arises, un- 
consciously to the patient and independent of his effort 
or control. If the lesion is low down (below the eleventh 
dorsal segment), there is usually retention of urine and 
feces, or complete relaxation of the sphincters. 
motor paralysis accompanies the voluntary paralysis, and 
results in cyanosis and coldness of the paralyzed limbs, 
and predisposes the parts to the development of bed-sores. 
The latter appear, very soon after the hemorrhage, on the 
prominent parts of the body which are subjected to press- 
ure; voluntary movements to relieve such pressure, or re- 
flex movements for the same purpose, being impossible 
on account of the lack of power and of sensation, for 
complete anesthesia and analgesia exist in the paralyzed 
limbs from the outset. Pain in the back, which occurs 
at the time of hemorrhage, does not usually persist. The 
danger in these cases is from the occurrence of bed-sores, 
or of cystitis,and consequent infection from these sources, 
with the development of septic fever. If the hemorrhage 
involves the respiratory centres in the upper cervical re- 
gion, sudden death takes place. This is rare. 

The symptoms described are those of a severe hemor- 
rhage, sufficient to destroy one or more segments of the 
cord; if the clot is a small one, however, they may be 
more limited and less serious, partial anesthesia and lo- 
calized paralysis, with atrophy, being the result. This, 
however, is the exception. Capillary hemorrhages give 
rise to wide-spread symptoms, which so closely resemble 
those of diffuse myelitis that differential diagnosis is im- 
possible. 

The prognosis is very bad in spinal apoplexy, for a de- 
struction of the spinal elements cannot be recovered from. 
The patients either die suddenly, or die of complications, 
or linger on for months with all the symptoms of chronic 
myelitis. In the lighter cases they may recover sufli- 
ciently to getabout, but some evidences of the hemor- 
rhage in the form of local paralysis or areas of anesthesia, 
always remain. 

The diagnosis is usually easy, the sudden onset of total 
paraplegia being characteristic. Im meningeal heemor- 
rhage the paralysis is less marked than the spasms, and 
anesthesia is rare. In poliomyelitis anterior there is 
marked constitutional disturbance, with fever, before the 
paralysis begins, and anesthesia is not present. Inacute 
central myelitis the onset is more gradual, the symptoms 
develop successively, they extend gradually to other 
parts, and fever is usual. 

Treatment cannot reach the disease, and hence resolves 
itself into a care of the patient, and such measures as are 
used in the management of a case of chronic myelitis. 

M. Allen Starr. 


SPINAL CORD DISEASES: HYPERTROPHIC SPI- 
NAL PACHYMENINGITIS. Derinrrion. — Hypertro- 
phic spinal pachymeningitis is a chronic inflammation of 
the spinal dura mater, limited in longitudinal extent, and 
more generally affecting the region of the cervical en- 
largement, but occasionally found in the dorsal region 
or lumbar portion of the cord. This inflammation gives 
rise to thickening and hypertrophy of the dura mater, 
and secondarily implicates the arachnoid and pia mater, 
causing their adherence to the former membrane. The 
hypertrophied membranes, by pressure, produce a second- 


ary transverse myelitis and atrophy of the nerve-roots. 


arising from the affected region. 

The cervical form of this affection, though mentioned 
by others previously, has been thoroughly studied and 
described by Charcot and his pupil Jeoffroy, from whom 
the greater part of our information is obtained. 

PATHOLOGICAL ANATOMY.—The primary and chief 
lesions of pachymeningitis spinalis hypertrophica are 
found in the spinal meninges, and particularly in the dura 
mater, On opening the spinal canal the marrow at the 
affected part is found to consist of a large fusiform tu- 
mor, filling the whole canal, and adherent or not to the 


558 


Vaso-~ 


vertebral ligaments. Upon section this tumor is found 
to be composed mostly of the hypertrophied dura mater, 
to which the other membranes, whether affected or not, 
are adherent, inclosing and making pressure on the 
spinal cord and nerve-roots. This tumor consists of a 
hard, fibrous, and dense tissue, arranged in concentric 
layers, and has for its origin an inflammation of thelin- 
ternal surface of the dura mater with proliferation of the 
connective tissue. 

As secondary lesions, we find the spinal cord com- 
pressed by this hypertrophied tissue as in a ring, and 
showing signs of transverse myelitis with ascending de- 
generation of the posterior columns. This transverse 
myelitis is caused by the compression of the cord, but it 
is believed in some instances to be due to extension of 
the inflammation from the meninges. The nerve-roots 
arising from the affected region are also compressed, 
pale, and atrophied, but the nerves beyond have been 


Fia. 8646.—Hypertrophic Cervical Pachymeningitis. A, Hypertrophied 
dura mater; B, nerve-roots passing through the thickened meninges ; 
C, pia mater adherent to dura mater; D, lesions of chronic myelitis; 
E, section of two newly formed canals in the gray substance. 


found normal. The muscles supplied by the affected 
nerves show signs of atrophic degeneration. 

Pulmonary tuberculosis or cystitis, with bed-sores, is 
generally found as the cause of death. 

Eriotocy.—This is a disease of adult life. No predis- 
posing cause is known, though syphilis and alcoholism 
are supposed to act as such, for a number of the ob- 
served cases were seen in inebriates or syphilitic persons. 

Exposure to cold and dampness is the only known ex- 
citing cause, though in some instances the inflammation 
may have extended from a previous perimeningitis, and 
in a case observed by me, and here related, a fall on the 
back of the neck seems to have acted as the exciting 
cause of the pachymeningitis. 

SYMPTOMS AND CLINICAL History.—Hypertrophic 
spinal pachymeningitis may be divided into two distinct 
stages or periods: The irritative or meningitic period, 
and the paralytic and atrophic, or myelitic, period. 

In this article we shall describe the cervical variety of 
the disease, which is the most common, and the only one 
which has been thoroughly observed. 

Irritative Pertod.—This affection, which is generally 
insidious, first shows itself in one of two forms, the cen- 
tral and the peripheral. The predominating symptoms 
in the central variety are pain and stiffness in the back 
of the neck, radiating to the occiput and head. The pain, 
at first mild in character and resembling that of wry- 
neck, presents distinct periods of exacerbation, and is 
generally worse at night ; in a short time it becomes con- 
stant, and is always aggravated by motion of the neck, 
rarely by pressure upon the spinous processes. Along 
the limbs dull pains of a rheumatic character are then 
experienced, and in the joints sharper shooting pains, at 
times increased by pressure. The joints remain normal 
as regards swelling and redness. In the fingers and 
hands there are numbness, formication, and a greater or 
less diminution of tactile sensibility. These peripheral 
pains are generally more marked on one side than on the 
other ; they are the first to show themselves in the periph- 
eral form of the disease. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Spinal Cord, 
Spinal Cord, 


Later on, the pains extend along the spine to the lumbar 
region and to the lower extremities, occasionally more on 
one side than on the other; they increase to such a de- 
gree that the patient is forced to give up his occupation, 
and at times to betake himself to bed. Nausea and vom- 
iting are frequent at this stage, and seem to further 
weaken the patient. 

This period lasts from two or three to five or six 
months, when, in some cases, there is a period of com- 
parative improvement, and in others. the second period 
is ushered in. 

Second or Paralytie Period.—In this period, also known 
as the chronic period, paralysis usually appears in one 
of the upper extremities, as a rule in the one in which 
the pains were first or more acutely felt, but it soon 
extends to the other extremity. This paralysis, which 
progresses with more or less rapidity, is always accom- 
panied by atrophy and diminution of electrical excitabil- 
ity. The atrophy, in the majority of instances, is limited 
to the pronators and flexors of the hands, and all the mus- 
cles supplied by the ulnar and median nerve, or is more 
marked in them than in the supinators, extensors, and 
other muscles supplied by the musculo-spiral nerve. 
This may be due to the fact that the lower portion of 
the cervical enlargement, from which the ulnar and 
median nerves arise, is more often implicated than the 
upper portion of the enlargement, from which arises the 
musculo-spiral nerve. In the non-atrophied muscles 
contracture sets in early, giving rise to peculiar deformi- 
ties, the more common of which is the claw, or preacher’s 
hand, in which the hand is extended at the wrist, the 
third phalanges extended and the two first remaining 
flexed. This deformity, though not found in this af- 
fection only, is, however, one of its marked character- 
istics. 

The paralysis next invades the lower extremities, but 
in these atrophy seldom or. never occurs ; at times, how- 
ever, the muscles of the lower extremities, as well as 
those of the trunk, tongue, and lips, all become atrophied. 
Paralysis of the muscles of respiration, bringing the case 
to a speedy fatal termination, rarely occurs. 

The sensory symptoms have not been so well studied, 
and do not seem to be as constant; there is first parees- 
thesia, followed later by anesthesia or hyperesthesia, or 
there is anesthesia of one extremity and hypersthesia 
of the other. 

Trophic changes have also been observed, such as itch- 
ing, dryness, and desquamation of the skin over the af- 
fected regions, or the development of a vesicular or bul- 
bous eruption over the affected hands and arms. Acute 
eschars form at times on the buttocks, over the sacrum, 
on the heels, or in the mucous membrane of the bladder, 
giving rise toa bad form of cystitis. The bladder and 
rectum are paralyzed late in the course of the affection. 

Occasionally convulsive motions of the limbs, amount- 
ing at times to spinal epilepsy, have been observed. The 
reflexes are exaggerated in some cases, in others they are 
not affected. 

When the dorsal region is affected, we have the atro- 
phy, paralysis, and trophic changes affecting the trunk ; 
early paralysis of the lower extremity, and complete im- 
mobility of the upper extremities. 

When the lumbar region is alone affected, the symp- 
toms are limited to the parts supplied from this portion 
of the cord. 

The following case illustrates the course of pachymen- 
ingitis hypertrophica spinalis ending in recovery : 

E. F——, white, male, aged forty-five, single, laborer, 
intemperate in habits, gives no family history of disease, 
but had syphilis twenty years ago. He was admitted 
into the ward for nervous diseases of Charity Hospital, 
on May 2, 1885, with the following history: One year 
before admission, the patient was thrown from a horse 
and fell on the back of his head and neck; he was able 
to pick himself up after the accident, and, though he suf- 
fered greatly with pain in the neck and head, returned 
home on foot, a distance of several miles ; he was con- 
fined to his room for several weeks, suffering from 
shooting intermittent pains in the back of the neck and 


head ; the neck was very stiff, and the least motion or 
touch on the parts gave rise to excruciating pains. Ac- 
companying this, and developing shortly after, were 
numb feelings and occasional shooting pains extending 
down the arms and hands, especially on the left side, the 
elbow and wrist were very tender and painful, making it 
almost impossible for him toraise hisarm. About twelve 
weeks after the injury the pains in the neck, head, and 
arm had greatly increased, and he could make little or 
no use of his upper extremities, which were stiff and use- 
less. About this time the muscles of the hand and fore- 
arm began to waste, and his hand was drawn back over 
the arm at the wrist, the fingers being extended ; he began 
also to feel weak and stiff in the legs, and to be troubled 
with retention of urine and costiveness ; the pains in the 
legs, however, were never so great that he could not 
move about, though he was incapacitated for work. 

Upon admission his general condition was found to be 
good ; there were no general symptoms; his arms and 
hands were almost completely paralyzed, the left more so 
than the right; there was atrophy of the pronators and 
flexors of the hands and fingers, and of the biceps; the 
extensors of the upper extremities and supinators were 
contracted. The deltoids were normal. He had the 
typical claw hands, and had to be fed, being unable to 
bring the food to his mouth. The lower extremities were 
well developed, but he complained of weakness causing 
tremor and stiffness ; his gait, when walking, resembled 
that of a patient with spastic paralysis. The. bladder 
was somewhat affected, the patient having to empty it 
almost hourly ; the bowels were costive, only acting 
when stimulated. The muscles of the neck and upper 
part of back were stiffened. Sensation, both general and 
tactile, was greatly diminished in the upper extremities, 
but the neuralgic pains in the head, neck, and arm had 
almost completely disappeared, coming on only at rare 
intervals ; sensation in the lower extremities was a little 
below normal. The patellar tendon reflex was exagger- 
ated, and there was marked ankle clonus in both legs. 
The faradic and galvanic irritability was present, but 
greatly diminished in the upper extremities, though al- 
most normal in the lower extremities, 

The patient was put on tonic treatment, and a mixture 
of the bromide and iodide of potassium, grs. xv. of the 
former and grs. x. of the latter, given three times daily ; 
dry friction was made over the extremities, and the con- 
tinuous current was applied to the back and arm, the 
faradic to the lower extremities. At the end of six 
months there was marked improvement, the patient felt 
stronger and could walk better, though the legs still felt 
stiff. He could also flex his fingers almost to the palm 
of his hand, and bring the right hand to within two 
inches of his mouth, and thus feed himself ; the pain in 
the back of the neck and limbs had disappeared, and, 
subjectively, sensation in the upper extremities was very 
much improved. Slight response in the atrophic muscles 
could be obtained with a twenty-four-cell bichromate of 
potash galvanic battery ; the hands and forearms looked 
a little fuller. The control over the bladder was nearly 
normal, the viscus being emptied only three or four 
times during the night, and about twice as often in the 
daytime ; the bowels acted without assistance. His con- 
dition continued to improve until December, 1886, when 
he left for Cincinnati, having obtained some occupation 
in that place as keeper in a warehouse. When he left 
the hospital he could be on his feet all day ; sensation 
was quite normal, and, aside from a slight stiffness in the 
leg, he felt no untoward symptom in walking. He could 
bring his hands to his mouth and shut the fingers, though 
he could not hold a weight. 

This case, on account of the rapid improvement and 
amelioration of the worst symptoms, should, in our esti- 
mation, be classed as a case of cure. 

CouRsE AND TERMINATION.—The course of the dis- 
ease is generally progressive, but the affection may last 
for a number of years. The termination is generally 
fatal, the more rapid cases terminating fatally in about 
five years, the slower ones lasting from fifteen to twenty 
years. Occasionally cases, like the one just reported, re- 


559 


Spinal Cord. 
Spinal Cord. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


cover. Charcot has reported a case, much more ad- 
vanced than ours, in which the same happy termination 
took place. ‘ : 

DraGenosis.—This affection may in its initial stage be 
confounded with torticollis. The fact that the whole 
neck is implicated, instead of one side, and the presence 
of radiating pains in the upper extremities, will, how- 
ever, suffice for a diagnosis. 

Hysteria is to be distinguished from the initial stage of 
the peripheral form by the other symptoms pointing to 
that hybrid affection. 

Progressive muscular atrophy is to be differentiated 
by the absence of painful symptoms, the more limited 
atrophies, and the difference in its seat, and by the ab- 
sence of the claw-hand. 

Myelitis can be distinguished only by the history of 
the case. 

Pott’s disease of the vertebre can usually be diagnosti- 
cated by its history. 

Proenosis.—The prognosis of pachymeningitis, as a 
rule, isunfavorable ; but, from what has been said above, 
a cure may be hoped for in a few cases, even after the 
symptoms denoting the secondary involvement of the 
nerve-roots and cord have appeared. In a number of 
cases, however, when the symptoms are meningitic only, 
much can be hoped for with appropriate treatment. 

TREATMENT.—In the first period of the affection, in 
robust and plethoric patients, antiphlogistic measures 
may be resorted to; but with the majority of cases the 
treatment must be symptomatic and carried out on the 
same general principles as that for other forms of menin- 
gitis. 

Sedatives, such as opium, but preferably chloral hy- 
drate and bromide of potassium, to relieve pain; bella- 
donna and ergot, to limit the extent of the inflammatory 
processes ; iodine and the iodides, to favor the reabsorp- 
tion of the exudate material, and to diminish connective- 
tissue proliferation, are called for. 

The use of the actual cautery to the spinal column, 
recommended by Jeoffroy and Charcot ; electricity, es- 
pecially the galvanic current, to the spine, and hydrothe- 
rapy are all at times indicated. 

In the second stage, the continued use of iodide of po- 
tassium in large doses ; of tonics, to keep up the patient’s 
strength ; counter-irritants, especially the actual cautery, 
to the spine; electricity, both galvanic and faradic; 
massage, etc., are of service, 


BIBLIOGRAPHY. 


Charcot and Jeoffroy ; De la Pachyméningite spinale hypertrophique. 

Bramwell, Byrom: Diseases of the Spinal Cord. 

Charcot: Lecons sur les Maladies du Systéme Nerveux. 

Rosenthal: Diseases of the Nervous System. 

Ross: Diseases of the Nervous System, vol. ii. 

Olivier: Maladies de la Moélle épiniére. 

Radcliffe, C. B,: in Reynolds’s System of Medicine, vol. i. 

Erb: Article in Ziemssen’s Cyclopedia of Medicine, vol. xiii. 

Haase, K. E.: Krankheiten des Nervensystems (being vol. iv., parti., of 
Virchow’s Handbuch der speciellen Pathologie und Therapie). 

J. Grasset: Maladies du Systéme nerveux, 3d edition. 


P. BH. Archinard. 


SPINAL CORD DISEASES: INJURIES AND 
WOUNDS. Injuries of the spinal cord and membranes 
were studied and described by Sir Astley Cooper and 
other surgeons of the last century with considerable mi- 
nuteness andcare. Microscopic study and the investiga- 
tions of neurologists have so supplemented clinical study 
that the pathology of diseases of the cord has been almost 
entirely rewritten within a short term of years, and these 
investigations are not to be left out of account in con- 
sidering the surgical diseases of the nervous system. 
Part, at least, of the changes resulting from injuries to 
the cord and membranes are identical with those found 
in disease. An intelligent understanding of their nature 
can, therefore, be obtained only through acquaintance 
with recent important investigations on the functional 
and organic diseases of the spinal cord. We cannot here 
enter into the pathological and normal anatomy as studied 
in disease and in experiments upon animals. This sub- 
ject has been fully discussed in a preceding article. 

It is sufficient to call attention to the importance of 


560 


these investigations, a knowledge of which is at the 
foundation of a proper understanding of the effect of in- 
juries upon this part of the nervous system. Not only 
are the local structural changes often the same in disease 
and in the results of traumatism, but secondary effects 
appearing in remote organs are frequently identical, what- 
ever the primary lesion. It is evident that much of the 
discussion of spinal injuries in surgical treatises is based 
upon clinical and not upon pathological data. It is also 
true that writers of eminence have treated this subject, 
which is often a medico-legal one, almost ina controver- 
sial spirit, drawing opposite conclusions in some instances 
from the same clinical evidence. 

Erichsen has collated numerous cases from the pub- 
lished works of Cooper, Bell, Abercrombie, Brodie, and 
others, which he has added to his own in illustrating cer- 
tain ideas on spinal ‘‘ concussion.” Page, on the other 
hand, has drawn largely from the same sources, and even 
from Erichsen’s own cases, to support views quite oppo- 
site. Neither writer utilizes to the full the best results of 
modern investigation on the pathology of the cord. We 
are therefore left with the impression that much of this 
discussion is but threshing old straw, so far as scientific 
interest is concerned, however much importance may at- 
tach to it in the eyes of lawyers and claim-agents. It is 
well, nevertheless, for all medical men who are subject 
to calls for expert testimony, and especially in railway 
practice, to be conversant with such works as that of 
Page. 

Causes.—The spinal cord is exceedingly well guarded 
from all external violence. Axially situated with refer- 
ence to all bodily movements, protected by its semi-rigid 
bony and ligamentous canal and by thick cushions of 
muscles, there would seem to be little liability of its re- 
ceiving mechanical injury except in destructive accidents 
to the vertebre. On the other hand, the fragile and soft 
texture of the gray matter of.the cord makes it more vul- 
nerable than most tissues. Even the white fibrous col- 
umns, Which surround and inclose the gray matter, are 
comparatively frail and intolerant of interference, so that 
slight causes, when persistent, may set up serious altera- 
tions of structure. It is not to be inferred that complete 
recovery cannot take place after considerable violence 
has been done to the cord-substance as well as the mem- 
branes, provided the source of irritation or compression 
has been completely removed. This mwst be true of 
slight lacerations, since it has been observed clinically in 
actual wounds of the cord-substance. 

Meryon describes a case of incised wound in a lad, fif- 
teen years of age, in which the spinal canal was penetrated 
by a knife between the tenth and eleventh dorsal verte- 
bree, and the cord was partially divided, so that there was 
escape of spinal fluid and paralysis of parts of the body 
below. The left leg and thigh were completely para- 
lyzed, and it was inferred—without doubt correctly—that 
the cord had been partially severed. The patient, not- 
withstanding, recovered entirely in two months. Many 
such cases of complete or partial recovery have been re- 
corded, which show that reparation is possible in the 
nerve-structure under favorable circumstances. It can- 
not be asserted that this is usual in penetrating wounds ; 
but in simple injuries, such as laceration of membranes, 
contusion, or ‘‘ concussion” of the cord, and small cir- 
cumscribed hemorrhages, even when accompanied by 
paraplegia, perfect recovery may often be expected. 

Slows upon the spinal column, without producing any 
fracture or displacement of the vertebrae, may cause symp- 
toms ranging from slight neuralgia to complete. para- 
plegia. ‘This is the simplest type of injury to the spinal 
cord or membranes, and is analogous to similar injuries 
to the brain from blows upon the skull. It cannot be 
said that this is very common in the typical form. 

In ‘‘ Guy’s Hospital Reports” for 1856 is described the 
case of a boy who was struck in the back with the fist, 
and shortly afterward developed pain in the extremities, 
difficult urination, spasm of the muscles, and other signs 
of spinal irritation. The patient soon died, and the au- 
topsy showed the spinal canal nearly filled with pus. It 
is so unusual for traumatic arachnitis to take a suppura- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Spinal Cord. 
Spinal Cord. 


tive form, when no external wound and consequent sep- 
sis has occurred, that some doubt may be entertained in 
this case as to whether the blow was the real cause of the 
disease. 

Genert describes the case of a woman, forty years of 
age, who received a blow upon the back, which was fol- 
lowed by pain and loss of voluntary motion, beginning 
in the right foot, and gradually extending over the body, 
with spasmodic contractions and ultimate death. The 
autopsy showed the posterior columns softened and in- 
flamed in the lumbar enlargement. 

By far the greater number of injuries to the spinal 
cord are the result of ¢ndirect violence. 

falis which produce no injury to the bones either of 
the extremities or of the spinal column are often followed 
by symptoms indicating functional or structural de- 
rangement of the spinal cord. Many observers have no- 
ticed the fact that the spine usually escapes injury when 
the extremities suffer, as in fractures and dislocations. 

It may be that some cases of spinal irritation pass un- 
observed on account of the graver trouble which is pres- 
ent. The enforced rest involved in the treatment also 
has a most favorable influence upon the speedy recovery 
of such cases, 

Erichsen inclines to the theory that the traumatism in 
one part of the body breaks the force of the blow re- 
ceived, and thus diminishes the violence of its effect upon 
the spine. He adduces the statement of watchmakers 
that, when a watch falls to the ground, ‘‘if the glass be 
broken, the works are rarely damaged ; if the glass es- 
cape unbroken, the jar of the fall will usually be found 
to have stopped the movement.” As an illustration 
rather than an exact analogy, this serves to explain how 
the sacrifice of one member may save the integrity of an- 
other. 

A blind man was admitted to my department, in Mercy 
Hospital, in 1880, who had walked out of a third-story 
window and struck upon his feet, fracturing both his 
thighs. It is easy to believe that, had the femurs not 
broken under the tremendous impact of the body, the 
contents of the spinal canal might have suffered from 
the shock. 

Extreme bending or twisting of the spinal column is re- 
sponsible for a large number of cases of irritation of the 
cord. 

Slight injuries to the vertebra, to the intervertebral 
disks, or to the ligaments may, just as in the case of other 
articulations, extend somewhat to surrounding parts, and 
give rise to localized meningitis and thickening. 

~Page has pointed out that irritation of the posterior 
common ligament cannot occur without risk of injury to 
the spinal membranes, not so much by their being impli- 
cated at the time of injury as by extension of the inflam- 
mation to adjacent parts. The ligamenta subflava are 
also, as he observes, in such immediate relation with the 
meningo-rachidian veins that laceration of their sub- 
stance will produce rupture of the veins and extravasa- 
tion of blood into the spinal canal, a state of affairs which 
may cause immediate impairment of function, followed 
by inflammation and degeneration of the cord. 

Railway accidents are the cause of a large number of 
alleged injuries to the spinal cord. This is universally 
known outside the profession, as well as init, and its im- 
portance lies chiefly in the number of suits for damages 
against railway companies which arise from it. LErich- 
sen declares that injuries received in railway accidents 
are not essentially different from those occurring else- 
where. That they are more common on railways is 
probably true ; but it is also a fact that such injuries are 
sometimes much exaggerated by patients from mercenary 
motives. 

Page, whose treatise is written with the intent to 
minimize the importance of this class of cases, neverthe- 
less gives detailed histories of 250 cases occurring in his 
own private and hospital practice, and intimates that he 
could furnish records of at least 500 from the same 
source. Many of the cases cited are fraudulent. Yet 
the fact seems evident that they are very numerous in 
railway surgery. 

Vout. VI.—86 


Symptroms.—The signs of injury to the cord are to be 
referred chiefly to perverted or impaired innervation of 
the parts below the lesion. 

Disorders of sensation are among the earliest symp- 
toms. 

Pain, which is for the most part absent locally, is often 
felt in the form of neuralgias of the parts supplied by 
the spinal nerves below the point of injury. These pains 
are usually radiating and intermittent, and are often ag- 
gravated by movements. Usually they precede paralysis 
where the latter occurs. 

Local tenderness is a symptom so inconstant as to be of 
little importance. When present, it may point to injury 
of the bones or spinal muscles. 

Anesthesia and analgesia are common symptoms of 
spinal injuries involving either the sensory nerve-roots 
or the anterior columns. Complete loss of sensation may 
come on when there is paraplegia. 

Hyperesthesia is also a prominent symptom in a certain 
number of cases, particularly in the earlier stages. Even 
when there is total paralysis of motion there may be ex- 
alted sensibility of the skin. <A light touch upon the legs | 
or genital organs may produce the sensation of severe 
cutting or burning. 

Disordered spinal refleres are closely allied to sensory 
disturbances, and perhaps to some extent dependent upon 
them. Exalted action may coexist with, and depend upon, 
increased sensibility. The so-called ‘‘ spastic paralysis ” 
is a form of paraplegia in which the limbs are suddenly 
and violently flexed or extended when touched, quite in- 
dependently of the patient’s control. The jerking may 
be so violent as to cause pain and visibly jar the bed. It 
has been likened to the snapping of a pocket-knife. The 
paraplegia of disease—as of Pott’s disease—is sometimes 
of this form. 

Continuous or tonic muscular spasm is a constant and 
early symptom of the milder forms of spinal irritation, 
especially those affecting the anterior columns. This is 
probably due to reflex irritation. 

Priapism, which is also common in injuries of the 
spine, may possibly be due to reflex action, or, as Agnew 
suggests, to paralysis of the sympathetic fibres within 
the cord. Bramwell attributes this symptom to irritation 
of the excitor fibres which pass down from the brain. 
Priapism is said by some authors to result only from 
injuries high up in the cord ; but Lidell quotes a case 
wherein it occurred from injury at the level of the tenth 
dorsal vertebra. Surgeon Tripler, U. 8. A., describes a 
case from an injury at the junction of the dorsal and 
lumbar vertebre. 

Impairment of reflexes is an important symptom of an- 
other class of cases which usually are accompanied by 
more or less analgesia and ansesthesia. Knee-jerk and 
ankle-clonus are very frequently entirely wanting, but 
the cremasteric and epigastric reflexes are also abolished. 
Such cases are apt to show more or less inco-ordination 
of muscular action, and consequent impairment of gait 
and movement. 

Motor derangements are present in most cases of spinal 
irritation. Inability to empty the bladder and rectum 
are common and early signs, with or without paralysis 
of the extremities. 

Partial or complete paraplegia is the most characteris- 
tic sign of injury to the cord, whether from wounds, 
fractures of the vertebre, or simple concussion. 

The loss of voluntary motion may be of all degrees, 
and with or without muscular rigidity or lack of co- 
ordination. 

Trophic disorders are seldom wanting in the paralyzed 
parts. Muscular atrophy is usually seen after a certain 
time has passed. Among trophic disorders may also be 
noted the ‘‘ neuropathic eschars” (Brown-Séquard) which 
form upon the sacral region in cases of paraplegia. These 
sometimes appear so early after injuries of the spine that 
they can hardly be due to pressure alone, like ordinary | 
bed-sores. They may also appear in other localities, 
Conant describes several cases in which they were seen 
upon the inner aspect of the thighs. Stephen Smith re- 
ports a case of injury to the spinal cord, followed by 


561 


Spinal Cord. 
Spinal Cord. 


neuropathic sphacelus upon the heel and ball of the 
. great toe. ‘ 

Another form of trophic disorder is the remarkable 
affection of the joints first observed in locomotor ataxia 
by Charcot, and called by him “arthropathy.” The 
limbs become suddenly swollen to an immense size, and 
are almost as suddenly reduced, after which the joints 
and burs are found distended with fluid. Remak and 
Patruban observed similar joint-affections in the disease 
called progressive muscular atrophy. Sir William Gull 
described a case of ‘‘ concussion of the spine” in which 
there was paraplegia accompanied by great enlargement 
and redness of the wrists and ankles, lasting four months. 

Excessive sweating and increase or diminution of tem- 
perature over limited areas of the skin are probably the 
results of vaso-motor derangements through the sympa- 
thetic fibres within the spinal cord. 

Cerebral and functional derangements largely predomi- 
nate over the symptoms of spinal irritation in a certain 
class of cases, particularly those resulting from railway 
accidents. While there may be a slight basis of spinal 
trouble, the chief symptoms in many of these cases are 
those of nervous prostration from fright and worry; and 
the trouble, so far as it can be located at all, is in the 
brain, and not in the spinal cord. Many of these cases 
need the attention, not of a surgeon, but of a neurologist. 

A misleading impression has ‘gotten abroad, not with- 
out some authority, that these symptoms, clearly of the 
mind, or at least cerebral, are the ultimate results of spi- 
nal concussion. There is nothing in the pathology of 
the cord, as now known, that will support this view, 
however. It is more scientific to separate carefully those 
symptoms which are spinal from those which are cere- 
bral, and much controversy can in the future be avoided 
by keeping this distinction in view. As to ‘*‘ railway 
spine,” it has very justly been said that ‘‘ railway brain” 
would be a more appropriate designation. Most of the 
symptoms alleged in these cases are not those of spinal 
origin. It is ‘‘safer and wiser to separate and differenti- 
ate those symptoms which are cerebral or psychical from 
those which can only find an explanation in some actual 
lesion of the spinal cord or of the nerves which are given 
off from it.” 

Headache, loss of memory, sleeplessness, melancholia, 
and ‘‘lack of business aptitude” are the symptoms most 
often spoken of in this relation. Impairment of vision 
does, however, occur in slight injuries of the cord. This 
is probably due to simple atrophy of the optic nerve and 
hyperemia of the disk (Albutt, Wharton Jones). 

Temporary impotence is not rarely an accompaniment 
of injuries of this class. Irregular attacks of nausea 
' from functional derangement are also quite common. 

The PATHOLOGY of injuries of the cord is to be under- 
stood only by keeping in mind the various columns of 
degeneration which have been mapped out by patholog- 
ical study. An understanding of the various functional 
disorders which may simulate organic diseases of the 
cord, and of the curious and interesting subject of spinal 
reflexes, is also a requisite for a thorough comprehension 
of the effects of injuries. These matters will be found 
adequately discussed elsewhere in this volume, and still 
more fully in the works of Bramwell, Gower, and other 
writers. 

The pathology of injuries is not wholly dissimilar from 
that of diseases of the spinal cord. In at least one affec- 
tion—tabes dorsalis or locomotor ataxy—there is evidence 
that idiopathic and traumatic cases may be identical in 
kind. Leyden maintained this view in 1868, and was 
corroborated by Topinard (1866). Petit (1879) also tries 
to show that ataxy may be of traumatic origin. Page, 
while not absolutely denying the possibility of this being 
true, holds it to be improbable, since it is a disease of defi- 
nite tracts, and it is not likely that these alone would be 
injured in case of an accident. Gower thinks this might 
result from the whole cord being at first involved, and all 
parts except the posterior columns recovering, leaving 
the latter degenerated. It is not to be forgotten that 
there may be syphilis back of such cases. 

In place of the term ‘‘ concussion of the spine,” it will 


562 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


———— 


be better, so far as possible, to use more definite terms. 
This we can now do with considerable certainty when 
speaking of many of the morbid conditions which result 
from injury of the cord and membranes. 

Intraspinal hemorrhage, following slight lacerations of 
the ligaments or nerve-substance, is the starting-point of 
many slight impairments of function as well as many 
grave ones. 

The close relation of the meningo-rachidian veins to 
the fibres of the ligamenta subflava makes it probable 
that they would be torn when the latter are ruptured. 
Hemorrhage may be slight in quantity, soas to form 
mere ecchymoses upon the surface of the cord or mem- 
branes, or it may fill the spinal canal and produce fatal 
compression. The signs of compression can hardly ap- 
pear as quickly as in the case of a fracture, and in many 
cases some hours or days elapse before serious impair- 
ment of function is noticed. Lidell believes the diag- 
nostic sign of hemorrhage to be the fact that the symp- 
toms begin at a point low down and gradually ascend as 
the level of the blood rises in the spinal canal. 

Brown-Séquard asserts that hemorrhage within the 
substance of the cord is distinguished from accumula- 
tions around it by the absence of convulsions, and the 
gradually diminished sensation in parts below. Hzemor- 
rhage around the cord compresses the roots of the spinal 
nerves, giving rise to convulsions as well as paralysis of 
motion. 

Traumatic meningitis of a subacute form is a common 
result of slight injuries of the spine. Some thickening 
of the membranes occurs when the irritation is persistent, 
and, doubtless, compression of the cord occurs in this way 
without actual inflammation of its substance, or myelitis. 
Serous or purulent exudation into the arachnoid, and 
congestion of the pia mater, with occasional ulceration 
and perforation of the membranes, are the principal feat- 
ures of this affection. 

Traumatic myelitis and meningo-myelitis of traumatic 
origin may be limited to the region where the injury has 
been received, or may extend so as to involve adjacent 
columns. Extension upward or downward to any great 
distance is not usual. The inflammation is of a subacute 
or chronic type, and quite commonly ends in complete 
resolution, with disappearance of the paralysis or other 
symptoms. <A few cases end fatally from paraplegia and 
final exhaustion. Gower saw a case of slow paralysis 
following a railway injury which ended fatally, and in 
which the autopsy showed the gray matter of the cord 
studded with numerous minute foci of chronic inflam- 
mation. 

Pure concussion, if it exist as a pathological state, may 
be defined as a ‘‘ stunned” condition of the cord, which 
is assumed to have undergone some form of molecular 
derangement too slight to reveal itself in the gross appear- 
ances, yet sufficient to cause functional derangement. 
There are well-attested cases in which paraplegia and 
death have occurred from supposed injury to the spinal 
cord, in which, on post-mortem examination, no injury 
to the nervous substance could be detected. Yet, if we 
remember the liability to overlook cerebral injuries, and 
even clots in the substance of the cord itself, we cannot 
always assert with positiveness that some important lesion 
may not have escaped notice. It is only within recent 
years, and in a very few hospitals, that post-mortem ex- 
aminations have been conducted exhaustively. Lidell 
describes a case of fatal injury to the cord, in which the 
autopsy at first showed apparently no lesion in the cord 
until, upon careful section, a globular clot was found at 
one point, in its very centre, which had so compressed its 
substance as to cause death. 

TREATMENT.—The treatment of injuries of the cord 
and membranes calls for rest, not merely physical but 
mental, and complete immunity from care and worry. 
The reason for this is that all parts of the nervous system 
suffer in these cases, and all parts respond unfavorably 
when any cause of nervous excitation exists. There are 
many cases in which the spinal symptoms alone are of 
importance, and others in which mental and psychical 
disturbances seem to be the main features, but all alike 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Spinal Cord. 
Spinal Cord. 


receive benefit from a somewhat prolonged rest in bed. 
The mechanical effect alone is of course considerable, 
but the functional rest which it gives to the reflex centres 
of the spinal cord, by the mere cessation of bodily move- 
ments, is equally important. 

Mechanical appliances for the fixation of the spinal 
column are more useful in irritations of the bones and 
muscles than of the cord itself. Yet it is often the case 
that all these structures are more or less strained and in- 
jured, so that what helps the recovery of one helps all. 
For sprains of the back, with or without definite injury 
of the cord, casts and splints are decidedly useful. By 
immobilizing the spinal column they aid materially in 
securing perfect rest to the injured cord and membranes, 
and so hasten their recovery. 

Sedatives should be used cautiously, and not too con- 
tinuously, where there is reason to suspect that a general 
condition of depression already exists. Bromides in mod- 
eration are allowable, particularly to induce sleep, the 
loss of which is of itself extremely depressing ; but Page 
warns us against the prolonged exhibition of the bro- 
mides, on account of their depressing effects. 

Wounpbs oF THE SprnaL Corv.—The results of 
wounds of the cord and membranes depend largely upon 
the failure or success of closure by first intention, the 
absence or presence of suppuration, or, in other words, 
of septic infection. 

Of the more favorable type a case has already been 
mentioned. 

Hurd (1845) described an instructive case of a man 
who fell upon his back in jumping from a wagon. 

‘In attempting to rise he found his lower extremities 
paralyzed ; calling for help, he stated that a chisel, which 
he had carried in his coat-tail pocket, was sticking in his 
back ; to extract it required the united efforts of several 
men. It measured five inches in length to the shoulders, 
was seven-eighths of an inch in width, and one-eighth 
of an inch in thickness at the cutting end. It had 
entered to the shoulders. During the extraction the 
patient suffered very little, but said he saw, apparently, 
vivid flashes of light, which were followed by total dark- 
ness. The wound was opposite the lower dorsal ver- 
tebre. There was total loss of cutaneous sensibility be- 
low the wound, with the total loss of voluntary motion, 
and paralysis of the bladder and rectum. 

‘The patient was prostrated for forty hours, and then 
reaction was followed by fever for several days. The 
wound healed rapidly. The urine was withdrawn by 
the catheter for eight days. Cutaneous sensibility re- 
turned on the fifth day, and imperfect use of the limbs 
about the fifteenth. After five years he still walked 
with crutches.” 

This case, which is not entirely exceptional, is an illus- 
tration of the favorable results which follow primary 
union and the avoidance of suppuration, While there is 
a lack of absolute proof that the cord was even partially 
severed, there is a strong probability, almost amounting 
to a certainty, that this was the case. 

The results of laying open the spinal canal, where septic 
infection occurs, are in startling contrast to the above. 

Acute purulent inflammation of the cord and mem- 
branes, well deserving the name foudroyant which has 
been applied to it, soon terminates the life of the pa- 
tient. 

‘Chills, followed by pyrexia and general hypereesthesia, 
with paralysis below the point of injury, usher in the 
attack. Tetanic spasms of the muscles occur, as in cases 
of cerebro-spinal meningitis, Delirium, coma, and death 
very shortly follow. Post-mortem examination reveals 
extensive inflammation of the meninges over the whole 
cord and base of the brain. 

Gunshot wounds of the spinal cord are not essentially 
different from wounds received in other ways. They 
are seldom uncomplicated by wounds or fractures of the 
vertebree. 

The treatment of wounds of the cord should be con- 
servative, so far as circumstances allow ; 7.e., the wound 
should be as little explored and disturbed as possible, 
save for disinfection in certain cases. 

; 


Primary closure should be sought by every means pos- 
sible. It is not to be forgotten that bullet wounds are 
often favorably inclined toward healiny even when the 
bullet is not extracted, and that, rather than disturb the 
newly formed coagula which seal such a wound, it is 
safer, in some locations, to leave the bullet. It is gener- 
ally safe to do this, since, from their form and unirritat- 
ing properties, leaden bullets are now known to be among 
the least objectionable of foreign bodies. The general 
principles of the treatment of wounds of the cord are 
the same as those to be followed,in cases of simple in- 
jury. Hdmund Andrews, 


SPINAL CORD DISEASES: LATERAL SCLEROSIS. 
(2) PRIMARY LATERAL SCLEROSIS.—Synonyms: Spastic 
spinal paralysis ; tabes dorsal spasmodique. 

Definition.—The disease is characterized by a gradu- 
ally progressing paralysis, which begins in the lower ex- 
tremities, is accompanied by greatly exaggerated tendon 
reflexes, muscular rigidity and contractures, and is not 
attended by sensory, trophic,.or visceral symptoms. The 
anatomical basis is supposed to be a primary sclerosis of 
the antero-lateral columns. 

Hiiology.—We know very little of the causes of the 
disease. It occurs chiefly in adults, more frequently in 
men than in women. Exposure, excessive venery, etc., 
have been assigned as causes in individual cases. Some 
cases occurring near Rome, several of which were in one 
family, seemed to be due to the effects of a leguminous 
article of diet, lathyrus cicera. 

Symptoms.—The disease begins with weakness in one 
or both lower extremities. There is an undue sense of 
fatigue on exertion, and an objective examination shows 
a slight paresis. There is at the same time some diffi- 
culty in walking, this being, at first, most noticeable on 
rising in the morning. As the paresis increases, motor 
irritation symptoms are soon manifested. These are at 
first slight clonic or tonic spasms of the affected muscles. 
They are most likely to occur when the patient is fa- 
tigued, are easily evoked by active or passive movements 
of the limbs, but often come on in the middle of the 
night. The tendency to muscular spasm—brought on by 
either a voluntary or a passive movement, or in a reflex 
way—increases to such an extent that complete muscu- 
lar rigidity and contractures of the limbs occur. This 
condition antagonizes every action of the patient, makes 
his voluntary efforts altogether futile, and, therefore, 
causes the paralysis to appear more complete than it 
really is. The rigidity can usually be overcome, in early 
periods, by slow persistent pressure, but when it becomes 
excessive it resists powerful efforts. The usual position 
of the rigidly contracted limbs is that of extension at 
the knees, the feet in the equino-varus position, and the 
thighs firmly pressing against one another. Their im- 
mobility is often interrupted by clonic spasms, and oc- 
casionally the limb is drawn for a short time into 
another position. 

A striking, and usually an early, symptom is the exag- 
geration of the deep reflexes. The patellar tendon reflex 
is greatly exaggerated; muscular contractions can be 
elicited by striking any of the tendons—the inner or outer 
hamstrings, etc., where tendon reflexes cannot be elic- 
ited, as a rule, in health—and even tapping over the peri- 
osteum will produce like manifestations. But the most 
striking of these phenomena is the ankle clonus, rapid 
and rhythmical clonic contractions taking place when the 
foot is sharply flexed, and continuing as long as the foot 
is held in a flexed position. When the reflexes are much 
exaggerated the clonic contractions, on evoking the ankle 
clonus, may not be limited to the ankle, but may extend 
to all the muscles of the extremity. The ankle clonus 
also becomes a disturbing element in walking, as every 
time the body rests on the toes in progressing forward 
there is a tendency to its production. 

The gait is very characteristic. As the legs are weak 
and stiff the feet cannot be freely lifted, and, when mov- 
ing forward, sweep the floor, making an almost charac- 
teristic scraping sound. At the same time, in order that 
the foot can be brought forward, it makes a wide out- 


563 


Spinal Cord. 
Spinal Cord. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


ward sweep. The gait is sometimes further impaired by 
clonic spasms of the muscles—those representing the foot 
clonus, as just described—which may cause a temporary 
halt in walking, or may make that act altogether impos- 
sible. Walking is more difficult on an up or down grade, 
and on an uneven surface, than on the level and on an 
even surface. It usually becomes easier after the patient 
has walked for a while. 

The disease slowly extends upward, involving the mus- 
cles of the abdomen, back, and upper extremities. The 
latter are usually affected to a less degree than the lower 
extremities, though exaggerated reflexes and muscular 
tension are associated with the-paresis. They may even 
be rigidly contracted. In that case the position is usu- 
ally one of slight flexion and pronation of the forearm, 
and strong flexion of the wrists and fingers, the arm be- 
ing pressed firmly against the body. 

In typical cases there are no further symptoms on the 
part of the nervous system. The sensibility is intact, 
the functions of the bladder and rectum normal, there 
are no trophic changes in muscles or skin, and no special 
changes in the electrical reactions. 

The symptoms do not always appear in the order just 
given. In rare instances the disease attacks the upper 
extremities before the lower, or occurs first in hemiplegic 
form, the arm being affected on the same side as the leg 


before the second lower extremity is involved. The 
progress of the disease is usually very slow. Though 


the patient be altogether bedridden, and without power 
of motion, the general health need not suffer. Unless 
there be some complication he may live to old age. 

Morbid Anatomy and Physiology.—Symptoms like those 
of spastic paralysis had been observed with various dis- 
eases, but Erb was the first to describe this as a separate 
and distinct disease, whose basis he believed to be a pri- 
mary sclerosis of the antero-lateral columns, especially 
the pyramidal tracts. His views have been pretty gen- 
erally accepted, but yet, it must be acknowledged, there* 
has not been much positive evidence to substantiate 
them. In a number of post-mortem examinations, where 
this disease was diagnosed during life, lesions in the 
brain, tumors in the medulla oblongata, diffused scle- 
roses, etc., were found. In only a few instances did the 
disease appear to be a primary sclerosis of the lateral 
columns. But it is probable, whether or not a primary 
disease be usually found, that the pathological changes 
in the lateral columns produce the symptoms of this dis- 
ease, for when spastic symptoms are found with multiple 
sclerosis, diffuse myelitis, etc., the lateral columns are 
found to be affected. 

The paresis or paralysis is explained by the destruction 
of nerve-fibres in the pyramidal tracts, the tracts convey- 
ing voluntary motor impulses. The motor irritation 
symptoms cannot be so satisfactorily explained. Charcot 
believes them to be due to dynamic changes in the large 
ganglion cells, these being placed in a state of irritation 
by the degenerated nerve-fibres of the pyramidal tracts, 
which terminate in them. Hughlings Jackson supposes 
that the influence of inhibiting centres in the brain is re- 
moved by the destruction of the pyramidal tracts, and 
thence arise the excessive motor manifestations. 

Diagnosis,—The symptoms of spastic paralysis may 
appear with multiple sclerosis, transverse or diffuse mye- 
litis, or brain lesions. In these cases we must look for 
the further symptoms of these various diseases, indications 
of involvement of the gray matter and posterior columns 
in transverse myelitis, optic atrophy, nystagmus, inten- 
tion tremor in multiple sclerosis, etc. In cases of mul- 
tiple sclerosis there may for a long time be no other 
symptoms than those of spastic paralysis, in which case 
a correct diagnosis would be impossible. 

Quite a number of cases have been reported in which 
there was apparently primary sclerosis in various strands 
of the spinal cord, termed combined systematic disease. 
In these, symptoms like those of lateral sclerosis were 
often found, but there were usually additional manifes- 
tations, symptoms on the part of the bladder, ete. 

Yet it is quite probable that, in case of primary disease 
in the lateral columns, there might, with the lapse of 


564 


Sy 


time, be extension by contiguity of surface, and thereby 
the number of symptoms as well as the extent of disease 
be increased. 

At present we can only make a diagnosis of spastic 
spinal paralysis. We cannot be certain, during life, that 
the disease in the lateral columns is primary, nor that it 
is altogether limited to that part of the cord. 

Prognosis.— When uncomplicated the disease does not 
appear to shorten life. It is sometimes capable of im- 
provement, and even cures have been reported. 

Treatment.—The treatment applicable in these cases is 
that usually adopted in locomotor ataxia and other forms 
of chronic myelitis. Rest in bed for a number of weeks, 
especially when there seems to be an exacerbation of 
the disease, may produce amelioration of the symptoms. 
Hydrotherapy in its various forms, sponge-baths, wet 
packing, cold, and in some instances hot, baths, deserves 
trial. Electricity is the therapeutic agent in most com- 
mon use, and, perhaps, of greatest power. Both the 
galvanic and faradic currents may be tried, and applied 
to the paralyzed muscles as well as over the spine. 
Probably most can be hoped from the central application 
of the constant current. 

Various drugs have been administered. Probably the 
greatest reliance has been placed upon nitrate of silver, 
and, especially when there has been an antecedent syph- 
ilitic history, iodide of potash. 

(0) AmMyoTropHIC LATERAL SCLEROsISs.—For both the 
description of the symptoms and knowledge of the anatom- 
ical character of this disease, we are chiefly indebted to 
Charcot. Though somewhat akin to the disease just de- 
scribed, it presents striking differences both in its symp- 
tomatology and morbid anatomy. It occurs chiefly in 
persons of middle age, but has been observed in chil- 
dren. 

Symptoms.—The disease usually begins with paralysis 
of the upper extremities, which is soon accompanied by 
atrophy and fibrillary contractions of the paralyzed mus- 
cles. Subsequently muscular rigidity and contractures 
occur, the arms assuming the position found in spastic 
paralysis, partly flexed at the elbows and -pressed against 
the body, forearms pronated, hands and fingers strongly 
flexed. These contractures may remain even when the 
muscles are almost completely atrophied. Usually, after 
the lapse of a number of months the lower extremities 
become involved. In them the manifestations are mostly 
like those of spastic paralysis—paralysis, exaggerated 
tendon reflexes, muscular rigidity, contractures—while 
little or no atrophy of the muscles is observed. The elec- 
trical reactions are altered according to the degree of mus- 
cular atrophy. In the lower extremities there may be a 
mere quantitative change, diminution of electrical irri- 
tability, while in the upper extremities the alteration is 
usually more marked, and, when the muscular atrophy 
is rapid, as often occurs in the small muscles of the hand, 
typical reaction of degeneration may be found. 

Ata still later period bulbar symptoms, those of glosso- 
labio-laryngeal paralysis—atrophy of the lips and tongue, 
difficulty in deglutition, indistinct speech, respiratory 
disturbances—appear, and finally carry off the patient. 

The symptoms do not always appear in the order de- 
scribed. Sometimes the disease begins in the lower ex- 
tremities, extending thence to the upper, and finally to 
the cranial nerves. Sometimes the disease begins as a bul- 
bar paralysis, though it need not, therefore, run a rapid 
course. 

The degree to which spastic symptoms, and to which 
muscular atrophy appear in both upper and lower ex- 
tremities is also quite variable, depending upon the part 
of the nervous system in which the morbid changes be- 
gan, and upon the extent to which the gray and white 
nervous tissues are respectively affected. 

The duration of the disease is usually from one to three 
years. The well-marked cases hitherto recorded termi- 
nated fatally. Death is generally caused by the bulbar 
symptoms. 

Morbid Anatomy and Physiology.—The morbid changes 
are almost, if not altogether, limited to the motor central 
and peripheral nervous apparatus, There is sclerosis— 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Spinal Cord. 
Spinal Cord, 


atrophy of the nerve-fibres and increase of the connective 
tissue—of the direct and crossed pyramidal tracts in the 
cord, often extending above the crossing of the pyramids 
in the medulla, and in two cases of Charcot and one of 
Koshewnikow, the morbid changes could be followed to 
the cortical motor area in the upper half of the central 
convolution. There is atrophy of the large ganglion 
cells of the anterior cornua, and of the cells of the nuclei 
of the affected cranial nerves. Certain of the cranial 
nerves, of the anterior roots of the spinal nerves, of the 
mixed nerves, and of the muscles, are also found in vari- 
ous stages of atrophy. 

As to the explanation of the symptoms, the muscular 
atrophy is due to the atrophy of the large ganglion cells, 
the bulbar symptoms to disease of the nuclei of the cra- 
nial nerves, the spastic phenomena to sclerosis of the py- 
ramidal tracts. The preponderance of spastic or atrophic 
manifestations is due to preponderance of the morbid 
process in the white or gray matter, respectively. 

Diagnosis.—The diagnosis must be based on the order 
of appearance of the symptoms, but chiefly upon the 
combination of spastic and atrophic phenomena. An 
early diagnosis is often impossible—for instance, to dis- 
tinguish the disease, when it begins with bulbar symp- 
toms, from ordinary glosso-labio-laryngeal paralysis. But 
some pathologists have considered these and some other 
chronic affections as really the same process, only in va- 
rying degrees of development. 

The prognosis is sufficiently indicated in the foregoing 
description. Such treatment may be resorted to as is 
employed in other chronic diseases of the cord. 

Philip Zenner. 


SPINAL CORD DISEASES: MENINGEAL H/EMOR- 
RHAGE. Derrnirrion.—Spinal Meningeal Hemorrhage, 
Hematorrhachis, Spinal Meningeal Apoplexy, is a hem- 
orrhage into the spinal canal in, between, or about the 
membranes of the spinal cord. As an uncomplicated 
affection it is of rare occurrence, but in cases of trauma- 
tism it is often associated with injuries of the cord it- 
self, 

VARIETIES.—The hemorrhage in spinal meningeal 
apoplexy may be either extra-dural, 7.e., outside of the 
dura mater, in the loose connective tissue between that 
‘membrane and the bony walls of the canal, or sub-dural. 
In the latter, the haemorrhage may be inter-arachnoideal, 
between the layers of the arachnoid, as formerly believed, 
or sub-arachnoideal, in the connective tissue between the 
arachnoid and pia mater, on the surface, or in the 
meshes of the pia mater, or on the surface of the cord it- 
self. 

PatTHoLocicAL ANATOMY. —In extra-dural heemor- 
rhage the blood is effused on the outer surface of the 
dura mater and in the loose connective tissue outside of 
that membrane. The effused blood, unless excessive in 
amount, is, as a rule, coagulated, and limited in longi- 
tudinal extent to the length of two or three vertebre ; it 
may surround the whole cord in the form of a ring, or 
be located on the anterior or posterior surface of the 
organ, more often the latter ; it follows, as a rule, the 
nerve-roots arising from the affected region. 

The dura mater and tissues around are stained, ecchy- 
mosed, and covered with clotted blood, to a greater or 
less depth. When there has been any compression of 
the cord or of the nerve-roots, these are found red and 
softened at the injured spot, and bloodless beyond. The 
spinal fluid is dark and turbid. The bloody effusion is 
more often limited to one spot, but it may occur in sev- 
eral places, and it. may be so profuse as to fill up the 
whole spinal canal. This form of meningeal hemor- 
rhage is the most common, comprising about three- 
fourths of the reported cases. 

‘In sub-dural hemorrhage, the inter-arachnoideal of 
some authors, the blood is generally fluid, sometimes, 
however, coagulated, and lies loosely between the dura 
mater and arachnoid. In this form, which is rare, the 
source of the hemorrhage is cranial or from rupture of 
spinal vessels. Hematoma of the spinal dura mater, 
pachymeningitis hamorrhagica, is, of course, not in- 


cluded. Pigmentation and ecchymoses of the meninges, 
with secondary inflammation, form the only pathological 
changes to be observed. 

In the sub-arachnoideal form the blood is diffused and 
coagulated beneath the arachnoid, in the loose connective 
tissue, or between the meshes of the pia mater and on the 
surface of the cord, encircling, either totally or partially, 
that organ. In longitudinal extent, the effused blood is 
limited generally to the length of two or three vertebre, 
and it may be found at two or more places. The mem- 
branes are stained and ecchymotic, and the cord is red- 
dened at. the affected spot, but there is little, if any, com- 
pression ; the spinal fluid is colored. 

The inflammatory signs following spinal meningeal 
hemorrhage are very limited, and consist in thickenings, 
adhesions, and pigmentation of the membranes. 

ErroLtocy.—The causes of simple uncomplicated hem- 
orrhage into the spinal meninges are not very well 
known. The peculiarity of the circulation in the spinal 
canal, in which a number of small vessels anastomose 
very freely, and so diminish the tension of the blood- 
column and equalize the pressure, does not favor its oc- 
currence ; and again, the degeneration of the coats of the 
vessels, which we see playing such an important part as a 
factor in cerebral hemorrhage, does not seem here to ob- 
tain so easily and is never so pronounced. Age does not 
seem to predispose in any way to it, and though the 
greater number of cases are found among men, this does 
not appear to be due to any particular susceptibility, but 
rather to the greater exposure to traumatism of that 
sex. 

Among the exciting causes traumatism is by far the 
most frequent ; to be brief, fractures and dislocations of 
the vertebral column, blows, and falls on the buttocks or 
feet causing concussion of the column, deserve to be spe- 
cially mentioned. Syphilitic caries of the vertebre, and 
the rupture of thoracic or abdominal aneurisms into the 
spinal canal, have been shown to have caused the affec- 
tion in some cases. The rupture of spinal vessels, either 
from degeneration of their coats or from other causes, 
and the gravitation of the blood in cranial hemorrhages, 
have been regarded as etiological factors in several cases. 
The sudden cessation of the menstrual flow, or hemor- 
rhoidal flux, violent bodily exercise, and the rupture of 
vessels in eclampsia, tetanus, and other spasmodic diseases, 
are believed in certain cases to be able to produce the 
affection. Finally, post-mortem examinations have shown 
that spinal meningeal apoplexy does occasionally occur 
in the course of long and protracted diseases, such as 
scurvy, purpura, typhus and typhoid fever, pyzmia, 
yellow fever, hemorrhagic malarial fever, etc. 

SYMPTOMS AND CLINICAL History.—The symptoms 
caused by hemorrhage into the spinal meninges will vary 
according to the locality affected, and the amount of the 
hemorrhage. The onset is, as a rule, sudden, though in 
exceptional cases it may be preceded for a day or two 
by feelings of languor, stiffness of the back and neck, 
and other indefinite symptoms. The most prominent 
symptoms are a sudden tearing pain in the back, at the 
site of the lesion, followed or accompanied by various 
symptoms denoting irritation, both of the motor and 
sensory nerve-roots, and of the spinal meninges. These 
are stiffness of the back, neck, and limbs, increased upon 
motion ; jerking, spasmodic contraction of the muscles, 
neuralgic pains, numbness, formication, and hypereesthe- 
sia of the parts. These irritative symptoms are soon fol- 
lowed by others of paralysis and anesthesia, but these 
are, as arule, never complete. The bladder and rectum 
are little, if at all, affected ; the mind is clear except in 
cases in which the shock is very great. The inflamma- 
tory reaction which follows is generally of short dura- 
tion, seldom lasting more than a day or two, and the 
fever and general symptoms are, on the whole, mild. 

The symptoms are more or less modified, according to 
the segment of the cord affected. When the hemorrhage 
occupies the cervical region, the pain and stiffness, to- 
gether with the hyperesthesia, are more marked, and 
sometimes altogether confined to the upper extremities 
and neck ; the breathing may, or may not, be disturbed, 


565 


Spinal Cord. 
Spinal Cord. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


according as the root of the phrenic nerve is implicated 
or not; interference with the cilio-spinal centre will 
cause flushing of the face and neck, and dilatation of the 
pupils, followed by paleness of the parts and contraction 
of the irides. 

When the lesion is situated inthe dorsal region, the 
stiffness and pain are limited to that region of the back 
and a distinct girdle sensation is complained of ; the 
patellar and other reflexes in the lower extremities are 
increased. 

When the lumbar portion is affected, the symptoms are 
referred to the buttocks, perineum, and genitals, and the 
bladder and rectum are, as a rule, partially paralyzed. 
The tendency of the affection is toward recovery, but 
that may sometimes be protracted. Death is not rare in 
excessive hemorrhages or in complicated cases. 

The following case is selected from several in my note- 
book, and serves to illustrate clearly the affection. 

H. B——, aged thirty-three, a car-driver by occupa- 
tion, drinks and smokes moderately, has never had syph- 
ilis, gives no family history of disease, has been subject 
to bleeding piles for years. About July 1, 1886, he had 
an attack of diarrheea, followed by costiveness, and from 
that time the bleeding from the hemorrhoids ceased. 
On July 3, about 9 P.M., he was sitting on his car, wet 
with perspiration, exposed to a rather cool breeze, when 
he felt a sudden tearing pain inthe back, in the upper lum- 
bar regiom; he tried to get up, but his legs became stiff and 
shaky, and he could not move them ; the affected parts 
were numb; he could not bear to have them touched, 
and he felt as if ants were creeping up his feet. In this 
condition he was taken home on a stretcher, the least 
motion of his back increasing the cramps and spasms in 
his legs, and giving rise to shooting pains. On‘the next 
day he had slight fever, and his other symptoms grew 
worse; he could not move the legs at all, and could not 
bear to have them touched ; there was retention of urine, 
with dribbling ; the bowels were costive. 

The patient was admitted in the ward for nervous dis- 
eases of Charity Hospital on July 7, 1886, when the fol- 
lowing notes of the case were made: General appearance 
good ; pulse, 108; temperature, 994° F.; respiration, 22. 
He complains of great pain, increased upon pressure and 
motion, over the lower dorsal and first lumbar vertebre, 
and of a girdle-feeling around the abdomen at about the 
level of the anterior-superior iliac spine; the lower ex- 
tremities are well nourished, but almost completely para- 
lyzed ; the muscles are flaccid, the bladder is unable to re- 
tain urine for any length of time, but the patient has time 
to call for assistance, and so keeps from wetting his bed ; 
the bowels are costive ; sensation, both general and tac- 
tile, in the affected part is very much lessened, and feel- 
ings of formication and numbness still persist. The pa- 
tellar tendon reflexes are greatly diminished, scarcely 
perceptible. The mind is clear, and the upper extremi- 
ties are normal. He was put on a mixture of five grains 
of iodide of potassium and thirty drops of the fluid extract 
of ergot every three hours ; small doses of morphine, with 
large doses of bromide of potassium, were given two or 
three times during the night to relieve the pain in the 
back and the crampy feelings which, he said, were always 
worse at that time ; counter-irritation by means of tinct- 
ure of iodine was made along the vertebral column 
every other day. 

On August 29th the pain in the back and the muscular 
spasms had greatly subsided ; the patient could lie on his 
back and permitted himself to be moved; he had some 
power in the lower extremities, but could not lift his feet 
from the bed; the anesthesia still persisted, though 
somewhat ameliorated; the formication and numbness 
were lessened; the bladder and rectum were normal. 
Electrical examination made at this time showed lessened 
galvanic and faradic irritability. Counter-irritation was 
then stopped and mild galvanic currents to the spine 
were begun, and the faradic current was applied to the 
affected extremities. Iodide of potassium was continued 
in ten-grain doses three times a day. In the latter part 
of September the patient was able to stand on his legs, 
the feeling in those parts slowly returning ; formication 


566 


had disappeared, and, aside from a slight numbness, the 
parts felt well. 

From that time the patient slowly improved until De- 
cember 18, 1886, when he was discharged as cured. 

Draqgnosis.—The suddenness of the attack, the acute- 
ness of the pain, the symptoms of irritation first, soon 
followed by mild symptoms of paralysis, the moderation 
of general symptoms and the rapid subsidence of the 
same, and the tendency to improvement and recovery, 
make simple uncomplicated cases of spinal meningeal 
hemorrhage in most instances easy of diagnosis. The 
affections with which it is most likely to be confounded 
are the following : Spinal meningeal congestion, medul- 
lary hemorrhage, spinal meningitis, myelitis, and simple 
concussion. In hyperemia of the spinal meninges the 
symptoms come on gradually and are not constant, re- 
missions occurring at different periods of the twenty- 
four hours. 

In medullary hemorrhage (spinal apoplexy) the symp- 
toms of paralysis and aneesthesia are sudden and com- 
plete, and the tendency to spasms is altogether absent. 
Death is rapid, or incurable paralysis is the result. 

Meningitis and myelitis can generally be recognized by 
their slower evolution, by the high fever, and by the 
general symptoms. 

In simple concussion spasm is generally wanting, and 
the symptoms of paralysis come on early. 

Proenosis.—The prognosis depends on the amount 
of hemorrhage and on the seat of the lesion. When the 
hemorrhage is small, the causal injury slight, the 
inflammatory and reactive symptoms mild, the paralysis 
not too extensive and profound, and the patient young, 
the prognosis, as arule, is favorable. But when, on the 
contrary, the shock is great and the hemorrhage profuse, 
when the cervical region is implicated, the paralysis 
profound, and the fever and general symptoms severe, the 
prognosis is correspondingly bad. The affection, how- 
ever, lasts for several months, even in the most favorable 
cases, 

TREATMENT.— The treatment should at first be directed 
to the limiting of the hemorrhage and the diminution of 
the reactive symptoms. For the first purpose, absolute 
rest in bed, on the side or on the abdomen, the internal 
and hypodermic administration of ergot in half-drachm 
or drachm doses every hour or two, or of ergotine in 
large doses, tincture of belladonna to the full physiologi- 
cal limit, cold applications to the back by means of ice- 
bags or otherwise, the local abstraction of blood by means 
of cupping, leeches to the back of the ear or to the anus, 
and, in plethoric subjects venesection, hot applications 
to the extremities, and repeated drastic purges, are to be 
recommended. To meet the second indication, cooling 
drinks and mild antipyretics are of service. Later on, 
the reabsorption of the effused blood should be facilitated, 
and the anesthesia and paralysis properly treated by 
means of counter-irritation to the spine by iodine, blister- 
ing, or dry cupping ; by the internal administration of 
the iodide of potassium in large doses, massage, passive 
exercise, the use of electricity, both galvanic and fa- 
radic, and the administration of small doses of mercury 
and general tonics. 

If pain be present, narcotics are naturally indicated ; 
to relieve spasms, the bromides and chloral hydrate are 
of great value. 

Much can be done to prevent the affection by proper 
treatment of suspended menstrual and hemorrhoidal dis- 
charges, and by relieving hyperemia of the cord. 


AUTHORITIES CONSULTED. 


Radcliffe, C. B., in Reynolds’s System of Medicine, vol. i. 

Ollivier : Maladies dela Moélle épiniére. 

Ross: Diseases of the Nervous System, vol. ii. 

Rosenthal: Diseases of the Nervous System, 

Charcot: Lecons sur les Maladies du Systeme nerveux, 

Bramwell, Byrom: Diseases of the Spinal Cord. 

Grasset, J.: Maladies du Systeme nerveux, 3d edition. 

Haase, K. E.: Krankheiten des Nervensystems (being vol. iv., part i., of 
Virchow’s Handbuch der speciellen Pathologie und Therapie). 

Erb: Article in Ziemssen’s Cyclopzedia of Medicine, vol, iii. 


P. HE. Archinard. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Spinal Cord. 
Spinal Cord, 


SPINAL CORD DISEASES: MULTIPLE (CEREBRO- 
SPINAL) SCLEROSIS. Synonyms: Disseminated scle- 
rosis ; insular sclerosis. 

DEFINITION.—This disease may present manifold symp- 
toms, the most common of which are paresis, with mus- 
cular rigidity and exaggerated tendon reflexes as in 
spastic paralysis, tremor brought on by voluntary move- 
ments, nystagmus, scanning speech, amblyopia, apoplec- 
tiform attacks, and impaired intellect. The anatomi- 
cal basis of the disease consists of disseminated patches 
of sclerosed tissue in various parts of the central and 
peripheral nervous systems. 

Errotocy.—An hereditary influence has been traced 
in a few instances. Charcot states that the disease occurs 
most frequently in females, but a number of other ob- 
servers do not concur with him in this view. It occurs 
most frequently between the ages of fifteen and thirty ; 
occasionally in young children; rarely, if at all, after 
forty. 

Traumatic influences, such as blows on the head, con- 
cussion of the whole body, exposure, hardship, over- 
work, and profound emotional disturbance, may all be 
mentioned as occasional exciting causes. In a number of 
instances the disease developed after the existence of an 
acute disease, typhoid fever, variola, etc. 

Symproms.—The areas of diseased tissue may involve 
any part of the nervous system and may occur in any 
number, while the disease may be of various degrees of 
severity ; and the symptoms, which are but the expres- 
sion of the locality and intensity of the disease, may 
make the most varied clinical pictures. There may be 
an entire absence of symptoms of disease of the nervous 
system, though sclerosed nodules are found post mor- 
tem ; or the disease may simulate various different or- 
ganic or functional nervous diseases. But, nevertheless, 
the sclerosis seems to have a predilection for certain 
parts of the nervous system, and we find, accordingly, 
in many cases similar, and almost characteristic, clinical 
appearances. 

A cerebral and a spinal form of multiple sclerosis are 
sometimes spoken of, but usually both brain and cord 
become involved in the disease, though it may have been 
present in the one some time before it was in the other. 
Generally the spinal cord is first affected. 

The disease usually begins very insidiously and is 
slow in its progress ; in rare instances it has an abrupt 
beginning, perhaps is ushered in by an apoplectiform at- 
tack. The earliest symptoms may be of cerebral origin, 
such as headache, vertigo, ataxic gait, and slight psychic 

-disturbances ; or there may be a slight tremor in one or 
both hands ; but more frequently the symptoms are those 
of spastic paralysis. 

At first there is weakness of one leg, then of both, at- 
tended by some difficulty in walking. Gradually, with 
increasing paresis of the limbs, there appear muscular 
rigidity, especially brought on by active or passive move- 
ments, exaggerated tendon reflexes, spastic gait, and, 
finally, rigid contractures of the limbs. The paresis, and, 
to a less extent, muscular rigidity, etc., at a later period 
affect the upper extremities, and to these is subsequently 
added another motor symptom—one of the most promi- 
nent and characteristic of this disease—the so-called in- 
tention tremor, tremor during the performance of a vol- 
untary act. Before it is otherwise noticeable, it may be 
observed inthe handwriting or other delicate movements 
of the fingers, especially if the act is slowly performed. 
The writing, if carefully observed, will be seen to be full 
of small indentations which occur with great regularity, 
indicating that the tremor is rhythmical. When the 
tremor is well marked any voluntary movement will 
cause it to appear, and it may be seen to some extent 
during rest. A common method of eliciting the symptom 
is to ask the patient to put a glass of water to his lips. 
The tremor increases and the oscillations of the hand are 
greater as the latter approaches the mouth. The trem- 
bling may become so violent that the water is thrown out 
of the glass and the effort proves futile. When the pa- 
tient is sitting quietly either there is no tremor, or slight 
movements of the head and trunk may be observed. If 


“mon symptom, and of value in diagnosis. 


he now perform a voluntary act, as lifting an arm, the 
tremor in the head and trunk increases at the’ same time 
that there is tremor of the acting member. When he at- 
tempts to walk there may be such violent tremor of the 
limbs and trunk as to make walking, or even standing, 
almost impossible. On the other hand, when the patient 
lies down and every part is well supported no tremor 
appears. None is observed during sleep. It is increased 
by emotional excitement. 

All the voluntary muscles may be thus affected, the 
head as well as the trunk and limbs. Tremor in the 
face is less commonly seen, though there may be irregu- 
lar movements, choreic in character, 

The distinctive features of the tremor are that it is 
rhythmical, and that it occurs only with muscular efforts. 
A very few cases have been reported where it continued 
even in rest, but such cases are exceedingly rare. The 
tremor is not found in all cases. It probably depends on 
the locality of the disease. It also disappears in any part 
when the latter has become completely paralyzed. 

The tremor can usually be easily distinguished from 
that of other diseases. In paralysis agitans, in the begin- 
ning (and it is only then that the two diseases could eas- 
ily be confounded), only a few fingers are affected, and 
the oscillations are fine and very rapid. At the same 
time the tremor has somewhat the character of co-ordi- 
nated movements. Thus the movement of the thumb 
upon the fingers has been likened to that of counting 
money, rolling pills, etc. The tremor of multiple scle- 
rosis is large and coarse, with no appearance of ¢o-ordi- 
nated action. In paralysis agitans, furthermore, the 
tremor is, to some extent, controlled by voluntary move- 
ment, and increases with rest, and the head is very rarely 
affected. When the tremor is violent it may have the 
appearance of the movements of chorea. But the latter 
occur during repose as well as during volitional acts, and 
they cause an intended movement to be made very irreg- 
ularly ; on the other hand, in multiple sclerosis the gen- 
eral direction of any movement is maintained, but the 
line of movement is an undulating one, the undulations 
playing equally up and down along the central line of 
direction. 

The next two symptoms seem to be similar in charac- 
ter to the tremor. The first is nystagmus, a very com- 
When not 
otherwise noticeable, it may be made manifest by move- 
ments of the eyes, strong convergence, or forced move- 
ments in some direction. The other symptom is scan- 
ning speech. Other changes of speech are sometimes 
present, but this is the most common and most char- 
acteristic, and, therefore, of high diagnostic value. The 
speech is slow and dragging, each syllable being pro- 
nounced separately as in the slow scanning of verse, 
and, therefore, termed scanning speech. If the patient 
attempts to speak more rapidly, his words are likely to be 
so jumbled together as not to be at all understood. The 
voice is monotonous to the highest degree. There is 
often tremor of the lips at the same time, and, on laryn- 
goscopic examination, there has been found to be dimin- 
ished tension of the vocal cords. 

Other ocular symptoms besides nystagmus are fre- 
quently found. Double vision, due to paralysis of some 
of the external muscles of the eye, occurs, just as in loco- 
motor ataxia, either as a transient symptom at an early 
period of the disease, or as a permanent condition at a 
later stage. Amblyopia is also a common symptom. 
Generally there is only impaired vision, not complete 
blindness. The ophthalmoscope reveals, in these cases, 
a discoloration of the disks, due to a degree of atrophy of 
the optic nerves. 

Headache and vertigo are often present, both in the 
early and in the later stages of the disease. The vertigo 
often occurs in paroxysms. Occasionally it is due to the 
double vision, but more frequently it is quite independent 
of the latter condition. 

The mental symptoms often play an important réle. 
Slight psychic symptoms may be manifested in the begin- 
ning of the disease if the latter first affects the brain, but 
the graver symptoms are, usually, late manifestations 


567 


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Spinal Cord. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Change in .disposition, irritability, loss of self-control, a 
tendency to laughing and crying, are common conditions. 
A certain impairment of intellect—weakened memory, 
a degree of apathy, etc.—is, also, not uncommon. Buta 
high degree of dementia is rare. It is only likely to oc- 
cur when the disease begins at an early age and there is 
arrested development of the brain, or when the patholog- 
ical process is very acute. Different forms of insanity 
are sometimes observed, most frequently melancholia, oc- 
casionally delusional insanity. 

Apoplectiform seizures, like those seen in general 
paralysis, are important symptoms. ‘They occur, accord- 
ing to Charcot, in one-fifth of all cases. After slight 
prodromal symptoms, headaches, etc., coma develops 
within a few hours, the temperature rapidly rises, often 
reaching 104° or 105° F., and at the same time the face is 
flushed and the pulse rapid. Hemiplegia, with flaccidity 
of the paralyzed muscles, is soon observed. Within a day 
or two consciousness returns, the temperature falls, and, 
within a comparatively brief period, the paralysis disap- 
pears. Such attacks may occur every few months, or 
very rarely. They usually leave the patient in a per- 
manently worse condition, thus marking the progress of 
the disease. Sometimes the patient dies in the attack. 
These seizures are very much like those of apoplexy, but 
post-mortem examinations reveal no anatomical basis for 
them. 

In the foregoing have been given the most common 
symptoms of multiple sclerosis, those found in the ma- 
jority of cases. But, on account of the distribution of 
the diseased areas, various other symptoms may be mani- 
fested. Thus the disease may attack the posterior col- 
umns of the cord, and ataxia, pain, aneesthesia, pareesthe- 
sia, etc., will be present; or it may involve the gray 
matter, when atrophy and paralysis of muscles will 
ensue. Or the disease may involve the whole thickness 
of the cord and produce the symptoms of transverse 
myelitis. When the posterior as well as the antero- 
lateral columns are affected, many of the appearances of 
Spastic paralysis are likely to be absent, especially the 
exaggerated tendon reflexes. Symptoms referable to 
the bladder, rectal, and genital functions are also likely 
to appear. If the disease involve the nuclei of the facial, 
hypoglossal, and pneumogastric nerves, the ordinary 
symptoms of labio-glosso-laryngeal paralysis will be 
manifested, and various local cerebral symptoms may 
appear, according to the location of the foci of disease. 

The course of the disease is a very chronic one. Char- 
cot has divided it into three stages—a division applicable 
to those cases which present the common clinical pict- 
ure. 

The first stage is from the beginning of the disease to 
the period of complete disability from paralysis and con- 
tractures of the limbs. This stage may last from two to 
six years or longer. The symptoms are very slow in 
their progress. They begin as spinal or cerebral, but 
both sets of symptoms appear before this. stage is termi- 
nated. There is often an arrest of the symptoms, or even 
improvement, which indefinitely prolongs this stage, and 
may give rise to delusive hopes of complete restoration 
to health. 

The second stage, that of the fully developed disease, 
may last also from two to six years. There seems to be 
little change in the patient during this period, and, 
though entirely helpless, he seems not to suffer in gen- 
eral health. 

The third stage is that of decline. The general health 
is affected, there is loss of appetite, wasting, etc. Cys- 
titis, decubitus, pyzemia, etc., may hasten the end. Or 
the latter may be due to an increase in the bulbar symp- 
toms, or to an apoplectiform attack. More frequently a 
fatal termination is caused by an intercurrent affection— 
pneumonia, typhoid fever, or, above all, phthisis. 

The average length of the disease is from six to eight 
years. In rare cases it terminates in a year or two. Oc- 
casionally it lasts twenty years. 

Morsip ANnAtTomy.—The pathological changes can 
usually be seen by the naked eye. They consist of nu- 
merous patches or nodules of sclerosed tissue scattered 


568 


throughout the nervous system. The nodules vary in 
size from merely microscopical proportions to that of a 
chestnut or larger, are rounded or irregular in shape, and 
may often be seen on the surface as slight prominences 
or depressions, but are found in larger number on mak- 
ing sections of the brain and cord. Their color is mostly 
of a gray or reddish-gray ; they are translucent, and 
have a firm, often cartilaginous, consistence. Many of 
the nodules are of the same color as the surrounding tis- 
sue, and are only distinguished by their consistency. In 
rare instances a few may be softer than the normal] tissue, 
probably indicating recent disease ; most of the nodules, 
on the other hand, doubtless being of very old standing, 
for such cases come to the post-mortem table only after 
the disease has existed a long time. The nodules seem 
to be quite distinctly circumscribed, but the microscope 
reveals that they merge imperceptibly into the healthy 
tissue. They are also quite distinct, as a rule, though 
occasionally they blend into one another. In rare in- 
stances there has been found a diffuse sclerosis in both 
the brain and cord, which, to some extent, has united the 
scattered nodules. On the other hand, secondary degen- 
eration seems rarely, if at all, to develop from the dis- 
seminated disease. : 

The number of nodules found in a single instance may 
be very small, or may run into hundreds. Their distri- 
bution in the cord is very irregular. In some sections 
they may be found in the anterior, in others in the pos- 
terior, columns ; in still others in the gray matter, or they 
may involve all these parts in the same section. Usually 
alarge number of nodules are found in the medulla, pons, 
and crura cerebri. It is very rare that these parts are 
found free from disease. In the hemispheres the walls 
of the ventricles, corpus callosum, and centrum ovale are 
favored seats of the disease. In the latter two localities 
the nodules are often quite large. Usually nodules are 
also found in the large ganglia, while the cortex gener- 
ally escapes. But few nodules are, as a rule, found in 
the cerebellum, and those in the central white matter. 
Similar nodules may be found in the nerves, most fre- 
quently in the optic nerves, but occasionally in the hypo- 
glossal, the nerves of the eye, and the roots of the spinal 
nerves. 

The microscopical appearances are those of interstitial 
myelitis. The nodules are mostly new connective tissue 
composed of very fine wavy fibrille. But in this new 
tissue the axis-cylinders of the nerve-fibres can usually 
be found in large numbers, though their medullary 
sheaths have disappeared. This is especially true of the 
nodules in the spinal cord. 

At the last meeting of the Society of German Natural- 
ists and Physicians, Adamkiewicz expressed the opinion 
that the disease is not interstitial, but develops primarily 
in the nervous tissue, beginning in the medullary sheaths 
of the nerves. He bases his opinion upon results ob- 
tained by a new method of staining the nervous tissue. 
His view is altogether at variance with that formerly 
held, and may be looked upon with doubt, at least until 
further corroboration. 

Morsip Puysrotocy.—Many of the symptoms are | 
easily explained by the lesions found : psychic symptoms 
by disease of the hemispheres, bulbar symptoms by le- 
sions of the medulla, muscular atrophy by lesions in the 
anterior cornua, anesthesia and ataxia by disease of the 
posterior columns, spastic paralysis by disease of the an- 
tero-lateral columns—in some instances cerebral lesions 
may produce the same symptoms—while amblyopia and 
some other symptoms are often due to nodules in the 
nerves themselves. 

The long retention of the axis-cylinders accounts for 
the usual presence of paresis rather than paralysis, for 
the anesthesia being slight, the amblyopia rarely ad- 
vancing to complete blindness, ete. (In locomotor ataxia 
there are also numerous axis-cylinders in the sclerosed 
area, and the symptoms usually point to only a partial 
loss of function.) Charcot attributes the tremor to the 
same condition. He supposes that the axis-cylinders 
continue to carry voluntary impulses, but, because they 
are bared of their medullary sheaths, they carry them 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


in an irregular, jerking manner, and hence the oscilla- 
tions in the voluntary movements. While this must be 
considered a mere theory, we can speak with more posi- 
tiveness of the location of the lesion as a cause of the 
tremor. It seems to be due to nodules in the medulla 
and pons, or, at least, in the basilar portions of the 
brain. In afew cases where the disease was limited to 
the cord no tremor was observed. On the other hand, 
when tremor was observed during life, nodules were al- 
ways found in the medulla and pons; when it was not 
observed, these parts were not affected to any extent. 

With a considerable degree of doubt, we may attribute 
the nystagmus to lesions in the corpora quadrigemina, 
the scanning speech to lesions in the medulla, the ver- 
tigo to lesions in the medulla or cerebellum. <A satisfac- 
tory explanation of the apoplectiform attacks has not yet 
been given. 

Dracnosis.—In some instances a diagnosis is made 
with the greatest ease, in others it is almost impossible. 
The most common clinical picture—paresis of the ex- 
tremities with exaggerated tendon reflexes, intention tre- 
mor, nystagmus, scanning speech, amblyopia, etc.—is so 
characteristic that it cannot be mistaken.* But some of 
the most characteristic symptoms may be wanting, and 
then the diagnosis is much more difficult. In this case 
the indications of multiplicity of lesions, and the very 
chronic course of the malady, must be the guides to di- 
agnosis. When the disease is limited to the spinal cord 
one can scarcely do more than guess in distinguishing it 
from other forms of myelitis. In such cases one must 
be on the lookout for cerebral symptoms. Optic atrophy 
is often a valuable diagnostic symptom, not only in this 
instance, but in excluding hysteria or other functional 
diseases which may simulate multiple sclerosis. 

When the sclerosis affects only the brain it may pre- 
sent some of the appearances of braintumor. Here, too, 
the indications of a multiple lesion, and the very slow 
course of the disease, may clear up the diagnosis. But 
there is another important distinction, in that brain tu- 
mors produce to a large extent general symptoms, those 
of intracranial pressure, such as severe headache, con- 
vulsions, and double optic neuritis; while sclerosis pro- 
duces merely local symptoms, those indicating the loss of 
function of the part affected by the disease. 

The tremor of alcohol, lead, and mercurial poisoning 
might be mistaken for this disease, but concomitant 
symptoms and the history of a cause will establish the 
diagnosis. The tremor of paralysis agitans, with which 
this disease was formerly confounded, is easily distin- 
guished by the appearance of the tremor, its being con- 
trolled to some extent by voluntary effort and increased 
during rest, and its very rarely affecting the muscles of 
the head and neck. Furthermore, paralysis agitans is 
rarely found in persons under forty years of age, while 
multiple sclerosis rarely occurs after thirty, and, apart 
from the tremor, the symptoms of the two diseases are 
quite different. 

Proaenosis.—Charcot believes that the disease may 
sometimes be cured, but the opposite view is generally 
entertained, though its arrest, and even improvement, for 
a number of years has been observed. It usually runs a 
very protracted course. When at its inception it mani- 
fests itself in various parts of the nervous system at the 
same time, it is likely to run a more rapid course. The 
occurrence of apoplectiform seizures, cystitis, bulbar 
symptoms, etc., hastens the fatal termination. 

TREATMENT.—The same treatment is applicable as in 
other forms of chronic myelitis, for which see Lateral 
Sclerosis. Philip Zenner. 


SPINAL CORD DISEASES: PROGRESSIVE MUS- 
CULAR ATROPHIES. With our increasing knowledge 
of progressive muscular atrophies the subject is con- 


* Schuler reported a case of tumor of the right hemisphere, in the 
neighborhood of the island of Reil, which produced the typical clinical 
picture of multiple sclerosis, and Westphal reported two cases with simi- 
Jar histories, in which no pathological changes were found post mortem. 
But these are such rare occurrences as not to materially impair the diag- 
nostic value of this clinical picture. 


Spinal Cord. 
Spinal Cord. 


stantly acquiring greater and greater complexity. What 
was apparently a single, homogeneous condition, has re- 
solved itself, on closer investigation, into a number of 
apparently distinct affections. 

The disease commonly known as progressive muscular 
atrophy was first described in 1850 by Duchenne and 
Aran, who regarded it as an independent affection of the 
muscles. In 1853 Cruveilhier obtained an autopsy on a 
case of this disease, and was led by what he there found 
to regard it as the result of atrophy of the anterior roots 
of the spinal nerves. In 1860 Luys first discovered an 
atrophic condition of the ganglion cells in the anterior 
horns of the gray matter of the cord, corresponding to 
the atrophied nerve-roots, and since that time the myelo- 
pathic (spinal) theory of the disease has been the prevail- 
ing one. In the past few years, however, the pendulum 
has swung in the opposite direction, and there is now a 
strong tendency to the adoption of Friedreich’s theory, 
that all these forms of muscular atrophy are myopathic 
in origin, and that spinal lesions, when present, are sec- 
ondary to changes in the muscles. 

A comprehensive view of the subject can be obtained 
by adopting Seppili’s classification. He divides pro- 
gressive muscular atrophies (amyotrophies) into the fol- 
lowing classes : 

A. Neuwropathic.—1. Peripheral (toxic, infectious). 2. 
Central (myelopathies). a. Progressive muscular atro- 
phy. 0. Amyotrophic lateral sclerosis. c¢. Deuteropathic 
spinal amyotrophies (from extension of disease to the an- 
terior horns). 

B. Myopathic. — Progressive muscular dystrophy, or 
progressive primary atrophy. a. Infantile progressive 
muscular atrophy. 0. Erb’s juvenile form of muscular 
atrophy. ¢. Muscular pseudo-hypertrophy. d. Leyden’s 
hereditary muscular atrophy. e. Transitional forms. 

In the following paper we shall adopt this classifica- 
tion, with slight modifications. 

_ For the sake of convenience we will begin with the 
consideration of progressive muscular atrophy of spinal 
origin. 

SPINAL PROGRESSIVE MuscuLar ATROPHY. Etdology. 
—This affection, when uncomplicated, occurs in males 
in the large majority of cases. It is proportionately 
more frequent in the female sex when it is associated, as 
so often happens, with bulbar paralysis. Among 16 un- 
complicated cases of which the writer has kept notes, all 
except one occurred in men. Among 214 cases collated 
by Friedreich and Eulenberg, 167 occurred in males, 47 
in females. This great disproportion between the sexes 
is, perhaps, owing to the fact that males are more ex- 
posed to the exciting causes of the disease. 

The disease begins most frequently between the ages 
of thirty and fifty years. Of the writer’s 16 cases 3 be- 
gan before the age of thirty years, 12 between thirty and 
fifty years, and 1 patient was nearly sixty years of age. 

A great many cases have been reported in which he- 
redity seemed to play an important part in the etiology, 
but the majority of such cases date back to the time 
when the differentiation between this and other forms of 
atrophy was not made very carefully. It is very prob- 
able that the majority, if not all, of these hereditary 
cases really belong to the myopathic class of atrophies. 
Cases seem to be more numerous in families in which 
there is a neuropathic tendency, but even this has been 
rarely observed in the cases under my own observation. 

Among the exciting causes may be mentioned pro- 
longed exposure to damp and cold, mental depression, 
syphilis, infectious diseases, and excessive work. Trau- 
matism sometimes appears to determine the occurrence 
of the disease in the injured part. A few cases have 
been seen in which it followed a concussion of the spine. 

The action of these exciting causes is not very impor- 
tant. They would probably prove inefficient were it not 
for the existence of some predisposing etiological factor 
whose nature is entirely obscure, and in many Cases 
they are probably mere coincidences. 

Symptomatology.—In the majority of cases the disease 
begins in the small muscles of one hand. The patient 
finds that he is gradually growing less able to execute 


569 


Spinal Cord. 
Spinal Cord. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


voluntary movements with the fingers, and at the same 
time the muscles undergo wasting part passwu with the 
loss of power. Then the paralysis and wasting spread 
to the forearm, usually implicating the flexors and exten- 
sors, and, next, the arm or shoulder of the same side. 
The other arm is then affected in a similar manner, but 
sometimes the disease appears in both arms almost at 
the same time. As the disease progresses the atrophy 
may attack the muscles of the back and lower limbs, the 
former being less severely affected, as a rule, than the 
other parts. The muscles of the face remain intact, ex- 
cept in those cases that are complicated with progressive 
bulbar paralysis. The wasting may be so extreme that 
the affected limbs finally seem to consist merely of skin 
and bone. Fibrillary contractions of the muscles are a 
very constant symptom in the parts affected. A fibre is 
seen to contract quickly, then the contraction subsides, 
and again appears in the same or an adjacent fibre. When 
the disease is widespread these contractions are some- 
times visible over a large part of the body. They may 
be seen in apparently healthy muscles, and then usually 
indicate the impending affection of these muscles. The 
mechanical excitability of the muscles is also-very often 
increased. 

The atrophied muscles present various electrical reac- 
tions. Sometimes there seems to be merely a simple 
diminution of faradic and galvanic excitability. Care- 
ful examination, however, will generally reveal evidences 
of partial or complete degeneration reaction (usually the 
former) even at a very early stage of the disease. The 
attention should be chiefly directed to the rapidity of 
contraction. Onaccount of the intermingling of healthy 
and degenerated fibres in the same muscle, the normal 
contractions of the former may hide the abnormal mode 
of contraction of the latter, but on making the current 
sufficiently weak the slowness of contraction is often 
made evident. AClC isoften stronger than CCIC. 

Cutaneous sensibility remains unaffected during the 
entire course of the disease. At the most the patients 
complain of a sense of numbness in various parts, usually 
the hands, or of a feeling of soreness or slight pain. 
Trophic disturbances in the skin and deeper parts are 
rare. The functions of the bladder and rectum remain 
intact until the end. 

The disease advances slowly, with alternate exacerba- 
tions and remissions, until the patient is reduced to a 
condition of absolute helplessness, and dies from exhaus- 
tion or from some intercurrent disease. The affection 
may last from ten to twenty-five years, or even longer. 


We will now discuss the symptomatology more in de-, 


tail. 

In a few cases the onset of the disease is preceded by 
- slight aching pain in the parts which are subsequently 
the first to be attacked, by a feeling of numbness which 
comes and goes, or by a sensation of coldness. When 
pain, or other sensory prodromal symptoms are promi- 
nent, it is doubtful whether the case should be regarded 
as one of pure progressive muscular atrophy. 

In the majority of cases the disease begins in the small 
muscles of the hands, usually on the right side. The 
thenar eminence is the first to be attacked; its normal 
rotundity disappears ‘and it becomes flattened. At the 
same time, or a little later, the interossei and hypothenar 
muscles are involved, the abductor indicis being espe- 
cially liable to suffer. Unless the patient is obese, de- 
pressions then become noticeable in the interosseous 
spaces. The function of all these muscles is impaired 
part passu with the wasting. The interossei adduct and 
abduct the fingers, and, at the same time, flex the first 
phalanx on the metacarpus, and extend the second and 
third phalanges. Hence paralysis of these muscles is 
followed by inability to adduct and abduct the fingers, 
and leaves the action of the long extensor and flexors of 
the fingers unopposed. This may result finally in the 
so-called ‘‘ main en griffe,” the first phalanges being hy- 
perextended, the second and third phalanges strongly 
flexed. The resemblance to the claw-hand is increased 
still further when the lumbricales are attacked, as they 
usually are at a very early period. As a result of the 


570 


wasting of these muscles the palm of the hand becomes 
hollowed out. The lumbricales simply aid the interossei 
in their action of flexion and extension, so that their 
paralysis increases the extension of the first phalanges, 
and flexion of the second and third phalanges. 

From the hand the atrophy usually spreads to the 
forearm. In some cases the muscles seem to be attacked 
quite uniformly, so that the forearm atrophies as a whole. 
As a general thing, however, the extensors are first in- 
volved, the supinator longus usually escaping until the 
flexors or biceps are attacked, or even until a later period. 
From the forearm the atrophy extends commonly to the 
arm, to the biceps and brachialis anticus, while the triceps 
often remains comparatively intact for along time. The 
various movements of the parts are enfeebled, according 
to the degree of the muscular wasting, but the power of 
flexion of the forearm on the arm is often retained long 
after atrophy of the biceps has taken place. The patient 
then effects this movement by the aid of the supinator 
longus, which is used as a flexor after the arm has been 
pronated. In those cases in which the deltoid remains 
intact the disproportion between the large shoulder and 
the shrivelled arm is very striking. The deltoid is the 
next muscle to be affected, though cases are quite com- 
mon in which this is attacked immediately after, or even 
before, the hand muscles. Here it is very evident that 
the muscle is not attacked as a whole, but that certain 
fibres are picked out here and there by the process, 
which gradually spreads until finally no muscular tissue 
may remain. In some cases the atrophy begins in the 
deltoid, and makes considerable progress in this region 
before it attacks the small muscles of the hand. With 
the advancing affection of the deltoid the power of rais- 
ing the arm from the side is gradually lost ; but, even after 
the muscle is apparently destroyed, the patient is often 
able to move the arm from the chest, to a certain extent, 
by throwing the limb out suddenly, with the aid of the 
pectorals and trapezius, or by sudden movements of the 
trunk. The normal prominence of the shoulder is lost, 
the head of the humerus is felt immediately beneath the 
skin, and the finger can be pressed into the joint cavity. 
The other arm is usually attacked before the disease has 
made very much progress in the arm first involved, and 
the affection runs approximately the same course in both. 

From the deltoids the disease spreads commonly to 
the pectorals, serratus magnus, the scapular muscles, 
latissimus dorsi, and the rhomboids. Asa result of the 
atrophy of these parts the patient loses the power of 
rotating the humerus, raising the arm above the horizon- 
tal, or drawing the shoulders backward. These muscles 
are usually attacked at about the same time on the two 
sides. If the serratus magnus is more markedly atro- 
phied than the other scapular muscles, the attempt to 
raise the arm beyond the horizontal line will be followed 
by marked separation of the scapula from the thorax 
(angel wing), so that sometimes the entire fist may be in- 
serted between the posterior border of the bone and the 
chest-walls. 

The deep muscles of the back and the abdominal mus- 
cles, particularly the former, are the next to be involved. 
The paralysis of the quadratus lumborum and erector 
spinee gives rise to a marked lordosis ; but whether this 
condition alone is responsible for the lordosis, as is gen- 
erally believed, is more than doubtful. In a case at 
present under my observation, in which there is paral- 
ysis of the deep muscles of the back, there is marked 
lordosis in the erect position, the pelvis being tilted for- 
ward at the same time. When the patient sits down, 
the weight of the trunk thus resting on the tubera ischii, 
and tilting the pelvis backward, the spinal column is 
perfectly straight. When this patient bends forward to 
touch the ground while sitting down, the pelvis is tilted 
forward and the glutzi muscles are relaxed. On now 
making the effort to assume the erect position, the pelvis 
is felt to become vertical and the glutzi muscles at the 
same time become firm and contracted. 

Atrophy of the abdominal muscles is usually not uni- 
form, some parts of the muscles being affected more se- 
verely than others. The upper part of the rectus is often 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


intact, while the lower part of the muscle is very feeble. 
This condition is first shown by the inability of the pa- 
tient, while in the recumbent position, to raise the trunk 
without the aid of the upper extremities. In the erect 
position there is marked lumbar lordosis, when the erec- 
tores spine are intact, from the unopposed action of 
these muscles ; but a vertical line from the most promi- 
nent part of the spine falls within the sacrum. Vigor- 
ous expiration is impeded, and micturition and defeca- 
tion are also interfered with when the abdominal muscles 
are wasted. The intercostals seem to be attacked much 
more often than the abdominal muscles, During inspi- 
ration the upper part of the thorax then remains mo- 
tionless while the lower part is raised. Expiration is 
interfered with to a greater extent, because the upper 
two-thirds of the thorax are continually in the expiratory 
position. This is owing to the fact that the natural ten- 
dency of the thorax to undergo narrowing—as the result 
of the elasticity of the parts—is no longer opposed by the 
tonic contraction of the intercostals. ' 

Paralysis of the diaphragm is usually a terminal phe- 
nomenon. After this occurs full inspiration is attended 
with sinking in of the epigastrium and hypochondria, 
and there is very little motion of the abdomen on expira- 
tion. The action of the intercostals and auxiliary muscles 
of respiration becomes exaggerated, unless these muscles 
are also paralyzed. The patient suffers constantly from 
dyspnea, and life is jeopardized by the mildest affection 
of the respiratory organs. 

According to the majority of writers, the muscles of 
the neck are attacked before those of the lower limbs. 
This has not occurred as a general thing in my experi- 
ence. I have usually found that the lower limbs are 
attacked soon after the upper extremities. The muscles 
of the anterior leg group, or the extensor quadriceps, 
are usually involved first. Then the disease spreads to 
the muscles of the buttocks or calves, lastly to the pos- 
terior thigh group. In some cases, indeed, the disease 
appears first in the lower extremities. Paralysis of the 
anterior thigh group causes inability to extend the leg, 
and therefore interferes very materially with walking or 
rising from a sifting position. In paralysis of the ante- 
rior leg group the toes do not clear the ground in walk- 
ing, and the thigh is therefore flexed more strongly at 
the hip, producing a very characteristic gait. 

Among the muscles of the neck the extensors of the 
head are usually the first to be involved. As a result of 
this lesion the head is held back, in order to throw the 
centre of gravity farther backward, and thus necessitate 
less muscular action on the part of the extensors. When 
the head is brought forward it is apt to fall upon the 
chest, and the patient then experiences difficulty in bring- 
ing it back into the vertical position. If the anterior 
muscles of the neck are also paralyzed, the patient has no 
control over the movements of the head, and it wobbles 
from one side to the other with the movements of the 
trunk. 

In advanced stages of the disease the patient is ren- 
dered absolutely helpless. He may be entirely unable to 
move a single part of the body, with the exception of the 
face and tongue. As a general thing, however, he is car- 
ried off by some intercurrent affection before this stage 
of utter helplessness is reached. 

From the very beginning of the disease, fibrillary * 
contractions of the muscles are an important symptom 
in the majority of cases, although they are not pathogno- 
monic. In some cases short, tluttering contractions of 
fibres in different parts of the affected muscles are seen 
almost constantly, coming on without any apparent cause. 
In other cases they are not visible, except after irritation 
of the parts, as, for example, after exposure of the integ- 
ument to the air, brisk tapping of the muscles with the 
finger, faradization of the muscles, etc. When the 
atrophy of the parts is complete the fibrillary contrac- 
tions cease. The contractions are too feeble to cause 
movement of the parts into which the muscles are in- 


* This term is a misnomer, since the contractions involve fibres or 
bundles of fibres; the term fascicular would be preferable. 


Spinal Cord. 
Spinal Cord. 


serted, except in the case of the small muscles of the 
hand. Here slight movements of the fingers are some- 
times produced. The contractions are sometimes ob- 
served in parts which are apparently healthy, but they 
then constitute an indication of approaching disease in 
the muscle in question. In not a few cases, however, 
these contractions are unnoticed during the entire course 
of the ailment. 

The mechanical excitability of the parts is sometimes 
greatly exaggerated, so that a slight tap may produce 
contraction, not alone of the muscle struck, but also of 
adjacent muscles. The changes in the electrical excita- 
bility of the muscles are very interesting and important 
from a diagnostic point of view. It has seemed to me 
that changes are present in all cases. At times the disease 
may make considerable progress before any other change 
is noticeable than simple diminution of irritability to both 
currents, corresponding to the amount of atrophy of the 
muscles. But in not a few instances we have observed 
decided changes at the very beginning of the disease. At 
the present time I have under my observation a case 
in which the disease has lasted only a few months, and 
the atrophy is confined to the small muscles of the right 
hand (thenar and hypothenar eminences, interossei). 
Nevertheless, the atrophic muscles present a distinct par- 
tial ‘‘ degeneration reaction” (slowness of contraction, ex- 
cess of An Cl C). It is often very difficult to detect the 
changes, because the degenerated fibres lie in the midst of 
healthy ones and the contraction of the latter may alone 
be evident. In addition, the increased excitability to the 
galvanic current found in complete De R (degeneration 
reaction) is usually absent. I have generally succeed- 
ed, however, in detecting the slowness of contraction of 
the atrophic fibres by using a mild current, which will 
produce a barely visible contraction of the healthy fibres. 
This phenomenon may also be made evident, even when 
the contraction appears of normal rapidity, by comparing 
the contractions with those produced in healthy parts. 
In some cases this is the only change noticeable. In 
others we also find predominance of An Cl C, or a ten- 
dency to tetanus during the passage of the current. 
When an exacerbation of the paralysis takes place very 
quickly, as sometimes happens, and is followed by rapid 
atrophy of the muscles, the latter may present all the 
changes of complete. De R. Diplegic contractions have 
also been observed by afew writers. This term is applied 
to the following condition : When a small anode is placed 
in the mastoid fossa, and a broad cathode between the 
scapule, muscular contractions are observed in the arm 
opposite to the anode. These diplegic contractions are 
regarded as a reflex phenomenon, but possess no diagnos- 
tic importance, as they are also observed in other condi- 
tions. 

The cutaneous and tendon reflexes are lost very early, 
even after comparatively slight atrophy of the muscles. 

The integument over the atrophied limbs is usually 
cool to the touch, and pale. Trophic changes in the skin 
are rarely observed. Gowers refers to a case in which 
the skin of the face became thin and smooth, so that the 
iris could be seen through the closed eyelids. Pemphigus 
vesicles have been seen upon the palm of the hand in this 
disease. The skin and nails are occasionally thickened, 
and the latter may become brittle and fissured. A scaly 
condition of the skin and a tendency to ulceration have 
also been noticed. Enlargement and tenderness of the 
joints are rare phenomena ; they are noticed particularly 
in the phalangeal joints, but have also been observed in 
the shoulders. I have seen a similar condition in the 
metatarsus during the early stages of the disease. 

Excessive local diaphoresis has been reportedina few 
cases. 

Among the rare phenomena noticed we may also men- 
tion the oculo-pupillary changes (contraction of one or 
both pupils, slow reaction to light), which are probably 
due to direct injury to the cilio-spinal centre in the cer- 
vical cord, and not to an affection of the sympathetic. 

In the majority of advanced cases the temperature of 
the skin is lowered over the affected parts, but in rare 
cases there is distinct elevation of temperature—some- 


571 


Spinal Cord. 
Spinal Cord. 


times as much as five degrees—in the atrophied regions, 
Grasset has observed local elevation of temperature, asso- 
ciated with redness and sweating, confined to the palmar 
surface of the first phalanx. 

In equally rare cases there is slight oedema of the hands 
and forearms, perhaps as the result of impairment in the 
circulation. These parts sometimes appear swollen from 
the increased development of subcutaneous fat. 

Micturition and defecation remain normal throughout 
the entire course of the disease, unless the abdominal 
muscles are seriously wasted. In three cases Rosenthal 
found a diminution of kreatinin in the urine. Slight 
diminution in the amount of urea has also been noticed. 
Frommann reports large deposits of carbonate of lime, 
which he attributes to absorption from the atrophied 
muscles. 

The disease always runs a slow, chronic course, and 
twenty or thirty years, or even more, may elapse before 
the fatal termination. In some the process spreads con- 
tinuously, in the majority a remission occurs after a cer- 
tain amount of progress has been made. This remission 
may last a variable period, from a few months to a num- 
ber of years. Even a permanent arrest of the disease has 
been reported. In rare cases the process is attended with 
sudden exacerbations. The patient suddenly suffers from 
a considerable increase of paralysis in a certain limb, and 
this is followed in a few days by rapid atrophy of the 
paralyzed muscles. 

In a not small proportion of cases the disease may be- 
come complicated at any stage by bulbar paralysis, or the 
latter may precede the former. 

Death usually results from this latter complication, or 
from diseases of the respiratory organs aggravated by 
paralysis of the muscles of respiration ; more rarely from 
intercurrent affections. 

Pathological Anatomy.—The affected muscles are pale, 
and it may be difficult to distinguish any muscular struct- 
ure in them. Under the microscope the changes are found 
to be confined almost exclusively to the muscular fibres. 
The capillaries of the interstitial connective tissue may 
be enlarged, the nuclei increased in number, and the 
fibrous tissue may present hyperplasia. Normal muscu- 
lar fibres may be seen among others which are very ma- 
terially altered. Some fibres simply appear to be nar- 
rowed. When this simple atrophy is far advanced, the 
hemoglobin in the fibre may disappear; in other cases 
pigment may be deposited within the fibres as yellowish 
and brownish granules, In others the transverse striz 
are less distinct, and the fibre is studded with minute 
granules of fat which in places have coalesced into larger 
or smaller globules. In advanced stages the entire fibre 
may be converted into a mass of fat globules. The longi- 
tudinal strie sometimes become very much more distinct 
than the transverse strie, giving the fibre the appearance 
as if it were split longitudinally, 

An important feature is the extreme rarity of hyper- 
trophy of the fibres. W. Mueller seems to have been the 
only one who observed, in addition to the presence of 
atrophied fibres, decided hypertrophy of other fibres. 
Fibres presenting very serious changes may be found 
alongside of others which are apparently normal. 

Our knowledge of the pathological anatomy of this 
disease, in perfectly uncomplicated cases, is extremely 
meagre. The majority of autopsies refer to cases which 
were complicated with bulbar paralysis, but we hold that 
such cases are as decisive with regard to the pathology of 
the affection as the uncomplicated cases. As we shall 
see later on, the process in both affections differs only in 
regard to localization. 

Struempell has described the post-mortem appearances 
in an uncomplicated case as follows: The spinal cord, as 
a whole, was narrow. Atrophy of the anterior horns and 
disappearance of the ganglion-cells in these parts in the 
cervical region were observed very distinctly in numer- 
ous preparations. The left lateral column was free. 
Slight atrophy of the cells existed in the lumbar region. 
In this case the atrophy was limited almost exclusively to 
the arms and shoulders, especially on the left side. 

In Pierret-Troisier’s case there was found degeneration 


572 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


of the ganglion-cells of the anterior horns, particularly 
on the right side; this horn was shrunken. The anterior 
nerve-roots were atrophied and contained numerous ex- 
tremely fine nerve-fibres ; some of the latter contained 
fat-granules, The white substance of the cord was nor- 
mal, 

In the large majority of cases, however, the spinal 
lesions were not confined exclusively to the anterior 
horns, and most of these cases present various symptoms 
which do not form part of the clinical history of pure 
spinal progressive muscular atrophy. 

In a case in which, in addition to the usual symptoms 
of the disease, the patient suffered from severe paroxysms 
of pain in the lower limbs and violent muscular twitch- 
ings, Charcot and Gombault observed the following 
post-mortem appearances: ‘There were profound altera- 
tions in the anterior horns of the cervical and dorsal cord » 
(the atrophy had involved the upper limbs, neck, and 
back). In the lower part of the cervical enlargement 
there was almost complete disappearance of the ganglion- 
cells and of a great part of the nerve-fibres in the anterior 
horns. The dimensions of the anterior horns were not 
lessened to a notable extent, probably because there was 
such an enormous development of capillaries in this re- 
gion. The lateral and posterior columns were intact 
throughout. There was sclerosis of the anterior root-zone 
in the cervical and dorsal regions. This sclerosis corre- 
sponded closely in degree with the lesion of the anterior 
horns, and was regarded by the authors as secondary to 
the latter. There was thickening and manifest inflam- 
mation of the pia mater at the emergence of the anterior 
roots. This was also observed over the remainder of the 
pia mater, but diminished posteriorly. There was a 
narrow zone of cortical sclerosis over the antero-lateral 
portion of the cord. The anterior nerve-roots of the 
cervical and dorsal regions were almost entirely de- 
stroyed. 

Numerous cases have been reported in which sclerosis 
of the pyramid tracts was found in addition to the lesion 
of the anterior horns. These cases should be included 
under the heading of amyotrophic lateral sclerosis, and 
will be found discussed in the article on that subject in 
this volume. 

Post-mortem examination has shown, however, that 
the intensity of the lateral sclerosis varies more or less 
in different cases, and that these variations correspond 
to differences in the severity of the spastic symptoms 
which are associated with those of progressive muscular 
atrophy. 

In order to secure a better understanding of the sub- 
ject, the question of diagnosis will not be discussed until 
we have described the clinical history of the myopathies. 

Prognosis.—The outlook is always unfavorable so far 
as regards recovery, and if the disease becomes compli- 
cated with bulbar paralysis, it is always fatal. The 
most that can be hoped for is cessation of the advance of 
the atrophy, or perhaps slight improvement. If the dis- 
ease does not attack the respiratory muscles life may be 
prolonged for many years, but, as a rule, the patient is 
finally reduced to a helpless condition. 

Treatment.—The majority of authors recommend gentle 
exercise, but it has seemed to the writer that complete 
rest answers best in these cases. At all events, we feel 
quite sure that this is true with regard to the wasted 
muscles. The only exercise to which these muscles 
should be subjected is that secured by the use of the 
interrupted galvanic current, which may be applied 
directly to the parts. The current should be mild and 
the sittings of short duration. 

The application of galvanism to the spine has also 
been recommended. This is done by placing both elec- 
trodes (large sponges) over the site of disease in the spinal 
cord, a mild uninterrupted current being applied for five 
or six minutes every day, or every other day. The sit- 
tings must be long continued, but even then we rarely 
obtain any decided benefit. Massage may also be em- 
ployed, but should be discontinued if it is followed by 
disagreeable sensations in the wasted muscles. Arsenic 
and strychnine have been administered internally, but do 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


not seem to be of much benefit. Gowers states that he 
has obtained the best results from hypodermic injections 
of strychnine, beginning with gr. 4; once a day and 
gradually increasing the dose to gr. 4;. But even this 
writer does not claim to have done more than check the 
progress of the disease. 

GLOSSO - LABIO- LARYNGEAL PARALysis. — Synonym : 
Progressive bulbar paralysis. Htiology.—Hardly anything 
is known concerning the origin of this disease. It is much 
more rare than progressive muscular atrophy. It ap- 
pears to be more frequent in the male than in the female 
sex. Among eight cases of which the writer has kept 
notes, five occurred in men, three in women. In three 
of the cases (two males, one female) the disease was 
complicated with progressive muscular atrophy. In one 
of the cases the affection began at the age of thirty-two 
years, in the others between forty and sixty years. It is 
rarely observed before the age of thirty-five years. He- 
redity seems to exert no influence in the development of 
the malady, and nothing whatever is known concerning 
other predisposing causes, 

We also possess very meagre information concerning 
‘the exciting causes of the disease. A number of cases 
have been attributed to injury, excessive exertion of the 
implicated muscles (blowing on wind instruments), de- 
pressing mental emotions, colds, and constitutional syph- 
ilis. But the influence of any of these factors is very 
problematical. 

Clinical History.—The disease generally begins with- 
out any prodromal symptoms, though the patients some- 
times suffer from pains in the back of the neck and 
shoulders. As a rule, the first symptoms are those of 
slowly advancing paralysis and atrophy of the tongue. 
The patient begins to experience a certain degree of dif- 
ficulty in articulation, especially of those consonants 
which are produced by the escape of air between the tip 
of the tongue and the upper incisors, or the anterior part 
of the hard palate (d, t, /, n, s). As the paralysis of the 
tongue increases, the difficulty in articulation increases 
part passu, and finally speech becomes wholly unintelli- 
gible. When this stage is reached, the tongue usually 
lies as an inert mass upon the floor of the mouth, and 
sometimes cannot be moved voluntarily to the slightest 
extent. Fibrillary contractions in the organ are often 

-noticéd from the very beginning. Atrophy of the tongue 

keeps pace with the paralysis. On account of the un- 
equal distribution of the atrophy, the surface of the or- 
gan presents depressions here and there. The organ is 
diminished in length as well as in its lateral! dimensions. 
I have seen this so marked that the patient was no 
longer able to grasp the tip of the tongue and draw it 
forward. The paralysis of the tongue also interferes 
with mastication and deglutition. On account of the in- 
ability to perform lateral movements of the organ, the 
patient is unable to remove the food from between the 
teeth and cheeks with the tip of the tongue, and gener- 
ally uses the finger for this purpose. The interference 
with the movements of the base of the tongue also causes 
difficulty in conveying the bolus of food into the 
pharynx. 

The paralysis of the tongue has usually not advanced 
very far before the lips become affected. In some cases, 
indeed, both parts appear to be attacked almost simul- 
taneously. ‘This is first shown by interference with the 
articulation of those sounds whose production depends 
mainly on movement of the lips (y, 0, f, v, m, 0, u). At 
the same time there is difficulty in whistling, etc. If 
the finger is inserted between the lips and the patient is 
directed to contract the parts in order to compress the 
finger, it will be found that this is done with much less 
vigor than in the normal condition. The coincident 
atrophy of the lips usually becomes distinctly visible 
after a while, though this does not always happen. But 
the atrophy of the orbicularis oris can always be detected 
by grasping the lip between the thumb and index-finger, 
and thus determining its thickness. When the atrophy 
has made considerable progress, the mouth is kept half 
open, and the saliva is constantly dribbling. This is 
partly owing to the fact that the presence of the saliva 


Spinal Cord. 
Spinal Cord. 


no longer gives rise to the involuntary reflex movements 
of deglutition, by means of which it is conveyed into the 
cesophagus, and the secretion therefore makes its escape 
anteriorly. Careful measurements, however, have shown 
that the quantity of saliva secreted in twenty-four hours 
is often much larger than normal. This has been attrib- 
uted by some to irritation of the salivary centre in the 
medulla oblongata. 

The muscles of the chin are usually attacked about the 
same time as the orbicularis oris, and the corresponding 
movements of the lower lip are lost in consequence. 
Other facial muscles are very rarely affected, those in- 
serted into the mouth (buccinators, levatores labii) being 
involved: more frequently than the upper facial muscles. 
In rare instances, however, all the external facial mus- 
cles are paralyzed, and the face then presents the ap- 
pearances of double peripheral facial paralysis. 

The affection of the facial muscles gives rise to a pe- 
culiar change in the physiognomy. On account of the 


Fig. 8647.—Case of Bulbar Paralysis Complicated with Progressive Mus- 
cular Atrophy. 


unopposed action of the muscles inserted into the angles 
of the mouth and the upper lip, the latter is elevated and 
the mouth made wider. At the same time the naso-labial 
folds are constantly deepened. The lower lip, on the 
other hand, droops from its own weight. As a result, 
the patient constantly has a mournful expression of the 
lower half of the face, and this is heightened during 
laughter by the contrast between it and the upper part of 
the face, which retains its mobility. (Fig. 3647.) 
Shortly after the development of the affection in the 
tongue and lips, the symptoms of paralysis of the phar- 
ynx and larynx begin and slowly progress. The mus- 
cles of the soft palate become paretic and the pillars of 
the fauces hang lower than normal. The posterior nares 
can no longer be closed perfectly during deglutition, 
and fluids are apt to regurgitate through the nose. For 
the same reason air escapes through the nose when the 
patient speaks, and speech assumes a nasal character. 
This also increases the difficulty in the articulation of 
labials, because a sufficiently strong current of air can- 
not be sent through the mouth to produce vibration of 
the lips. In the earlier stages of the affection this can 
be remedied to a certain extent by closing the nostrils, so 
that the entire current of air is forced to pass through 
the mouth. The paralysis of the pharyngeal constrictors 
increases still further the difficulty in deglutition. The 


573 


Spinal Cord. 
Spinal Cord. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


interference is first noticed with regard to solid food, so 
that the patient is compelled to confine himself to semi- 
solid, and then to purely fluid, articles of diet. 

The laryngeal muscles are usually the last to be af- 
fected. The constrictors of the glottis are first attacked. 
The consequent inability to close the glottis permits the 
entrance of particles of food into the trachea and bron- 
chi, and this may be followed by lobular (foreign body) 
pneumonia. At the same time the inability to close the 
glottis necessarily prevents vigorous cough, and may thus 
prove a very serious matter in the course of otherwise 
mild diseases of the lungs or bronchi. The muscles 
moving the vocal cords may also be attacked in compara- 
tively rare cases ; this condition may be recognized during 
life with the aid of the laryngoscope. In such patients 
the voice becomes feeble and hoarse, and, finally, com- 
plete aphonia may result, although this is exceedingly 
rare. 

The dangers arising from the paralysis of the pharyn- 
geal and laryngeal muscles are increased still more by the 
fact that there is very often an early impairment of reflex 
action after stimulation of the mucous membrane. Kris- 
haber has reported two cases in which this symptom was 
a premonitory manifestation of the disease. 

In rare cases other nerve-tracts are also attacked. This 
is seen most frequently in the muscles of mastication 
(motor root of the fifth nerve). The masseters and tem- 
porals then undergo atrophy, and mastication is still fur- 
ther interfered with. The atrophy of the temporals is 
visible to the naked eye, and that of the masseters may 
be felt by grasping the muscle between two fingers in- 
serted in the mouth. 

Paralysis of the ocular muscles has also been noticed 
in rare cases, and may result in strabismus or ptosis. As 
a matter of course, the atrophy of the ocular muscles can 
only be inferred from their loss of function. 

The electrical reactions of the paralyzed muscles are 
obtained with difficulty. The hypoglossal nerve is best 
reached by applying one electrode to the back of the 
neck, the other (small) electrode above and behind the 
hyoid bone. It is usually preferable to apply the small 
electrode to the tongue itself—this should be protruded 
as far as possible—and direct application may also be 
made to the velum palati and pharyngeal constrictors. 
Few patients, however, would consent to the latter manip- 
ulation. 

The electrical irritability of the muscles, according to 
many writers, is simply diminished, but direct electriza- 
tion of the tongue and lips will usually show partial de- 
generation reaction. Sometimes the formula of reaction 
is unchanged, and there is merely delayed and prolonged 
muscular contraction. Even this change may be so slight- 
ly marked, that comparison with healthy individuals is 
necessary in order to detect the deviation from the nor- 
mal rapidity of contraction. Diplegic contractions are 
sometimes obtained in this disease as in progressive mus- 
cular atrophy. 

Sensation remains unaffected in the mucous membrane 
covering the paralyzed muscles. At the most there may 
be slight aberrations of the sense of taste, but this can be 
explained by the fact that the mouth is generally lined 
with thick, glairy saliva, and that the tongue is usually 
coated. 

Headache is occasionally a prominent symptom. The 
pain is referred usually to the frontal or occipital regions. 
Severe pains are also experienced occasionally in the back 
of the neck, particularly in those cases which are compli- 
cated with progressive muscular atrophy. 

The disease usually runs a slowly progressive course, 
and lasts from two to five years. In some cases quite 
sudden exacerbations are observed. Remissions are also 
possible. In a case under the writer’s observation at 
present, the first symptoms appeared more than six 
years ago. Soon after the patient came under treat- 
ment (five years ago) the symptoms began to improve 
slightly, and have remained at a standstill for the last 
three years. 

But such a course is entirely exceptional. The patients 
gradually grow weaker and weaker, and finally die of in- 


O74 


-two extremes is found every possible gradation. 


anition, perhaps accelerated by ‘‘ foreign-body pneumo- 
nia,” resulting from the aspiration of food into the air- 
passages. In certain patients respiratory and circulatory 
symptoms are observed in the later stages of the disease. 
Without any apparent exciting cause, severe attacks of 
dyspnoea suddenly develop and may even prove rapidly 
fatal from suffocation. The causation of these attacks is 
obscure, 

In other cases the pulse is excessively slow, or it may 
be so rapid that it can hardly be counted. The patient 
suffers often from palpitation of the heart. This symp- 
tom is undoubtedly due to the spread of the bulbar lesion 
to the nucleus of the pneumogastric. Syncope ensues, 
but usually disappears very quickly, to reappear sooner 
or later. The patient may pass safely through a large 
number of these attacks, but they are not infrequently the 
immediate cause of death. 

Bulbar paralysis is often complicated by progressive 
muscular atrophy or amyotrophic lateral sclerosis, The 
symptoms of the former affection may either precede or 
follow those of the latter, 

The intellect is usually unaffected throughout the en- 
tire course of the disease. But the patients generally . 
recognize the hopelessness of their condition at an early 
period, and exhibit a tendency to weep on very slight or 
no provocation, 

In the large majority of cases the muscles are attacked 
in a typical order—first the tongue, then the lips, final- 
ly the velum palati, and the pharyngeal and laryngeal 
muscles. In exceptional cases, however, this order is 
not maintained. Duchenne observed paralysis of the 
velum palati and lips prior to that of the tongue, and 
this sequence has been seen by others. 

Pathological Anatomy.—In the majority of cases the 
medulla oblongata, the site of the disease, appears un- 
changed to the naked eye. In some cases, however, the 
organ appears somewhat smaller than normal, and pre- 
sents peculiar depressions in the floor of the fourth ven- 
tricle. As arule, macroscopic changes are noticeable in 
certain of the bulbar nerves, the hypoglossal, facial, 
pneumogastric, spinal accessory, sometimes the glosso- 
pharyngeal, in rare cases in the motor root: of the fifth 
nerve and the abducens. The nerves in question are 
smaller than normal, and have a grayish, translucent 
look. ‘ 

Under the microscope the changes are very pronounced. 
They may be confined exclusively to the nuclei of the 
nerves mentioned above and their intra-medullary nerve- 
tracts, or the white matter may also be implicated to a 
certain extent. 

As we are led to expect from the clinical history of the 
disease, the lesion is most marked in the nuclei of origin 
of the hypoglossal nerves. The ganglion-cells in this 
region present all stages of atrophic degeneration. Some 
have merely lost their prolongations and have become 
more rounded, and perhaps the nucleus is recognized 
with difficulty. Or, in addition, the protoplasm of the 
cell contains an unusual amount of brownish or yellow- 
ish pigment. In the most advanced stages the cell is 
merely represented by a shapeless mass of pigment, its 
original structure being entirely lost. Between these 
The 
changes usually diminish in intensity from within out- 
ward. 

Some observers have also described changes in the neu- 
roglia and blood-vessels surrounding the ganglion-cells. 
The neuroglia may be increased in amount and present a 
more fibrillated structure than normal. In comparative- 
ly recent cases it sometimes contains compound granular 
corpuscles. The walls of the blood-vessels may be thick- 
ened, their nuclei increased, and the surrounding lym- 
Dae spaces may contain an increased number of round 
cells. 

Similar changes, though usually less pronounced, are 
found in the nuclei of the pneumogastric and spinal ac- 
cessory nerves, the inferior nucleus of the facial, some- 
times in the glosso-pharyngeus, trigeminus, and abducens. 
It is a peculiar and significant fact that the nucleus of 
the acoustic nerve always escapes, so far as I have been 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Spinal Cord. 
Spinal Cord, 


able to ascertain from a quite careful review of the litera- 
ture of the subject. 

In a large proportion of cases analogous lesions are 
found in the ganglion-cells of the anterior horns of the 
cervical cord. 

But the lesion is not confined, in very many cases, to the 
ganglion-cells of the medulla. Déjerine has collected the 
reports of twenty-two cases of bulbar paralysis, and found 
that in the majority there was sclerosis or atrophic de- 
generation of the pyramid tracts. This is usually most 
marked in the medulla,.and diminishes in intensity in an 
upward and downward direction. In two.cases Déjerine 
found that the lesion extended into the cerebral peduncles, 
and was entirely similar in appearance and localization 
to the descending degeneration occurring after a lesion 
of the motor tract in the brain. 

Under the microscope the affected nerves are found to 
contain an increased number of narrow fibres, and some 
fibres may even disappear completely, leaving merely the 
empty sheath. Granulo-fatty degeneration is also visible 
in some fibres. There is no notable change in the inter- 
stitial tissue. 

The paralyzed muscles present the same appearances 
under the microscope as in cases of progressive muscular 
atrophy. 

Diagnosis.—The diagnosis of chronic progressive bul- 
bar paralysis is usually not a very difficult matter. The 
symptoms of acute bulbar paralysis resulting from hem- 
orrhage, thrombosis, or embolism of the medulla oblon- 
gata, are. very similar to those of the chronic affection 
under consideration, but a mistake is prevented by the 
acuteness of the onset—usually as sudden as a stroke of 
apoplexy, though sometimes a few days may elapse be- 
fore the bulbar symptoms are fully developed in cases of 
thrombosis. Even if we should be unable to obtain the 
clinical history of the disease, a mistake may be avoided 
from the fact that the paralysis, in acute bulbar lesions, 
is disproportionate to the muscular atrophy. In addition 
there is very often hemiplegia of motion, while sensory 
disturbances are also very apt to be present. 

Tumors of the medulla, which are fortunately very 
rare, are excluded with greater difficulty, because they 
usually grow very slowly (the majority of these tumors 
are solitary tubercles). In the beginning the diagnosis 
_ may be almost impossible, but the tumor soon gives rise 
to compression of adjacent parts, and to general cerebral 
symptoms, and thus enables us to exclude bulbar paraly- 
sis. The symptoms of compression consist of paralyses 
of motion and sensation in the limbs, along the course of 
distribution of the bulbar nerves, of mellituria, etc. The 
general cerebral symptoms consist of headache, choked 
disk, vomiting, etc. 

Pseudo-bulbar paralysis is the term applied to a bulbar 
complex of symptoms, which is due to lesions in other 
parts of the brain. It is usually the result of bilateral 
lesions of the internal capsule, corpus striatum, etc., but 
Kirchoff observed a case in which the bulbar symptoms 
resulted from embolism of the right middle cerebral ar- 
tery, with secondary softening of the right corpus stria- 
tum, lenticular nucleus, and internal capsule. Barlow 
has also described a similar case, in which the bulbar 
symptoms followed embolic softening of the lower por- 
tion of the central and adjacent convolutions of one 
side. These cases can generally be excluded by the sud- 
den onset of the symptoms, which are usually attended 
with cerebral disturbances, and by the absence of atro- 
phy in the muscles or of changes in their electrical excit- 
ability. 

plac facialis (bilateral facial paralysis) could only 
be mistaken for bulbar paralysis on the most superficial 
examination. The patient, it is true, suffers from paral- 
ysis of the lips and disturbance of deglutition, on ac- 
count of the food slipping between the cheeks and teeth ; 
but the movements of the tongue and pharyngeal mus- 
cles are not interfered with, and the facial paralysis af- 
fects all the muscles of the face. 

Oppenheim has reported a remarkable case of unavoid- 
able error in diagnosis. The patient, twenty-nine years 
of age, first suffered from weakness in the hands and 


legs, then from difficulty in speaking and paresis of the 
lips, finally from difficulty in deglutition. There was 
also difficulty in opening and closing the mouth, and im- 
perfect motion of the velum palati during phonation. 
Attacks of dyspnoea occurred subsequently, and speech 
became exquisitely bulbar in character. The tongue 
could be moved in all directions, but with difficulty. 
Electrical reactions were normal. On autopsy, nothing 
was discovered in the muscles, nerves, or central nervous 
system. 

It is difficult to say how a mistake could have been 
avoided in this remarkably obscure case. Perhaps the 
absence of changes in electrical excitability might have 
aroused suspicions. 

Prognosis.—Bulbar paralysis is almost always fatal. A 
few cases have been reported in which very marked im- 
provement or even recovery has been reported, but this 
mere fact casts a doubt upon the diagnosis. Even a 
standstill which lasts more than a few months is a rare 
event. We may mention, however, that the patient 
shown in Fig. 3647 has fully held her own for the last 
two years. The patient either dies slowly from inani- 
tion, or death may occur suddenly from one of the acci- 
dents described in the section on Clinical History. 

Treatment.—In a disease of this nature our therapeutic 
resources are utterly useless. Chief attention should be 
paid to the prevention of inanition, fluid food being ad- 
ministered through the cesophageal sound as soon as the 
disease has advanced to such a stage that there is danger 
of the entrance of food into the larynx and trachea. 

Galvanization has been recommended in the form of 
stabile transverse currents through the medulla, one elec- 
trode being placed on each mastoid process, or move- 
ments of deglutition are produced by placing the anode 
on the back of the neck, and the cathode (with interrupt- 
ing handle) on the side of the larynx. 

Strychnine, iodide of potassium, and nitrate of silver 
have been recommended, but no good results are ever ob- 
tained from any method of treatment. 

PSEUDO-HYPERTROPHIC PARALysIs. — Htiology. — In 
very many cases this disease has an hereditary basis. It 
often appears in brothers and sisters at about the same 
time in life. Meryon described eight cases in one family, 
Gowers four in one family. The writer has seen four 
(sisters) attacked in one family, two (brothers) in another. 
The hereditary influence is always transmitted by the 
mother, despite the fact that the disease generally at- 
tacks the male sex. 

Age is another powerful predisposing factor, the dis- 
ease almost always beginning during childhood. It is 
generally observed between the ages of two and five 
years, and is often noticed as soon as the child begins to 
walk. In rare cases, adult life is reached before the dis- 
ease manifests itself. Among 100 cases collected by 
Seidel, 94 began before the end of the fifteenth year. 

Sex also exerts a potent influence, boys being attacked 
much more frequently than girls. Among 220 cases col- 
lected by Gowers, 190 occurred in boys, 30 in girls. 

Hardly anything is known concerning the exciting 
causes. A few cases have been found to develop after 
acute infectious diseases, exposure to wet and cold, and 
injury, but it is difficult to determine whether there is 
any real connection between the two series of events. 

Clinical History.—The first indication of the disease 
is very often the tardiness with which the child begins 
to walk. This ability is acquired very slowly, and the 
child is soon tired by the exertion. If he has learned to 
walk before the onset of the disease, it is found that his 
gait loses in freedom and vigor, he becomes unable to 
run with ease, or to go up and down a flight of stairs, 
and finally even walking is attended with difficulty. At 
the same time the lower limbs begin to grow larger. The 
apparent hypertrophy may begin simultaneously in both 
calves, or it may first attack one, later the other. From 
the calves the pseudo-hypertrophy usually extends to the 
thighs (chiefly the anterior muscles) and the glutei. The 
lumbar muscles are very often the next to be attacked, or 
they may appear to be feeble from the start. Coinci- 
dent with the enlargement of the various muscles is dim- 


575 


Spinal Cord. 
Spinal Cord.. 


inution in their power. The enlargement often spreads 
to the muscles of the upper limbs, though these are more 
often wasted, and present a striking contrast to the ex- 
cessive proportions of the lower limbs. The shoulder 
muscles are very often affected, particularly the deltoids. 
The muscles of the arm may be enlarged, but are also 
often wasted ; those of the forearm usually escape for a 
very long time. The small muscles of the hand are 
hardly ever attacked. . 

The face is also involved in rare cases. The masseters 
may be enlarged, and the same condition has been ob- 
served in the tongue. 

The enlarged, as well as the atrophied, muscles suffer 
diminution of 
power, and this 
givesrise tochar- 
acteristic symp- 
toms. 

Until recently 
it was supposed 
that fibrillary 
contractions in 
the affected 
muscles never 
occur in this dis- 
ease, but, as we 
shall see later 
on, there are 
some exceptions 
tothis rule. This 
is also true of the 
degeneration re- 
action. Asa 
rule, however, 
there is merely 
diminution of 
faradic and gal- 
vanic contractil- 
ity. Sensation 
remains 
turbed through- 
out the disease. 

After it has 
lasted a variable 
length of time, 
wasting appears 
in all of the hy- 
pertrophied 
muscles. The 
disease is slowly 
progressive, and 
death generally results from pulmonary affections, the 
gravity of which is increased by the muscular weakness, 
or from some other intercurrent disease. 

We will now give amore detailed description of the 
individual symptoms. 

Enlargement of the calves is usually the first symptom 
noticed, though sometimes the awkwardness and clumsi- 
ness Of gait first attract attention. On the other hand, the 
size of the gastrocnemii may remain unchanged for a 
considerable time, despite the steady advance of the ana- 
tomical changes in the muscles. The enlargement of the 
calves is sometimes extremely great, and they may even 
attain a size of fifteen or sixteen inches in a boy ten years 
of age. The power of these muscles usually diminishes 
in inverse proportion to their increase in size, but their 
vigor sometimes remains approximately normal for quite 
along time. True hypertrophy of these parts has been 
observed in rare cases. 

The anterior leg group of muscles is not often enlarged, 
but the loss of power is usually more marked than in the 
calf. As a result, contracture of the latter takes place, 
and the heel is constantly drawn up, so that the patient, 
while standing, cannot bring it to the floor, and it is dif- 
ficult to bring the foot to a right angle with the leg by 
passive motion, The movements of flexion and exten- 
sion of the foot are necessarily interfered with, and the 
patient separates the feet in walking to a greater extent 
than usual, in order to widen the base of support. The 


Fic. 3648.—Pseudo-hypertrophic Paralysis. 


576 


undis-: 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


calf muscles may remain firm—indeed, they may even as- 
sume an almost stony hardness,—but they do not pre- 
sent the elastic resistance of normal muscle. 

The muscles of the thighs, buttocks, and back are usu- 
ally the next to be involved. In many cases the buttocks 
alone undergo hypertrophy, and there may then bea very 
striking contrast between the large calves and buttocks 
and the wasted thighs. The loss of power in these parts 
gives rise to very peculiar disturbances in the position of 
the body when the patient stands, walks, or rises from 
the recumbent position. ‘ ; 

When the patient stands erect the heels are usually 
raised slightly—sometimes very markedly, as shown in 
Fig. 3648—from the floor, and the weight of the body is 
thrown farther forward upon the ball of the foot. In 
addition, the pelvis becomes flexed on the thighs, and 
this tends to throw the centre of gravity still farther for- 
ward. Hence the back is thrown backward in order to 
maintain a balance, and forms a very prominent curve 
in the lumbo-dorsal region (lordosis), so that a line dropped 
from the most prominent part of the dorsal spine often 
falls several inches behind the most projecting part of 
the sacrum. This peculiar deformity disappears, as a 
general thing, when the patient sits down, and is prob- . 
ably not due, as has been believed by the majority of 
writers, to paresis of the extensor muscles of the back. 
When the patient sits down the weight of the trunk can 
be felt to tilt the anterior superior spinous process of the 
pelvis upward, and, as this takes place, the lordosis dis- 


Fie, 8649.—Psendo-hypertrophic Paralysis. Position assumed by the 
patient in attempting to rise from the floor. 


appears, the spine becoming straightened. It is much 
more probable, therefore, that the lordosis is due to the 
tilting forward of the pelvis on account of the weakness 
of its extensors, and not to the paresis of the extensors of 
the spine. 

Certain characteristic phenomena are also observed in 
the act of walking. When standing erect the patient as- 
sumes the position described above. Then, as the act of 
walking is begun, the pelvis is raised very high on the 
side of the swinging leg, in order to allow the drooping 
toes to clear the ground. At the same time the trunk is 
carried far over toward the active leg, in order to bring 
the centre of gravity within the ball of the foot, and thus 
an oscillation is produced which resembles the waddling 
gait of aduck. I am able, from observation in a num- 
ber of cases, to confirm Ross’ opinion, that this is the 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Spinal Cord. 
Spinal Cord, 


, 

result of contraction of the gluteus medius—this can 
be readily felt on applying the hand to the buttock 
during the act of walking—and not, as Duchenne and 
the majority of other writers have believed, of paral- 
ysis of this muscle, All the movements in walking are 
slow and deliberate, and the patient is often compelled, 
in advanced cases, to aid himself in maintaining his 
equilibrium by making balancing movements with the 
hands, like a rope-walker. As the disease progresses 
still further, locomotion becomes impossible, and the 
patient is confined to the bed or chair. 

In rising from the floor to the erect position, the fol- 
lowing peculiar manceuvres are adopted: The patient 
first rolls over on his hands and knees; then the body is 
brought into the position shown in Fig. 3649, this move- 
ment being effected in great part by extension of the 
arms, which raises the trunk from the ground, and thus 
allows the lower limbs to be brought, with comparatively 
little effort, into the partly flexed position. The patient 
next places the hands in succession above the knees (Fig. 
3650), at the same time pushing back the thighs, thus 
straightening the lower limbs and elevating the trunk 
still further. The next movement is to place the hands 


Fig. 3650.—Pseudo-hypertrophic Paralysis. Patient ‘*climbing up his 
thighs” in the attempt to raise himself to the erect position. 


on successively higher portions of the thighs ¢‘‘ climbing 
up the thighs”) until the erect position is assumed. 
This peculiar method of assuming the erect position is 
not, however, pathognomonic of pseudo-hypertrophic pa- 
ralysis, and I have often observed it in Pott’s disease, 
whether in children or adults. 

It is very rare to find hypertrophy so marked a feature 
in the disease of the upper limbs as in that of the lower, 
though cases have been described in which it was found 
in almost all the muscles of the body. In the upper 
part of the body the enlargement is limited much more 
often to certain portions.. For example, the deltoids 
alone may be enlarged, or perhaps the deltoid and arm 
muscles on one or both sides. Hypertrophy has also 
been found in the muscles of the neck, back, and ab- 
dominal walls. The muscles of mastication (masseters 
and temporals) may be implicated in rare cases, and the 
tongue has been found a third larger than normal, so 
that deglutition and articulation were interfered with to 
a serious extent. According to Coste and Gioja, the lat- 
ter condition was associated, in one of their cases, with 


VoL, VI.—37 


the symptoms of hypertrophy of the heart. Gowers says 
that, next to the muscles of the calf, the infraspinatus is 
enlarged most frequently and markedly ; the supraspi- 
natus is also prominent at times. 

But wasting is a much more prominent feature than en- 
largement in the affection of the upper limbs and trunk. 
This atrophy usually begins earliest and is most pro- 
nounced in the pectoralis major, particularly its lower 
half. The latissimus dorsi is also apt to be affected at an 
early period. According to Gowers, this is an important 
diagnostic sign and is sufficient to exclude the spinal form 
of muscular atrophy. Next, the scapular muscles under- 
go atrophy, and the process then creeps down the arms, 
the forearms being involved later and less frequently 
than the arms. The small muscles of the hand suffer in 
very few cases, and thus offer a striking contrast, in the 
majority of cases, to spinal progressive muscular atrophy. 
The muscles of the neck do not often undergo degenera- 
tion, though the process has been observed, in a few cases, 
in the sterno-mastoids. Even those muscles of the upper 
limbs which have undergone primary hypertrophy waste 
away after a comparatively short time. The diaphragm 
has, in a few cases, been found degenerated on post-mortem 
examination. When the atrophic process is far advanced 
in the upper limbs, the contrast with the enlarged lower 
limbs is especially striking. Paralysis of the muscles 
goes hand in hand with atrophy, and not only interferes 
with the specific movements of the upper limbs, but also 
with those movements of the lower limbs which had 
formerly been aided by the upper. 

As the disease advances the patient finally becomes 
unable even to sit up, and is confined permanently to 
bed. 

Fascicular contractions are hardly ever observed in this 
malady. Inthe rare cases in which they are present, 
they are not found throughout the entire course of the 
disease, and are not so apt to occur spontaneously, or with 
such frequency and vigor, as in spinal progressive muscu- 
lar atrophy. 

The electrical contractility of the muscles is usually 
diminished quantitatively, without any change in the 
mode of reaction. The diminution in the faradic and 
galvanic excitability, when the currents are applied di- 
rectly to the muscles, seems to correspond with the dimi- 
nution in the amount of normally acting muscular fibres. 
The electrical reactions through the nerves, however, are 
often stronger to both currents than when these are applied 
directly to the muscles. In rare cases partial degenera- 
tion reaction is observed in certain of the muscles. In 
Schultze’s case, for example, distinct slow contractions 
were obtained in the left deltoid muscle with the galvanic 
current, and in addition the AnClC was more marked 
than the CaClIC. Similar reactions were obtained in the 
first and fourth interossei and in the muscles of the thenar 
eminence. Other cases have also been reported in which 
the DeR was present. It must be remembered, however, 
that these changes in electrical excitability are very 
rare. 

The patellar tendon reflex is usually diminished or lost 
at a comparatively early period, but this is merely the 
result of the loss of power in the quadriceps, and is not 
at all significant of any spinal affection. 

Sensation may remain unaffected throughout the en- 
tire course of the disease. At first there are not infre- 
quently vague pains in the lower limbs, and sometimes 
spasmodic twitchings in the calves, attended with pain- 
ful sensations. After the disease has made some prog- 
ress, the patient is apt to suffer from violent pains in the 
back, especially after he has remained in one position for 
a little while. The hypertrophied or atrophied muscles, 
especially the former, may be more or less tender on 
pressure. 

The integument often presents a bluish-red, mottled ap- 
pearance, particularly over the lower extremities. In 
these cases the skin is often cooler to the feel than nor- 
mal. On the other hand, the integument of the hyper- 
trophied calves sometimes has a higher temperature than 
that of the thighs or abdomen. Ord has observed an in- 
creased temperature of from one to two degrees. 


- 577 


Spinal Cord. 
Spinal Cord. 


Seidel has found that the increase in temperature pro- 
duced by contraction of the degenerated gastrocnemius 
is from one to two degrees less than that resulting from 
contraction of the healthy muscles. 

The functions of the bladder and rectum are usually 
intact, although obstinate constipation is not an infre- 
quent symptom, especially if there is weakness of the 
abdominal muscles.. The mental functions are commonly 
unaffected, but not a few patients are feeble-minded and 
even idiotic. Vigoroux reports a case which was com- 
plicated with Thomsen’s disease. 

The disease is slowly progressive, although there may 
be long intervals in which it is at a complete standstill. 
Even after the patient is confined helplessly to bed, he 
may linger for ten years or more. Death results gen- 
erally from some pulmonary affection, such as bronchitis, 
phthisis, or pneumonia, which is aggravated by the feeble- 
ness of the respiratory muscles. In some cases even the 
intercostals become feeble, and this adds a new danger 
to any intercurrent lung affection. As a rule, death 
occurs within fifteen or twenty years from the incep- 
tion of the disease, and few patients live beyond middle 
age. 

ee PROGRESSIVE MuscuLarR ATROPHY.—This 

disease forms a clinical variety which, in typical cases, is 
quite distinct from other forms of progressive muscular 
atrophy of myopathic origin. It almost always begins 
before the age of twenty years, being most common 
in childhood. It is also often observed at puberty or 
during infancy. The hereditary element is the most 
striking feature in the etiology of this affection, and it 
occurs with comparative infrequency in isolated cases. 
Unlike pseudo-hypertrophic paralysis, it is not infre- 
quent in girls. 

Some writers believe that the pathological process in 
this disease is essentially distinct from that characteristic 
of pseudo-hypertrophic paralysis, but this position does 
not seem to be well established. 

It begins generally in the shoulders and arms, some- 
times in the lower limbs and back, and not infrequently 
in both localities at the same time. Throughout the 
disease atrophy of muscles constitutes the striking feature, 
but may also be attended with hypertrophy—sometimes 
true, sometimes false—in certain parts. 

The atrophy, which is the first symptom, begins gen- 
erally in the muscles of the scapula, shoulder-girdle, and 
arm proper ; it then appears in the muscles of the back, 
buttocks, and thighs. The muscles below the elbow and 
knee are attacked late and with comparative infrequency. 
In the forearm, the supinator longus is most frequently 
affected, while the small muscles of the hand almost al- 
ways remain normal, at least until a late stage of the 
disease. In the legs the peronei may be diseased at an 
early period, while the gastrocnemii long retain their 
normal bulk and power. 

In certain parts, on the other hand, true or false hy- 
pertrophy of the muscles may be observed, the former 
appearing to constitute a compensatory process by which 
nature attempts to repair the damage done by the paraly- 
sis. These muscles include particularly the deéltoids, 
gastrocnemii, supraspinatus and infraspinatus, the teres 
major and minor, triceps, and sartorius. 

As in pseudo-hypertrophic paralysis, the pectoralis 
major, with the exception of the clavicular portion, and 
the latissimus dorsi are very constantly affected. The 
rhomboids, serratus magnus, biceps, brachialis anticus, 
supinator longus, and back muscles seem to be involved 
next in frequency to the pectoralis and latissimus dorsi. 

When the disease attacks the lower limbs, it is found 
that the glutei, quadriceps, and anterior leg group, espe- 
cially the tibialis anticus, are affected most constantly. 
The sartorius and gastrocnemii may escape for a long 
time, or may undergo true hypertrophy. Even in such 
cases, however, it is not uncommon to find that the 
hypertrophic muscles finally succumb to the atrophic 
process. A few cases have been reported in which the 
diaphragm and abdominal muscles also seemed to be in- 
volved. 

Charcot has reported an interesting case in which the 


578 


4 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


4 
symptoms, so far as regards the distribution of the paral- 
ysis, corresponded exactly with Erb’s juvenile form, but 
in which the bulk of the muscles did not undergo any 
change. 

As in pseudo-hypertrophic paralysis, sensory disturb- 
ances remain absent, fibrillary contractions of the para- 
lyzed muscles are observed very rarely, and there is 
simple diminution of electrical excitability to both -cur- 
rents, corresponding to the diminution in muscular bulk. 
The latter statement does not hold good in all cases, 
however, inasmuch as partial degeneration reaction may 
be present in certain muscles. 

The disease may last from twenty to thirty years, or 
even longer, and its advance may alternate with periods 
during which the process seems to be kept in abeyance 
for years. “ 

The following abstract of the history of a case (vide 
Figs. 3651, 3652, and 3653) now under the writer’s obser- 
vation, also furnishes an excellent illustration of the diffi- 
culties of diagnosis. For a number of years the patient 
had been regarded as a typical example of progressive 
muscular atrophy of spinal origin. 

James M., forty-nine years of age. 


Family history 
negative. 


Patient had measles when ten years of age, 
typhoid fever at twenty- 
five; worked in iron 
works between the ages 
of eighteen and twenty- 
seven’ years. When 
twenty-seven years of 
age, after running two 
miles, he felt 4 lightness 
in the head and his 
sight left him for about 
ten seconds; he then 
vomited a good deal. 
He felt weak for a 
couple of days, but then 
returned to work. Af- 
ter this he would often 
feel stiff, sore, and 
weak in the back and 
legs after keeping still 
for a little while, but 
this would wear away 
after working. Two or 
three months later, he 
felt numbness in the 
tips of the fingers ; this 
feeling would come and 
go. Weakness then de- 
veloped in the right 
shoulder and arm, but 
the patient did not no- 
tice any wasting until 
two years had elapsed. 
Next the left arm grew 
weak, then the legs. 

He entered Bellevue 
Hospital in 1869 (vide 
Fig. 3651, from a pho- 
tograph taken at that 
time), and there gained sixty pounds in weight and grew 
somewhat stronger. At the end of a year he became 
slightly worse, and has grown rapidly worse in the last 
few years. The patient says the left calf has grown two 
and a half inches smaller in the last couple of years. 
He never saw any fibrillary contractions, but says that 
he has felt them during the last three or four years in 
various parts of the body, and also in the orbicularis pal- 
pebrarum. 

Present Condition: Intelligence very good, nothing 
abnormal noticeable about the face or neck. Arms very 
much atrophied as compared with the shoulders and 
forearms. Right arm 8% inches, left arm 8% inches. 
Supination of left forearm is impeded as a result of old 
injury to the elbow. Right forearm 10% inches, left fore- 
arm 9% inches. ; 

Right side; Hand, thenar and hypothenar eminences 


Fra. 3651.—Case of Juvenile Progressive 
Muscular Atrophy. (After a photo- 
graph taken in 1869.) - 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Spinal Cord, 
Spinal Cord, 


normal, flexion and extension of hand on forearm nearly, 
though not quite, normal; movements of fingers ap- 
proximately normal. Flexion of the forearm on the arm 
is accomplished mainly by contraction of the supinator 
longus. Extremely feeble action of biceps and triceps. 
The deltoid is weak, but the arm can be raised to a hori- 
zontal position ; trapezius well retained ; no rhomboids 
can be seen or felt ; the scapule cannot be approximated 
closer than seventeen and a half inches by voluntary ef- 
fort. On the patient attempting to raise the arm, the low- 
er angle of the scapula is separated more than three inch- 
es from the thorax. The latissimus dorsi appears to be 
lost. The supraspinatus seems normal, infraspinatus de- 
cidedly hypertrophied, but its power is somewhat di- 
eters Only a few fibres of the pectoralis can be 
elt. : 

Left side: Hand, slight depression over the dorsal 
interossei ; diminished abduction and adduction of ring- 
finger ; index-finger can be adducted fairly, but abduc- 
tion is nz’. Other movements of the fingers appear nor- 
mal. The extensors of the wrist are much feebler than 

the flexors, and all the 
muscles of the arm are 
extremely wasted and 
feeble. The muscles of 
the shoulder and upper 
part of back are in 
about the same condi- 
tion as those on the 
right side, 

The deep muscles of 
the back can hardly be 
felt (there is considera- 
ble subcutaneous adi- 
pose tissue throughout 
the entire body). The 

glutei do not seem very 

much wasted, but have 
a doughy feel when re- 
laxed. The patient can 
flex the thighs on the 
abdomen, but not with 
normal vigor. .The 
quadriceps and ham- 
string muscles are very 
much atrophied on both 
sides. Right thigh, 17 
inches; left thigh, 164 
inches. Adductors of 
thighs atrophied and 
flabby. Rotators seem 
moderately vigorous. 
Left anterior leg group 
very much wasted and 
soft, with correspond- 
ing diminution of pow- 
er; right anterior leg 
group not much affect- 
ed. Right calf muscles 
are a little soft, but not 
much wasted; those of the left leg are considerably 
wasted and paretic. Right leg, 13% inches; left leg, 12 
inches. Slight patellar tendon reflex is present on both 
sides. 

At the beginning of full inspiration there is slight sink- 
ing-in of the epigastrium, and the abdominal walls re- 
main almost motionless. On forced expiration there is 
slight contraction of the abdominal muscles, most marked 
in the upper part of the recti abdominis. 

While standing there is very marked: lordosis, but this 
disappears in the sitting position and the back becomes 
straight. The lordosis is evidently owing to the tilting 
forward of the pelvis, thus necessitating a compensating 
curve in the dorsal spine to maintain the equilibrium. 

The reaction of the wasted muscles to faradism is di- 
minished throughout the body ; this is also true, in the 
main, of the galvanic reactions, but certain muscles also 
present slight qualitative changes in galvanic excitabil- 
ity. In the triceps, for example, the muscular contrac- 


Fic, 8652.—Front View of Same Pa- 
tient. (After. photograph taken in 
1887.) 


tion is slow, and AnCIC = CCIC. This condition is also 
observed in the flexors of the left forearm. 

The patient has the waddling gait of pseudo-hyper- 
trophic paralysis, and rises from the sitting posture by 
“climbing up the thighs.” Sensation is normal through- 
out the body; micturition and defecation are not inter- 
fered with. The disease has now lasted twenty-two 
years and, with the present slow rate of progress, the 
patient may live many years longer. 

INFANTILE PROGRESSIVE MuscuLAR ATROPHY.—Du- 
chenne was the first to describe this affection, which he 
regarded as identical with spinal progressive muscular 
atrophy. 

The disease usually begins about the age of five or six 
years, but it has also been known to begin in later youth, 
or even in adult life. Asa rule, it first appears in the 
muscles of the face. The muscles attacked most con- 
stantly are the zygomatics and orbicularis oris. The 
wasting of these parts produces a peculiar change in the 
physiognomy. When the patient laughs the angles of 
the mouth are drawn upward instead of upward and out- 
ward, by the unopposed ac- 
tion of the levator labii su- 
perioris, At the same time 
the lips are kept slightly 
separated on account of the 
paralysis of the orbicularis 
oris, and the pronunciation 
of the labials is interfered 
with. The lower lip is pen- 
dulous and prominent, and. 
often somewhat thickened. 
This latter symptom is not 
so constant, however, as has 
been supposed by the French 
writers. The face has a pe- 
culiar expression of mental 
hebetude, although intelli- 
gence isunaffected. Insome 
cases the orbicularis palpe- 
brarum, buccinator, and 
frontalis muscles also un- 
dergoatrophy. The tongue 
always remains unaffected, 
as do the muscles of masti- 
cation and those of the ve- 
lum palati. Gowers has de- 
scribed a peculiar case which 
resembled the disease under 
consideration, and’in which 
the ocular muscles were also 
paralyzed, but he was un- 
prepared to make a positive 
diagnosis, 

The atrophy next attacks 
the shoulder and arm, and 
then spreads to the corre- 
sponding parts on the oppo- 
site side of the body. The 
shoulder-girdle and thoracic 
muscles are involved in 
turn, and finally the lower limbs, particularly the flexors 
of the thighs. 

The forearms, with the exception of the supinator lon- 
gus and the hands, are rarely attacked, though a few 
cases have been reported in which the muscles of the 
thenar and hypothenar eminences had entirely disap- 
peared. 

The supraspinatus, infraspinatus, and teres major and 
minor, are rarely attacked ; the pectorals and latissimi 
dorsi are very commonly wasted. 

The atrophy of the face may last five years, or even 
much longer, before any evidences of the spread of the 
disease become noticeable in the limbs or trunk. 

In some cases the disease has begun in the arms or 
hands, and then spread, at a later period, to the face. 
This is especially apt to happen when the affection be- 
gins, as it rarely does, after the patient has arrived at 
manhood. 


Fia. 3653.—Side View of Same Pa- 
tient. (After photograph taken in 
1887.) 


579 


Spinal Cord. 
Spinal Cord. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Hypertrophy of the muscles is never observed in con- 
nection with the atrophy, so far as I have been able to 
learn from the literature of the subject, with the excep- 
tion of a case reported by Westphal, in which there was 
also pseudo-hypertrophic paralysis of the buttocks and 
thighs. As a rule, the electrical excitability of the af- 
fected muscles is simply diminished, but indications of 
partial DeR have also been reported in a few cases. 

Heredity is the only known etiological factor in this 
rare disease. Duchenne reported, among others, two cases 
in a brother and sister ; the father began to suffer from 
progressive muscular atrophy at the age of forty-eight 
years, but the face was not involved ; the paternal grand- 
father had also suffered from some form of progressive 
muscular atrophy, which had advanced to such a stage 
as to render him entirely helpless. Westphal observed 
the disease in a woman who also suffered from paranoia, 
with periodical alternations between depression and exal- 
tation and diabetes insipidus during the periods of ex- 
altation. 

In a considerable proportion of cases the disease does 
not run the typical course just described, and there are 
numerous transitions from one type to another. For 
example, Charcot has described a case in which the 
localization and course of the disease were similar to those 
of pseudo-hypertrophic paralysis, but the affected parts 
presented no increase in size. Again, Landouzy and Dé- 
jerine claim that the infantile form of progressive muscu- 
lar atrophy is always attended by atrophy alone; but 
Westphal has described a case which was associated with 
marked pseudo-hypertrophy of the buttocks and thighs. 
In like manner I could show from the literature of the 
subject, did space permit, that there are transitions be- 
tween all the varieties of myopathy, and it often depends 
upon personal bias whether the case is placed in one or 
the other category. 

The disease may last very many years, and does not 
often prove directly fatal to life. 

In concluding the clinical history of the various forms 
of progressive muscular atrophies, I will briefly refer 
to a peculiar variety, described by Charcot and Marie 
(Tooth has applied the term peroneal type to this affec- 
tion), and which seems to occupy a position apart from 
the other forms. I will. merely give a brief abstract of 
their paper (Rev. de Méd., 1886, p. 97). 

The disease always begins in the lower limbs, usually 
in the extensors of the great toe or the common extensor, 
or the peronei. This is the first noticeable symptom, 
though it is probable that the paralysis really begins in 
the intrinsic muscles of the foot, but escapes notice on 
account of the unimportance of these parts. All the 
muscles of the leg are gradually involved, the calves 
remaining unaffected longer than the other parts. Pa- 
ralysis and atrophy go hand in hand, and finally become 
complete. The thighs continue normal for a certain 
length of time. The vastus internus seems the first to 
be attacked, the adductors are well preserved, and the 
flexors of the thigh are but little affected. 

The hands become affected in from two to five years 
after the atrophy has begun in the legs. The change 
always appears first in the small muscles of the hands, 
and then extends to the forearms. The interossei are not 
always affected in a uniform manner. The extensors of 
-the forearm usually suffer before the flexors; the prona- 
tors and supinators are attacked very late, if at all; the 
supinator longus is always normal. AJl other muscles 
remain intact. 

Fibrillary contractions are very distinct, except in the 
last stage of atrophy. The direct muscular excitability 
is diminished in the affected parts, and this is true of the 
tendon reflexes. 

In completely wasted muscles the electrical excitability 
is lost. In those less affected there is DeR ; AnClC = or 
>CaClC, the contraction is slow, and faradic contractil- 
‘ity is abolished. In slightly affected muscles there is 
simple diminished reaction to both currents. 

The muscles do not undergo contracture ; the integu- 
ment of the affected parts presents well-marked bluish or ~ 
reddish marbling. The subcutaneous adipose tissue may 


580 


be increased. The temperature of the affected limbs 
is considerably diminished. These symptoms are less 
marked in the upper than in the lower limbs. 

In four cases, sensation was undisturbed. In one of 
Eichhorst’s cases there was hypereesthesia of the dorsum 
of the foot ; in another case there was diminished sensi- 
bility in the legs. 

In one of Charcot’s cases there was anesthesia to touch 
and temperature, which became less marked in the upper 
part of the limb. There were also retardation and per- 
sistence of sensation, and the muscular sense was also 
slightly affected. This patient suffered from pains in the 
lower limbs. . 

Pains have also been observed in other cases, but do 
not seem to be an essential feature of the symptomatology.. 
Cramps in the calves were noticed in almost every case. 
The other bodily functions were normal. 

The disease generally begins in childhood or youth. 
Among 19 cases, 14 began before the age of twenty-two 
years. In one of Eichhorst’s patients the disease was 
perhaps congenital; in another it began at the age of 
thirty-six years ; in two of Wetherbee’s patients, at thirty- 
nine years. 

Pathological Anatomy.—A. number of cases have been 
reported in which the most careful and competent exam- 
ination failed to reveal the slightest evidences of change | 
in the nerves or spinal cord. In a number of other cases 
slight lesions have been found in the spinal cord, but 
these were entirely disproportionate to the muscular dis- 
ease, and were probably either secondary or mere coinci- 
dences. ; 

‘‘Granular disintegration”’ of various parts of the spi- 
nal cord has been observed a number of times by various 
English writers, but there is very little doubt that this le- 
sion is an artefact, produced during the hardening of the 
tissues in alcohol. 

Changes in the muscles, on the other hand, are found 
in all cases, but while the histological appearances ure 
quite distinct from those described in spinal progressive 
muscular atrophy, those found in the various myopathies 
differ greatly from one another. : 

I will first give the results of my own examinations. 

In a case of pseudo-hypertrophic paralysis, I observed 
the following: A large amount of adipose and fibrous 
tissue was situated between the muscular fibres. A few 
capillaries were found distended with blood, their walls 
thickened, and presenting nuclear proliferation. The vas- 
cular changes constituted a minor part of the morbid pro- 
cess, The muscular fibres were very markedly changed. 
They were very unequal in size, and few of them main- 
tained the same dimensions throughout their entire length. 
A few fibres had a peculiar convoluted appearance, and 
a number branched dichotomously. In many the trans- 
verse strive were indistinguishable, in others they were less 
distinct than the longitudinal stria. Even in those fibres 
in which the transverse striz were distinct, they did not 
seem to be as far removed from one another as in the 
normal condition. Some had a homogeneous swollen ap- 
pearance (vitreous degeneration), and the sarcolemma 
had a jagged outline as if it were distended by its con- 
tents. In many places the muscle nuclei within the sar- 
colemma were increased in number, rounded, and only 
about a third the length of the normal nuclei. There 
was very great increase in the number of nuclei upon and 
around the sarcolemma. 

In a case of Erb’s juvenile atrophy the appearances 
were very similar to those just described, but not identi- 
cal. The blood-vessels did not seem to be changed, but 
there were broad bands of fibrous tissue, containing nu- 
merous nuclei, and here and there a few clumps of adi- 
pose cells, running between the muscular fibres. The 
latter were very scanty and presented a striking contrast 
in size. The majority were very large, but a consider- 
able proportion were much narrowed. Almost all had a 
vitreous appearance, but the strie were distinct. In not 
a few there was transverse fissuring, and rarely longi- 
tudinal fissuring. No dichotomous fibres were seen, but 
there were a few convoluted ones. The nuclei within 
the sarcolemma were slightly increased. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


In Schultze’s case, which also resembled Erb’s juve- 


nile form, the increase of connective and adipose tissue 
between the muscular fibres was comparatively slight. 
- Most of the latter were unchanged in size, but some were 
hypertrophied. There was increase of sarcolemma and 
muscle nuclei; the striz were preserved ; some of the 
hypertrophic fibres branched dichotomously. Schultze 
also observed a peculiar vacuolization of certain fibres. 
In some the vacuole included almost the whole width of 
the fibre, leaving only a small rim of muscle-tissue at 
the circumference. In others there were several vacu- 
oles in one fibre, with a delicate meshwork of muscle- 
tissue between them. 

In a case of atrophy with implication of the facial 
muscles (infantile progressive muscular atrophy), West- 
phal examined a piece of the left deltoid. He found 
simply hypertrophy of fibres (0.185-0.203 mm. wide, the 
normal width being 0.010-0.062 mm.), which otherwise 
looked normal ; there was also some increase in the num- 
ber of sarcolemma nuclei. 

Gowers believes that the apparent hypertrophy is the 
result of ‘‘a vital contraction excited by the process of 
excision.” This seems to be disproved by Schultze’s 
case, in which the hypertrophy was observed on post- 
mortem examination, and not after excision in the living 
subject. 

Hardly anything is known concerning the pathologi- 
cal anatomy of the peroneal type described in the section 
on Clinical history. Charcot and Marie suggest that it 
is the result of peripheral neuritis, and in three cases in- 
terstitial neuritis was really found on autopsy. It must 
be admitted, however, that our knowledge of this affec- 
tion is too imperfect to warrant us, for the present, in 
drawing any conclusions with regard to its pathology 
and pathological anatomy. 

Pathology.—Extreme views are entertained with re- 
gard to the pathology of the affections under considera- 
tion. Some pathologists look upon them as being purely 
myopathic, others are inclined to regard them as purely 
central in origin. The majority of writers, however, 
look upon some of them as myopathic, others as myelo- 
pathic. 

With regard to the pathology of bulbar paralysis, there 
can be very little doubt. It was long supposed, in 
accordance with the teachings of Duchenne, that this 
disease differs essentially from the progressive muscular 
atrophy usually regarded as spinal in origin, in the fact 
that the paralysis and atrophy of the muscles do not go 
hand in hand, the former being usually far advanced 
before the latter is appreciable. This statement is not 
in accordance with the facts, and the apparent discrep- 
ancy arises from the frequent difficulty of detecting 
atrophy in the affected parts. In more than one case 
I have remarked the failure of good observers to de- 
tect atrophy of the orbicularis oris in progressive bulbar 
paralysis, although this becomes evident at once as soon 
as the lips are grasped between the fingers, and the 
thickness of the muscular tissue is compared with that in 
healthy individuals. 

In the tongue the atrophy is usually evident from a 
very early period in the disease. In all other respects 
this disease runs the same course as myelopathic progres- 
sive muscular atrophy, and the frequent combination of 
lateral sclerosis with one or both of the above-mentioned 
diseases points to the intimate relations between these 
three affections. Indeed, it seems very probable that 
they all are the result of one underlying cause, which, 
for some unknown reason, attacks only the motor sys- 
tem (one case of amyotrophic lateral sclerosis has been 
reported, in which not alone were the pyramid tracts in- 
volved in their entire course through the brain, but also 
the ganglion-cells of the motor cortical zone), and that, 
as the localization of the lesion takes plaee in one or the 
other locality, we shall find the symptoms of bulbar paral- 
ysis, progressive muscular atrophy, or amyotrophic later- 
al sclerosis. 

The histological appearances of the paralyzed muscles 
also furnish a strong argument for the nervous origin of 
bulbar paralysis. Although our knowledge of the mor- 


Spinal Cord, 
Spinal Cord, 


bid anatomy of the muscles in the various muscular 
atrophies is still imperfect, nevertheless I think I am 
warranted in saying that the morbid appearances in those 
forms which are undoubtedly myopathic, are very dif- 
ferent from those observed in paralyses of undoubted 
spinal origin, for example, acute anterior poliomyelitis ; 
and also from those found in bulbar paralysis and the 
so-called spinal progressive muscular atrophy. The con- 
stant occurrence of the degeneration reaction is another 
important point in favor of the nervous origin of the dis- 
ease. As we have seen in thie section on clinical history, 
this is exceedingly rare in the various forms of myo- 
pathy, and has been observed hitherto only in lesions of 
cae pele! nerves or the anterior horns of the spinal 
cord. 

The theory of the other school proves too much. If 
the spinal lesions, as is claimed, are secondary to the dis- 
ease of the muscular system, there is no apparent reason 
why advanced stages of the latter should not always 
give rise to lesions of the cord. That this is not true is 
proven by numerous cases in which the central nervous 
system was found intact., This very fact seems to me 
to prove that the myopathic theory is insufficient for all 
cases, 

The frequent combination of bulbar paralysis with pro- 
gressive muscular atrophy points to the similarity of the 
two affections. Moreover, the clinical history is practi- 
cally the same if we take into consideration the vital im- 
portance of the parts affected. In addition to the fact 
that the anterior horns of the spinal cord have been 
found diseased in pure cases of progressive muscular 
atrophy, we have the further fact that the symptoms of 
the disease are also observed in other affections of the 
spinal cord which extend to the anterior horns (deutero- 
pathic). 

We are therefore forced to the conclusion that bulbar 
paralysis and progressive muscular atrophy are due to 
primary lesions of the motor cells in the medulla oblon- 
gata and anterior horns of the spinal cord, respectively. 
The lesion in question is apparently of the nature of a 
simple atrophic degeneration, but some pathologists. re- 
gard it as inflammatory initsnature. We possess insuffi- 
cient data to decide this question, although I think the 
weight of evidence is in favor of the former view. 

On the other hand, there are undoubted cases of pri- 
mary myopathic disease, such as pseudo-hypertrophic 
paralysis and its allied affections, and it seems as if these 
latter diseases were more frequent than was formerly 
supposed. Many cases which were regarded as central 
in origin are now placed in the category of myopathic 
affections. But what the nature of the muscular lesion 
is 1 am unable to state. The theory of its inflamma- 
tory character does not seem to be in accordance with 
the pathological appearances. Nor is there, in my opin- 
ion, any satisfactory foundation for the theory that the 
changes in the muscular fibres are the result of com- 
pression, due to primary increase of the interstitial con- 
nective and adipose tissue. We may merely beg the 
question by saying that the disease is the result of a 
trophic disturbance in the muscular substance itself, re- 
sulting from a congenital or acquired anomaly of nutri- 
tion in the muscular system, and which probably gives 
rise secondarily to the changes which are observed in 
the interstitial tissue. We are also entirely in the dark 
with regard to the differences in the localization of the 
affection. It must be left to future investigations to de- 
cide whether these variations are the result of vital dif- 
ferences in etiology, or whether they are different forms 
of one disease. The prevailing opinion, at the present 
time, is very decidedly toward this latter theory. 

The nature of the lesion in the ‘‘ peroneal type” of 
muscular atrophy must be left for future investigations. 
We may say, however, that the strong hereditary, ele- 
ment and the clinical history seem to indicate a periphe- 
ral, rather than a central, origin. 

Diagnosis,—We will first consider the differential diag- 
nosis of spinal progressive muscularatrophy from atrophy 
of myopathic origin. 

The occurrence of fibrillary contractions is an impor- 


581 


Spinal Cord. 
Spinal Cord. 


tant sign. This symptom is quite constant in myelo- 
pathic atrophies, and until very recently it was supposed 
never to occur in the myopathic affections. We now 
know, however, that it is observed in rare cases of the 
latter. In myopathies, however, the symptom is not a 
prominent one, and does not appear to be of long dura- 
tion. 

The electrical reactions of the paralyzed muscles fur- 
nish another differential sign. As a rule, complete or 
partial (usually the latter) degeneration reaction is ob- 
served in myelopathic atrophy, even at an early stage of 
the disease. As we have pointed out in the remarks on 
symptomatology, this symptom may be elicited with dif- 
ficulty when the healthy fibres in a muscle predominate 
over the atrophic ones ; and if the latter are very scanty 
in proportion to the others, even the most careful exam- 
ination may not disclose any change. In myopathic 
atrophies, on the other hand, simple diminution of excit- 
ability to both currents is the almost invariable rule, al- 
though recent observations have shown that partial de- 
generation reaction is present in some cases. 

As a general thing, the diagnosis can be made from the 
manner in which the disease spreads from one part of 
the body to the other. Myelopathic progressive muscu- 
lar atrophy begins almost invariably in the small muscles 
of the hand or in the shoulders, and then spreads to the 
muscles of the arms and trunk. In the myopathies, the 
small muscles of the hand are hardly ever attacked, even 
after the disease has lasted a Jong time and made great 
advances in other parts of the body. Furthermore, spinal 
progressive muscular atrophy usually attacks one muscle 
after another in such a way that we can follow its course, 
while the myopathic forms attack whole groups of mus- 
cles at apparently the same time. For example, the for- 
mer disease will attack one interosseous muscle after 
another, then successive muscles of the thenar and hy- 
pothenar eminences, next the muscles of the arms, etc. 
But in the myopathic forms, for example in pseudo- 
hypertrophic paralysis, the patient will be found suffer- 
ing, at the beginning of the disease, from weakness of al- 
most all the muscles of the lower limbs and back, though 
some are affected more severely than others. 

Heredity as an etiological factor is found almost ex- 
clusively in the myopathies, so that the occurrence of 
muscular wasting in more than one member of the same 
family is a strong argument in favor of its myopathic 
origin. The latter diagnosis is favored in an equal meas- 
ure by the occurrence of the disease in childhood or 
_ youth. 

Finally, the microscopical examination of excised por- 
tions of the affected muscles may throw some light on 
the diagnosis. In wasting of central origin, the muscle 
usually presents, at least for a long time, the evidences 
of simple degenerative atrophy ; in myopathies hyper- 
trophy of fibres is found in almost all cases, the trans- 
verse and longitudinal striation is usually quite well pre- 
served, and interstitial changes are found at an early 
period. 

In conclusion, it may be said that, while a careful 
examination of all the facts will generally enable us to 
decide between the muscular or central origin of the dis- 
ease, in some the doubts can only be dissipated by post- 
mortem examination. 

A few words with regard to the differentiation of spinal 
progressive muscular atrophy from other diseases of the 
nervous system. 


At the onset of the malady the diagnosis of lead palsy 


is sometimes excluded with difficulty. The latter may 
begin apparently in the interossei and, in exceptional 
cases, the muscles of the thenar and hypothenar emi- 
nences undergo early atrophy. As a rule, however, the 
supinator longus escapes on the extensor side of the fore- 
arm, and the flexors remain normal, or approximately so. 
But if we remember that the wasting of lead palsy may 
also extend to the muscles of the arm and shoulder—in- 
deed, sometimes tothe lower limbs—and that DeR is pres- 
ent, it is evident that mistakes may arise. A case is at pres- 
ent under the writer’s observation in which the interossei, 
thenar, and hypothenar eminences were first attacked, 


582 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


and for some time it was regarded as probably a case of 
progressive muscular atrophy. The patient has no blue 
line on the gums, no mode in which lead could have 
entered the system can be discovered, and chemical ex- 
amination of the urine for lead was attended with nega- 
tive results. The diagnosis of lead palsy was made on 
account of the previous occurrence of abdominal colic 
(without any ascertainable cause), the paralysis of the 
extensors without implication of the flexors, the com- 
plete DeR at an early period, and the comparative rapid- 
ity of improvement under treatment. In this case, as in 
a number of other undoubted cases of lead palsy, the 
supinator longus is also paretic, though not to such a 
marked degree as the extensors, 

Deuteropathic progressive muscular atrophy, 7.e., that 
form of disease in which the atrophy results’ from the 
extension of a lesion in other parts of the spinal cord to 
the anterior gray columns, is distinguished from the pro- 
topathic variety by the presence of the symptoms of the 
primary disease (pains, ansesthesia, occurrence of paraly- 
sis before the development of atrophy, interference with 
the functions of the bladder and rectum, etc.). 

After the diagnosis of myopathy has been made, the 
special variety is recognized by the localization of the 
wasting and hypertrophy of the muscles, and the course 
of the disease as described in the section on clinical his- 
tory. A large number of cases, however, constitute 
transitions between the different types there mentioned, 
and cannot be definitely relegated to any special class. 

Prognosis.—Complete restoration of parts which have 
undergone wasting or hypertrophy never seems to occur. 
In all cases, the chance that the disease will not shorten 
life is so much greater, the later the period at which the 
disease begins. When this takes place in adult life, the 
patient may live to an advanced age, unless carried off 
by an intercurrent disease. It must always be remem- 
bered, however, that diseases of the respiratory organs 
are a special source of danger in myopathies, on account 
of the frequent implication of the respiratory and abdom- 
inal muscles. 

In pseudo-hypertrophic paralysis the lease of life is 
usually shorter than in the other varieties, but even here 
the disease may come to an apparent standstill for years. 
More rapid progress is often made after the patient is 
permanently confined to bed. 

Treatment. — Pseudo-hypertrophic paralysis does not 
seem to be influenced by treatment. Massage and elec- 
tricity have been recommended. Benedikt claims to 
have cured five cases by galvanization of the sympathetic, 
but his statements should be received with a great deal of 
caution. Uhde and Gowers have derived benefit from 
cutting the tendo Achillis when walking is prevented by 
contracture of the calf muscles. Duchenne reports two 
cases in which the disease was arrested by prolonged fara- 
dization of the muscles. . 

Better results seem to have been obtained by faradiza- 
tion and galvanization of the muscles in the other forms 
of myopathy, notably in Erb’s juvenile form. 

Leopold Putzel. 


SPINAL CORD DISEASES: SPINAL HEMIPLEGIA. 
Synonym: Brown-Séquard’s Spinal Paralysis.—Spinal 
hemiplegia is the name, not of a disease, but of a group 
of symptoms, produced by unilateral lesions of the 
cord. Such lesions are in part of traumatic origin, such 
as gunshot wounds, or wounds with sharp instruments, 
resulting in partial destruction or section of one-half of 
the cord, the injury being limited to that side; in part 
the result of disease, as compression of one-half of the 
cord by a tumor, or blood-clot, circumscribed sclerosis, 
etc. Similar manifestations have been produced by ex- 
perimental hemi-section of the cord in animals, especially 
at the hands of Brown-Séquard. It was the latter who first 
drew a clear picture of spinal hemiplegia, based partly 
upon his experiments, partly upon the analysis of reported 
clinical cases. Both the clinical picture and the physi- 
ological conclusions drawn from it, though often looked 
upon with distrust, are now pretty generally accepted. 
Yet, future modifications of the physiological views are 


REFERENCE HANDBOOK OF 


Spinal Cord. 


THE MEDICAL SCIENCES. Spinal Cord. 


not improbable. This is more likely to be true of the 
paths of the sensory fibres, the study of which has al- 
ways met with great difficulties, than of the motor fibres, 
whose course seems to be pretty definitely determined. 
Modifications are the more probable, because the lesions 
of the cord upon which physiological views are based— 
experiments on animals are not now referred to, because 
their results are not always directly applicable to man— 
have rarely the precision necessary for exact conclusions, 
and observations in different cases have been, to some 
extent, at variance with one another. 

The most prominent symptom is motor paralysis of 
only the lower, or of both lower and upper extremities, 
according to the location of the lesion. It is on the side 
of the lesion, though there is also, at times, slight pare- 
sis of the other side. There is often a temporary vaso- 
motor paralysis on the side of the lesion, indicated by a 
rise of temperature of the paralyzed limb. There is at 
the same time sensory paralysis—anesthesia—of the oppo- 
site side of the body, while there is heightened sensibility 
—hyperesthesia—on the side of the lesion. But this is 
only true of certain kinds of sensibility—that to touch, 
pain, temperature, etc.—while the muscular sense is abol- 
ished on the side of the lesion. 

The physiological deductions from these clinical data 
are as follows: The motor fibres run in the cord on the 
same side as are the muscles supplied by them. They 
cross to the other side in the medulla oblongata. The 
slight paresis sometimes found on the other side is per- 
haps due to a small number of the motor fibres decus- 
sating with those of the opposite side in their passage 
through the cord, or, perhaps, each cerebral hemisphere 
is, to a certain extent, related to both sides of the body. 

The sensory fibres pertaining to muscular sense also run 
through the cord on the same side, while all the other 
sensory fibres, very soon after their entrance into the 
posterior roots, decussate with those of the other side and 
run to the brain in the opposite side of the cord. Brown- 
Séquard believes that there are different nerve-fibres for 
the different kinds of sensibility—touch, temperature, 
pain, ete.—and that they lie in different parts of the cord ; 
for there may be loss of one kind of sensibility and not 
of others, or one may be affected to a greater extent than 
the others. If this be true, those of pain and tempera- 
ture are most nearly related, for they are usually affected 
to about the same degree. 

The symptoms thus far given are those of severance or 

destruction of the nerve-strands in the cord. But there 
may be further symptoms dependent on injury of nerve- 
cells in the cord, or of the nerve-roots, or due to second- 
ary degenerations. Destruction of the large ganglion- 
cells causes muscular atrophy. This atrophy is found 
in the muscles innervated from the level of the lesion. 
Destruction of the anterior nerve-roots also causes muscu- 
lar atrophy ; destruction of the posterior roots, aneesthe- 
sia. The latter is always on the side of the lesion. 
Therefore, on the side of motor paralysis the hyperes- 
thesia is limited above by an anesthetic border. Second- 
ary degeneration of the lateral columns below the seat 
of lesion causes muscular rigidity, exaggerated tendon re- 
flexes, etc., in the parts affected by motor paralysis. 
* In some instances temporary paralysis of the bladder 
and rectum was observed. Rarer occurrences were acute 
decubitus on the side of sensory, and inflammation of the 
knee-joint on the side of motor, paralysis. — After disap- 
pearance of paralysis of the lower extremity ataxia has 
been observed, probably due to injury of the posterior 
column. Philip Zenner. 


SPINAL CORD DISEASES: SPINAL IRRITATION. 
INTRODUCTION AND DEFINITION.—A]though the complex 
of symptoms described by older authors under the name 
of Spinal Irritation has no pathological anatomy beyond 
the very probable one assigned to it by Hammond, of 
anemia of the posterior columns of the spinal cord, the 
affection is, nevertheless, of sufficient importance, and is 
frequently enough met with, to deserve to be retained in 
the more recent nosology of nervous diseases. It is an 
affection characterized by acute pain in the spinal region, 


always increased by pressure over the spinous processes, 
and is associated with various disturbances of sensibility 
along the course of the spinal nerves, arising from the 
affected region, and with certain visceral functional de- 
rangements ; the motor nerves are also affected, but in a 
lesser degree. 

Spinal irritation is most frequently found in women 
between the ages of fifteen and thirty-five years. These 
subjects frequently present symptoms of hysteria, but 
the affection is often enough observed independently of 
the latter malady, and is occasionally seen in men, so 
that its distinct identity cannot be seriously doubted by 
anyone with moderate experience. 

ErroLocy.—Among the predisposing causes of spinal 
irritation, sex comes first in order. As already men- 
tioned, women are peculiarly liable to this affection, and 
those who show greater tendency to hysteria are more 
frequently attacked, but at times even the most phleg- 
matic become victims to it, and men arenotexempt. This 
disease is most frequently seen between the ages of fif- 
teen and thirty-five years, and therefore young adult life 
would seem to predispose to it ; but it occasionally occurs 
at a later period, and even in old age, and it has been ob- 
served, though rarely, in childhood. The hysterical 
temperament, even in those who have never had any dis- 
tinct hysterical attacks, must be considered as an efficient 
predisposing cause. Also, heredity plays an important 
role, the disease being very often met with in members 
of a neurotic family. In a number of cases the disease 
cannot be traced to any special cause. Anything that 
weakens or excites the nervous system may act as an ex- 
citing cause ; such are strong emotions, violent passions, 
grief, fright, care, love, anxiety, mental over-exertion, 
etc. ; also violent bodily exercises, excessive watching or 
working at night, forced marches, strains, falls, or blows 
on the back, insufficient physical exercise, abuses in 
venery, onanism, excess in the use of alcohol or tobacco, 
frequent ungratified sexual desires, bad food, and ex- 
hausting diseases, such as typhoid, malarial, and scarlet 
fevers, dysentery, diphtheria, ete. 

Formerly affections of peripheral organs were credited 
with bringing on the disease in a number of cases, but 
this is no longer thought of. 

Symproms.—The development of the disease is usually | 
gradual, the first symptom being a slight feeling of dis- 
comfort, scarcely amounting to pain, somewhere over 
the spine, more generally in the dorsal region and be- 
tween the scapule. This is at first felt only after un- 
usual fatigue or exertion, but very soon becomes constant 
and amounts to severe pain. This pain varies consider- 
ably in intensity at different times and in different pa- 
tients, and it is described as a sharp, burning, boring, or 
lancinating pain ; it is always increased by pressure on 
the spinous processes of the vertebrae; occasionally the 
skin in the region of the pain is very hyperesthetic, and 
contact with the clothing even is insupportable ; at other 
times the pain in the back is so slight as to escape the 
patient’s attention, who complains only of the excentric 
symptoms to be presently mentioned, and the pain is ex- 
cited only by pressure over the spine. The location of 
the pain varies much in different patients, and in the 
same patient at different times ; its most usual seat is the 
dorsal region, between the shoulder-blades, and the next 
most common locations are in the back of the neck, and, 
less frequently, in the loins; occasionally it is felt over 
the whole spine. Hammond, and others after him, de- 
scribe a deep-seated pain over the other vertebre, which 
is increased by pressure or movements of the spine. 

Besides this pain, and more noticeable to the patient, 
are a number of excentric symptoms, more or less 
referable to disturbances of sensibility and of the func- 
tions of the vegetative organs, but also affecting, though 
to a lesser extent, the motor apparatus. The symptoms 
vary according as the pain in the back affects different 
portions of the spine. When the cervical spine is com- 
plained of we have neuralgic pains, and various pares- 
thesia, such as tingling, formication, and a feeling of 
heat or cold in the neck, chest, and upper extremities ; 
at times vertigo, headache, noises in the ear, disturbances 


583 


Spinal Cord. 
Spinal Cord. 


of vision, fulness and a sense of constriction across the 
forehead, and tenderness of the scalp, especially in the 
occipital region. In some cases distinct disturbances of 
the functions of the mind, sleeplessness, etc., also nausea, 
vomiting, hiccough, palpitation, and pain in the stomach, 
fibrillary twitchings or stiffness, clonic or tonic contrac- 
tions, or more or less violent choreic movements of the 
muscles of the arms and neck, and occasionally loss of 
power in the upper extremities. These symptoms are, of 
course, only in part present in each case, and vary con- 
siderably in intensity in different cases, 

When the dorsal portion of the spine is complained of 
we have, besides pain and tenderness in that region, 
intercostal neuralgia, infra-emammary pain, gastralgia, 
nausea and vomiting, dyspepsia, gastric flatulence and 
acidity, heartburn, palpitations, and attacks of syncope, 
and some slight disturbances in the sensibility or motility 
of the lower extremities. — 

When the lumbar portion is affected the symptoms are 
tenderness in the lumbar spine, neuralgic pains, with for- 
mication and other paresthesiz round the abdomen and 
down the lower extremities, cold feet, at times spasm of 
the neck of the bladder giving rise to retention or incon- 
tinence of urine, costiveness, and pain in the rectum, 
uterus, and ovaries ; also at times weakness of the lower 
extremities, or contractures, spasms, or clonic movements 
in the same. 

When the whole spine is affected we have more or less 
a combination of the above, the symptoms being the 
most prominent in those regions which are supplied by 
the nerves arising from the cord at the point of the great- 
est spinal tenderness. 

The symptoms of spinal irritation are, as a rule, alle- 
viated by rest in a horizontal position. 

CouRSsE AND Duration.—The course of the disease 
can be inferred, from what has been already said, to be 
very fluctuating, improvement and relapses alternating 
in quick succession without any apparent cause, the 
chief symptoms sometimes rapidly changing and affect- 
ing different regions of the spine and body. Its course 
is in some Cases very acute, the disease developing rapid- 
ly and terminating in the same manner. In most cases, 
however, it runs a chronic course, developing slowly, 
and is equally as siow in improving, lasting months, or 
even years, under the most efficient management. Some 
patients suffer more or less all their lives from some form 
or other of the affection. As a rule, however, a cure 
may be promised as a result of proper medical and hy- 
gienic treatment. 

The question, ‘‘Can the disease lead to some more 
dangerous spinal affection ?” may with safety, I be- 
lieve, be answered in the negative, if we take into ac- 
count the views of the more recent authors, who certainly 
have had better opportunities to study the disease, and 
who have not confounded it, as older authorities occa- 
sionally did, with organic affections. 

As to the true nature of the affection, nothing is posi- 
tively known; numerous hypotheses have been advanced 
to explain it, but none is absolutely proven. Some au- 
thorities claim that it is due to hyperemia of the cord, 
while others, with Hammond, and I believe with some 
reason, assert that it is due to anemia of that organ. 

CasE I.—C. B , white, female, aged thirty-one ; has 
been married two years, has one child living, does not 
belong to a neurotic family, gives no history of hysteria 
or any other nervous disease. She is a housemaid, but is 
much above her class in education, and is quite refined 
in manners, and evidently has seen better days. About 
a year before her application to me for treatment, the 
initial symptoms of her affection began to show them- 
selves. After a period of prolonged grief she began 
to be troubled with an uneasy, painful feeling in the 
spine, about the upper dorsal region, after every severe 
exertion ; this feeling soon became continuous, and was 
increased whenever she was accidentally touched on her 
back at that part of the spine; she was always easy at 
night, or when lying down. With the increase in sever- 
ity of the pain she was also troubled with attacks of 
breathlessness and palpitation, and had a constant sharp 


584 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


stitch in the infra-emammary region on the left side. Her 
appetite soon began to fail, and she was greatly troubled 
with nausea and occasional vomiting ; her head, she said, 
was not quite right, and she was troubled with some dizzi- 
ness; she felt weak in the legs, and had feelings as of ants 
crawling between the skin and flesh of the lower limbs. 
She remained pretty much in that condition, one day 
feeling badly and the other better, for about six months, 
when she was forced to relinquish work and went to 
consult a physician, who treated her several weeks for 
dyspepsia, but with no relief. She became almost bed- 
ridden at that time, and, after changing several medical 
advisers, sent for me in December, 1884. I found the 
patient in nearly the condition described, though very 
much weaker and considerably emaciated ; she remained . 
altogether indoors, getting up from bed two or three 
times during the day, and only for a few minutes ata 
time. She felt well only while in the supine posture ; 
her only nourishment consisted of two or three cupfuls 
of milk and weak beef-tea. I had no difficulty in im- 
mediately recognizing in her affection spinal irritation. 
I prescribed first a little whiskey and milk-punch at fre- 
quent intervals, day and night; this she retained with 
comfort. I then ordered a more generous diet, and gave 
internally one-sixtieth grain of strychnine three times a 
day, progressively increasing the dose, and the compound 
syrup of hypophosphites ; I also began electrical applica- 
tions, using the galvanic battery, and applied ascending 
and descending currents to the spine for from five to ten 
minutes every day. Ina month’s time the patient was 
so much benefited that she was able to come to my office, 
and in a few weeks more I discharged her cured. I 
meet this patient at frequent intervals, and she has had 
no return of her affection. 

Case II.—In the summer of 1883 I was called in con- 
sultation by Dr. Bemiss, to see one of his patients in 
Ward 18 of the Charity Hospital. A. R , aged nine- 
teen, white, male, born in New Orleans, had had ma- 
larial fever of an intermittent type for some weeks. 
When examined he had been free from fever for some 
days, but he complained of exquisite pain on pressure 
over the lower dorsal vertebre, with great weakness, pain, 
and numbness in the lower extremities ; he felt compara- 
tively at ease when lying down, but could scarcely stand 
on his legs; he had no gastric trouble, but had some 
difficulty in voiding his urine and was costive. 

The case was pronounced one of spinal irritation, and 
the patient, being put on progressively increasing doses 
of sulphate of strychnine, with a generous diet and free 
stimulation, made a rapid recovery. 

In searching over the patient’s history no tendency to 
neurotic affections could be detected, and the malarial 
fever was evidently the sole cause of the spinal irritation 
in his case. 

Case III.—M. B , white, female, aged twenty-six, 
who has had one child, is highly nervous, but has never 
had any hysterical attack ; gives a history of spinal irrita- 
tion affecting the upper dorsal region four years ago, . 
lasting several months, and being followed by complete 
recovery. She was admitted to Charity Hospital medi- 
cal service in the early part of 1886, where she remained 
several months ; she was then transferred to the gyneco- 
logical ward, and was operated on for lacerated cervix 
uteri with success, but with no improvement in her gen- 
eral condition. In October, 1886, she was transferred to 
my service, presenting the following symptoms: Great 
tenderness over the lumbar spine, great pain and tender- 
ness in the lower part of the abdomen and the lower ex- 
tremities, inability to stand from weakness of the legs, 
retention of urine of several months’ duration from spasm 
of the sphincter of the bladder, amenorrhcea of four 
months’ standing, and costiveness. The muscles of the 
paralyzed parts were stiffened but well nourished, and 
responded normally to irritation. Treatment for spinal 
irritation. The patient was discharged, cured, two months 
after admission. 

DraGenosis.—Spinal irritation, when fully developed, 
with all its regular complex of symptoms, is not difficult 
to recognize. In forming a diagnosis the principal points 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Spinal Cord. 
Spinal Cord. 


to be relied on are: The presence of pain in the back, 
developed or increased by pressure over the whole or 
part of the spine; excentric symptoms, affecting chiefly 
sensibility, but to a slighter extent the motility also, of 
parts of the body receiving their nerve-supply from the 
affected portion of the cord, and various visceral disturb- 
ances already mentioned; the changeable character of 
the symptoms and the fluctuations in the course of the 
disease ; and finally, the want of proportion between the 
severity of the subjective and the mildness of the objec- 
jective symptoms. 

The diseases with which it is more likely to be con- 
founded are: The earlier stage of myelitis and spinal 
meningitis; spinal hyperemia, hysteria, and_ spinal 
neurasthenia. 

In myelitis we have absence of hyperesthesia and ten- 
derness, except on deep pressure over the spine; severe 
paralysis of sensation and motion in the extremities, and 
complete visceral paralysis; painful contractures and 
spasms, the absence of the nervous condition found in 
spinal irritation, and generally a fatal termination. 

Meningitis spinalis is more difficult of differentiation ; 
stiffness and painful contraction of the muscles of the 
back, pain in the spine, increased by motion, but not 
affected by pressure, with absence of tenderness in the 
part, the presence of fever, late paralysis, etc., will, as a 
rule, however, be sufficient to enable us to establish the 
diagnosis of meningitis. 

Hyperemia of the cord is still more difficult to dis- 
tinguish from spinal irritation ; indeed, some authors 
claim, as stated above, that the symptoms of the latter 
disease are due to a congested condition of the spinal 
marrow. The general absence of tenderness or pain in 
the spinal region, and the fact that the symptoms are 
aggravated by the recumbent position on the back, are 
characteristics of importance in spinal hyperemia, and 
will generally suffice to distinguish it from irritation. 

‘Hammond proposes as a test between these affections 
the relief given in hyperemia and organic spinal diseases 
by the administration of ergot, while spinal irritation is 
made worse by the drug; and, on the other hand, the 
marked improvement in the symptoms of the latter affec- 
tion caused by the use of strychnine, and the aggravation 
of spinal hyperzemia and the other diseases by the exhibi- 
tion of this drug. 

The characteristic globus, general spasms, and other 
symptoms of hysteria will suffice to establish a diagnosis 
between this affection and spinal irritation, though it 
must be remembered that the two are frequently found 
associated. 

Neurasthenia spinalis, though resembling the disease 
under consideration, will be recognized by the fact that 
it is usually found in the male sex, by the absence of ex- 
treme spinal tenderness, and by the general preponder- 
ance of motor symptoms over those referring to sensi- 
bility. The two diseases have, however, an undeniable 
general resemblance. 

Angular curvature of the spine from vertebral caries 
is not likely to be confounded with spinal irritation, and 
its characteristic symptoms need not be referred to here. 

Proaenosis.—The prognosis is in general favorable, the 
majority of cases being cured, and a large number of the 
others benefited by judicious treatment. In a minority 
of cases improvement is, however, very slow, and at times 
imperceptible, and in others relapses are very frequent. 
Death has never been known to be caused by this affec- 
tion, but some of the patients are doomed to a tedious 
illness, lasting perhaps for years. i 

TREATMENT.—The main treatment in spinal irritation 
should be directed to the removal of the cause of the af- 
fection, and to the improvement of the tone of the gen- 
eral nervous system and of the spinal cord in particular. 
It will suffice for us to refer our readers to the causes 
already mentioned to see how best they may be re- 
moved. To obtain the second object, hygienic and me- 
dicinal means are to be employed, such as a generous 
diet with plenty of wine and other stimulants, passive 
and active exercise for short intervals in the open air, 
the keeping of the recumbent posture for the greater part 


of the time, etc. The judicious use of certain drugs 
presently to be mentioned, and of electricity, is also nec- 
essary. 


Cupping and blood-letting are scarcely ever indicated ; 


- counter-irritation to the spine by means of blisters, tar- 


tar-emetic ointment, or iodine, is of great use; hot ap- 
plications to the back, or the use of the ascending gal- 
vanic currents with the two poles on the spine, one 
above and the other below the tender part, are recom- 
mended by Hammond as of great service in diminishing 
the tenderness. 

Of the drugs themselves strychnine, in progressively 
increasing doses, is very useful; the phosphide of zinc in 
one-tenth grain doses three times a day, phosphorus, and 
phosphoric acid, are also of service. Opium, the bro- 
mides, and chloral are sometimes indicated, and general 
faradization with central galvanization is also recom- 
mended. Mountain- and forest-air is to be advised. 
Cold-water baths have proved beneficial in some cases. 


AUTHORITIES CONSULTED. 


Ross: Diseases of the Nervous System, ‘vol. ii. 
Rosenthal: Diseases of the Nervous System. 
Haase, K. E.: Krankheiten des Nervensystems (being vol. iv., part i., of 
Virchow’s Handbuch der speciellen Pathologie und Therapie). 
Charcot: Le¢ons sur les Maladies du Systeme nerveux. 
Grasset, J.: Maladies du Systéme nerveux, 8d edition. 
Erb: Article in Ziemssen’s Cyclopedia of Medicine, vol. xiii. 
Bramwell, Byrom: Diseases of the Spinal Cord. 
Radcliffe, C. B., in Reynolds’s System of Medicine, vol. i. 
Ollivier: Maladies de la Moélle épinicre. ; 
P. H. Archinard. 


SPINAL CORD DISEASES: TABES_ SPINALIS. 
This term is applied rather vaguely to all forms of spi- 
nal disease attended by slow wasting of the substance 
of the cord, but of the posterior column especially. I 
think it is better than ‘‘ locomotor ataxia,” which is the 
term in popular use, or ‘‘tabes dorsalis,” which just 
now it is the fashion to apply to cases of locomotor 
ataxia when there are only a few or no motor disorders. 
‘‘Locomotor ataxia” is simply a clinical appellation, 
and its symptoms are not necessarily due to posterior 
column disturbances, but to lemniscal lesions, alcoholic 
neuritis, or other conditions. There is still a condition 
which is denominated ‘‘ ataxic paraplegia,” which is, af- 
ter all, a hybrid disease. ‘Tabes spinalis may be said to 
be an affection confined for the most part to the posterior 
column of the spinal cord, and attended by abolition or 
impairment of centripetal transmission and the irritation 
of the posterior nerve-roots, with varying sensory derange- 
ments, abased or increased tendinous reflex activity, mo- 
tor inco-ordination, optic-nerve atrophy, and frequently 
various evidences of derangements of the sympathetic 
nervous system. 

Although Todd directed attention to a variety of symp- 
toms which are now recognized as those of the disorder, it 
is to Romberg! that the credit belongs of first accurately 
describing the disease under the name of tabes dorsalis, 
and who, presented an autopsy made by Froriep in which 
degeneration of the posterior parts of the cord was 
found. In 1868-78, Duchenne de Boulogne revived in- 
terest in the subject by an elaborate and advanced con- 
sideration of the subject, and about the same time Trous- 
seau, Charcot, Pierret, and other writers in France, and 
Westphal in Germany, added much to the literature, espe- 
cially of the morbid anatomy. In Charcot’s early work 
he established the existence of trophic changes, both os- 
seous and dermal, and very little has been since added to 
his description of the arthropathies. 

In England Russel Reynolds was among the first to 
consider locomotor ataxia, objecting. to the prefix ‘‘ pro- 
gressive,” which had been applied by Duchenne, and latter- 
ly Buzzard and Gowers have written well and extensively. 
In 1870-75 American writers, including Hammond, Cly- 
mer, Seguin, and myself, described the affection and pre- 
sented cases. 

The disease is one of a chronic and progressive nature, 
and while there are rare exceptions to this rule—espe- 
cially those of traumatic causation—the greater number 
run a prolonged course marked by three stages: 1, The 


585 


Spinal Cord. 
Spinal Cord. 


prodromal, or pre-ataxic of some authors ; 2, the developed, 
or ataxic ; 8, the degenerative, or stage of decline. ‘There 
are irregular varieties, one of which is known as the /e- 
reditary, or family, in which the subjects are young echil- 
dren, and there is a family history ; and Obersteiner and 
others have considered an ascending form which event- 
ually has a cerebral extension, and is expressed by symp- 
toms of mental disorder. There is also a form described 
by Fournier as sclérose cérébro-spinale postérieure, which 
is so irregular as to lead me to divide all cases of the dis- 
ease into the syphilitic and non-syphilitic, the former, as 
it will be seen later on, being largely in the majority. 

ErroLtoay.—It was the generally entertained belief, un- 
til within a few years, that locomotor ataxia was due in 
nearly all instances to sexual excesses, an impression 
which probably grew out of the fact that most of these 
patients were syphilitic, and many syphilitic patients 
were amorous free lances. The real nature of the syphi- 
litic causation was lost sight of until ten or twelve years 
ago, when Erb ‘and others brought forward most aston- 
ishing statistics. The conclusions of the first author are 
very extreme, and he holds that ninety per cent. of all 
patients have a history of specific disease. In Germany 
and elsewhere he has many supporters, but there are a 
few men of temperate diagnostic zeal who reduce the 
proportion of syphilitic cases. Seguin has been unable 
to find more than twenty per cent.* 

My own experience leads me to the conclusion that 
there are two classes of cases which possess some common 
characteristics, but which are very dissimilar in some 
ways. In one of these syphilis plays an active part, in 
the other there is no veritable specific history ascertaina- 
ble. If we group these cases together a very high percent- 
age of syphilitic cases is to be found, but the ratio of the 
hybrid cases,t in which syphilis is undisputed, is great to 
those of regular type and conventional progress. Of this 
class it is probable that fully ninety per cent. are syphilitic. 
Of what may be called the fixed-type class, there is not 
more than twenty per cent., or even less, where a reliable 
history of syphilis is to be found. 


Locomoror ATAXIA OF IRREGU- | LOCOMOTOR ATAXIA OF REGULAR 
LAR TYPE (SYPHILITIC). TYPE (RARELY SYPHILITIC), 


Of rapid progress; prodromal Of slow progress ; first stage of- 
stage short: ocular symptoms early | ten long—ten or twelve years; Ar- 
and diversified ; tendon reflex usu- | gyle- Robertson symptom; pains 
ally returns and is exaggerated, or | and absent reflexes almost only early 
is exaggerated from injury; mental | ocular symptom ; slow white atro- 
symptoms marked ; optic neuritis; | phy; ataxia of slow origin and bi- 
choked disk; ataxia irregular; pos- | lateral; plantar anzesthesia usually 
sible extension to ‘‘ general pare- | well distributed; mental defects 
sis;” aneesthesia often irregular, rare; arthropathies common. 

Arthropathies uncommon. The Rarely helped by iodide of potas- 
young subjects with local cranial | sium. 
paralysis complicated with ataxic | 
symptoms are usually syphilitic. 


Buzzard calls attention to the error one may fall into by 
impulsively choosing syphilis as a cause, when the pains 
and early symptoms may have preceded the syphilis for 
some years. I have borne this in mind in the examina- 
tion of every case, and can support his views most em- 
phatically.. So far as sexual excesses go, I believe that 
any method of cohabitation which implies repeated spinal 
shock and exhaustion, must invite the approach of dis- 
ease, and it is probable that forced and frequent connec- 
tion, especially when the pleasures of Bacchus and Venus 
are enjoyed simultaneously, may sometimes originate a 
spinal exhaustion which will soon terminate in sclerosis ; 
but thisisrare. The exceedingly fanciful ideas in regard 
to these causes entertained by the Germans are sometimes 
very laughable and improbable, and one writer in Ziems- 
sen gravely alludes to the perils of coition in the erect 
posture, while another finds that twelve of his cases were 
addicted to the habit of cottus reservatus, a method which 
in this country, I believe, is common only in the Oneida 
community. 

Sudden exposure to damp and cold, for which the per- 


* Buzzard, while admitting that his notes are imperfect, found that 25 
of 53 cases had a syphilitic history. Of Fournier and Erb's 127 cases, 59.8 
per cent. were syphilitic. The average percentage of five American au- 
thors was 41.4. 

+ Many of them cases of ataxic paraplegia. 


586 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


son is unprepared, is quite likely to cause the disease. 
As instances I may mention patients who fell overboard 
or who stood in wet places while shooting. One patient 
left his warm bed and descended into his yard to chase 
burglars, without taking the precaution of putting on 
shoes or slippers. ‘Traumatic cases of the malady are by 
no means unusual, though the exact manner in which 
injury gives rise to the disease is a matter of doubt. In 
making this assertion I leave out of question the cases 
of actual local vertebral violence, and the production of 
spinal bone lesions, and possibly meningitis confined 
chiefly to the posterior part of the cord. Railway con- 
cussion has resulted in a manifestation of symptoms in- 
dicative of locomotor ataxia. It is not of these cases I 
speak, however, for the morbid expressions are usually 
diverse. The traumatic scleroses are those, strange to 
say, where the rapid appearance of symptoms of pos- 
terior column disturbance has followed fracture of one 
of the long bones. I have seen several such cases. 

Hereditary cases are of a distinct type, and I am con- 
vinced are not purely localizable posterior sclerosis. I 
feel sure that the real cause of such congenital disease is 
often a syringo- or hydro-myelia, the cavity occupying 
the posterior half of the cord. 

Tabes is rarely found in women, and I can recall but 
a dozen personal cases of several hundred I have seen 
during the past twenty years, and four of these were 
syphilitic subjects. But two of these patients were class- 
ical cases, and the symptoms were due to lesions limited 
to the posterior root-zones of the spinal cord. Of Eulen- 
berg’s 149 cases, 128 were males and 21 females. The 
experience of other authors is my own. As to age we 
find that, except in rare instances, the disease seldom at- 
tacks individuals under twenty. Leyden fixes the limit 
as between the twenty-fifth to forty-fifth years. 

Of Eulenberg’s cases, to which allusion has just been 
made, the ages of invasion were : 


Male. Female. 
Belowijl0:: Prat eee oe eee 1 
LO to 205th, as eae Sec eae 2 0) 
BO 40! SOF Oe, Oh Pe ee, Bax TaD 12 
30 to 40 Le Pie oe Lee eee 39 v's 
40 TOO, Poa es Pee eer oe 47 1 
50 TOGO ae ee. we Cee 5 0 
Over 00;7/amaa Fee ea eee eee 0 0 


Symproms.—The prodromal symptoms of tabes are 
vague and irregular, but, like the early indications of so 
many serious nervous diseases, are mostly sensory. For 
a long time the early advances of the malady may be dis- 
regarded by the patient or his friends, and the pain as- 
cribed to several causes. Many ataxics are regarded in 
the beginning as hypochondriacs, even by competent 
medical men, and sometimes a careful examination will 
fail to reveal anything positive ; for while the two earliest 
positive indications—the Argyle-Robertson pupil and the 
absent tendon reflex—are to be determined in the majority 
of cases at a time when nothing else is manifested, there 
are many exceptional cases where the ocular symptom is 
not present, and where it is possible to evoke a patellar ten- 
dinous reflex by proper excitation. In the ordinary cases 
the patient complains at a very early period of fatigue 
and uneasiness in the lower extremities, and some per- 
sons have likened the sense of tingling and fatigue to 
that which follows a long walk. The muscles at the 
back of the thighs and legs are tired and sore, and the 
ankles and knees are ‘‘ weak” and ache. Slight exer- 
tion produces discomfort, and after a while actual pain 
of a shifting character and some plantar formication. 
Mental feebleness is also manifested, sometimes the pa- 
tient being depressed or peevish, and hypochondriacal. 
He is annoyed, morbidly conscious of the attitude of his 
friends, and fearful of some impending disaster. Appe- 
tite and flesh are often reduced, and the bowels become 
sluggish. Some of my patients have complained of 
headaches, and these have been dull, lasting for several 
hours, and with subsidence there has been a free action 
of the kidneys, with the elimination of a large quantity 
of clear urine. The vision is more or less impaired, and 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


transient attacks of diplopia are annoying. 
undergoes a change in its susceptibility to light stimu- 
lation, which has been described by Argyle-Robertson. 
This consists in preservation of the ability of the eye to 
accommodate with, of course, normal contraction or dila- 
tation, but a failure of pupillary response to light stimu- 
lation ; and it has been found that, owing to the abolition 
of the skin pupillary reflex, no dilatation of the pupil 
follows the pinching of the neck, which is the case in the 
normal individual. This symptom is by no mfeans con- 
stant, but is a very common and suggestive indication. 
-In many cases we find even the pre-ataxic stage of the 
malady marked by disappearance of the patellar tendon 
reflex. The absence of the knee-jerk, which was first de- 
scribed by Westphal, may be determined best by mak- 
ing the patient sit upon a high table or desk, so that his 
thighs are well supported and his legs hang loosely at 
right angles. Then a smart blow may be struck with a 
ruler or small percussion hammer just below the patella, 
or to one side over the fibular head. No movement of 


extension may follow, though a light tap over the vastus » 


externus may evoke a well-marked contraction. The 
loss of the reflex may be unequal, that is, it may be pres- 
ent on one side and absent on the other. The other re- 
flexes of the lower extremities are apt to be lost or dimin- 
ished. Mitchell and a host of other observers have shown 
that the tendon reflex varies under different conditions. 
According to the latter, the action of the will in some 
other direction is apt to increase or conserve an appar- 
ently dormant reflex. This I have not been.able to verify. 
This bluntness of the reflex is quite apt to be found in 
other places, and the reflex functions of the bladder are 
deranged, with a resulting difficulty in voiding urine. 

Brissaud has devised a remarkably ingenious appara- 
tus, by which the force of the knee-jerk may be exactly 
measured. In some cases, even at a very early stage, the 
tendinous reflex will be increased. 

THE EsTABLISHED DIskASE.—After a variable siege of 
premonitory symptoms we come to the pre-ataxic stage, 
which is often of long duration, and is characterized by 
the advent of pain, the loss of the tendinous reflex, the 
occurrence of pupillary changes. The pains of the ataxic 
are peculiar and almost unique. They are paroxysmal, 
fugitive, and intense—and, like those of the uncompli- 
_ cated neuralgie, are greatly aggravated by change of 
barometric pressure. ‘I have kept the records of one pa- 
tient for several years, and in his case every easterly or 
southwesterly wind was preceded by an exacerbation of 
leg pain, which was as certain as the barometer. The 
pains more often have their seat in the thighs—usually 
the inner surface—but the tract of the great sciatic may 
be the chosen spot. With great suddenness a twinge 
of the most intense description. will affect a spot not 
much larger than a quarter. Light at first, it increases 
in gravity, and, after a few minutes or a few hours, sub- 
sides and attacks some other spot. The quality of the 
pain has been likened to the tearing of flesh, the intro- 
duction of red-hot needles, and to various methods of 
torture—and the names terebrating, needle, boring, stab- 
bing, have been applied, and fulgurating, lightning, with 
regard to their suddenness and violence. Sometimes the 
ankles or soles of the feet may be the seat of the painful 
spots, and I have often found the popliteal space to be 
the locality. In some cases the pains dart up and down 
the course of anerve. There is a second variety, which 
is dull and in some respects resembles.rheumatism ; with 
this there is pain on movement, and considerable inter- 
paroxysmal soreness. The pains of posterior spinal scle- 
rosis are by no means regular in their expression, for the 
patient may have them on one side or on both, and with 
varying degrees of severity. Subjective coldness of the 
limbs is common, and with the pain there is often cramp- 
ing of the toes, and clonic contractures of the lower ex- 
tremities, which is semi-involuntary. The patient does 
not seem to be free from suffering at any time that may 
be counted upon. The suffering is perhaps more ex- 
treme at night and more constant. In some cases the 
ataxic pains choose sites which are peculiar—the light- 
ning pain attacking parts about the anus or running up 


The pupil | 


| spfuol cords “NY 
\ Spinal Cord.» ON 
ie. {YA ald 


Ni | , 
the rectum, and with this there is a sense-of ‘perinéaY 
weight and some tenesmus. Testicular pains are rare, 
but are sometimes found, nevertheless, and. clinicians 
have called attention to a horrible form of misery which 
consists in vaginal and vulvar pains, which are Dae 
in sclerosis in women—which is rare. 

After a variable siege of pain lasting from a few 
months to even twenty years, we find other sensory 
manifestations, such as anesthesia, hyperesthesia, and 
paresthesia, delayed conduction of sensation, and a loss 
of the muscular sense. As the disease is more often in 
the lumbar part of the cord than elsewhere, we naturally 
find most of the trouble below the waist. The anesthesia 
may be uneven at first, and afterward general, or, if there 


' be ascending degeneration, the fingers, hands, and arms 


are involved. A rare locality in cases in which the tabes 
invades the upper part of the cord is the episternal. 
In a few cases I have found a circumscribed area of an- 
sesthetic skin in this situation. The common form is that 
known as ‘‘ plantar,’ and much of the patient’s unsteadi- 
ness is due to his inability to preserve his sense of con- 
tact. When his eyes are closed he readily falls, or when 
he washes his face he is apt to pitch forward. At night 
it is impossible to walk about the room without support 
of some kind. This aneesthesia of the soles may be un- 
equal, so that perverted impressions are received. <A 
feeling as if foreign bodies were in the shoes is a familiar 
complaint. Sometimes the sensation is compared by the 
patient to that which might be produced by sand or wool 
beneath the feet ; again, as if the stocking was down at 
heel. A more grave, and correspondingly rare, form of an- 
eesthesia is that of the vagina or rectum, and if the upper 
tracts be involved we find occasionally a faucial and 
buccal aneesthesia ; but these phenomena do not belong 
to true cases of tabes spinalis. 

Tactile sensation is decidedly blunted, and the per- 
ception of painful contact as well. Various experiments 
have been undertaken to determine the time of trans- 
mission of a pin thrust, for instance, in the lower ex- 
tremities. In some cases the delay in perception is equal 
to a quarter of a minute. We may find that the painful 
impression is transferred and felt on the opposite side 
(allochryia), a curiosity described by Hammond ; or it 
may be perceived several times after one irritation. In 
fact, all sorts of sensory anomalies are presented. The 
patient loses his ability to appreciate weight, and is unable 
to make comparisons. 

In some cases the ‘‘ constricting-band” symptom is 
presented, which, however, is more common in acute 
myelitis than in the disease under consideration. This 
girdle sensation, or pareesthesia, is often found at the 
same time with vesical atony. The superficial reflexes 
are exaggerated until the plantar anzesthesia is complete, 
though the knee-jerk be absent. 

In the established disease the pains in the lower ex- 
tremities are not those alone which annoy the patient. 
Intense, lancinating pains, called by the French crises 
gastralgiques, invade the trunk and much torture results. 
The pain is colicky, but much more violent than the 
familiar condition of suffering, and is fugitive. Some- 
times it is attended by diarrhcea and by bloody discharges 
from the lower bowels, as well as vomiting. Cardiac 
pains like those of angina pectoris are features of tabes, 
but rare. In some examples of the disease the gastric 
crises take the place of the fulgurating pains in the lower 
extremities, and are a feature of the second stage ; but in 
many cases the distal pains occur from time to time in 
the well-established malady. 

As the central process of disease is confined chiefly to 
the dorsal and lumbar region of the cord, we find corre- 
sponding motor disturbances chiefly of the lower ex- 
tremities. The patient begins to grow clumsy and awk- 
ward, not from. a loss of power, but from an impaired 
ability to grasp the amount of muscular force he desires 
to use. When he stands with his feet approximated lat- 
erally, he sways to and fro, and often has to extend his 
arm, as a rope-walker would, to preserve his balance. 
When he walks there is rigidity, especially when descend- 
ing a staircase or crossing a street, when he is in danger 


587 


i > 


lp 


Spinal Cord. 
Spinal Cord. 


of being run over. He comes down upon his heels, and 
these will be found worn. He spreads his feet, and the 
gait is swaying, the soles being ‘‘ brought down with a 
slap,” which gives his propulsion an appearance never to 
be mistaken. When he attempts to turn there is much 
tottering, and when he is embarrassed he is sometimes 
almost helpless. If the disease advances beyond this, 
defective co-ordination is seen when he attempts to 
perform acts requiring delicacy of adjustment—such as 
buttoning his clothing, winding his watch, writing, or 
using small instruments of any kind. He is unable to 
localize small spots. 

The ocular symptoms of tabes are numerous. I have 
already alluded to the pupillary derangements, and, en 
passant, to the atrophy. There may be paralysis of the 
third nerve, usually single, but occasionally double. (See 
Charcot’s case.) In fact, any of the muscles of the ball 
may be paralyzed, or all of them, giving rise to oph- 
thalmoplegia externa. 

A slow atrophy beginning in the early stage of the dis- 
ease is a frequent symptom, and with it we find color- 
blindness and limitation of the field of vision. In one 
case of my own, a woman, there is very slight ataxia, 
absent reflex, light pains, a gradual loss of vision, and in- 
tense headache. In fact, this headache is very common 
with the neuritis of tabes. 

The sexual organs undergo changes which consist 
usually of a tendency to priapism, nocturnal emission, 
and other evidences of irritability in the beginning, and a 
complete loss of power later on. The action of the blad- 
der is impaired and the urine is passed slowly, and often 
falls with but little force from the end of the penis. It 
often contains a large quantity of the earthy phosphates 
or epithelial débr7s, and decomposes rapidly. 

When the ataxic stage has existed for some time, the 
sympathetic nervous system seems to participate in the 
production of symptoms, and a variety of trophic changes 
occur which have elsewhere been described. (See Arthro- 
pathies.) Articular destruction, with luxation resulting 
from absorption of the heads of the long bones, especially 
of the lower extremities, is common. The alveolar pro- 
cesses undergo a change, so that the teeth become loose 
and drop out even when they are sound. 

Various skin disorders, among them herpes and pem- 
phigus, are found in old cases, and there may be der- 
mal roughening or thickening. The nails, too, become 
affected, as Charcot has pointed out, and even exfolia- 
tion occurs. One evidence of a sympathetic complica- 
tion in tabes is the acceleration of the pulse, which is per- 
manent. 

A grave trophic degeneration is that known as pe7rfo- 
rating ulcer, and is peculiar to tabes. Luckily itis a rare 
feature. An indolent ulcer 
forms usually upon the sole of 
the foot, which may lead to 
‘the necessity of amputation. 
The last stages of tabes are 


Fia, 3654.—Perforating Ulcer of the Foot in Tabes. (Gowers.) 


* 


those attended by complete helplessness. The motor dif- 
ficulties increase, the patient becomes thin and feeble, and 
the possible existence of repeated gastric crises, with vom- 
iting and diarrhcea, leads to great exhaustion. Tubercu- 
losis is not a rare result of such malnutrition. In some 
cases the arthropathies cripple the patient to such an ex- 
tent that he passes the last years of his life in bed. 
Morzsip ANATOMy.— When the spinal cord is removed 
and examined, it is possible to find some external pinkish- 


588 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


gray discoloration at its posterior part. When a trans- 
verse section is made, this same opalescent appearance is 
detected. It is uneven both as to extent and situation, 
but more uniformly present in the lumbar region than 
elsewhere, though plaques of sclerosis are often found 
at higher levels or in the trunks of nerves. The finger 
passed over the posterior surface of the cord often re- 
veals an induration. When a transverse section is made, 
discoloration may be detected by the naked eye betwcen 
the two posterior cornua, which is somewhat translucent. 
The microscope reveals 
characteristic appearances 
in the lumbar, dorsal, and 
cervical portions of the 
cord, and the extent of the 
sclerosis depends largely 
upon the duration of the 
disease. We may find that 
the entire tract included by 
the commissure in front, 
the external roots laterally, 
and the posterior boundary 
of the cord, is the seat of a 
dense hardening, or we may 
appreciate various degrees 
of transformation. The 
most constant appearance, 
when the morbid process 
can be recognized at all, is 
adjacent to the posterior 
cornua, and next the col- 
umn of Goll or postero- 
median columns. In as- 
cending degeneration we 
find in the cervical and dor- 
sal regions a density of ten- 
sion in these columns, even 
when there is a more com- 
plete increase of neuroglia 
below ; while the postero- 
external columns are longer 
exempt from involvement. 


Fie. 8655.—Diagrammatic Repre- 


sentation of Common Areas of 
Sclerosis. A, Sclerosis of postero- 
median columns (Goil’s column), 
most distinct in cervical region. 
B, Sclerosis of entire posterior col- 
umns, OC, Sclerosis of parts of pos- 
tero-median and postero-external 


The gravity of alteration is 
usually at first seen quite 
posteriorly, and even af- 
ter extension the fibres of 
connective tissue  radiat- 
ing from the periphery are 


columns, leaving central parts ex- 


aes thicker than elsewhere. 


In some cases we find a 
tract of healthy tissue surrounded by a territory of scle- 
rosis. In this form of sclerosis, as in others, the nerve- 
elements are more or less destroyed and their places are 
filled by thickened trabecule containing nuclei. The 
vessels found have thickened walls, and the outer coats 
are especially the seat of degeneration. Broken-down 
elements, amylaceous corpuscles, and the like are seen. 

Numerous associated changes are often present—such 
as atrophy of the spinal nerves, meningeal thickening, and 
extensions of the morbid process into the lateral columns, 
and even the gray matter, are found. It is rare for any 
disappearance of the large nerve-cells of the anterior 
horns to take place, unless there is an associated atrophic 
condition. Sclerosis of the cranial nerves, or of the pons 
and posterior cerebral ganglia, are found in a small num- 
ber of cases. 

DraGnosis.—Tabes spinalis is apt to be confounded 
with disease of the pons, alcoholic neuritis, cerebellar 
disease, cerebro-spinal sclerosis, and certain hysterical 
affections. In the early stages the pains are apt to be 
mistaken for those of rheumatism or neuralgia, but the 
peculiar nature of the symptoms—the non-involvement 
of the articulations and the association of the lost knee- 
jerk—are guides which should not be disregarded, and the 
same may be said of the Argyle-Robertson symptom. In 
some cases of disease of the pons there is inco-ordination, 
but the other associated symptoms—especially the pupil- 
lary contraction and absence of lightning pains—are sug- 
gestive. Alcoholic neuritis occasionally gives rise to 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Spinal Cord, 
Spinal Cord, 


_— ——+- 


inco-ordination and ataxia. The pains in the lower ex- | suggest themselves ; but the physician is urged to care- 


tremities are, however, nearly always present, and there 
is tenderness of the plantar surfaces, glossy skin, and or- 
dinarily atrophy. In many cases there is noticeable 
mental weakness. In cerebellar disease there is reeling 
and vertigo, and the walk is rather that of a drunken 
man. There is nystagmus, double neuritis, headache, and 
vomiting, none of which symptoms are ordinarily found 
in tabes. The tremor of cerebro-spinal sclerosis is not 
found in tabes ; the mental dulness of the former is char- 
acteristic, and the speech disturbance is unknown in the 
spinal affection. The pains of tabes are never found in 
any of the forms of coarse disease I have mentioned. 

Proanosis.—Tabes spinalis is a progressive and fatal 
affection, and I do not know of a well-authenticated cure. 
In making this statement I exclude the syphilitic cases, 
but these even are only rarely cured by any treatment. 
The duration of the disease is exceedingly variable, and 
may extend from a few months to twenty years or more. 
The traumatic and some syphilitic cases are rapid in 
their development and unfavorable progress. The course 
of the disease is marked by periods of temporary im- 
provement, and is retarded by proper therapeutical meas- 
ures. I have effected an apparent improvement, in some 
cases, which has lasted several years, but the symptoms 
returned and the disease advanced. Optic-nerve atrophy 
is an exceedingly bad feature, and the development of 
the second or ataxic stage is an almost positive sign of 
a hopeless prognosis. Of the reported cures, doubtless 
these include examples of ataxia due to alcoholic neu- 
ritis, hysteria, or plantar anzesthesia of limited dura- 
tion. 

TREATMENT.—In specific cases our main reliance must 
rest upon heroic doses of the iodide of potassium—even 
several hundred grains daily may be given if the patient 
can bear such a quantity. The use of alkaline waters as 
a vehicle will enable him to take a much larger dose with- 
out gastric derangement than if water or other men- 
struums are used. Nitrate of silver and the tribasic 
phosphate sometimes improve tlie patient’s condition, but 
arsenic is one of the best agents, and Gowers speaks highly 
of its efficacy in his hands. There is nothing, I am con- 
vinced, so important, not only in tabes, but all other 
forms of sclerosis, as rest. When. this is possible we may 
greatly relieve, if not permanently improve, the patient, 
and a lady who consulted me after the development of 
the second stage, and who took to her bed and remained 
there for six months, has had very little trouble for sev- 
eral years, her gait being almost unaffected, and her pains 
entirely absent. I have known of very decided relief 
afforded in other cases by enforced rest. The gastric 
crises and occasional diarrhoea are best helped by mor- 
phine, and at such times rest is more important than at 
any other. Cod-liver oil and the hypophosphites are 
especially serviceable in the third stage. 

The pains of the first stage are very difficult to relieve, 
except by morphine, which, strange to say, is usually well 
borne, and I have never seen the formation of the habit 
but twice. Sometimes the cases are helped by the salicy- 
late of soda, antipyrin,. or acetanilide (antifebrin), the 
latter by the mouth or subcutaneously. Various au- 
thors recommend the local application of chloroform, 
the tincture of aconite, or bisulphide of carbon by means 
of pledgets of cotton in wide-mouthed bottles. _Cod-liver 
oil and the fats are necessary, and the discontinuance of 
tobacco, alcohol, except in an easily assimilable form, 
sexual intercourse, and exposure to extremes, is impera- 
tive. A warm winter climate should be selected—one of 
low elevation and withal dry is better than any other ; 
and if it is possible to go to some sulphur bath, such as 
Sharon or Richfield, or the springs of Virginia in this 
country, or Aix-la-Chapelle, or those in the south of 
France, the patient will doubtless obtain much benefit. 
I would advise Southern California or Thomasville, Ga., 
or, in fact, any inland warm place. The Florida sea- 
coast is not recommended, but such pine districts as 
that in the neighborhood of Seville, Fla., are suggested. 
I will say nothing about a variety of agents for the relief 
of special symptoms, vesical or trophic, for remedies will 


fully attend to the many little disturbances that may 
without care attain a dangerous magnitude. 

It will be found that the patient’s comfort can be 
greatly increased by the use,of leaden insoles which are 
heaviest in front. Allan McLane Hamilton. 


1 A Manual of the Nervous Diseases of Man, New Sydenham Transla- 
tions, vol. ii., p. 395. i853. 


SPINAL CORD DISEASES: TOXIC SPINAL PA- 
RALYSIS. Paralysis may be caused by various toxic 
agents, among the more Important of which are lead, 
alcohol, arsenic, phosphorus, mercury, carbonic oxide, 


-carbon sulphide, tobacco, camphor, ergot, and copaiba. 


The paralysis may occur in hemiplegic or paraplegic 
form, or may attack only groups of muscles, but in most 
instances its exact character has not been definitely deter- 
mined. 

The toxic paralysis most carefully studied is that due 
to lead-poisoning. It is most commonly found in the 
form of wristdrop—paralysis of the extensors of the fin- 
gers and wrists—but lead may cause far more exten- 
sive paralysis. Post-mortem examinations in such cases 
have revealed extensive degeneration of both muscles 
and nerves, and in a number of instances disease of the 
anterior cornua of the cord. The view now most com- 
monly accepted is that the disease is primarily an an- 
terior poliomyelitis—inflammation of the gray matter of 
the cord—and that the pathological changes in the mus- 
cles and nerves are secondary effects. Lead-paralysis 
would then be a spinal paralysis. But many still believe 
that it is mainly a peripheral paralysis, primarily in the 
nerves and muscles. Their opinion is based upon the 
extensive disease in the latter, and the ofttimes negative 
results of examination of the cord. The question cannot 
be considered as definitely answered. 

One of the most common, if not most common, forms 
of toxic paralysis is that due to alcohol. Most post- 
mortem examinations of such cases in recent years have 
revealed the presence of multiple neuritis, with, in some 
instances, inflammatory changes in the cord at the same 
time. Alcohol-paralysis seems, then, in greater part to 
be a peripheral paralysis, due to neuritis. _ 

Arsenical paralysis, especially in its clinical aspects, 
has been carefully studied in recent years. It sometimes 
has the appearance of peripheral paralysis, sometimes 
occurs in paraplegic form, and occasionally simulates 
locomotor ataxia, with ataxic gait, absence of patellar 
tendon reflexes, etc. It is not improbable: that most of 
these paralyses are also due to neuritis, The same patho- 
logical basis may exist in the other forms of toxic paral- 
ysis, which have been less carefully studied. We may 
therefore be permitted to discontinue the discussion of 
the subject in this article, which is to treat only of spinal 
paralysis, particularly as it requires much further eluci- 
dation before anything can be stated definitely. But it is 
not improbable that toxic agents produce paralysis some- 
times through the central nervous system, brain, or spinal 
cord, sometimes through the nerves ; and the question is 
yet to be answered to what extent neuritis, especially 
multiple neuritis, so much spoken of recently, is due to 
conditions of the central nervous system. 

Philip Zenner. 


SPINAL CORD DISEASES: TUMORS OF THE 
CORD AND ITS MEMBRANES. Tumors within the 
vertebral canal, whether they spring from the cord itself 
or the meninges, produce symptoms mainly through ir- 
ritation or destruction of nervous tissues. As they can 
rarely, if ever, be differentiated during life, it is conven- 
ient to treat of tumors of the cord and of the membranes 
at the same time. 

The larger number of intraspinal tumors grow from 
the membranes, from the dura mater more frequently 
than from the pia mater ; a smaller number originate in 
the cord, either in its substance or in the peri-ependy- 
mal tissue around the central canal. Some intraspinal 
growths spring from the bone or intervertebral sub- 
stances, others from the tissues outside the vertebre, 


589 


Spinal Cord. 
Spinal Cord. 


entering the canal through the intervertebral foramina. 
Circumscribed inflammatory exudations, from caries of 
the vertebre, and hematoma, as they may produce sim- 
ilar manifestations, are sometimes included among in- 
traspinal tumors. 

The most common forms of tumors springing from the 
membranes are fibroma, sarcoma, and gumma; from the 
cord itself, glioma and tubercle. Among the tumors 
less frequently found in the cord or its membranes may 
be mentioned psammoma, lipoma, myxoma; tumors of a 
mixed type, myxo-sarcoma, glio-sarcoma; and parasitic 
growths, echinococcus, more rarely cysticercus. Neuro- 
mata, especially false neuromata, are found on the spinal 
roots, sometimes in large numbers. Enchondromata, 
sarcomata, and cancerous tumors sometimes spring from 
the bones or intervertebral tissues and compress the cord. 
Primary carcinoma is scarcely, or not at all, found in 
the cord or its membranes, but secondary deposits, espe- 
cially after primary disease of the breast, are not very 
rare. 

Tumors are most frequently single, but neuromata on 
the spinal roots are often multiple, and tubercles in the 
cord, though usually solitary, may occur in larger num- 
ber, while secondary carcinomatous deposits are, perhaps, 
usually multiple. 

The shape of intraspinal tumors is usually round, oval, 
or elongated. Their size is necessarily very limited, 
varying from that of a hemp-seed to the diameter ot an 
inch or more. Tumors in the dura mater are usually 
larger than those in the pia mater. In the cord they 
rarely exceed one-half inch in transverse diameter, but 
sometimes have quite a considerable vertical extent, in 
some instances of glioma and myxo-glioma reaching the 
whole length of the cord. 

Tumors may be found anteriorly, posteriorly, or lat- 
erally in the membranes, and therefore encroaching upon 
the cord, sometimes in one direction, sometimes in an- 
other. They may also be found in any part of the verti- 
cal extent of the cord or membranes, though tubercles 
are said to occur most frequently in the lumbar enlarge- 
ment, and gliomata in the cervical region of the cord. 

The tumors are usually distinctly circumscribed ; some- 
times—this is especially true of gliomata—they blend 
with the cord-substance. 

The secondary changes in the nervous structure, pro- 
duced by the compression or destructive action of the 
tumor, are of the greatest importance in the production 
of symptoms. Tumors growing from the membranes 
usually produce decided inflammatory or atrophic changes 
in the spinal roots and cord. The spinal roots are usu- 
ally swollen and red, or ina state of inflammatory soft- 
ening ; in other instances they are degenerated and atro- 
phied. Compression of the cord causes it to be flattened 
or narrowed at the point of pressure; sometimes pro- 
duces an entire solution of continuity at that point, 
the extremities of the upper and lower segments being 
connected together by membranous tissue. The patho- 
logical changes in the cord-substance are sometimes only 
atrophy of the nervous elements, but usually there is a 
secondary myelitis, termed compression-myelitis. The 
cord is in a condition of white or red softening, with 
small extravasations of blood in the softened area, the 
microscope revealing granular cells and fragments of 
nervous elements. The inflammatory process is likely 
to extend some distance below the seat of compression, 
especially in the gray matter; and occasionally it ex- 
tends a short distance above the point of compression. 
Degeneration of the white columns of the cord above 
and below the lesion, according to the Wallerian law of 
secondary degenerations, is usually found. A localized 
chronic meningitis in the neighborhood of the tumor, 
often resulting in an increase of fluid within the verte- 
bral canal, is frequently present. 

Tumors in the substance of the cord compress and 
push apart the component parts. They may merely pro- 
duce atrophy of the neighboring tissues, but generally 
cause more or less inflammation. Often they produce 
transverse myelitis, with all its symptoms. Secondary 
degeneration takes place just as after other considerable 


590 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


lesions of the cord. The tumor may also produce a lo- 
calized meningitis and morbid changes in the spinal 
roots. 

Various secondary changes also take place within the 
tumors themselves, such as softening and formation of 
cavities. Some cases of syringomyelia—cavities in the 
centre of the cord—a very interesting pathological con- 
dition, though of little practical importance, as it usually 
produces no symptoms, are merely secondary cavities in 
the middle of atumor. Hemorrhages sometimes occur 
within the tumor or in the surrounding tissues. This is 
most likely to take place in those rich in blood-vessels— 
angio-gliomata and angio-sarcomata. 

The secondary changes in the spinal roots and cord 
just described, and the symptoms induced by them, are 
produced to a variable degree by different tumors. These 
effects depend upon various factors, of which the most 
important are location, size, consistency, rapidity of 
growth, and tendency to destroy neighboring tissues. 
The last two qualities are especially important. Rapidly 
growing tumors produce great irritation, and have a spe- 
cial tendency to produce inflammatory changes. On the 
other hand, psammoma, a hard but slow-growing tumor, 
is slow to produce symptoms. Those tumors which have 
a tendency to destroy surrounding tissues—tubercles, to 
some extent gummata, but especially carcinomata—pro- 
duce very intense symptoms. Consistency is also im- 
portant. ‘Tumors softer than the cord may produce few 
symptoms. This has been found with cysticerci, for ex- 
ample. Gliomata, also of soft consistency, do not produce 
symptoms in proportion to their size and rapid growth. 
This seems to have been true of those which extended al- 
most the entire length of the cord. As to location, those 
outside the dura mater usually compress the cord less 
than those within it. The same is true of tumors in the 
more spacious parts of the vertebral canal—the middle 
and lower parts of the lumbar region. 

It is to be remembered, as regards symptomatology, 
that some of the secondary effects of tumors, as localized 
acute myelitis, hemorrhage into or about the tumor, are 
sudden in onset, and that, therefore, the clinical history, 
which is mainly that of gradual progression of symp- 
toms, may present acute exacerbations, often followed by 
temporary improvement. 

ErroLogy.—Some tumors, as gumma and tubercle, are 
due to diathetic conditions. In case of the latter, tu- 
bercles are almost always found in the lungs or the brain, 
often in the spinal meninges. Carcinoma is almost al- 
ways secondary. Parasitic tumors—echinococci and cys- 
ticerci—have their usual cause. Beyond this the causes of 
intraspinal tumors are very obscure. Injuries—blows 
to the spine, etc.—seem often to be the etiological factor. 
Exposure, nervous shocks, etc., have been assigned as 
causes, though their influence in that direction is doubt- 
ful. 

Symproms.—Usually the first symptom, and the most 
prominent one throughout the course of the disease, is 
pain. This is often intense, and of a shooting, boring, 
or tearing character. In the beginning it is commonly 
limited to one side, and radiates along the course of the 
nerves given off at the level of the tumor. It may be 
thus localized on one side for a long time before it affects 
the other side or extends to other parts of the body. 
Such pain is due to irritation of the spinal roots, and is 
chiefly produced by tumors of the membranes. On the 
other hand, in intramedullary tumors, when the sub- 
stance of the cord is directly irritated, the earliest pains 
may be in lower parts of the body, and not at the level 
of the tumors. 

There is often pain in the back over the seat of the 
tumor, also tenderness to pressure. The pain may be in- 
creased by movement of the spine, especially if made in 
such a manner as to compress the tumor. Such move- 
ment may produce not only local, but also excentric pain. 
The latter symptom is probably found in proportion as 
the meninges, and especially the bone, are involved in 
the morbid process, 

In addition to the pain there is often hyperesthesia or 
pareesthesie—numbness, tingling, formication, etc.—in 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the painful area, and frequently a sense of constriction, 
or girdle sensation, near the level of the tumor. 

Along with the symptoms of sensory irritation just 
described there are often signs of motor irritation—mus- 
cular spasms. They are more marked with tumors of the 
membranes than with those of the cord. There is often 
rigidity of the muscles of the back opposite the lesion, 
sometimes spasms of the abdominal muscles; and not in- 
frequently spasms, even contractures, of the limbs. The 
latter are sometimes due to irritation of the spinal roots. 
In other instances they are late manifestations, and due 
to secondary changes in the cord. 

Paralysis is a common symptom, but it usually ap- 
pears after irritation symptoms have been present for 
some time. Motor and sensory paralyses may appear at 
the same time, or one may appear before the other, the 
motor more frequently preceding, although this depends 
upon whether the anterior or posterior portion of the cord 
is first affected by the tumor. The paralysis is usually 
gradual in its development, beginning with paresis of 
one member, which increases to paralysis, extends to the 
other side, and finally involves every part below the 
seat of lesion. If the tumor is in the cervical region 
the paralysis usually begins in the arm, though some- 
times it appears first in the lower extremity ; but usually 
the four extremities and the trunk finally become para- 
lyzed. When the paralysis gradually increases from pa- 
resis to complete paralysis it is not liable to any improve- 
ment. But the paralysis does not always progress in this 
manner. Sometimes there is a sudden and considerable 
increase of the symptoms, due to an acute myelitis about 
the tumor, or to hemorrhage. If the lesion be in the 
cervical region, sudden paralysis of the four extremities 
may occur. In such instances there is often subsequent 
amelioration of the symptoms. The anesthesia, like the 
motor paralysis, is usually partial at first, and gradually 
becomes complete. It generally corresponds in distribu- 
tion to the motor paralysis. But in some cases of uni- 
lateral lesion we have the picture presented by spinal 
hemiplegia, viz., motor paralysis with hypereesthesia on 
one side, and anzesthesia on the other. In that case there 
is usually anesthesia at the level of the tumor on the side 
of motor paralysis, due to injury of the posterior spinal 
roots. <A striking feature often presented is the presence 
of severe pain in areas of profound anesthesia. This 
condition has been termed anesthesia dolorosa. 

Ataxia has been observed in some cases where the pos- 
terior columns were compressed, The infrequency of 
this symptom is, probably, to be accounted for by the 
existence of the motor paralysis. 

Atrophy of muscles is found to the extent that the an- 
terior spinal roots are destroyed, or the anterior cornua 
are affected, by the secondary myelitis. It is always an 
indication of the level of the tumor. If the latter be in 
the upper part of the cervical enlargement, the atrophy 
is chiefly in the muscles of the upper arm; if in the 
lower part of the cervical enlargement, in the muscles of 
the forearm and hand; if in the dorsal cord, in the mus- 
cles of the trunk ; if in the upper lumbar region, in the 
muscles of the hip; if in the lower lumbar enlargement, 
in the muscles of the leg. The extent of the atrophy is 
especially great when the tumor involves the lumbar cord 
or the cauda equina, on account of the number of nerves 
likely to be compressed. In other instances, too, the ex- 
tent of atrophy may be considerable, because the second- 
ary myelitis often extends for some distance below the 
tumor, and chiefly in the gray matter. 

The electrical reactions are altered only in the atrophied 
muscles. In these the reaction of degeneration is more 
or less distinctly marked. In other paralyzed muscles 
the electrical reactions are normal. The state of the re- 
flexes varies in different parts of the body, In the parts 
corresponding to the level of the tumor, where muscular 
atrophy is found, they are usually abolished, while in 
the lower part of the body both skin and tendon reflexes 
are increased, and there are often, at the same time, the 
other phenomena of spastic paralysis. Thus, if the tu- 
mor be in the cervical region, the skin and tendon re- 
flexes of the upper extremities may be abolished, while 


Spinal Cord. 
Spinal Cord. 


those of the trunk and lower extremities are much exag- 
gerated. If in the dorsal region, the skin reflexes of the 
thorax or abdomen may be abolished, the reflexes of the 
lower extremities exaggerated. If in the lumbar region, 
the patellar tendon reflexes, etc., are abolished ; and if 
the lesion extend sufficiently low in the cord, all the re- 
flexes in the lower extremities may be abolished. 

In addition to those already mentioned, other symp- 
toms of profound disease of the cord may be found. 
Vaso-motor manifestations—heat, more frequently cold- 
ness, in the paralyzed extremities, sometimes cedema ; 
symptoms on the part of the rectum and bladder—incon- 
tinence of faeces and urine, cystitis, pyelitis, etc.; genital 
symptoms—impotence, priapism, etc., and decubitus, are 
more or less common, 

A few words as to the peculiar symptoms of tumors at 
different elevations of the cord. ‘Those in the cervical 
region are most likely to be attended by rigidity of the 
spine. They may produce respiratory symptoms, as 
cough and dyspnea, also pupillary symptoms, contrac- 
traction or dilatation. If in the uppermost part of the 
cord, symptoms on the part.of the cranial nerves may 
appear—dysphagia, disturbances of speech, sometimes 
optic neuritis. Tumors in the dorsal region can often 
be more exactly localized than those in the cervical or 
lumbar region, because the nerves of this part are not so 
crowded and do not unite in plexuses. Tumors in the 
lumbar region of the cord more frequently cause bed- 
sores and paralysis of the bladder and rectum than those 
in other parts of the cord. The same is true of tumors 
of the cauda equina. The vesical symptoms are always 
early, and the paralysis of the bladder is likely to be very 
marked. When there is more than one tumor, the symp- 
toms of lesions in different parts of the cord may ap- 
pear, When their number is multiple, the symptoms of 
some of the tumors may be concealed by those of others. 

In a general way, differences may be noted in the 
symptoms of tumors of the cord and of the membranes. 
The root symptoms are usually earlier and more severe 
with tumors of the membranes, while the cord symptoms 
come on at a later period. Pain, tenderness, and rigidity 
of the spine, as well as increase of pain on movement, are 
more common in tumors of the membranes. On the 
other hand, cord symptoms, paralysis, etc., and especially 
muscular atrophy, are usually earlier manifestations and 
more extensive in tumors of the cord. 

The course of the disease is variable, depending upon 
the location, rapidity of growth, etc., of the tumor. Usu- 
ally pain in a limited part on one side of the body is the 
earliest symptom, and months or years may pass before 
other symptoms appear. ‘The paralysis usually begins as 
a paresis, and increases gradually in extent and intensity. 
The symptoms may progress steadily, or may be station- 
ary for a longer or shorter time, or there may be a sudden 
increase of symptoms, often followed by improvement. 
Sometimes such different periods may alternate with one 
another. Cystitis and decubitus are usually late mani- 
festations. The duration of the disease is from six 
months to eight or ten years or more. The average dura- 
tion is from one to three years. 

Draenosis.—The diagnosis must be based on, firstly, 
the presence at the same time of both severe irritation 
symptoms—severe pain, muscular spasm, etc.—and_ pa- 
ralysis ; secondly, the gradual increase both in the inten- 
sity and extent of the symptoms, especially the indica- 
tions of lateral extension of the disease from one side of 
the cord to the other ; thirdly, local pain, tenderness, and 
immobility of the spine in the neighborhood of the tu- 
mor; also increase of pain on movement. The knowl- 
edge of causal relations may assist in the diagnosis. A 
history of constitutional syphilis should arouse a sus- 
picion of gumma in the cord or membranes. With a 
primary cancer of the breast, and the clinical picture of 
paraplegia dolorosa—paraplegia with intense neuralgic 
pains—there can scarcely be any doubt as to the presence 
of intraspinal carcinomatous deposits. 

Yet it must be acknowledged that it is often difficult 
or impossible to diagnose the presence of tumors. If soft, 
and slow in growth, they produce scarcely any symp- 


591 


Spinal Cord. 
Spinal Nerves. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


toms. In others the clinical history presented is very 
obscure: Especially in the beginning, when pain may be 
the only symptom, is the diagnosis doubtful. 

The diseases most likely to be confounded with intra- 
spinal tumors are tumor or caries of the vertebra, some 
painful forms of myelitis, and multiple neuritis. In the 
first there are more pronounced symptoms of disease of 
the bone, and slighter symptoms of disease of the nervous 
structures, and deformity appears, sooner or later, to clear 
up the diagnosis. In myelitis the pains are usually less 
severe, there is rarely the same kind of extension of 
symptoms, and the local pain, tenderness, rigidity, and 
pain on movement of the spine are rarely, if ever, found. 
In multiple neuritis the tenderness to pressure over the 
course of the nerves should be a valuable guide in form- 
ing a diagnosis. 

After atumor has been diagnosed it becomes next a 
question as to its locality and nature. The location of 
the tumor is to be determined by the height of the pa- 
ralysis and the presence and location of the localizing 
symptoms—pain, spasm, muscular atrophy, and abolished 
reflexes. The nature of the tumor may be inferred from 
the presence of certain systemic conditions, syphilis, tu- 
berculosis, or cancer; or of tumors, neuroma or sarcoma, 
in other organs. If none of these conditions is found, 
we can only be guided in our surmises by the general 
fact that the most common tumors in the cord are glioma 
and tubercle ; in the membranes, sarcoma, fibroma, and 
gumma. 

Proenosis.—The prognosis of intraspinal tumors is 
exceedingly grave. Only in cases of syphilomata is there 
much prospect of a cure, and if symptoms have been 
present a long time, treatment may often fail, even in 
these cases. Tumors of a malignant type usually cause 
the greatest suffering, and run the most rapid course. 
Tumors in the cervical region are likely to run a more 
rapid course than those of the cauda equina, where there 
is more free space and the nervous structures are of less 
vital consequence. 

TTREATMENT.—In cases of syphilomata very active 
treatment with both the iodides and mercury should be 
instituted. The same treatment showld be tried where 
there is any suspicion of syphilis, for these are the only 
cases in which a cure can be hoped for. Beyond this the 
chief consideration is to afford the patient relief by the 
administration of anodynes. As the disease is often of 
long standing they must be carefully administered. 

Since this article has been in type, Gowers and Horsley 
have reported the successful removal of a tumor (British 
Med, Jowr,, January 28, 1888), The more precisely a local 
diagnosis can be made, and the less the cord is involved 
in the growth, the more hopeful will be the outlook for 
such operations in the future. Philip Zenner. 


SPINAL NERVES are those which emanate wholly 
from the spinal cord. They are more regular in their 
structure and arrangement than are the cranial nerves, 
arising always in pairs from either side of the spinal cord, 
each nerve having two roots connected with the horns of 
gray matter, a posterior or sensory root upon which a 
ganglion is developed, and an anterior or motor root 
which has no nervous connection with the ganglion. 
They unite immediately beyond the ganglion to form a 
mixed trunk. 

Comparing this now with the cranial nerves, it will be 
seen that there is no perfectly clear and well-marked 
distinction of anatomical characters, for the hypoglossal 
and spinal accessory arise in part from the spinal cord, 
and in lower vertebrates they are unquestionably spinal 
nerves. ‘In human embryos the hypoglossal has a pos- 
terior root on which a ganglion is formed. Yet it may be 
said that on the whole the cranial nerves are formed upon 
amore primitive type. Animals of a simple structure, 
like the ascidians, from which vertebrates are derived, 
have for a body a simple muscular sac, and the nervous 
apparatus consists of a central ganglion from which pro- 
ceed two sets of nerves, one conveying impressions from 
the external surface of the ganglion, another distributing 
impulses from that ganglion to the muscles which con- 


592 


tract the sac. The two sets of nerves, afferent or sen- 
sory, and efferent or motor, are entirely distinct, resem- 
bling in this the majority of the cranial nerves in man. 
It would seem that the greatly accelerated development 
of the anterior pole of the body mainly relates to the 
nervous system and its coverings, and that the peripheral 
nerves have not been able to 
acquire that regularity and 
symmetry which character- 
-.....,Hetoderm. jze the other parts of the 
body, where the development 
has been slower and the sta- 
bility greater. 

In the lowest vertebrates 
the spinal nerves arise by a 
Re Notochord, single root, which conveys 

both sensory and motor im- 
Fic. 3656.—Cross-section of Em- Pulses. 
bryo of Chick before the Appear- In foetal life these nerves 
ance of the Spinal Nerves, (Af- originate as outgrowths from 
ter Marshall. ) = 
the central nervous system. 
At the time the medullary groove folds over to form the 
neuro-central canal, there arises directly along the edges 
of the seam made by the union a longitudinal band of 
cells known as the neural crest. (See Fig. 3656.) 

This becomes larger at points corresponding to the 
segments of the body, and pushes out processes laterally 
which become the posterior nerve-roots. At first these 
are connected across the back of the cord by means of 
the neural crest, 
but as they increase 
in size they acquire 
a secondary attach- 


Neural crest. 


.Medullary tube. 


....Muscle-plate. 


Neural crest. 


__ Secondary attachment, 


— 


ment near the pos- £° gga S_.:---- Ectoderm. 
terior horns of the 

spinal cord and the 

crest disappears. { M us cle- 
The ganglion soon BA orp 
appears as a swell- { roe. 


ing upon the bud- 
ding root, and may 


Notochord. 

be covered by an 

eshte Gar Anterior root. 

Srithe cen meee Fic, 3657.—The pene eae Stage. (After 
3657. ) 


Duval, however, considers that it is developed inde- 
pendently, and afterward becomes united to the cord 
through the posterior root, and thus explains the fact that 
the trophic centre for the posterior root resides in the 
ganglion, while that for the anterior root is, as is well 
known, in the anterior horn of the cord. The motor 
roots arise later and separately, as distinct extensions from 
the ventral surface of the cord (Fig. 3658). 

The spinal nerves are regularly arranged in pairs, which 
correspond to the 
segments or meta- 
meres of the ver- 

...-Hctoderm. tebrate body. 
Thirty-one of 
these pairs are- 

Posterior 82 tiSfactorily 
| root, | made PoUlmeanG 
aaa Rauber has rec- 


-Ganglion, 


crete ognized the rudi- 
ixe 4 
{ nerve, 2 BR EB Oreo 


other pairs which 
Notochord. do not (as far as 
known) leave the 
spinal canal, but 
remain in the 
cauda equina of the spinal cord, the atrophied vestiges of 
a period when the posterior pole of the body was more 
developed than at present. 

The nerves pass from the spinal canal through the in- 
tervertebral foramina, and are divided into cervical, dor- 
sal, lumbar, sacral, and coccygeal groups, corresponding 
to those regions of the spine. It was the original inten- 
tion of Willis to have the names correspond invariably to 


Fie. 8658.—The Same, when the Formation of 
Nerve-roots is Completed. (After Marshall.) 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the vertebra wnder which the nerve passes out. Thus 
the fifth lumbar nerve passes out between the fifth lum- 
bar vertebra and the sacrum, and the fifth sacral between 
the sacrum and the coccyx. He considered the subocci- 
pital nerve, which passes out between the occipital bone 
and the first cervical vertebra, as a cranial nerve. Vicq 
d’Azyr pointed out that in its origin and anatomical 
character it was a spinal nerve, and, therefore, added it 
to the cervical nerves—which deranged the scheme for 
that region. The eighth cervical nerve, therefore, emerges 
below the seventh cervical vertebra, and so on. It will 
be evident that this method of readjusting the nomen- 
clature occasioned less change in the existing terms than 
any other scheme would have done. Coues has proposed, 
however, to rearrange the entire series, and commencing 
at the first cervical, to renumber all the nerves, naming 
each from the vertebra over which it passes out. This 
would not only be an advantage in nomenclature, but 
also represent more accurately the metameric relations of 
the nerves. As the body has grown proportionately 


Spinal Cord, 
Spinal Nerves, 


nerve, and then turn backward at an acute angle to enter 
the chorda tympani. It is not by any means infrequent 
to find a considerable variation in the relative size of con 
tiguous nerves, the fibres usually assigned to one appar- 
ently passing to the other. Fine fibres not connected 
with the nerve-roots may arise directly from the spinal 
cord and supply the meninges of the vertebral canal. 
The ganglia may vary. Instead of a single collection of 
gray matter, there may be several masses scattered along 
the posterior root in an almost continuous chain, as if in 
the embryonic development of the root from the cord 
there had been a continuation outward of the gray mat- 
ter of the posterior horn. If we attempt to trace the 
fibres of the roots to their intimate connections in the 
cord, we find the subject involved in difficulty. The 
fibres of the sensitive roots on entering the postero-lateral 
groove may be divided into two groups, which pass on 
either side the substantia gela- 
tinosa. The external set appear 
to ascend somewhat, and then 


faster than the cord, the central attachment of the nerves “7h Q 
is invariably higher than their peripheral distribution. : 4 
According to the generally accepted arrange- 1 ig 
ment, the nerves are classified in pairs, as follows: ' i S 
Cervical Hy 3 
CORVICAINELVeSh cx tant oo st site She 8 plexus. { of “a 5 
eae RORVES ce reed Bae | es ee 12 Til S 
RPI ATALIETVORONE acer Tt Ome st as aa < watt te 5 Dicer - 
PACEBIP GT VES er Dad. 2s icc Votes set 5 nerve. as ee alt 
Coccygeal nerves (two being rudimen- Brachial : it 
POD tiancat hatte save u's s.s cutee § 3 plexus, ies ts, 
WRGSTAN, OF 2? osha p ae a Ss eee he 33 ah 
The size of the posterior roots is greater than that of il 
the anterior, as is the case with sensitive nerves generally. fh ] 
It appears to be necessary to have a large number of in- | either jointhefibre- ft i; 3 
dependent fibres for the conveyance of the multiform im- | plexus or pass to the hel : Pde: 
pressions from the outer world, while, after these impres- | anterior horn; the aig *-§ 6th Fg 
sions have been transmitted into comparatively simple | internal set pass, i it es ie 
motor impulses, a less number of separate tracts is re- | some to Clarke’s | ri igh 5 
quired. Stilling carefully determined the comparative | column, some _ to willy <2 -*Sth 7 
area of the cross-sections of the roots in a female subject | the opposite side | ee oe | 
of twenty-six years, and found the total of the anterior | through the gray § it Saat 
roots to be 35 to 86 square millimetres, while the posterior | commissure, and & ---~-L0th | 
roots amounted to from 54 to 57 square millimetres. some pass upward §& | Pe 
There is also a variation in the size of the nerve ac- | and are lost. a Neer itl ee 
cording to the activities of the part of the cord from The fibres belong- £| ¢ y |, err ae 
which itis given off. Those nerves which supply the ex- | ing to the anterior $ 5 i ’ 
tremities are necessarily much larger than those which | roots are many of “| & Ui tect 
merely go to the body-wall. Not only is the area to | them directly de- | E Hoe ay | plexus. 
which they go larger, but the differentiation of organsis | rived from the mo- 5 
carried to a far greater extent. These nerves are given | torcells of the ante- | eS 
off opposite the cervical and lumbar enlargements of the | rior cornu. Some } ¢ 
cord. According to Stilling, the sixth cervical exceeds | of them, however, | > a 
A S F 5 ~=- af Sacral 
the others at the cervical enlargement, while the second | come from the lat- 7 Peas 
is the largest of the sacral nerves. eral column of the | 


The ganglia upon the posterior roots are usually found 
in the intervertebral foramina, except in the case of the 
sacral and coccygeal nerves. The point of emergence of 
the trunks of these is a considerable distance below the 
origins of the nerves, and the ganglia are. withdrawn 
within the spinal canal by the downward growth of the 
column, and lie between the dura mater and the wall. 
The size of the ganglia is in proportion to that of the 
nerve upon which it is found. 

The characters which have been given for the spinal 
nerves are not entirely invariable. There may be certain 
fibres which do not leave the spinal canal. These may 
pass directly from one pair of roots to the other with out- 
ward convexity (ansa centripetalis, Hilbert), in which 
case they appear to be related to the fibres of recurrent sen- 
sibility, or they may pass from one root with an outward 
concavity (ansa centrifugalis) to the root next above or 
below, without connection with the cord. The meaning 
of this is not very clear; but it should be remembered 
that fibres may be displaced from their origin in the 
course of development in such a way as to deceive one 
as to their actual course. For instance, there is no doubt 
that fibres run down along the main trunk of the facial 


VoL. VI.—38 


cord (crossed pyra- 
midal tract), and we 
have no absolute 
anatomical demon- 
stration of their ori- 
gin. yy} 
~ It should be remembered, as a Yf 
matter of practical importance, Y 
that the nerve-roots usually in- 
cline downward somewhat from 1G. 8659-—Diagram showing 
their point of emergence to reach Fa Renee tae aie the 
the intervertebral foramina, Ow- Origin of the Spinal Nerves, 
ing to the lengthening of the 

canal already adverted to. The first and second cervical 
are exceptions, the former ascending slightly, and the 
latter being horizontal. Those below increase in their 
obliquity from above downward. Thus, while the lower 
cervical nerves leave the canal the space of an entire ver- 
tebra below their emergence from the cord, the dorsal 
nerves have an interspinal passage of from two to three 
vertebrae ; and for the lumbar and sacral and coccygeal 
nerves it is still greater, for the cord ends at the first lum- 
bar vertebra. Because of this fact it would be quite 


593 


Spinal Nerves. 
Spinal Nerves. 


possible to have a lesion affecting a nerve in the spinal 
canal considerably above its point of emergence, and 
symptoms might be caused which would be improperly 
referred to a lower situation if this fact was not taken 
into account. . 

The following table, from Tillaux, shows the relation 
between the spines of the vertebree and the origins of the 
nerves. 


Nerve. Relation to Vertebral Spines. 


Cervical I. At level of foramen magnum. 
II. A little below the occipital bone. 
III, A little below the middle of the space between the occipital 
bone and the spinous process of the axis. 
IV. At the spinous process of the axis or above. 
VY. Third vertebral spine or above. 
VI. Below 3d, but above 4th. 
VIL. From spine of 4th and above, to spine of 5th. 
VIII. From spine of 5th to above spine of 6th. 
Dorsal I: Above spine of 6th to the 7th. 
II. Seventh cervical to 1st dorsal. 
III. From 1st dorsal to middle of interval between it and 2d dor- 
sal. 

IV. From just above to a little below 2d dorsal. 

V. From just above to a little below 8d dorsal. 

VI. From just above to a little below 4th dorsal, 

VII. Fifth dorsal to above. 

VIII. From 5th dorsal to a little above 6th. 

IX. From 6th dorsal to a little above 7th. 

X. From 7th dorsal to a little above 8th. 

XI. From 8th dorsal to a little above 9th. 

XII. From 9th dorsal to a little above 11th. 


The five lumbar nerves arise successively from the 
spine of the 11th dorsal vertebra to the spine of the 12th. 

The five sacral nerves and the: coccygeal arise succes- 
sively from the spine of the 12th dorsal vertebra to that 
of the 1st lumbar. 

It follows from this table that any lesion which para- 
lyzes the neck and limbs must be above the 5th cervical 
vertebra. The phrenic nerve cannot be affected unless 
the nerves from which it arises (8d and 4th cervical) are 
involved. The centre for them is above the axis. A 
luxation of that vertebra is not, therefore, necessarily 
immediately fatal. A dislocation of the atlas is at once 
followed by death. 

A lesion at the 12th dorsal vertebra paralyzes the sacral 
plexus at the 11th dorsal, the lumbar, and sacral. If at 
the 5th dorsal, the abdominal walls are also paralyzed ; 
and at the 3d dorsal the paralysis will reach the 3d in- 
tercostal space. If at the 6th or 7th cervical, all the in- 
tercostal spaces are paralyzed. ‘These relations are also 
illustrated in Fig. 3659. 

After leaving the intervertebral foramen the mixed trunk 
soon divides into branches which have special relations 
to the different portions of the body-wall. <A dorsal 
branch (Fig. 3660) goes to supply the muscles and struct- 


Spinal cord. 


Anterior root.......... 

....Dorsal branch, 

Mixed nerve .... 5H 
Ganglion. 


Posterior root, 
Sy ri pathetic Merve wecumeas cess accel eens hie 


Visceral branch........ Sd PRR rae ee ee 


Ventral branch........, yh oho dode Ss A 
Fie. 3660,—Diagram of a Spinal Nerve. 


ures surrounding the neuro-central tube. Some sensitive 
fibres, which appear to relate to this branch, do not leave 
the main trunk of the nerve, but run back along the mo. 
tor root and supply the membranes of the cord. It is those 
that produce the phenomena of ‘recurrent sensibility ” 
which occur when the motor root is cut. A neutral 
branch goes to the muscles of the general body-wall 


594 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


(somatopleure), and a visceral branch connects with the 
great sympathetic cord and proceeds to the alimentary 
canal and its annexes (splanchnopleure). 

The visceral branch gives off a fine twig, which, unit- 
ing with another from the sensory root, forms the nervus 
sinu vertebralis of Luschka, which passes in at the inter- 


Fie. 3661.—Diagram showing the Spinal Cord from before, with the At- 
tachment of the Principal Nerves. On the right-hand side of the dia- 
gram the connections with the sympathetic nerve are shown; on the 
left-hand side, the plexuses of the anterior roots. (From Ferrier.) 


vertebral foramen and supplies the walls of the canal 
and the bodies of the vertebra. 

The dorsal or posterior branches are usually much 
smaller than the ventral, corresponding to the area of the 
tube for which they were originally intended ; but when 
that tube expands greatly, as in the cranium, the dorsal 
branches at once increase greatly in size, and that of the 
first cervical nerve exceeds the ventral branch. They 
supply the skin and deep muscles on the posterior part 
of the neck and the back, including the lumbar and sa- 
cral regions and a portion of the gluteal region. Two of 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Spinal Nerves. 
Spinal Nerves. 


these nerves only have received special names. These 
are the first and second, known as the suboccipital, and 
the great occipital nerves. These supply the posterior 
part of the neck and scalp as far as the vertex. In dis- 
ease of the cervical vertebree they may be affected and 
occasion persistent pseudo-neuralgic pains. 

The ventral or anterior branches (see Fig. 3661) form 
the principal nerves of the body and limbs. They do 
not usually pass singly to their destination, but after a 
short course unite with each other to form plexuses, in 
which the original fibres are mingled intimately. These 
plexuses form two grand divisions, corresponding to the 
chief nerves ; the upper one, constituted by the anterior 
branches of the cervical and the first dorsal nerves, is 
known as the cervico-brachial plexus; the lower one, 
made up of all the lumbar, sacral, and coccygeal nerves, 


Ts Ceivicalice. .eiscc meee 6 


II. Cervical 


III. Cervical 


VI, Cervical? ... 3.4. i. 


VII. Cervical...... 


VIII. Cervical....... oe sees car 
To Dorealiete cca. 0s, ste os ee pee ae eS eae 
a a a a eaves elects ns 


Fig. 3662.—Diagram showing the Origin of the Principal Nerves of the Cervico-brachial Plexus. 


is called the lumbo-sacral plexus. These, again, have 
been subdivided into portions which correspond to the 
parts which they supply. These divisions are shown in 
the following table, modified from Schwalbe : 


. 1-4 = cervical plexus. 
. 5-8, D. 1 = brachial plexus. 
. 1-3, L. 4 = lumbar plexus. 
lexus ischiadicus: 
Ti. BS Veo 4s 
Plexus pudendalis, or pu- 
dendo-hezmorrhoidalis : 
S, 3, 4, 5 (8. 2): 
Plexus coccygeus, or sacro- 
coccygeus: 
LS. 5, Co. J 


Pl. cervico-brachialis... | 


| 
Pl. lumbo-sacralis...... | Sacral plexus. 


C.. cervical; D., dorsal; L., lumbar; §S., sacral; and Co., coccygeal 
nerves. 


Seow) 


‘It will be seen that there remain eleven dorsal nerves 
that are not classed as assisting in the formation of the 
plexuses. It should be remembered, however, that both 
the second and eleventh dorsal send branches to the 
nerves derived from the plexuses, and that they might 
therefore properly be included in the table. The an- 
terior roots of the dorsal nerves generally pass forward 
and form the intercostal nerves. 

By far the most important of these plexuses are the 
brachial and the ischiadic, which supply the great nerves 
for the limbs. The upper extremity is supplied from 
five spinal nerves, while to the lower and larger limb no 
less than nine contribute. 

The intermingling of nerve-fibres in the plexuses is so 
great that the nerves which are given off as ultimate 
branches have most of them an origin from several of 


.... To rectus capitis anticus major and longus colli. 
Ls OC BVI OO RTE a Te eit rae Occipitalis minor, 


aialaie elereyaucvelele: Mtretheiaete eet hol traeteiets Communicans noni. 


BOO OCHICII SOLO aERS Sth COE Superficialis colli. 
a iousiershavers..evebsiets Deena eee Eee ALIICUIATIS Mays. 


- ee pci Nirnciweres Guha amese oe een To sterno-mastoid. 


Sigs Valea vayaier sy steceiese eisisicie e) nih coeua) esis ty cise. ov avstare To trapezius. 
BA AES Ogre nis Haas OATICR EE ec ere Supraclavicular. 


Ree ett les oReterotesteicastee cote otnis eacater emake art retere erste per ase Phrenic, 
Beat: Stes oie ec ren eee LO Subela Vian. 
Sfoloiereia’sidlove icra tetevsakics’ Aber To levator anguli scapule, 
.......To rhomboidei. 


Bye POR Se aNerareieh ahora treishaie’ Se crete raeiehivtce ately anetaata Suprascapular. 


Subscapular. 
Circumflex. 


Dania Sale: eloveterwiaisiainie cis Sicrere Ne a sealer e ciate) ss Posterior thoracic. 


Sy eq ealereverelcisisasiasa pists ce Anterior external thoracic. 


slaje afelaie sinis distaste wis we eyereeleue sess oye. ate ean To teres major. 


rd ott SRR ee Nena ON ERE Stee adorn ie, Niel Sie hi a tenar eee eheherare Siekers Median. 


sivas oes a © pete, Shee bi elsiat elie! 40s) alsa. s) sale, =) = (= sie Scat 


pe PSE Sotho ichcroce nod a toe ogeu Boe Intercosto- humeral. 


(After Féré.) 


the spinal nerve-roots. Many attempts have been made 
to thoroughly trace out the origin of each nerve. It is 
almost impossible to do this, and, because of the intimate 
intermingling of the fibres, different observers have ob- 
tained results which are not entirely identical. 

It is probable that, as far as regards the formation of 
plexuses, that the individual variations are very great. 
The brachial plexus is by far the most regular, because 
of its peculiar relations to the axillary artery, yet it is 
certainly very variable both in its composition and its 
arrangement—so much so that the purely typical form 
is rarely seen in the dissecting-room, In the formation 
of plexuses it would seem that there is merely a contin- 
uation of a tendency which can be noted throughout the 
nervous system. Within the sheath of every large nerve 
the fibres are constantly interweaving among each other 


; 595 


Spinal Nerves. 
Spinal Nerves. 


in an irregular manner, so that the relative arrangement 
changes indefinitely, even in a very short distance. 

The question to be solved, however, is not whether the 
ultimate nerves arise from certain definite cords of the 
plexuses, but from what part of the spinal cord they can 
be derived. Féré, after combining the data of others 
with those from his own dissections, prepared diagrams 
similar to those shown in Figs. 8662 and 3663, and they 
may be said to represent our present knowledge on this 
subject. In studying lesions of the cord it is often nec- 
essary to determine from the symptoms the point at 
which the disorder is situated, and these diagrams per- 
mit us to ascertain the approximate area of the cord 
which is affected when symmetrical impairment of mo- 
tility or sensibility occurs. 

Our knowledge of the muscular system is not suffi- 
cient to enable us to fully understand the meaning of this 


I. Lumbar 


III. Lumbar 


TVe and Ver Guumbar.... eerie 


TSS acral ee tse cares sete tae 4 


TL Sacralins cose tae occcee oe sie's 


TEES Sacral ions asia cise cisie setts 


IV. Sacral 


Vs acral/ccns. cia cts torte ee cats 


OCoccyzealatam alle ee een ent 


Fig, 8663.—Diagram showing the Origin of the Principal Nerves of the Lumbo-sacral Plexus. 


arrangement. It only appears from a study of the dia- 
grams that those nerves which represent the widest range 
of activity are those which have the largest area of origin 
from the cord, and that certain nerves appear to be mere 
appendages to others. Examples of this may be seen in 
the internal cutaneous nerves of the arm, which seem to 
belong to the ulnar, and the obturator, which is related 
to the anterior crural. It is noticeable that the nerves 
which supply the distal ends of the limbs are derived 
from roots farther from the brain than those which sup- 
ply the proximal ends of the same limbs. As a general 
rule (subject, however, to many exceptions), the muscles 
are innervated by the same nerve which supplies the 
skin over their insertions. * 

It has been surmised that this plexiform arrangement 
is necessary in order to supply the muscles and other or- 
gans with twigs from various sources, so that if one 
source of supply is injured or cut off the other may be 
used. It is not quite clear how this can be done. If 
the entire history of development were known, from the 


* This is generally known as Hilton’s law, but it was formulated by 
Peyer and W. Krause, some time previous to the publication of Rest and 
Pain, 


596 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


time that the buds for the limbs were formed by the 
fusion of lateral elements from the somites of the trunk, 
the relative arrangement of the musculo-nervous canal 
could probably be cleared up. It will be necessary to 
await further embryological investigations before this 
obscure subject can be fully elucidated. 

The cervical plexus is formed by the anastomoses of 
the anterior branches of the first four cervical nerves to- 
gether with the hypoglossal. The loop supplied by the 
latter cannot, however, be traced to the hypoglossal nu- 
cleus, but is really derived from the first and second cer- 
vical nerves, as will be seen in Fig. 8664. This loop sup- 
plies all the muscles of the jaw and infrahyoid region, 
usually assigned to the hypoglossal, leaving ‘for that 
nerve merely the task of providing motor influence for 
the intrinsic fibres of the tongue. The hypoglossal side 
of the loop is known as the descendens noni nerve, and 


.++++2-.+Llio-hypogastric, 


ee ee a Y 


......e-Llio-inguinal. 


External cutaneous. 


ie ate eetenie aisle we wlata ele taetie ote verte Genito-crural. 


Obturator. 
a Giarelavens aicvele'ereverens Nish ard coh Steyee otevarce Superior gluteal. 


a sléiel slelaloitietsleaisiagiets saa ae ACCESROLy, ODbUTaLOr. 


sisleleejeieie'e sistatelepuleiess Ae oie .. External popliteal. 


SS nt emcee ccc ewer er ccnaes Internal popliteal, 


mr ietes Gre areiic wie oie. atasb sun aarti pie laces Small sciatic. 

Sade wo o's aralate: area Ore, ateveteemsietete tence Internal pudic. 

arale'sre sisistisnete ns aersfeiere ieee Anal cutaneous. 

wiaatel steielae otetereeatates To the hypogastric plexus. 

PE BSC CCAS Un COI oS Oho Gp uorne To levator ani. 
ee SOO Oe bia opratcieeoun. aa Coccygeal, 

Pais Cia tors eis a diet s sisters ste Walvetineh oe nae OL SpPHINCter ani: 


(After Féré. ) 


is of some surgical interest, as it usually lies directly on 
the carotid sheath, and may be in the way when ligation . 
of that vessel is attempted. 

The following table! gives a general view of the com- 
position of the cervical plexus : . 


Cervical Plexus of Nerves. 


Anterior) (SUPERFICIAL (Ascend- 


Occipitalis minor. 
Auricularis magnus. 


branch of BRANCHES| ing set. ( Superficialis colli. 
1sT CERVI- | 45 (antegu=) 
CAL nerve. | 5 mentary ). 
ea ed lor ps | pees) } Supra-clavicular branches. 
branch of : 
2D CERYI- j ( Communicating. 
CAL nerve. | 4 Rect, cape aNne. 
Anteri 3 Cites (ee hoo te t 
nterior nterna ect. cap. ant. 
branch of | > set. ) Muscular. ) “minor eee 
3D CERVI- | 6 | Rect. cap. later- 
CAL nerve. | 8 alis, 
: o Communicans noni. 
-Anterior DEEP | PHRENIC. 
branch of | BRANCHES. | 
4TH CER- ( Sterno-mastoid. 
VIOAL Levator anguli 
nerve. scap. 


rapezius. 
Scalenus med. 


( Muscular. 
External T 
set, 


Communicating. 


Spinal Nerves. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. altel ad os 


plying that muscle, its influence is so much predominant 
that the other nerves (branches from the intercostals) are 
not able to do the work. Its most exposed situation in 
the neck is where it lies in front of the scalenus anticus 
muscle. It may here be wounded by a stab. It also 
may be compressed by an aneurism when it passes into 
the thoracic cavity between the subclavian artery and 
vein, behind the sterno-clavicular articulation, or by peri- 
cardiac effusion as it passes down between the pericar- 
dial and pleural cavities. 

The cutaneous supply of the neck is derived from the 
cervical plexus, the areas being approximately shown in 
the annexed diagram, Fig. 3665. 

The brachial plexus supplies the arm and shoulder. 
Muscles which morphologically belong to the arm, like 
the latissimus dorsi, although far removed in their ori- 
gin, are supplied by it. It is subject to very great varia- 
tion, but it nevertheless may be reduced to a general 
plan, which may be said to be typical. A great many 


Fia. 3665.—The Nerve-supply of the Posterior Portion of Head and Neck. 
(Modified from Flower.) 1, Region supplied by the great occipital 
nerve; 2, region supplied by the auriculo-temporal nerve; 3, region 
supplied by the small occipital nerve; 4, region supplied by the great 

\ auricular nerve ; 5, region supplied by the third cervical nerve. 


So of the variations depend upon the fact that the different 
ot cords which compose it may unite sooner or later than 
Fie. 3664.—Connection of the Hypoglossal with the Cervical Nerves. usual. Fig. 3666 shows a type to which all variations 


(Hall.) XII, Hypoglossal nerves; I, II, III, anterior branch of cervi- : : 4 if 
cal nerves ; D, D', rami communicantes noni; a, branch of first cervi- oe a be reduced. It will be seen that the Ist dorsal and 


cal nerve, which sends a twig, ¢, centrally upward, and gives off twigs 8th cervical are the first to unite. Then the dth and 6th 
sential ho net Leon ; fie a descending | cervical combine, while the 7th remains free. There are 
aanen ee ie aansendions nent oe eon leg for etree aera | tus formed three stems, which Schwalbe calls primary 
g, the bundle from first and second cervical, uniting with f! from third trunks. From each of these there is given off an an- 
cervical ; 42, branch to thyro-hyoid; ge, branch to genio-hyoid. terior and a posterior branch. The three posterior 
y mae ? , branches unite to form a single cord, the anterior branch 

The most important nerve, clinically, is the phrenic, as | of the 1st and 2d trunks form another, while that of the 
when it is injured paralysis of the diaphragm imme- | 3d trunk remains ununited. There are thus formed 
diately ensues, for though it is not the only netve sup- | three cords which have a definite relation to the axillary 
= artery, lying posteriorly, externally, and internally from 

Ge V it. Krom these cords the main nerves are given off : from 


ee! the external the musculo-cutaneous, and one branch of 

F he ae the median ; from the internal the other branch of the 
CVI ae / ye 

_M ‘ana / ae ‘ median, the ulnar, and the internal cutaneous ; from the 


posterior the radial (musculo-spiral) and the circumflex. 


¢.ViL 


Muse. C ul; 
Meoian 
Raolz acl 
Umar 


Fic. 3666.—Diagram of a Typical Brachial Plexus. (Schwalbe.) I, II, III, Principal trunks; @!, a?, a3, anterior branches ; .p!, 92, %, posterior 
branches ; 1, 2, 3, cords. 


C.V 
daa 


597 


Spinal Nerves. 
Spleen, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


The following table! shows the other details of distri- | magnus muscle, its branches appearing laterally from it 


bution of the plexus : 


The Brachial Plexus. 


( Posterior thoracic (external respiratory nerve 
of Bell). 


Supraspinatus. 
Suprascapular........ Infraspinatus. 
Shoulder-joint. 


Subclavius. 


S ii ; 
IMMISCIIaAT CO) eemienieete enone Mee 


| | Levator anguli scap- 


Branches above the clavicle. { | Rhomboidei muscles. 


ule. 


{| Communicating (to phrenic nerve). 

; (Internal anterior 
thoracic. 

Interna] cutaneous. 

Lesser internal cuta- 


From inner cord..... 4 neous (Wrisberg’s 
nerve). 

Inner head of median 
nerve. 


| Ulnar nerve. 


| ssa anterior 
: thoracic. 
Branches below the Plavies | From outer cord ..... External cutaneous. 
Outer head of median 
| nerve. 
ist subscapular nerve. 
2d subscapular nerve. 
3d subscapular nerve. 
Radial nerve. 
Circumflex nerve. 


(From posterior cord. 


Rauber endeavors to simplify the plexus still more by 
considering the division as arising still further back. His 
scheme is shown in Fig. 3667. He divides each root at 
once into an anterior and posterior branch. The latter 
forms the posterior cord. The 8th cervical and 1st. dor- 
sal form the inner cord, then the 5th, 6th, and 7th unite 
to form the outer. There is thus a division of regions 
which control the entire arm. 

The muscles of the dorsal region, extensors and supi- 
nators, are generally controlled by the radial, those of the 
palmar surface by the musculo-cutaneous above and the 
median below, the hand being divided between the me- 
dian and the ulnar. The radial side of the arm is sup- 
plied by nerves which have a higher origin in the cord 
than the ulnar side. The thumb side of the hand is 
therefore to be considered as that which was originally 
directed forward. 

An inspection of Fig. 3668 will show that a similar 
law governs the cutaneous nerves of the arm. 

One of the mooted points in anatomy is the so-called 
antero-posterior symmetry of the limbs. Most anatomists 
hold that the radial side of the arm corresponds with the 
tibial side of the leg ; but others, among whom may be 
mentioned Wyman and Coues, suppose that the fibula 
and the radius are homologous. Wilder advances a the- 
ory that the limbs are reversed repetitions of each other, 
corresponding as an image in the mirror corresponds to 
the object producing the reflection. It will be seen that 
the distribution of nerves throws some light on this sub- 
ject. 

The lumbar plexus is buried in the fibres of the psoas 


Fig. 8667.—Diagram showing the Plan of the Brachial Plexus, according to Rauber. 


598 


mE 


or passing out below. The following table! shows its 
general distribution : 


( Ilio-hypogastric nerve. F 
| [lio-inguinal nerve. Bien oro baat’ 
ist LUMBAR Communicating to 2d lumbar. VE. 
uy | nerve. | rete, : 
7, é enito-crural nerve. . om 
© % |; External cutaneous nerve. eg OBE 
B lop LUMBAR | | Communicating to 3d lumbar. 4 
5 nerve. fe 
5 | } a pak a peter crural nerve. 
5 art of obturator nerve. . 
cs | &| Part of accessory obturator pe AA ae 
= |38D LUMBAR! a nerve. . 
= nerve. | a Communicating to 4th lumbar. 
= 
e Hi. Aj Boe a puterioy crural nerve. 
TH LUMBAR art of obturator nerve. Gi 
iven off by the 4TH 
nerve. Lene accessory obturator LUMBAR NERVE. 
Lumbo-sacral cord. J 


It controls the psoas and iliacus, and the great extensor 
and adductor groups of the thigh. It sends no muscular 
branches below the knee. 


B. A, 


SPORTS SS 


iA 
Wen 
3 
LA 


Fria. 3668.—Cutaneous Distribution of the Nerves of the Arm. ‘A, Pal- 


mar aspect; B, dorsal aspect; sc, suprascapular nerves; ax, circum- 
flex nerve ; c.m, lesser internal cutaneous ; c. med, internal cutaneous 5 
c.l, musculo-cutaneous ; 7, radial; m, median ; 2, ulnar, 


The sacral plexus, on the contrary, controls 
the great gluteal flexor and rotator groups of 
muscles, the thigh, and all the muscles below the 
knee. The cutaneous distribution (Fig. 3669) is 
such that the lumbar plexus (higher roots) gen- 
erally innervates the anterior surface and tibial 
edge, while the sacral plexus supplies the pos- 
terior surface and the fibular edge. Thus the 
conclusion arrived at from comparative anatomy 
and embryology, that the tibial and radial bor- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


ders of the two limbs are properly comparable, is here 
confirmed. 


Fic. 3669.—Cutaneous Distribution of Nerves of Lower Extremities, 
A, Anterior view; B, posterior view; d./, d.s, dorsal branches of lum- 
bar and sacral nerves; v.s, inferior gluteal; 7.h, ilio-hypogastric; g, 
ilio-inguinal ; 7.7, genito-crural; c.l, external cutaneous; c.cr, middle 
cutaneous; 0, obturator; c.p, lower sciatic; sa, saphenous; p.e, ex- 
ternal popliteal ; y.m, post-tibial; sw, saphenous; y.s, musculo-cutane- 
ous; p.p, anterior tibial; m, internal plantar; /, external, 


The general distribution of the sacral plexus is shown 
in the following table :! 


Distribution of the Branches of the Sacral Plexus. 


Gluteus medius muscle. 

Gluteus minimus muscle. 
Gluteus medius muscle. 

Inferior branch. Gluteus minimus muscle. 
Tensor vaginee femoris. 


Superior branch, } 
SUPERIOR 
GLUTRAL. 


[ 5 bid again : 

urator internus, 
"branches. | Gemellus superior, 
* | Gemellus inferior. 


| Quadratus femoris. 


ARTICULAR coer Pe 
branches. i To hip-joint. 


Spinal Nerves. 
Spleen. 


f Inferior gluteal 


branch. i Gluteus maximus muscle. 


Infers , if eee Ss Ubelbaae 

njerior puden- } Integument of upper and inner part of 
SMALL dat branch. i the thigh, us : 
SCIATIC. | Integument of scrotum or labium. 


Inteyument over 


j gluteus 
maximus muscle. 


Ascending. { 
Cutaneous 
branch. 
; { integument of inner and 
Descending. outer sides of posterior 
( aspect of the thigh, 


Articular (to hip-joint). 


6 f pe auees er tia 
REAT emimembranosus. 
SCTATIC. Muscular........ 4 Semitendinosus. 
| Biceps flexor cruris. 


§ EXTERNAL POPLITEAL. 


Wlerminalyy.c. .: 3. 
( INTERNAL POPLITEAL. 


{ Cutaneous or ( Integument of anal region, 
| superficial , scrotum, penis, and labia. 
IRA OO Mason hadee 4 perineal. sphincter ani muscle. 


IMinsculattiee sists Muscles of the perineum. 


PupDIC 4 Inferior heemorrhoidal. 
NERVE. | 
Dorsal nerve of \2éegument of the dorsum and sides of 


Zs penis 
nis. Li * 
gee ( Brancli to corpora cavernosa. 


Frank Baker. 


1 Darling and Ranney: The Essentials of Anatomy. 


SPLEEN, DISEASES OF THE. Inrropuction.—It 
is now generally admitted that the only ascertained 
function of the spleen relates to the production of the 
white and to the destruction of the red blood-corpuscles. 
Physiologists adduce, in support of this view, the facts 
that the blood of the splenic vein contains a larger num- 
ber of white corpuscles than that of the corresponding 
artery, particularly in cases of splenic leucocythemia, 
and that the opposite numerical relations obtain with 
regard to the red corpuscles. Writers upon physiology 
also advance the theory that the spleen’acts asa vascular 
diverticulum for the portal venous system, and conjecture, 
from the invariable presence of uric acid, leucin, and 
xanthin in the spleen, that this organ is the seat of va- 
rious undetermined metabolic processes.!' Since our 
knowledge of the physiology of the spleen is so meagre, 
it naturally follows that the relations of splenic diseases 
to morbid systemic conditions still constitute a terra in- 
cognita presenting a large and inviting field for original 
physiological, clinical and pathological research. 

Most of the diseases of the spleen are, thus, acknow]l- 
edgedly interesting rather as concomitants of other mor- 
bid conditions than because they exert any known direct 
influence upon the economy at large. On this account 
they are generally cursorily considered in systematic 
treatises upon clinical medicine, being regarded by many 
authors as of decidedly secondary importance. It is, 
however, desirable to emphasize the fact that splenic dis- 
eases often serve as trustworthy indices of other morbid 
states, and furnish valuable corroborative evidence of 
their existence at a stage when prophylactic measures may 
yet be successfully employed, or roborant treatment ad- 
vantageously inaugurated. 

The writer’s opinion, that the spleen should be careful- 
ly interrogated in every clinical examination, influences 
him to preface this article by a few hints in regard to the. 
methods of investigating the physical condition of this 
organ. 

It is important that the diagnostician have definite 
ideas relative to the normal shape and position of the 
spleen, inasmuch as diseased conditions susceptible of 
diagnosis almost always betray themselves by alterations 
in one or the other of these physical features. The means 
of physical examination at the physician’s command 
are inspection, auscultation, palpation, aspiration and 
percussion. The four former modes of investigation 
afford no assistance in the examination of the normal 
organ, while percussion gives only approximately correct 
information, as isevidenced by the discrepancies between 
the statements of different well-qualified observers. This 
diversity of opinion may be accounted for by the fact 
that the spleen varies very notably, in weight and size, 
in different healthy individuals, under varying conditions, 


599 


& 


Spleen. 
Spleen. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


and at different ages. Gray states that the weight of the 
spleen at birth is, in proportion to that of the entire or- 
gan, as one to three hundred and fifty, and in adult life 
as one to from three hundred and twenty to four hun- 
dred, while the proportion in old age is as one to seven 
hundred. The same author gives the average weight of 
the spleen, in adult life, as seven ounces, and the length 
as five, the breadth as from three to four, and the thick- 
ness as from one to one and a half inches, respec- 
tively.? 4 

One great source of difficulty in accurately outlining 
the spleen is the occasional superimposition of neighbor- 
ing organs, viz., of the stomach in gastric tympanites or 
in the progress of normal digestion, of the colon in dis- 
tention of that viscus, and of the lung in emphysema or 
in other pulmonary diseases. 

Percussion shows, however, that the average normal 
adult spleen extends from the upper border of the ninth 
rib to the lower margin of the eleventh rib, where the 
splenic flatness imperceptibly merges into that of the 
kidney, and from about one and a half inch to the left 
of the spinal column, posteriorly, to the middle axillary 
line, anteriorly.* In practising percussion of the spleen, 
the examiner should place his patient upon the right 
side, or in the semi-prone position, the body being in- 
clined toward the right, in order that the stomach be 
prevented, so far as possible, by the force of gravity, 
from becoming interposed between the spleen and the 
abdominal wall. It is also useful to employ percussion 
during alternate full inspiration and complete expiration, 
in order to discover to what extent the lung overlaps the 
spleen in these opposite phases of the respiratory cycle, 
and to ascertain the extent of displacement of the organ 
occasioned by the ascent and the descent of the dia- 
phragm. 

It is only in diseased conditions of the spleen that in- 
spection, auscultation, palpation, and aspiration furnish 
positive information, If the organ be sufficiently en- 
larged, inspection may show an unusual prominence of 
the abdominal parietes in the hypochondriac region, or 
even in the epigastric, the umbilical, the lumbar, the 
iliac and the hypogastric regions. Pulsation of the 
spleen, perceptible to the touch, has been noted in cases 
of free aortic regurgitation. Auscultation may reveal 
friction sounds due to peri-splenitis, or, possibly, the hy- 
datid thrill, while the palpating fingers encounter a 
smooth, ovoid tumor, usually hard, smooth, and rounded 
above, and presenting a notch or depression in its an- 
terior border. In cases of only moderate enlargement 
palpation may be usefully employed in the following 
manner: The patient, being on his right side, is in- 
structed to flex his thighs and legs, thus relaxing the ab- 
dominal walls, and to alternately inhale and exhale as 
fully as possible. The examiner meantime places the 
thumb of his left hand in the left lumbar, and the corre- 
sponding fingers in the hypogastric region, and making 
deep pressure endeavors to grasp the spleen. Percus- 
sion, under these circumstances, shows flatness involving 
the normal splenic site and the other abdominal regions 
occupied by the tumor. If the patient assume the genu- 
pectoral position an enlarged spleen will often fall for- 
ward, and it may be made to rise on expiration and to 
descend during inspiration, if adhesions do not prevent it 
from so doing. Aspiration may be employed as a means 
of differential diagnosis in cases of fluctuating splenic 
tumors, as in hydatids and in abscess. 

The chief abdominal tumors liable to be mistaken for 
an enlarged spleen are renal growths involving the left 
kidney, feecal accumulations in the splenic flexure of the 
colon, gastric neoplasms, abscesses in the abdominal walls, 
or tumors of the pancreas, of the left lobe of the liver, of 
the omentum and of the ovary. 

Tumors of the left kidney may be distinguished from 
splenic enlargements by the facts that they are more 
fixed ; that, with the exception of movable kidney, they 
do not follow the respiratory movements of the dia- 
phragm, and that they are not displaced from their orig- 
inal position by changes in the patient’s position. The 
renal tumor will also usually occupy a position posterior 


600 


to the site of splenic enlargements, and may cause char- 
acteristic urinary symptoms. 
Fecal masses in the splenic flexure of the colon may 


| closely simulate splenic tumors, but they are usually of 


elongated form, their long axis corresponding to the 
course of the intestine, in which direction they may be 
spontaneously or artificially displaced. They may, more- 
over, be indented with the finger, and may then retain the 
digital impression, owing to their inelastic character. In 
many cases fecal tumors may be removed by the judi- 
cious and persistent use of purgatives and of laxative 
enemata. 

Malignant gastric growths generally do not occupy the 
position assumed by splenic tumors, are usually of small- 
er dimensions, do not readily change their place during 
respiration or on palpation, and are attended with a famil- 
iar train of diagnostic symptoms. 

Chronic abscess of the abdominal walls may be distin- 
guished by its superficial character, its traumatic ori- 
gin, and by the absence of sufficient causes for splenic 
enlargements. For the differential diagnosis between 
tumors of the spleen and pancreatic, hepatic, omental and 
ovarian enlargemenis, of which the first are less frequent 
than splenic tumors, and the others, from their position 
and history, are not likely to be confounded with these, 
the reader is referred to the writer’s article on Abdominal 
Tumors, in this HANDBOOK. 

AcuUTE SPLENIC Tumor. Definttion.—Sudden enlarge- 
ment of the spleen occurring in various febrile and infec- 
tious diseases, and due either to combined congestion and 
hypertrophy, or, in cases of short duration, to congestion 
alone. The physiological enlargements of the organ, 
incident to digestion and to menstruation, are not gen- 
erally included in the category of splenic tumors, al- 
though, strictly speaking, they might be classified under 
this heading. 

Etiology.—This form of splenic tumor occurs with 
great constancy in some of the infectious diseases, as in 
typhoid and in typhus fever, relapsing, intermittent and 
remittent fevers. It is also generally observed in the 
course of septicemia, pyzmia, acute yellow atrophy of 
the liver, acute miliary tuberculosis, erysipelas, puerpe- 
ral fever, dysentery, splenic fever, scurvy, glanders, 
ulcerative endocarditis, variola, scarlatina, cerebro-spinal 
fever, diphtheria and acute follicular tonsillitis. It is 
sometimes scen in pneumonitis, acute pharyngitis, pri- 
mary and secondary syphilis, and in acute coryza, gastro- 
enteritis and rheumatism. Acute splenic tumor may, 
moreover, be due to sudden occlusion of the portal vein 
in pyle-thrombosis or pyle-phlebitis, and to traumatism. 
Congenital acute splenic tumor sometimes occurs in chil- 
dren whose mothers have suffered from malarial fever 
during their pregnancy. 

Pathogeny.—The splenic enlargement is generally ex- 
plained by the assumption that the micro-organisms 
which constitute the materies morbt in many of these 
diseases accumulate in the spleen, owing to the filter- 
like arrangement of its vessels, occasioning congestion 
and inflammation both mechanically and by the irritat- 
ing quality of the excrementitious products resulting from 
their retrograde metabolism. The discovery of numer- 
ous micro-organisms in the spleen pulp, after splenic 
fever and pyzemia, lends probability to this view of the 
pathogeny of acute splenic tumefactions, which is, how- 
ever, not yet universally accepted. 

Pathological Anatomy.—In those forms of acute splenic 
tumor which are of very short duration, the only morbid 
anatomical change is a more or less intense hyperemia, 
Should, however, the pathological process, to which the 
splenic tumor is secondary, be at all protracted, the 
spleen, besides increasing in size, even to two or three 
times its normal volume, becomes soft, and sometimes 
almost diffluent. Its color is reddish-brown, or reddish- 
blue, and is sometimes mottled gray and red. Peri- 
splenitis may exist. On section the pulp becomes ele- 
vated above the cut surface of the capsule. The 
Malpighian bodies, which are generally not seen, may be 
plainly discerned in some cases, and are occasionally 
notably enlarged, particularly in scarlatina.® The trabe- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Spleen, 
Spleen, 


cule are ordinarily obscured by the swollen pulp. The 
microscope shows the essential lesion to be either an 
hyperzemia, in cases of short duration, or an hyperplas- 
tic splenitis chiefly affecting the corpuscles of the splenic 
parenchyma, ‘The interstices of the pulp often contain 
an abnormally large number of red and white blood-cor- 
puscles, and some cells of varying size, pigmented, or 
fatty and granular. These inflammatory changes gener- 
ally undergo rapid resolution after the cessation of the 
primary disease. In cases of typhoid and relapsing 
fevers this retrogressive change is, however, often long 
delayed, and in malarial disease particularly, when the 
patient suffers from repeated attacks, or the lesions may 
persist indefinitely, constituting one variety of chronic 
splenic tumor. 

Clinical History.—An acute splenic tumor, of moder- 
ate or even of considerable size, may not reveal its pres- 
ence by any subjective phenomena, or these may be 
masked by the symptoms of the primary disease. Often, 
however, the enlargement causes a vague sense of weight 
and discomfort in the left hypochondrium, with tender- 
ness on pressure, and occasionally even pain, which, 
although ordinarily dull and constant, may, rarely, be 
sharp and shooting, radiating even into the left arm and 
leg. In the latter case, the existence of peri-splenitis 
may be rationally inferred. Rupture of the spleen has 
been known to occur in typhoid and intermittent fever 
and in other infectious diseases, but it is extremely rare 
and is hardly to be anticipated, except as the result of 
traumatism. If rupture occur, it will almost necessar- 
ily prove fatal from hemorrhage, shock, or peritonitis. 
It is desirable that statistics be gathered bearing upon 
the frequency with which, in infectious diseases, acute 
splenic tumor is developed in anticipation of the char- 
acteristic constitutional symptoms. It is to be hoped 
that the physician of the not distant future may be en- 
abled, having early discovered the approach of infectious 
diseases by splenic enlargement, to sometimes adopt effi- 
cient abortive measures of treatment. Mosler describes 
a murmur heard over the spleen during the febrile 
paroxysm of intermittent fever, and holds the opinion 
that the murmur is due to contraction of the splenic ar- 
tery in the cold stage of the fever.° 

Diagnosis.—In a case of splenic tumor, found coinci- 
dentally with an acute febrile disease, the only question 
requiring attention from the differential diagnostician 
relates to the exclusion of chronic splenic tumor. The 
previous history, particularly if it embrace records of 
thorough physical examinations, may here be of great 
service. Failing this, the disappearance or persistence 
of the tumor, after defervescence, will furnish the re- 
quired information. 

Prognosis.—This relates, first, to immediate danger 
from the splenic tumor, and, second, to the liability to 
the development of chronic splenic tumor as a sequela 
of the acute. Life is only imperilled, in acute splenic 
tumor, by the rare occurrence of rupture ; while a chronic 
tumor is not developed, even in malarial fevers, provided 
that proper and persistent antiperiodic treatment be 
adopted. 

Treatment.—Therapeutic measures especially directed 
to the splenic tumor are rarely required. The primary 
disease takes precedence of this, its local manifestation, 
and treatment adapted to the cure of this malady will 
effect all the improvement in the condition of the spleen 
that can be expected from internal medication. Should 
the pain be excessive or lancinating, local revulsive ap- 
plications, as dry cups and iodine, or hot fomentations, 
together with anodynes internally administered, will gen- 
erally fulfil the indications for treatment. 

CHRONIC SPLENIC Tumor. Stiology. — The chief 
causes of chronic splenic tumor are malarial fever or the 
malarial cachexia, leucocythemia, and pseudo-leucocy- 
themia. This form of tumor is also often found in 
those who have long resided in malarial districts, even 
although they have never suffered from any form of 
malarial disease. Of less importance, as etiological 
agents, are all the causes of mechanical obstruction to 
the portal system, of which the splenic vein is an impor- 


tant radicle. In this category belong hepatic cirrhosis, 
pyle-phlebitis, abdominal neoplasms pressing on the por- 
tal vein, thoracic tumors obstructing the inferior vena 
cava, mitral and tricuspid valvular lesions, interstitial 
pheunionitis or fibroid phthisis, chronic pleuritis with 
retraction or with great effusion, and pulmonary emphy- 
sema. Many of these conditions are, however, often 
found without a coexistent splenic tumor, and even when 
the spleen is abnormally small from fibroid contraction 
or from simple atrophy. Syphilis is said to occasionally 
produce this lesion independently of its own characteris- 
tic form of splenic tumor, and, in rare instances, no cause 
for the enlargement can be ascertained. 

Morbid Anatomy.—The size of the spleen is augmented 
sometimes to an enormous extent. The organ has been 
known to weigh fifteen or sixteen times as much as in 
the normal state.7 Its shape remains unchanged ; its 
consistency is greatly increased, and its color is, as a rule, 
dark red or brownish-black, but it may be normal or 
mottled. The capsule is thickened and may be adherent 
to surrounding viscera, as the result of antecedent peri- 
splenitis. On section the cut surface is seen to be smooth 
and indurated. The glomeruli and trabecule may be 
either almost invisible or very distinct. The microscope 
shows the lesion to consist in chronic hypertrophic sple- 
nitis, involving especially the trabecule, but often both 
these and the splenic cells. Pigmentation of the cells in 
the pulp, of the Malpighian corpuscles, or of the trabe- 
cule is not uncommon. For the pathological anatomy 
of leucocythemia and of pseudo-leucocythemia, the 
reader is referred to the articles in this HANDBOOK treat- 
ing of these subjects. 

Clinical History.—The subjective symptoms are essen- 
tially the same as those of acute splenic tumor, viz., slight 
pain, tension, or fulness, and a dragging sensation in the 
left hypochondrium, sometimes notably increased by the 
assumption of the lateral decubitus. In some cases there 
may be splenic ectopia. We may have certainsymptoms 
due to the pressure of the tumor upon adjacent viscera, 
such as cardiac arhythmia, gastric disturbances, obstruc- 
tion of the colon, and chronic ulcer of the leg from in- 
terference with the blood-current in the ascending venous 
channels. Gerhardt described a pulsating splenic tumor 
presenting a double murmur in a case of aortic insuffi- 
ciency.® All the above symptoms are insignificant when 
compared with those due to the diseases causing the splenic 
hypertrophy. 

Diagnosis.—For the chief differential points between 
chronic splenic tumor and other abdominal tumors, the 
reader is referred to the introductory remarks on the 
differential diagnosis, and for a fuller exposition of the 
symptoms and signs characteristic of other splenic tumors 
likely to be mistaken for this form of tumefaction he 
may consult the remarks made in this article regarding 
the other causes of splenic enlargement. Acute splenic 
tumor is easily distinguished by its brief duration, waxy 
spleen by the pre-existence of suppurative diseases, syphi- 
litic degeneration by the history of a constitutional taint, 
and hydatids by fluctuation, thrill, and aspiration. If 
the chronic splenic tumor be due to malaria, the peculiar 
cachexia of chronic paludism may be present and pig- 
ment particles be found in the blood ; if to leucocythe- 
mia, the blood will present an excess of white corpus- 
cles; if to Hodgkin’s disease, the lymph-glands will 
probably be enlarged. 

Prognosis.—The exact share borne in the lethal issue of 
any disease of which chronic splenic tumor is a subordi- 
nate clinical feature, by the pathological condition of this 
organ can, with our present knowledge, only be conject- 
ured. If vital organs are affected by pressure, the in- 
fluence of the tumor can but be prejudicial to the general 
strength. We can only repeat that the prognosis, as to 
life, will depend on the primary disease, and not on the 
secondary splenic condition. If new connective tissue 
has been formed in the spleen or in its capsule, a com- 
plete resolution is, of course, not to be expected. ' 

Treatment.—In chronic splenic tumor from malaria, 
quinine and arsenic are useful, and removal from a ma- 
larial district is to be strongly recommended. In any 


601 


Spleen. 
Spleen. 


form of chronic splenic tumor, electricity and ergot may 
be tentatively employed, the latter perhaps best, hypo- 
dermatically over the region of the spleen. Da Costa 
reports a case of splenic leucocythemia_ successfully 
treated with ergotin thus administered.? Ice-bags con- 
tinuously employed for long periods may render con- 
siderable service, probably in the same way as ergot and 
electricity, ¢.e., by stimulation of the intrinsic splenic 
muscular fibres. Counter-irritation, by means of tincture 
of iodine carefully employed, has been productive of 
good results. Occasional depletion of the portal system 
by mild cathartics is to be recommended whenever the 
chronic splenic tumor is due to portal obstruction. If 
aneemia and asthenia are present, ferruginous tonics and 
roborant measures are, naturally, indicated. Extirpa- 
tion of the spleen may be considered, as a last resort, 
when the tumor is so large as to produce injurious press- 
ure on important organs, or is progressively increasing 
in size. Crédé believes that the operation is justifiable. '° 
Collier found that out of twenty-nine operations tabu- 
lated by him sixteen were performed for the removal of 
leucocythemic spleens and were all fatal, while eight of 
the remaining thirteen patients made good recoveries. 1! 

PERI-SPLENITIS. Definition.—Acute or chronic, local- 
ized or diffuse inflammation of the capsule and of the 
peritoneal investment of the spleen. 

Httology.—Peri-splenitis is caused by great over-disten- 
tion of the capsule, as in cases of malarial fever and of 
other infectious diseases, by extension to the capsule of 
interstitial splenitis, by involvement of the capsule in in- 
flammations of neighboring tissues, as in perinepbhritis, 
in gastric ulcer or cancer, and in general or localized 
peritonitis. Chronic peri-splenitis often occurs with 
chronic splenic tumor. It may be a sequel of acute 
capsulitis, or be coincident with chronic peritonitis. 
Some writers maintain that peri-splenitis may be caused 
by chronic alcoholism and by syphilis. 

Pathological Anatomy.—In acute peri-splenitis fibrin 
and pus are formed upon the peritoneal coating of the 
capsule. In chronic peri-splenitis the capsule is more 
or less thickened from the development of new connec- 
tive tissue. It may be adherent, through the medium of 
this new tissue, to adjacent organs. Its color is lighter 
than normal, and the new tissue, particularly in localized 
peri-splenitis, is dense and of cartilaginous firmness. It 
may have undergone calcification. The new connective 
tissue sometimes assumes the form of nodules or of pap- 
illary outgrowths. In peri-splenitis of apparently syphi- 
litic origin the connective tissue may form small, opaque, 
whitish plates or disks. 

Clinical History.—In some cases of malarial and other 
fevers a friction-sound is heard over the enlarged spleen 
during the respiratory movements. This is the first, 
and in mild cases the only, symptom of peri-splenitis. 
Severer cases will be attended by the lancinating pain 
which is characteristic of local peritoneal inflammation, 
which is aggravated by movements of the diaphragm, or 
by changes in position, and which may radiate into 
the left arm or thigh. Beyond this there will be no 
symptoms or signs until after the development of adhe- 
sions between the spleen and neighboring organs, when 
the spleen may remain immobile during respiration and 
present certain irregularities and prominences to the pal- 
pating fingers. Adhesions may be assumed to exist if 
there is no enlargement of the spleen during acute in- 
fectious diseases, or if splenic dulness persists after the 
occurrence of intestinal perforation. 

Diagnosis.—Peri-splenitis is to be distinguished from 
perihepatitis over the left lobe of the liver, and from the 
first stage of pleuritis, particularly of diaphragmatic 
pleuritis. The differentiation is often very difficult, and 
is largely based upon the clinical history of these dis- 
eases. Thus the effusion of pleurisy, and the larger area 
over which hepatic friction-sounds are audible will 
somewhat assist the diagnostician. 

Prognosis.—This is invariably favorable in simple 
cases, since peri-splenitis leaves no after-effect, unless it 
be pain from traction of an enlarged spleen upon newly 
formed peritoneal] adhesions. 


602 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Treatment.—This will embrace measures for the relief 
of the pain in the earliest stage of the inflammation, such 
as the application of hot fomentations, of revulsives, and 
of counter-irritants. For severe pain anodynes may be 
administered by mouth or hypodermatically.. The pain. 
due to traction of the spleen upon peritoneal bands and 
adhesions may be mitigated by the use of a belt or girdle 
for the support of the enlarged organ. 

INFARCTION. Stiology.—Splenic infarction is due to 
embolism of the splenic arterioles. These vessels belong 
to the class of arteries known as end-arteries, 7.¢., they 
do not terminate in anastomosing capillaries, but in in- 
tercellular vascular spaces. The most favorable condi- 
tions for the occurrence of hemorrhagic infarction are 
afforded by this vascular arrangement and by the ab- 
sence of valves in the splenic vein, which allows the free 
regurgitation of venous blood. The emboli causing ob- 
struction of these arteries usually come from the left. 
heart or the aorta, but in pysemic cases they may pro- 
ceed from the lungs, or, possibly, from even more remote 
parts of the body. They consist, either of vegetations 
from the endocardium, of atheromatous particles, of 
fibrin detached from thrombi, or of colonies of micro- 
organisms surrounded by fibrin. Splenic infarctions 
may be classified as simple and mycotic, in accordance 
with the character of the emboli which cause them. 

Pathological Anatomy.—Simple splenic infarctions are 
wedge-shaped, corresponding to the conical area sup- 
plied by the obstructed arteries, and generally near the 
surface. The apex of the wedge is directed toward the 
hilum, while the base often projects above the surface. 
There may be but one infarction, or there may be many 
infarctions. The size of the infarction varies ordinarily 
from that of a pea to that of an egg, but it may be much 
larger, owing to the coalescence of adjacent areas of in- 
farction. If such a coalescence be established, the char- 
acteristic wedge-shaped or conical form may be no longer 
preserved. On section the infarction is found to be 
either hemorrhagic, white, or mixed. In recent cases it 
is usually firm, whitish in the centre, and red at the 
periphery. Localized peri-splenitis may be found over 
the base of the infarction. In cases of longer standing 
the color is yellowish-white, from pigment absorption 
and from fatty degeneration of the cells. In some cases 
an infarction may soften and be absorbed, leaving a 
cicatrix. Again, it may successively undergo fatty, 
cheesy, and calcareous degeneration. Rarely it suppu- 
rates. The microscope shows that the hemorrhagic in- 
farction is made up of red blood-corpuscles and of com- 
pressed splenic tissues, while in the white infarction the 
cells are in a condition of coagulation necrosis. Mycotic 
infarctions are surrounded very early by zones of in- 
flammation, due to the irritation of the micrococci, and 
the pathological changes soon pass into those of splenic 
abscess (quod vide). 

Clinical History.—Simple splenic infarctions give rise 
to no symptoms, unless from accidental causes they oc- 
casion acute splenitis and perisplenitis, diseases de- 
scribed in this article under those headings. They are 
therefore devoid of importance, inaccessible to diagnosis, 
and claim no treatment, often being found at autopsies 
of persons in whom their existence was not suspected. 
The clinical history and the treatment of mycotic in- 
farctions merges into that of metastatic splenic abscess, 
to be presently described. 

Apsscess. LHttology.—There are two chief varieties of 
splenic abscess, namely, those due to traumatism, to 
extension of inflammation: from neighboring viscera, or 
to simple embolism, which are quite rare, and those 
caused by septic embolism, which are frequent. The 
former class of abscesses is caused by wounds or contu- 
sions of the spleen, by the extension of inflammation 
from the stomach in cases of gastric ulcer or cancer, by 
the presense of neoplasms, or, very infrequently, by sup- 
puration of a simple infarction. An abscess of this kind 
may complicate typhoid, relapsing, or intermittent fever, 
and sometimes may be developed without known cause. 
The second variety of abscess is the result of mycotic. 
endocarditis or of pyzmia. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Pathological Anatomy.—Abscesses of the former variety, 
which, in contradistinction from those due to septic em- 
bolism, may be designated as simple abscesses, are gen- 
erally, although not necessarily, larger than the latter. 
They may lead to the destruction of the entire parenchy- 
ma of the organ, the capsule becoming distended with 
pus and disintegrated splenic tissue. On section the 
trabecule may be seen traversing the diffluent mass, or 
they, too, may have been broken down. The capsule is 
indurated, thickened, often adherent to other organs or 
tissues, and occasionally destroyed by the advance of the 
abscess toward the surface of the spleen. Smaller sim- 
ple abscesses may become encapsulated, and, eventually, 
be reabsorbed, leaving a cicatrix, or they may undergo 
caseous and calcareous degeneration. Splenic abscesses 
in any of the above stages, latent as regards symptoms 
and signs during life, may be discovered at autopsies 
held upon the victims of various diseases. Large ab- 
scesses may rupture and discharge their contents either 
into the peritoneal cavity, the colon, the pleural cavity, 
upon the cutaneous surface, into the renal pelvis, or into 
the retro-peritoneal tissues. 

Septic abscesses are ordinarily of small size, because 
the diseases to which they owe their origin are so often 
rapidly fatal. Their form may be that of a splenic in- 
farction, from which they often develop, namely, wedge- 
shaped, the base being directed toward the surface, or it 
may be very irregular, when the area involved in the in- 
farction has undergone complete necrosis. On section 
one finds a central mass, which the microscope shows to 
be made up of leucocytes, granular amorphous detritus, 
and micrococci, surrounded by coagulated fibrin and 
bordered by a dark congested zone of otherwise normal 
tissue. 

Clinical History.—The symptomatology of splenic ab- 
scess is not well made out, on account of the great rarity 
of the disease. The symptoms of abscesses other than 
mycotic, as described by those authors who have ob- 
served them, are merely those of suppuration in any tis- 
sue, and collectively known as hectic fever, together 
with pain and tenderness in the left hypochondrium, de- 
pendent upon peri-splenitis and upon peritoneal adhesions. 
The pain is said to have radiated, in some cases, into the 
left shoulder. Rupture of the abscess into the perito- 
neum causes fatal peritonitis ; rupture into the pleura and 
the bronchi, pleuritis, bronchitis and pneumonitis. In 
a case of supposed splenic abscess, treated by the writer, 
pus was abundantly discharged by the bronchial tubes and 
recovery took place. Rupture into the stomach or into 
the intestine would be followed by the vomiting or by 
the dejection of pus and blood, and rupture into the kid- 
ney by pyuria and hematuria. The physical signs, if 
the abscess be of considerable size, are those of splenic 
enlargement with possible fluctuation ; but in small ab- 
scesses, terminating by caseation and calcification, these 
signs would probably be absent. 

The symptoms and signs of mycotic abscess are usually 
negative, or are completely masked by those of the coex- 
isting endocarditis or pyemia. They rarely occasion 
tenderness, pain, or perceptible splenic enlargement, ex- 
cept in chronic pyemia, when they may, by the coales- 
cence of several small foci of suppuration, become large 
and fluctuating. Should the capsule and the peritoneum 
covering the spleen become involved, there may be con- 
siderable lancinating pain and marked tenderness. 

Diagnosis.—Simple splenic abscess, large enough to 
present physical signs, might be mistaken for perine- 
phritis, for pyelo-nephrosis, for sacculated empyema 
occupying the most dependent part of the left pleural 
cavity and for hydatids of the spleen. The exclusion of 
all these diseases but the last one might prove almost im- 
possible, except by exploratory incisions. Some assist- 
ance in making a diagnosis might be derived from the 
fact that a splenic abscess which had not caused adhe- 
sions of the spleen would descend on inspiration, which 
a perinephritic, nephritic, or pleural abscess would not 
do. Hydatids of the spleen would furnish a character- 
istic fluid on aspiration. Carcinoma of the cardiac ex- 
tremity of the stomach and pancreatic tumors may also 


Spleen. 
Spleen. 


be mistaken for splenic abscess. The existence of my- 
cotic splenic abscess can generally only be suspected 
when local signs are developed in pyemic cases, but the 
large abscesses of chronic blood-poisoning are more easily 
diagnosticated. 

Prognosis.—Mycotic abscess is not, in itself, fatal, but 
the pyeemia of which it is a subordinate feature offers a 
grave prognosis. Simple abscesses are usually fatal, 
either by rupture or by gradual exhaustion. The prog- 
nosis is, however, by no means hopeless, since rupture 
onto the surface, or in almost any direction save that of 
the peritoneum, may be followed by recovery. 

Treatment.—In suspected cases of beginning simple 
abscess, active prophylactic treatment must at once be 
adopted. This treatment will embrace saline laxatives, 
local abstractions of blood and ice-bags kept constantly 
applied. Bartholow recommends warm fomentations, 
turpentine stupes and hot poultices, besides the free ad- 
ministration of quinine.!” Fluctuating abscesses, simple 
or pyemic, should be evacuated with strict antiseptic 
precautions. The smaller mycotic abscesses are not 
amenable to treatment. 

Waxy SPLEEN. Litology.—Amyloid disease of the 
spleen occurs under the same circumstances which occa- 
sion waxy changes in other organs, namely, during pro- 
tracted suppurative diseases, particularly in those aftect- 
ing bone or pulmonary tissue, and in syphilis. Malarial 
disease is sometimes included in this category of causes, 
and, in rare cases, no cause can be discovered. This dis- 
ease of the spleen is rarely encountered except in cases 
presenting waxy changes in the liver, the kidney, and 
the intestine. 

Pathological Anatomy.—There are two varieties of amy- 
loid spleen. The former is known as the ‘‘ sago spleen,” 
and the latter as diffuse waxy disease of the spleen. In 
the former variety the organ is sometimes enlarged, and 
is sometimes not so. In the latter, the spleen is en- 
larged, tenacious, and indurated, its capsule being tense 
and glistening and its edges blunt or rounded. On sec- 
tion the ‘‘sago spleen” presents grayish, round, or oval 
translucent bodies scattered through splenic tissue, which 
may either be otherwise healthy, or may, also, be invoived 
in the same pathological change. The above-mentioned 
granules correspond to the Malpighian bodies, and vary 
in size from about one twenty-fifth to about one-eighth 
of aninch. In the diffuse variety of amyloid spleen the 
degenerative change is generally held to have invaded all 
the splenic tissues, but chiefly the pulp and the trabecu- 
le. On section the cut surface is waxy and more or less 
translucent, varying in color from a grayish-red to a dark 
grayish-brown. It is probable that the waxy change oc- 
curs first in the walls of the arteries, in both varieties, 
and subsequently involves the other structures. The 
tests for the waxy material are as follows: If Lugol’s 
solution, z.e., the compound solution of iodine, be applied 
to the cut splenic surface, those tissues which have un- 
dergone the amyloid change will assume a mahogany 
color, the normal tissues merely taking on a yellowish 
tint. A still more delicate test-fluid is a solution of 
methyl violet, which imparts a red color to amyloid ma- 
terial, the normal splenic tissues becoming distinctly 
blue. 

Clinical History.—No symptoms can be directly re- 
ferred to waxy changes in the spleen, unless the organ 
has become so much enlarged as to cause a feeling of ful- 
ness, of weight, or of traction. The other symptoms ob- 
served, in any case, will almost invariably be due to the 
amyloid disease in other organs, as diarrhoea in intestinal 
disease, and characteristic urinary symptoms in amyloid 
kidney. There is usually profound anemia, with all 
its symptoms, and hemorrhages from mucous surfaces 
may occur. On physical examination the spleen is found 
enlarged and hardened, but it is smooth, retains its shape, 
is not adherent to any other organ, and is movable. 

Diagnosis.—This must ordinarily be based upon the 
concomitant symptoms of waxy change in other organs, 
t.e., in the liver, the kidneys, and the intestine, together 
with the physical signs and the early history of suppura- 
tion or of syphilis. Chronic splenic tumor might be er- 


603 


Spleen. 
Splints. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, 


— 


roneously considered as waxy spleen, but the history of 
antecedent malaria, and the microscopical examination 
of the blood, would exclude both ‘‘ ague-cake” and leuco- 
cythemia; while the absence of general glandular en- 
largements would disprove the existence of pseudo-leuco- 
cythemia. ; chee 

Prognosis.—This is bad, not from the amyloid disease 
of the spleen, but from the existence of the same change 
in other and vital organs. 

Treatment.—The treatment is almost wholly prophy- 
lactic, embracing removal of all possible foci of suppu- 
ration and the eradication of the syphilitic cachexia. It 
is possible that the waxy disease, if not far advanced, 
may disappear, but it is uncertain whether there be ther- 
apeutic means of hastening the resolution. 

SpLentc NEopLasMs. 1. SypuHriiis.—Splenic syphilis 
may be congenital or acquired, circumscribed or diffuse. 
The acquired form is not very common, while congeni- 
tal splenic lesions are found in perhaps one-fourth or 
one-third of all cases of hereditary syphilis.'* 

Pathological Anatomy.—In the early stages of syphilis 
the spleen may be-enlarged by congestion, and, perhaps, 
by moderate hyperplasia, thus constituting one variety 
of acute splenic tumor, as in other infectious febrile dis- 
eases. We have already stated that lardaceous splenic 
disease, as well as diffuse interstitial hyperplasia, is some- 
times caused by syphilis. As these lesions have been 
described under their respective titles, it now only re- 
mains to mention the other pathological change wrought 
in the splenic tissues by the syphilitic virus, viz., the so- 
called gummata. These gummata are generally small, 
some of them being no larger than a grain of millet-seed, 
others as large as a small bean or lentil. They are, or- 
dinarily, not numerous, and may be either distinctly cir- 
cumscribed or somewhat diffused. They are usually 
situated near the surface of the spleen. Syphilomata 
are, at first, reddish-white, assuming, when less recent, a 
yellowish tint, and becoming dry, tough, and almost 
cheesy.!4 

Clinical History.—This is negative. The diagnosis can 
hardly be made with any degree of certainty. The ex- 
istence of gummata may be, at most, suspected, if splenic 
tumefaction, with peri-splenitis, develops during the de- 
monstrated growth of syphilomata in other organs, waxy 
disease having been excluded. 

Treatment.—Acute splenic tumor, due to syphilis, may 
be reduced by the speedy adoption of specific treatment. 
Splenic gummata are often readily amenable to treat- 
ment with large doses of potassium iodide or to the mixed 
treatment, while diffuse syphilomata are uninfluenced 
by any therapeutic measures. 

2. TUBERCLE.—Acute splenic tumor, without tuber- 
culous deposits, occurs during the progress of acute tu- 
berculosis. Splenic tubercles, proper, are apparently 
either always secondary to tuberculous growths in other 
organs, or appear, simultaneously with widely dissemi- 
nated tuberculous growths, during the course of acute 
miliary tuberculosis. In the former case the tubercles 
are often not very numerous and are visible to the naked 
eye, varying in size from that of a millet-seed to that of 
a pea, the largest ones being doubtless composed of sev- 
eral smaller aggregated tubercles. These growths are 
sometimes called solitary tubercles. They are, at first, 
grayish and translucent, assuming later a yellowish or 
cheesy appearance. Their histological features are the 
same as in tubercles of other organs, and they generally 
contain numerous bacilli. They are found in the trabe- 
cul, the capsule, the Malpighian bodies,;in the pulp 
and in the walls of the small arteries! (vdde article Tu- 
bercle, in this HANDBOOK). 

The splenic tubercles developed in acute miliary tuber- 
culosis are often invisible to the naked eye,:and are dis- 
tinguished with difficulty even by the microscope, since 
their structure, at an early stage, closely resembles that 
of the splenic pulp. Tubercles of the spleen are alike 
devoid of interest for the clinician, the diagnostician, and 
the therapeutist. é 

3. MALIGNANT TuMoRS, CARCINOMA AND SARCOMA. 
—These new-growths are hardly ever primary, but usu- 


604 


ally develop secondarify to other malignant tumors, 
either by metastasis or by direct extension from a pri- 
mary neoplasm in the stomach, the liver, the pancreas, 
and the mesenteric or retro-peritoneal glands. Jeannel 
states that only seven primary splenic cancers have been 
reported.'® Splenic carcinomata are ordinarily of the 
medullary variety and are often pigmented. These ma- 
lignant tumors grow with great rapidity, and, if super- 
ficially located, may be discovered by palpation. As a 
rule, they escape detection. Their presence may be in- 
ferred if enlargement of the spleen be coincident with 
the development of malignant growths in other, and par- 
ticularly in abdominal, organs. These tumors are of little 
clinical significance, and affect the prognosis unfavor- 
ably only in that they give evidence of a more or less 
wide distribution of the carcinomatous or sarcomatous 
disease. 

4, Ecutnococcus.—This is one of the rarest of splenic 
tumors. It develops, usually, simultaneously with hyda- 
tids in other abdominal organs, particularly with hepatic 
echinococcus. The disease attacks both sexes with ap- 
proximately equal frequency, and is chiefly found in 
middle-aged persons. 

The etiology is the same as that of hydatid disease, 
wherever located, the cause of the disorder being the 
entrance of the scolices of the tenia echinococcus into, 
and their establishment in the spleen. 

It has been asserted that echinococci of the spleen are 
generally secondary to other hydatid tumors of the ab- 
dominal organs, but this question is not definitely set- 
tled. 

Morbid. Anatomy.—As a rule, there is but one mother- 
cyst, within which numerous daughter-cysts develop, 
but there may be a large number of mother-cysts. The 
hydatids are ordinarily developed from the capsule of 
the spleen or from its serous investment, but they may 
originate in the spleen pulp, which, in either case, is de- 
stroyed by the pressure of the tumor. The cyst usually 
increases slowly in size, if uninfluenced by treatment, 
and, after months or years, finally ruptures into the perito- 
neum, into some hollow abdominal viscus, as the alimen- 
tary canal, into some thoracic cavity, as the pleura or 
the pericardium, or onto the cutaneous surface. In more 
favorable cases the cyst may remain stationary in size, 
occasioning no noteworthy splenic lesion. Suppuration 
of the cyst may occur, or the cyst may undergo calca- 
reous degeneration, remaining encapsulated and innoc- 
uous. - 

Clinical History.—Small, and sometimes even large 
hydatid cysts may give rise to no symptoms or physical 
signs. When, however, a certain size is attained, the 
patient may complain of weight, tension, and pain, either 
constant or intermittent, over the region of the spleen, 
which organ, on physical examination, may be found 
enlarged in various directions and displacing abdominal 
and thoracic viscera. Emesis may thus be occasioned 
by pressure upon the stomach, and obstipation by ob- 
struction of the large intestine. If peri-splenitis coexists, 
a friction, sound may be perceived. The hydatid thrill 
is occasionally present, as well as fluctuation. If the 
cyst ruptures, the symptoms will vary with the organ 
into which the discharge occurs, and need not be here 
enumerated, since they are almost identical with those 
occasioned by the rupture into these various viscera of a 
splenic abscess, and are described under that caption. 
Suppuration of the cysts will occasion the familiar symp- 
toms of hectic fever. 

Diagnosis.—The establishment of a differential diag- 
nosis involves the exclusion of abscess and of solid splenic 
tumors. Aspiration will distinguish between these and 
hydatids, if the characteristic saline fluid, containing 
hooklets, be obtained. Fluctuation will, when present, 
exclude solid tumors, and the hydatid thrill is pathogno- 
monic. Small or encapsulated hydatids will elude diag- 
nosis, and it may be impossible to distinguish between 
simple splenic abscess and suppuration of an hydatid 
cyst. 

Prognosis.—This is very bad, but not hopeless. Rupt- 
ure does not necessarily occur, but when it does happen 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


is almost always fatal. The growth of the cyst may be 
spontaneously arrested, and calcification sometimes ren- 
ders the tumors harmless, while judicious treatment 
may materially assist nature in effecting a cure. 

Treatment.—The treatment to which the majority of 
writers lend the weight of their authority consists in the 
partial evacuation of the cyst, or cysts, by which pro- 
ceeding the death of the parasites is brought about, and 
absorption, atrophy, and calcareous degeneration of the 
remaining contents of the cyst are favored. The evacua- 
tion of the fluid should be accomplished by means of a 
very small trocar, and it is advisable to excite localized 
adhesions between the cyst and the abdominal wall by 
means of caustics before aspiration is attempted. The 
operation and the whole after-treatment should be con- 
ducted in accordance with the most approved antiseptic 
principles. Should suppuration of the sac occur spon- 
taneously, or as a result of aspiration and the ingress of 
air, a free opening must be made and efficient drainage 
afforded. 

5. MiscELLANEOvUS TumMors.—Other and rarer splenic 
tumors than those above described are fibromata, angio- 
mata, dermoid, and other cysts, besides calcified cysts 
containing the pentastomum denticulatum. All these 
new-growths are generally of so small size as to be quite 
devoid of clinical interest. 

RUPTURE OF THE SPLEEN. /ttology.—Rupture of the 
spleen may be either spontaneous or traumatic, but tri- 
fling injuries may so often provoke apparently spontane- 
ous lacerations that a sharp dividing line cannot be drawn 
between these two varieties. The so-called spontaneous 
ruptures generally occur in cases of acute splenic tumor 
complicating typhus, typhoid, and intermittent fevers, or 
other infectious diseases, as well as in abscess, aneurism, 
varices, or hydatidsof thespleen. Traumatic rupture re- 
sults from violence direct, or rarely indirect, exerted, in 
almost all cases, upon an enlarged and softened organ. 
Falls, kicks, and blows, fracture of the ribs, and pene- 
trating wounds are the most common traumatic causes, 
while acts of emesis, convulsions, and the contortions of 
parturition have been noted as rarer causative events. 

Pathological Anatomy.—Spontaneous rupture usually 

occurs at a single point, while traumatic rupture may 
cause lacerations in several different places. Autopsies, 
-in cases of rupture, reveal the diseased condition of the 
organ which predisposed to rupture, and the presence of 
blood and débris of the splenic tissues in that organ or 
cavity into which these materials have been discharged. 
If the patient’s life has been sufficiently prolonged, there 
will be found evidences of the secondary disease due to 
the rupture, as of peritonitis, pleuritis, or pericarditis. 
In distinctly traumatic cases there may be contusions or 
other visible surface evidences of violence, or these may 
be wanting. 

Clinical History.—The symptoms are those of rupture 
of any vital abdominal organ, and they particularly resem- 
ble those following perforation of the bowel, with or with- 
out hemorrhage into the peritoneal cavity. The leading 
symptoms are a feeling as if some vital organ had sud- 
denly given way, and violent pain over the spleen, soon 
followed by acute anemia and rapidly increasing asthenia. 
Death, either immediately or after a few hours, is the 
almost inevitable result. Recovery may, however, take 
place, if the rupture is slight and does not occur into a 
serous cavity. The treatment, which is usually unavail- 
ing, embraces absolute quietude, applications of ice to 
the abdomen, and generous doses of morphine, hypoder- 
matically administered. 

EcroPrA AND MALFORMATIONS.—Cases of splenic ec- 
topia, or floating spleen, are comparatively rare. They 
may result from failure of the suspensory ligament and 
of the gastro-splenic omentum to retain the organ in 
place. Such failure may be due to congenital relaxation 
of the ligaments, to their abnormal length, to traction 
upon them of an enlarged spleen, or to traction upon the 
spleen exerted by the contraction of newly formed peri- 
toneal bands. Atrophy of an criginally normal or of 
an hypertrophied spleen may be caused by torsion or 
compression of the splenic vessels incident to the organ’s 


| 


Spleen. 
Splints, 


displacement. Ectopia is to be differentiated from simple 
enlargement by the aid of physical exploration, and the 
spleen, having been restored to its normal position by 
careful manipulations, is to be retained there, if possible, 
by proper bandages or by abdominal supporters. 

The spleen may be displaced, either upward or down- 
ward, by abdominal or thoracic diseases of such a char- 
acter as to forcibly press upon the organ. Among such 
diseases are to be mentioned tumors, ascites, tympanites, 
emphysema, pleuritic effusions, pneumothorax and spinal 
curvatures. Lifting great weights and paroxysms of 
coughing may act as exciting causes of these displace- 
ments, which, in turn, cause various pressure symptoms, 
among which are vesical and rectal tenesmus, paresis of 
the lower extremities, emesis, and constipation. The 
spleen may sometimes escape into a hernial sac, either 
abdominal or thoracic, and it may, rarely, be found on 
the right side, in cases of visceral transposition. 

Two spleens, either of the same size or of different 
sizes, have been found in the same subject, and small 
accessory spleens, of various shapes, are often seen. The 
spleen may, in very rare cases, be congenitally absent in 
persons whose other organs are all present, and acepha- 
lous monsters have sometimes rudimentary spleens, or 
no spleens whatever. William H. Flint. 

1M. Foster: Text-book of Physiology, pp. 59,60. Philadelphia, 1885. 
Kirke’s Handbook of Physiology, vol. ii., pp. 8,4. New York, 1885. 

2 Gray: Anatomy, Descriptive and Surgical, p. 822. Philadelphia, 1883. 

3A, Flint, Sr.: Manual of Auscultation and Percussion, pp. 37-89, 
1885. Figs. from Weil’s Handbuch d. topo. Percussion, Atkinson, I. 
E.: Diseases of the Spleen, Pepper’s System of Medicine, vol. iii., p. 951. 
1885. 

4 Loomis: Lessons in Physical Diagnosis, p. 151. New York, 1874. 

5 Delafield and Prudden: Handbook of Pathological Anatomy, p 362. 
1885. 

68 Hichhorst: Handbook of Practical Medicine, English translation, 
vol. iv., p. 42. William Wood, 1886. 

7 Hertz: Ziemssen’s Encyclopedia, American edition, vol. ii., p. 629. 

8 Hichhorst: Op. cit., p. 44; 

9Da Costa: American Journal of the Medical Sciences, January, 1875, 
p. 11%. 

10 Crédé: Centralblatt f. d. Med. Wissensch., June 23, 1883, p. 445. 

11 Collier ; Lancet, February 11, 1882, p. 219. 

12 Bartholow: A Treat. on the Prac. of Med., p. 191. New York, 1880. 

13 Atkinson: Op. cit., p. 971. 

14 Mosler: Ziemssen, vol. viii., Am. ed., p. 485. 

15 Delafield and Prudden: Handbk. of Path. Anat. and Histol., p. 365. 
1885, 

16 Jeannel: Jaccoud’s Nouv. Dict. de Méd. et de Ch., vol. xxx., p. 503. 


SPLINTS. The study of splints and methods of splint- 
ing is a very interesting one, both to the practical surgeon 
and to the medical historian. 

Ingenuity—and too often misapplied ingenuity—has 
been expended lavishly in devising splints of the most 
curious and complicated character, intended to fulfil 
a number of different indications; splints elaborately 
carved and often based on false anatomical principles ; 
splints capable of adapting themselves—in a measure— 
to adults or to children ; splints that have been expected 
to supplement and improve upon the surgeon’s faulty 
work in reduction of fracture, and which have, accord- 
ingly, failed of their purpose. 

The shops are filled with almost innumerable varieties 
of splints, devised for the cure of every conceivable fract- 
ure. Especially numerous are those for fractures of the 
femur and of the lower end of the radius. If it is true— 
which I do not allege—that no obstetrician considers him- 
self eminent in his specialty until he has devised some 
modification of the obstetric forceps which shall bear his 
name, it is much more true that almost every surgeon 
who has written a book—and many who have not—in- 
vents some special splint. 

It is undeniable that some of the splints stand for < 
principle, and deserve permanent recognition, The vast 
majority, however, are relegated by the succeeding gen- 
erations into oblivion with their authors. This fact is 
strikingly impressed upon the reader of the surgical 
works of the last century and the early decades of the 
present. Here, as in regard to other therapeutic agencies, 
the pendulum of medical opinion has swung at times 
from extreme to extreme. 

John Bell declared the appliances for treating fracture 
in his day to be ‘‘instruments of torture more terrible 


605 


Splints.. 
Splints. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


than those used by the Inquisition for that purpose,” and 
substituted therefor much simpler means. Such com- 
plicated engines, intended to war against deformity, are 
not without their types at the present time. 

Looking at the other extreme of opinion, we find that 
at times certain reputable, but misguided, sur- 
geons have actually advocated the treatment of 


Fie. 3670.—MacIntyre’s Wooden Splint for Fractures of the 
Leg. 


many or all fractures of limbs with no splint save a roller 
bandage! And others have even done away with this, 
preferring absolutely nothing. Such absurdities as these 
are probably the natural revulsion following the contem- 
plation of limbs permanently deformed from splints im- 
properly devised and unskilfully applied. 

Those surgeons who are pre-eminently successful with 


Fia. 3671.—Suspension of the Leg from a Wire Cage. 


their fracture cases are not necessarily the ones who have 
the largest armamentarium of ready-made splints, of 
myriad shapes and sizes, wherefrom to select for the 
treatment of any given case. In fact the reverse is often 
true, and the greatest surgeon possesses few or no stock- 
splints; but, from splint materials nearest at hand, or 
readily obtained, makes at 


short notice for each case . 

a separate and differing 
splint ; one that shall vary ' 
with the infinite variety of 6 ie 
individual requirements, Py 


Fie. 3672.—Volkmann’s Sliding Leg-rest. 


and which is therefore apt to be better than the ready- 
made article. ; 

To effect this, a certain degree of deftness and ingenuity 
is necessary ; but this is true of all branches of surgery. 


606 


And the man who is lacking in this essential will do 
wisely to choose for his field another department of med- 
icine. : 

In this article will be discussed mainly the materials 
used in splinting and the modes of application. Only in- 
cidentally are appliances peculiar to some special bone- 
lesion named, and these are more appropriately studied 

in conjunction with the phenomena, subjective and ob- 

jective, which call for their application. Accordingly, 

the reader is referred for such information to the ap- 

propriate headings, as Fractures, Pott’s Disease, etc. 
) Splints are usually divided, for convenience of clas- 

sification, into two broad groups: the rigid and the 

plastic. The latter are those composed of substances 

capable of being made to assume a soft and pliant 
condition, and subsequently of hardening and maintain- 
ing the shape into which they have been modelled. The 
plastic splints have been in turn subdivided into movable 
and immovable, which classification seems to the writer 
an utterly useless one, inasmuch as each and all members 
of the ‘‘immovable” plastic group can at will be so fash- 
ioned as to become easily capable of removal. 

Not as to substance, but as to method of splinting, the 
division ¢tmmovable splints becomes of some practical 


Fia. 3673.—Adaptation of the Double-inclined Plane to the Upper Ex- 
tremity. 


value. The discussion is not yet ended, in the profes- 
sion, as to the relative value, in acute injuries, of the class 
of immovable dressings of which that made of gypsum 
stands as a type. ‘They have certain advantages ; their 
objectionable features are also now well recognized. In 
the hands of competent and‘experienced men they are 
almost invaluable at times. In other hands they are oc- 
casionally either inefficient as a means of maintaining 
rigidity, or actually dangerous to life or limb. Besides a 
modicum of experience in the technique 
of their application, it is essential to 
the well-being of the patient that the 
surgeon should recognize certain fixed 
limitations to their employment. An 
immovable splint should never be ap- 
plied to a limb immediately upon the 
receipt of the injury, or within a few 
hours thereafter. Considerable inflam- 
J, mation and swelling inevitably follow the fract- 
ure, and continue for several days; and as the 
splint under consideration encircles the limb, 
it may cause agonizing pain by opposing an un- 
yielding barrier to this swelling. 

With the ordinary removable splints a patient so 
troubled could easily free himself. Not so in this 
case ; and if the surgeon be a country practitioner, 
and hardly able to call again soon, the outcome is 
occasionally most deplorable. From obstructed circula- 
tion gangrene of the point of greatest pressure, or even of 
the entire extremity, may supervene. This result is, for- 


_ tunately, rare, but as a danger it must be borne in mind. 


Should the patient with fracture be seen first at a 
period when the inflammation and consequent swelling 
are at their height, it would probably be wise to wait 
and not attempt reduction then, unless the fragments be 
in a decidedly bad relation to each other. But certainly, 
if splinting be attempted, here is another counter-indica- 
tion to the use of the immovable method. Upon the 
subsidence of the congestion the limb will quickly re- 
sume its normal size, and a splint closely fitting the limb 
vesterday may to-morrow be so loose as to aid little in 
immobilization. The surgeon will consequently have 
either to cut out a longitudinal strip of the splint, and 
then by bandage or straps narrow it transversely, or what 
is probably better and simpler, to remove it and make a 
new one; either expedient being more annoying and 
tedious to the attendant than the application of some sim- 
ple, temporary, removable splint. 

It cannot be gainsaid that it isa most desirable thing 
to have a fractured member freely exposed to the sur- 


geon's eye ; and that this is impossible by Pini re <n 
the immovabie method is a strong objection arian ata 2 aca 


to it. If a strip be cut out, as just men- / 
tioned, then we cease to be discussing im- \ 
movable splints, for such a splint can easily 
be sprung off by the patient himself. 

In recent years even the time-honored 
roller-bandage, wherewith the limb is to be 
swathed from the digit-tips to above the 
splint-top, has often been discarded, and wisely. <A prop- 
erly applied splint should rarely cause much circulatory 
obstruction ; and it is well for the surgeon, at least early 
in bad cases, to be able to watch the whole length of the 
limb. 

The proper time, then, for the application of an im- 
movable splint is after the swelling has completely dis- 
appeared, and not before. Even now the limb must 
unavoidably atrophy somewhat from disuse, so that 
what was originally a closely fitting jacket will become 
less so; but this may not now interfere greatly with its 
practical usefulness. 

It is greatly to be desired that a patient shall not be 
confined to his bed, or even to his room, when avoidable ; 
and in certain fractures of the lower extremity the im- 
movable splint gives us a means, probably better than any 
other, of permitting locomotion while yet the bone is 
knitting, with safety to the case. ; 

We may name, among the rigid, non-plastic, splint 
materials in more or less common use, the following : 
Wood, tin, sheet zinc, telegraph wire, wire gauze, glass 
splints. 

Besides these, there are many substances used, in tem- 
porary or field work, in the absence of more usual means, 
as plaited unbroken straw, bundles of rushes or stout 
grass, small fagots of twigs. In fact, the list is al- 
most limitless. 


Belonging to a somewhat plastic group are the 7 


Fie. 3675.—Wire Leg-splint, with Foot-piece and Horizontal Rest. 


following: Pasteboard, felt, leather, fresh bark, vulcan- 
ized rubber, celluloid, veneering. 

Substances of an entirely plastic nature, which are 
sometimes employed: Plaster-of-Paris, silicates, gutta- 
percha, paraffine, stearine, starch, dextrine, chalk and 
gum, glue, glue and zinc oxide, tripolith, clay, shellac 
cloth or paper, collodion cloth or paper, adhesive plaster. 

Among the rigid splint-materials wood is most used. 
Any thin board will do, preferably one splitting and 
working easily. A piece of pine shingle will often serve 
our purpose excellently, where a simple straight splint is 
required. This must be cut of the desired shape, and 
then properly padded on the side next the skin. The 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Splints. 
Splints. 


padding is not to be left loose, but is to be bandaged, 
or strapped with adhesive strips to the splint. In lieu 
of this, a method which I often employ is to cause either 


| cotton or wool sheet-wadding—cut of the required size 
_ and of double or triple thickness if needed—to adhere to 


the splint by a few strokes with the paste-brush. This 
saves quite a little time. 

The term ‘‘ coaptation-splint ” is usually employed to 
designate an affair of thin wood, backed by thinner 
leather or cloth, and split through at frequent parallel 
intervals down to the backing ; thereby permitting this 
short splint to be wrapped around the limb just opposite 


iS 
iS 
ri 


535 


Fre. 3674.—Wire Splint for Horizontal Suspension of the Arm. 


the line of fracture. It is often used to prevent lateral 
motion, in conjunction with some extension apparatus. 

Carved and elaborately contrived wooden splints in- 
numerable are in the market. Fig. 3670 indicates one, 
asasample. This one, like almost all of them, can be 
perfectly supplanted by a plastic splint, with or without 
a telegraph-wire skeleton, and which can be made and 
fitted in place by the surgeon in half an hour, 

Fracture-boxes properly belong in the list of wooden 
splints. They are generally elevated, to permit of easy 
return circulation, and have hinged sides. In the in- 
flammatory stage of a compound fracture it may be wise 
to rest the limb in such an apparatus, dressed and bol- 
stered with small cheese-cloth bags filled with moistened 
antiseptic sawdust, bran, or peat. At the present day, 
however, fracture-boxes are not much in vogue. 

Although not strictly a part of the subject, it may be 
well to note that heat and annoyance from weight of 
bedclothing on the lower limb may be avoided by the 
use of a protecting cage. Such a contrivance can easily 
be made in a few minutes with three half-hoops 
from a barrel, and three laths, the whole being 
bound together firmly at the points of contact. 

With a similar, but somewhat stouter, cage a 
supporting point can be given for a moderate 
degree of suspension, as indicated in Fig. 3671. 

Still another simple and practical apparatus 
—although not a splint—is Volkmann’s sliding 
leg-rest, made of three-sided wooden strips, 
shown well in Fig. 8672. By diminishing fric- 
tion, it enables extension to be effectively accom- 
plished with a minimum of weight, and is 
much less cumbersome and expensive 
than the railways, with wheels, etc., for 
the same purpose, over or under which 
the leg rests or is slung. 

Fig. 3673 shows a simple and satisfac- 
tory means of adapting the double-in- 
clined plane to the upper extremity. In the treatment 
of fractures of the humerus some degree of abduction is 
often desirable, and Middeldorpf’s wooden triangle is one 
method of accomplishing this. 

In splinting the shaft of the femur the posterior double- 
inclined planes have been generally supplanted by the 
wire anterior splint of Nathan Smith, which better ac- 
complishes the same object. Three main methods are 
used here after reduction : a, Simple immobilization by 
any means ; }, immobilization plus horizontal extension ; 
ce, immobilization plus elevation, both leg and thigh being 
in flexion to relax muscular traction on the fragments. 

Where the fracture is a very oblique one, the frag- 


607 


Splints. 
Splints. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


— 


ments readily sliding past one another after reduction, 
shortening will probably best be limited by horizontal 


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Fic. 8676.—Strips of Wire Gauze, bound together, ready for Application. 


extension. In Smith’s method extension cannot be ef- 
fectively accomplished, the splint being fastened to the 
thigh above the 
point of fract- 
ure and to the 
body. How- 
ever, some 
modification, 
as Hodgen’s, in 
which the pel- 
WLSeis) moe 
reached by the 
splint, may permit effective extension by this means. 
Smith’s splint, easily made of bent telegraph wires by 
anyone, seems worthy of much attention, as representing 
a principle. It has been discussed under 
Fractures. Regarding the upper extrem- 
ity, the same idea is illustrated in Fig. 3674. 
Wire of telegraph size, or larger, is much 
used to-day, either embedded in plastic 
splints as a stiffener, or as a skeleton frame, 
simple in manufacture and easily made 
aseptic. Such a wire leg-splint, with foot- 
pieces and horizontal rest, is shown in Fig, 
3675. Sheets of wire gauze, cut of 
the proper size, are sometimes em- 
ployed, properly padded—Figs. 3676 
and 3677, 
An excellent example is seen in 
Fig. 3678, of a simple iron suspen- 
sion-splint, arranged to permit easy 
freeing for passive motion and 
; change of angle. This is a 
Hi device of Esmarch, from whose works several 
cuts in this article are taken, others being after 
Hueter, Volkmann, Neuber, etc. 
Metal is in very few instances employed di- 
rectly in contact with the tissues in splinting— 


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Fie. 3677.—Wire-gauze Splint, with Cotton Padding, applied to the Arm. 


Sheet-zinc splints are in one sense plastic, since they can 
be bent and hammered with moderate ease into desired 
shapes. With a heavy pair of shears and the sheet of 
zinc to be found beneath almost every stove the surgeon 

can do effective work. 

ye Tin, that is, tinned sheet-iron, if of or- 
WA arene ae dinary thickness, is rather too 
flexible for use in extempo- 
rized splints. It can be bought 
stamped into fairly rigid 
shapes, as for shoulder-caps 
and Colles’-fracture dressings, 
but, as previously re- 
‘marked, properly extemporized 
splints are very apt to be best. 
Narrow strips of tin, with a 
number of nail-holes driven in 
them to hold the plaster, are 


oN 


ates 


Sete areeece often employed between the 


layers of a gypsum splint to ef- 
fect rigidity with slight weight. 
LE 2 The glass splint—such as that 
of Neuber, Fig. 3679—is some- 


what employed in Germany, especially where continuous 


irrigation or wet dressings are intended. It can easily be 
rendered aseptic, but its cost and brittleness render it 
practically out of the field. 

Turning now to the more or less plastic group, we find 
as its most 
prominent 
member paste- 
board. Of 
various thick- 
nesses, from 


mill-board or 
binder’s-board 
downward in 
the scale, de- 
cidedly cheap, light, and easily moulded, it is an excel- 
lent splinting material, and one greatly used in place of 
wood in New York. 


It can be obtained thick enough to 


Fig. 3678.—Esmarch’s Apparatus for Suspension of a Limb. 


stand the strongest strains, if doubled. The best way to 
soften it for plastic purposes is to hold it in steam, as 
from a kettle, until it yields readily to pressure. If 
dipped in water, be careful that too much of the sizing 
be not dissolved out. For short splints the covers of an 
old book can always be utilized. Fig. 
3680 indicates a simple method in which 
stout pasteboard can readily and without 
softening be made to form an angular 


splint for the elbow. Two lines running 


Fra. 8679.—Neuber’s Glass Splint. 


for example, in Malgaigne’s hooks for fracture of patella 


or their modifications, and in Hahn’s nails, or screws, 
ete., for excisions. 


608 


lengthwise, and the width of the limb 
apart, are to be barely scratched, to in- 
sure the pasteboard bending along them. 
The transverse line is also scratched, and 
then cut through from the edges as far as 
the longitudinal lines. The splint being 
firmly tied at any desired angle by cord 
passed through holes in it, is padded to fit. Fig. 3681 
shows the same splint applied. 

Fig. 3682 is a mill-board model for a shoulder-cap. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Splints. 
Splints. 


The lines A B, C E, and D E, are to be cut completely 
through. Fig. 3688 shows—the shading, however, being 


omitted—the inside of the same when in shape for appli- _ 


cation. The angles C B E, and 
DB E, in the former figure, are 


will set in about ten minutes; but should the specimen 
be an old one, the splint may remain soft an hour or even 
longer. In an emergency very good work can be done 


seen to cross one another in this, 


strengthening this part of the 


splint. Through the holes indi- 


cated the cord is passed which 


i] 


holds the splint in curvature. A 


moderate amount of steaming or 


soaking makes the shaping a more 


easy matter. The interior is, of 
course, padded with wadding. 
These examples are merely a few 
of the many ways in which paste- 
board and similar material can be 
used. 

Felt—well stiffened by shellac 


Fia. 8680.—Pattern of a Pasteboard Arm Splint. 


—is not commonly available for extemporaneous splint- | with the common gypsum to be obtained of any plasterer, 


ing, and is rather expensive. It is moulded by exposure 
to either moist or dry heat. 

_ Hither sole or bridle leather may perhaps be found at 
hand, and soaked in hot water it becomes quite pliable, 
and subsequently and rapidly stiffens. In country prac- 
tice fresh bark, from most smooth-barked trees, espe- 
cially if taken during the time that sap is rising, can be 
modelled sufficiently well for good work. 

Of late, veneering has been considerably employed in 
one or two of our hospitals. It comes in very thin sheets 
of white-wood, extremely cheap. Hot water renders it 
almost as easily bent as pasteboard, the new shape being 
retained when dry again. 

A very valuable splint is that introduced by Schede, 
of Hamburg—made of vulcanized rubber. This, in thin 
strips, can be bent to the desired shape by immersion in 


which should generally, before using, be freshly baked 
on a stove until moisture is no longer given off. 

If it be desired to hurry the setting, the use of hot in- 
stead of cold water will do this. Also, the less water 
used, the quicker the hardening. Common table-salt dis- 
solved in the water will also hasten 
matters, as would almost any crystal- 
line substance. Either alum, silica, or 
cement-powder may be used, but salt, 
being the cheapest, is most commonly 
employed. I think that when salt has 
been freely employed, the splint, al- 
though setting quickly, is not quite as 
rigid as it would otherwise be. The 
use of dry heat will be referred to pres- 
ently. 

Setting may be retarded by the ad- 
dition of starch, dextrine, glue, muci- 
lage, gelatine, beer, milk, or borax; 
or by using plaster which has been ex- 
posed for some days to the air. 

In regard to the material employed 
as a vehicle for the plaster, it is rather 
indifferent—any loose-textured fabric 


will do, and if properly made the splint 


Fie. 3681.—Pasteboard Arm Splint in Position. 


very hot water, or by oiling and heating, as with a spirit- 
lamp. When cold it is entirely rigid, and can be easily 
rendered aseptic. 

Celluloid splints may be substituted for the vulcanite, 
and moulded somewhat by the use of boiling water. It 
would hardly do to use oil and the lamp with them, 
celluloid being almost as inflammable as gunpowder. 

The list of entirely plastic materials which I have 
given comprises several which are not commonly prac- 
ticable, nor perhaps even desirable, as a first choice. 
Probably the oldest, as it is also the best, of the plastic 
splint materials is plaster-of-Paris (gypsum). This sub- 
stance, after being pulverized finely and heated so that 
its water of crystallization—which is about one-fifth of 
the gypsum—is driven off, is in fit condition to use. If 
it is now wetted, it will reabsorb water and crystallize 
(set) into a mass almost as hard as stone. It is an inter- 
esting fact that, if in making the gypsum anhydrous the 
heating be carried too far, the ‘‘ setting” will thereafter 
not occur, the affinity for water being destroyed. The 
objections to plaster are few—the only urgent one being 
its relative weight. This can be in part overcome by a 
method to be mentioned subsequently. The advantages 
of plaster are numerous—it sets quickly, and yet not too 
rapidly for a skilled worker ; it is very cheap; is easy 
and not sticky to handle ; is porous, and does not shrink 
in setting. 

The best to work with is fine dentist’s plaster, recently 
prepared and kept protected from the atmosphere. This 


Vou. VI.—89 


will be sufficiently strong. For most 
purposes cheese-cloth or other gauze 
bandages, rubbed with dry plaster 
while’ being rolled, are best. These 
being stood in water, on end, until all 
the bubbles escape, are then, thoroughly wet, to be ap- 
plied without reverses, which are here quite unnecessary. 
After from three to six thicknesses of such bandages, 


Fie. 3682. Fia. 3683. 


Fias, 8682 anp 36$3,—Mill-board Model for a Shoulder-cap. 


each thoroughly rubbed and smoothed with the hands 
before the next is applied, a final coating of dry plaster, 
dusted on and rubbed in as it moistens, leaves a surface 


609 


Splints. 
Splints. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


very smooth and even. If now the splint be hot-ironed 


with an ordinary flat-iron, or, as I have seen used, with a 
miniature stone garden-roller, the heat so applied drives 
off the superficial moisture, aids rapid setting, and leaves 
This method of hastening the 


a rather glazed surface. 


AWS 


F1a. 3684.—Wooden Strips to be incorporated in a Plaster-of-Paris Splint. 


setting of the plaster is hardly worth the trouble it takes, 
except in the application of the plaster jacket to the body, 
in cases which do not bear kindly the partial suspension 
necessary. , 

To avoid the weight of a splint made as just described, 
we often employ stiffeners of various kinds placed _be- 
tween the bandages, and in lieu of some of them. For 
instance, thin wooden strips (Fig. 3684), or pieces of paste- 
board, or strips of wire-gauze or of 
tin are used. 

For field work, a readier means 
than that just given—unless gyp- 
sum rollers are at hand—is the Ba- 
varian or book- back splint, or some 
modification of it. This is figured 
elsewhere (Fig. 1388, Vol. III.). It 
is sufficient, therefore, here to say 
that cloth, as, forexample, a blanket 
of doubled thickness, has a straight 
seam sewn through both layers, 
which seam is so placed as to run along the back of 
the limb; plaster. cream is spread thickly between 
these layers, and they are wrapped about the limb. 
When the splint has set it is opened in front, and the 
seam at the back acts as a hinge. The two halves 
are held in contact with the limb by straps or a roller. 

A favorite method with the late Professor Little, of 
this city, was to cut several thicknesses of cotton-cloth 
or muslin the length of the splint desired, and not quite 
wide enough to meet in front at any point, so that an un- 
covered longitudinal strip of skin is left. These layers 
were then immersed and thoroughly soaked in plaster of 
the consistency of cream, and applied directly to the skin, 
which was either simply oiled, or, if hairy, shaven and 
oiled. A roller-bandage held the splint in place, and, 


H \N 
HAAN 
ANA 
i NY \\ = 
AY NUON 


AN 


Fia. 3686.—Interrupted Gypsum Splint, suspended by a Stout Wire, 


after setting, this was cut away in front. Such a splint 
is easily sprung off, and on again. Gypsum splints pos- 
sess considerably more of elasticity than would naturally 
be supposed. 


610 


0 Ok en 


Fie, 3685.—Interrupted Gypsum 


It is not usual to allow the gypsum to come into direct 
contact with the skin, as in the instance just mentioned. 
In the Bavarian splint the inner layer of blanket is the 
protection. When the ordinary method, with the plaster 
bandage, is the one adopted, it is best to cover the limb 
first with a flannel roller, or else 
with a layer or two of woollen, 
or several layers of cotton wad- 
ding—the latter being thinner 
than the woollen. Wadding, 
rather than batting, should be 
employed, the wadding being of 
uniform thickness. Whether 
flannel roller or wadding be our 
choice, it should be turned up 
over the ends of the plaster splint, 
in order to protect the flesh 
against a sharp edge. 

If we wish to have our result 
appear extremely neat and work- 
manlike—certainly, next to the patient’s safety and com- 
fort, an object to be desired—we may wrap about the 
limb two strips of plush or velvet, each three or four 
inches wide—with the nap turned toward the skin—mark- 
ing thus the upper and lower limits of our splint. The 
limb between these strips is to be covered as usual by 
flannel or wadding. The plaster roller then applied 
covers one-half the width of each strip, and, when the 


‘ PS Bee 
Loy tes 
Sul UL 


SS 


splint begins to harden, the strips 
are turned up over its ends, bring- 
ing the right side of the plush or 
velvet outermost. 
Gypsum splints made with an 
interruption are often used, as in 
compound injuries, or in excision 
of joints. Fig. 8685 shows such a splint, interrupted by 
ordinary hoop-irons embedded in the plaster, and suffi- 
ciently arched to allow the application of thick dressings 
between them. In Fig. 3686 is shown a similar splint, 
but suspended from a stout wire properly bent, and run- 
ning along the front of the limb between the layers of 
plaster bandage. Here, in order to remove any possible 
danger of flexion, a posterior wooden splint is first ap- 
plied, and over it the plaster. 
When the presence of a com- 
pound fracture, or some other 
reason, compels the formation 
sa of a fenestra in the splint, this 
. VARA is best made as follows: Cover- 
ing the wound, a saucer of the 


Splint. 


fs proper size for the fenestra is 
A = placed, bottom upward. Over 
YS Sy this the usual plaster is applied, 
\ and when it has set the promi- 


nence made by the saucer easily 
enables one to cut out a circle 
of just the right size, at the 
right spot. This is better than 
using a wad here, being as 
sharply defined, and avoiding 
the pressure on the wound 
which the latter necessitates. 

Fig. 3687 shows a fenestrated 
splint. It isa mistake, in a case requiring immobiliza- 
tion of the knee, not to carry the gypsum up nearly to 
the body. If the splint stops low in the thigh, as figured 
here, muscular action is more apt to break it. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


If there be a discharge from the wound, or if moist 
dressings are to be applied, it is necessary to protect the 
edges of the fenestra, and prevent fluids trickling be- 
tween them and the skin. By far the neatest means of 
accomplishing this is to cause a sheet of thin rubber— 
gutta-percha tissue—to adhere to the skin all around the 


wound on the one hand, and to the external. surface of 
the splint on the other, by painting the skin and the splint | 


| 


with strong liquor gutta-perche (gutta-percha dissolved 
in chloroform). 
In young children it is best to paint with an alcoholic 
solution of shellac a plaster splint which, from its posi- 
tion, would otherwise be liable to become softened and 
broken through repeated wetting with urine. Shellac, 


Splints. 
Splints. 


a quarter of an hour of steady application the softened 
splint may be cut with moderate ease. 

Still another expedient: Soak a narrow strip of cloth, 
or a piece of tape, in sweet-oil, and place it along the 
limb, upon the wadding or other subdressing, at the 
line to be subsequently cut. Then apply, over strip and 
all, the gypsum dressing. It will be found that the oil 
renders the plaster somewhat softer at 
this point than elsewhere. 

Plaster splints, however, do not by any 
means necessarily always encircle the 
member. Their shapes are legion. A 
simple straight splint, for instance, is 
quickly made by running the wet plaster 
bandage up and down the limb, repeat- 
ing until a sufficiently great strength is 
reached. An anterior splint for suspen- 
sion can be fashioned with ease in the 
same way, wire loops for the tackle be- 
ing embedded at proper intervals, etc. 
The silicates. (‘‘ water-glass”’) as a plas- 
tic agent have the 
advantage of ex- 
treme lightness of 
the splint, when 
hard ; but harden- 
ing requires a long 
time—nearly three 


days with silicate 


Fig. 3687.—Fenestrated Gypsum Splint. 


moreover, prevents the gypsum from rubbing off, and 
thus marking dark clothing. 

The question how best to remove a plaster splint en- 
circling either a member or the trunk, is a practically in- 
teresting one. The ordinary method is to endeavor to 


cut through it by the aid of a knife and much muscular | 
As a plaster dressing becomes about as hard as | 
stone, such attempts are not soothing tothe temper. The | 


effort. 


violent efforts made are also more or less dangerous to 
the patient, if the knife be not carefully guarded. 

If the surgeon employs gypsum with some degree of 
frequency, it will repay him to procure the instruments 
shown in Figs. 3688 and 3689, or some modifications of 
them. The saw, on the plan of Hey’s saw, will be valu- 
able. The plaster shears selected should, like these, 
have a flat under-blade, great leverage, and an ample 
grasp for the hand, and should not, like Esmarch’s, have 


Fia. 3688.—Szymanowski’s Plaster Shears. 


scissor handles through which only a finger and thumb 
can be passed. 

For those who but semi-occasionally use plaster, there 
are other expedients which will lessen the fatigue. For 
instance, with a glass rod dipped in some strong acid 
capable of attacking the plaster—as nitric—draw a line 
where it is desired to make the section. With a cheap 
knife—for the acid will ruin it—cut along this line. Re- 
peat the line of acid, and then the cutting, as often as 
needed. Each application of the acid will enable the cut 
to go a little deeper, without much effort. 

Another method is to lay upon the splint cloths taken 
from boiling water, and repeat again and again. After 


of soda, which is 
=. Cheaper than that of potash ; 
two days with a mixture of 
the silicates ; about thirty to 
forty hours with silicate of 
retro potash ; and less than aday 
if some substance, such as 
magnesia, chalk, slaked lime, or cement 
be freely mixed with the solution, making 
it of a consistency like that of honey. In 
this way it will dry more quickly than a 
starch bandage, though, of course, not near- 
ly so rapidly as gypsum. 

A saturated solution of the silicate de- 
sired is made, and bandages or other mate- 
rial are soaked in this, and applied just as 
with plaster. It is very sticky, and hence 
more disagreeable to manipulate than the 
latter. The solution should be freshly 
prepared, as, if old, it is capable of irri- 
tating the skin quite severely. When the 
splint is in place, a final brushing with al- 
cohol will leave a surface of almost glassy 
smoothness. 

It is, of course, essential that the limb 
be held rigid while setting is going on, 
and therefore a temporary wooden splint 
over the water-glass is needed, Ifa jacket 
for the body be desired, some surgeons 
have advocated covering the silicate splint 
with one of plaster-of-Paris, the latter to be 
cut off and removed later, when the water-glass splint be- 
neath has hardened. This seems to the writer unnecessary 
trouble, as a simple plaster jacket can, by the aid of stif- 
fening strips, be made to combine lightness with strength. 

The water-glass jacket may be cut like that of gypsum, 
and held together with straps or lacings. 

Most of the remaining plastic materials are hardly 
worthy of detailed notice as a first choice, because of 
relative expense, of too prolonged or too brief a period 
of setting, or of various other objections. 

Starch is sometimes employed, made by stirring with 
cold and then adding boiling water. The thick muci- 
lage resulting is either brushed on layer after layer of 
applied bandage, or the fabric used is first soaked with 
it and then applied. This makes a light, cheap dressing, 
but hardens slowly—in thirty to forty hours—and con- 
tracts somewhat. Flour paste, or white of egg and 
flour, may be used as a substitute. 

Dextrine—‘‘ British Gum ”—is made by adding dilute 


611 


Fire. 3689,— 
Plaster Saw. 


Splints, 
Sponge-Grafting. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


* 


sulphuric acid to starch at boiling-point. It is dissolved 
in as little alcohol as possible, plus a little water. Cam- 
phor added seems to aid hardening. Apply as with 
starch. 

Thick glue, to which alcohol is added to promote more 
rapid drying; glue or mucilage and chalk—as, equal 
parts of gum arabic and precipitated chalk ; or glue and 
zinc oxide, will effectually stiffen the material with 
which they are impregnated. The second mixture har- 
dens more rapidly than starch, requiring from four to five 
hours. The third sets still more quickly, though quite 
slowly as compared with gypsum. Too great a propor- 
tion of oxide of zinc should be avoided, as it renders the 
splint brittle. 

Gutta-percha makes an excellent but rather expensive 
splint. That it is not sufficiently porous is an objection 
urged against it, in common with several others of this 
group, <A sub-dressing is always used, and this objec- 
tion seems to me, therefore, unimportant. The gutta- 
percha should be softened by immersion in warm, not hot, 
water. If the latter is used, the outside will become very 
soft and adhere to everything it touches, before the rest 
is affected by the heat. When warmed through and 
softened so as to be workable, it may be made flat and of 
any desired. thickness, by means of a wet rolling-pin on 
a wet board. Then soften again and instantly apply. 
It sets almost at once, requiring rapid work. 

Tripolith is a substance which also sets very rapidly 
—too rapidly, in fact. It is a gray powder, of lime, sili- 
con, and iron oxide—not so heavy as gypsum, and is 
manipulated by the same methods as the latter. 

Either paraffin or stearin may be used, melted and 
painted freely on the bandaged limb with a brush. Such 
splints are not quite as rigid in midsummer as in cold 
weather. In removing them, a hot blade aids the cutting. 

In an emergency, clay moistened and rubbed thickly 
into and upon the meshes of the roller, or other sub- 
dressing, will do. Aswith many of the dressings alread 
described, the application of dry heat about the finished 
splints—as by hot bricks, or bottles filled with boiling 
water—will aid evaporation and shorten the tedious 
hardening process. 

Shellac cloth—as several layers of cotton cloth soaked 
in a saturated solution of shellac in alcohol and pressed 
together into a solid whole—may be obtained ready pre- 
pared ; it makes a very desirable splint, and one which 
is rendered perfectly plastic by immersion in hot water, 
and afterward sets moderately quickly. As compared 
with a gypsum splint, it is, of course, more expensive. 

A similar dressing may easily be extemporized, if de- 
sired, by soaking sheets of blotting- or wrapping-paper, 
or thin cloth in the shellac solution just mentioned, or 
in collodion. In a case of Pott’s disease recently pub- 
lished, the operator, Dr. Taylor—not having gypsum or 
any splint material other than this at hand—first made a 
mould of the back with shellac blotting-paper, and when 
this mould had hardened, added to it alternate layers of 
fresh shellac blotters and glued coarse linen, until suffi- 
cient resisting power had been produced. 

As a splint, adhesive plaster is only in one sense prop- 
erly a member of this group. It does not ‘‘set.” It is 
not much harder when cold than when warm, being eas- 
ily flexible at all times. But in several instances it has 
been advocated as a splint, notably in Pilcher’s method 
of treating Colles’ fracture, which consists in supporting 
the fragments after reduction by wrapping a number of 
times about the wrist a narrow strip of adhesive plaster, 
until the splint is about two inches wide and moderately 
stiff and firm. Rubber plaster is rather too soft for this 
purpose. 

This is only one among scores of different devices for 
the cure of this particular bone-lesion. It seems to the 
writer that it is rather a trivial matter which splint be 
chosen in Colles’ fracture, and not worthy the numerous 
volumes which have been devoted to it. If the fragments 
have been disengaged and restored to good position, any 
splint which will keep them quiet is the right one. If the 
fragments have not been properly reduced, no splint wil! 
do this, and deformity will be inevitable. 


612 


In concluding this article, it is hardly necessary to say 
that much of the subject-matter is as old as Surgery, and 
for the rest the writer is largely indebted to very many 
authors well known in their specialty. 

Robert H. M. Dawbarn. 


SPONGE (Zponge fine, Codex Med.). The household 
articles known by this name are the horny or silky skele- 
tons of several species of invertebrate animals belong- 
ing to the Order Ceratosa, inthe great Group Parazoa or 
Spongie. The commercial sponges are colonial in their 
composition, although the outlines of individuality are 
very obscure. They are soft, porous, gelatinous bodies, 
perforated by numerous openings communicating with 
irregular, ramifying cavities within them, as well as with 
digestive and respiratory chambers, and more or less regu- 
lar tubes or canals. These minute chambers are lined with 
flagellated cells, which are probably the organs of nutri- 
tion as well as those by whose movements a constant 
stream of water is kept flowing into the sponge through 
the fine pores and out through the larger openings. 
Sponges are all aquatic, and those of commerce all of 
marine origin, growing upon rocks or other firm founda- 
tion, at a depth of from six toa hundred or more feet 
below the surface of the water. They are of slow growth, 
requiring from three to six years to attain a useful size. 
The mode of collection varies with the depth at which 
they are found as well as with the habit and outfit of the 
collector ; sometimes they are torn off the rocks by tongs 
or hooks, sometimes dredged for, but more generally they 
are gathered by divers from boats ;. these again may go 
down unprotected for three or four minutes at a time, or, 
equipped with modern diving-suits, make longer and 
deeper searches. Finally, the cultivation of sponges by 
fastening bits upon boards or sticks, and then sinking 
them to the bottom, has been proved practicable. When 
the sponges have been brought to land they are rubbed 
with sand or bruised to break up the soft parts, or ex- 
posed to the air until decomposition sets in, and then 
repeatedly washed and squeezed until they are clean. 
They are then dried and sent to market, where they are 
carefully trimmed and assorted, according to kind, fine- 
ness, size, and shape, into numerous grades. 

There are several distinct kinds, dependent upon the 
species producing them : 

1. The Levant or Turkey Sponge, from Huspongia 
(Spongia) officinalis Linn., the finest and most expensive 
of all, from the waters surrounding the Grecian Islands, 
Asia Minor, Syria, etc. It has a soft, fine, very elastic 
texture, a light color, and great toughness of fibre. In 
shape it is rounded, tuberculated, lobed, hemispherical, 
cup-shaped, or irregular: it is very free from its gelati- 
nous flesh when prepared for the market. 

2. The Zimocca Sponge, from Huspongia Zimocca O, 
Schmidt ; also a fine, strong, valuable sponge, but harsher 
to the feeling than the preceding, and not nearly so ex- 
pensive. 

3. The Mediterranean Bath Sponge, from Hippospongia 
equina O. Schmidt ; in large, soft, rounded masses, with 
a loose texture and very large reticulating canals. 

Besides these, this country is supplied in great abun- 
dance with very cheap sponges from the West Indies ; 
they are much inferior in texture and durability to the 
Mediterranean products: they are, 

4. The Reef Sponge, Huspongia officinalis, var. tubulif- 
era, is the common cheap, fine ‘‘ slate sponge,” it is 
coarser, less elastic, and very much more tender than the 
Turkey sponge, and is of more or less conical shape, with 
a broad, cut base. 

5. The Sheepswool, Velvet, and Grass Sponges, from vari- 
ous species of Hippospongia. 

CoMPosiITION.—Sponges contain a considerable quan- 
tity of fine sand, and sometimes pebbles, entangled in 
their meshes, which can generally be removed by mechan- 
ical means; there is also a varying amount of calcareous 
concretions or fragments, which stick more tenaciously 
and often have to be dissolved by dilute acid. These 
being removed, the remainder is nearly all a peculiar elas- 
tic, durable, nitrogeneous substance called Spongin, closely 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


related in composition and texture to silk. Besides this, 
there are a little iodine, bromine, salt, etc. 

Uses.—These are mostly mechanical or household, and 
familiar to everyone. Carbonized sponge, Spongia usta, 
now obsolete, used to be given for the same conditions 
for which iodide of potassium is now used, and owed its 
value to the presence of that element. 

In surgery sponges have long been used for packing 
and dilating cavities, and as absorbers of blood in opera- 
tions. The general acceptance of antiseptic methods in 
surgery has caused them to be looked upon less favor- 
ably than formerly, and requires a special preparation 
before they are to be used at all. For surgical opera- 
tions the fine, soft, Turkey sponges, though dear, are 
the best. With care in washing and sterilizing, in pri- 
vate practice they may be used repeatedly, and ‘so their 
first cost made less of an objection, or the fine West 
India sponges may be used once and thrown away. The 
bath and sheepswool varieties are too porous and soft to 
be of any use as blood-absorbers. A sponge of a size 
convenient for the hand and operation, and of a rounded 
shape, without large canals or deep constrictions, should 
be selected. They may be bought already bleached or, 
better, unbleached, and bleached by the surgeon, who 
should always superintend the sterilizing and preserva- 
tion of them. They may be bleached by a chlorine solu- 
tion, being carefully watched, and removed before they 
have acquired a bright, golden-yellow hue; it is, how- 
ever, a poor method, and apt to rot them. Dilute sul- 
phurous acid or a bromine solution is better, but perhaps 
the best method of all, for surgical use, is that by means 
of permanganate of potash and oxalic acid, as follows: 
After beating and shaking, or dissolving out all mineral 
impurities, soak the sponges in a strong (say, one per 
cent.) solution of permanganate of potassium, then rinse 
them and wash in a solution of oxalic acid, strong enough 
to taste sharply sour, stirring and pressing them until 
the color of the permanganate is entirely discharged ; 
then wash very thoroughly with clean water. If they 
are not white enough, repeat the whole process again, but 
do not leave the sponges longer than necessary in the 
acid. They are then bleached, but not sterilized ; for 
the latter purpose soak them for an hour or more in a 
five per cent. solution of carbolic acid, to kill active or- 
ganisms ; wash in clean water until the carbolic acid is 
removed, then set in a pail of water in a warm place for 
twenty-four hours in order to germinate the spores, and 
finally put again in five per cent. solution of carbolic 
acid. They may be kept in this solution, renewing it oc- 
casionally, until needed, or they may be pretty safely put 
in a sterilized bag of several thicknesses of close cotton 
cloth and kept dry until wanted. Corrosive sublimate in- 
jures sponges very quickly, alcohol shrinks them and tem- 
porarily destroys their elasticity, hot water damages them 
permanently, and alkalies or strong soap-solutions dis- 
solve them. After having been used, the cleansing and 
sterilizing process is to be repeated in full. 

Sponge tents, now but little used, are made by soaking 
fine, tough sponge in melted cocoa-butter, or in mucilage 
or alcohol, and winding very hard to cylindrical shape 
with strong twine ; when dry or cold the cord is removed 
and the surface is filed or pared to shape. 

Ether sponges are fine Turkey sponges of large size, 
requisite fineness, and of aregular cup-shape. No inhaler 
has yet been made so safe or comfortable to the patient 
as these, but they are wasteful of ether. W. P. Bolles. 


SPONGE-GRAFTING. The recent introduction of 
sponge-grafting as a means of promoting the repair of 
chronic ulcers and other solutions of continuity rebel- 
lious to ordinary treatment, has proved of such service 
in the hands of those who have resorted to it, that we 
cannot too urgently advocate its claim to the attention 
of the surgeon. We are indebted to D. J. Hamilton, the 
distinguished Professor of Pathological Anatomy, Aber- 
deen University, for the introduction of this material for 
the cure of ulcers. 

That we do not here exaggerate the value to be at- 
tached to sponge-grafting, the relation of the following 


Splints, 
Sponge-Grafting. 


case, occurring in the writer’s practice some time since, 
amply demonstrates. This case presented itself just at 
the time when the writer was in receipt of a letter, ac- 
companied by a package of sponge, from Professor Ham- 
ilton, and it was determined to make a practical test of 
the method at once. Pieces of these sponges were ad- 
justed to nearly every portion of the ulcerated area, cov- 
ered with oil-silk, and daily cleansed with carbolized 
water. When it became necessary to remove any piece 
of sponge which had not remained aseptic, the bare spot 
was at once covered with a fresh piece. This treatment, 
persevered in for one month, brought about a gradual 
development of granulations, and finally resulted in a 
perfect cicatrization of the ulcer. It is worthy of note 
that this case had been under treatment for a very long 
time, and the presence of the offensive discharge had 
evidently influenced the general health of the patient ; 
but notwithstanding this, and the fact that the area of 
ulceration was so extensive, the wound healed promptly 
under this treatment. It is equally of importance to state 
that there has been but little contraction of the cicatricial 
tissue, though several years have now elapsed since re- 
covery. 

In almost every hospital ward the surgeon is con- 
fronted with a class of ulcers that persistently resist all 
attempts to promote their healing. Repair can take place 
only through a healthy granulating process, and when 
cicatrization is postponed the cause must be referred to 
some abnormal condition of the granulations. The sev- 
eral forms of diseased granulations, whether fungous, 
hemorrhagic, croupous, or diphtheritic, may be ren- 
dered healthy by well-directed treatment. But it often 
happens that, in the absence of any specially diseased 
state of the granulations, unless it be the want of nutri- 
tive power to sustain themselves, their functional activi- 
ty becomes too soon exhausted, and, in consequence, 
the process of cicatrization is delayed. In this state of 
relaxation and collapse, all granular appearance disap- 
pears, cell-proliferation ceases, pus-cells no longer emi- 
grate, the vascular loops droop, fall over, become throm- 
bosed, degenerate, and disintegrate ; and this morbid 
process is repeated as often as the pressure from below 
forces other vascular loops to the surface. To offer 
these weak and disorganized granulations a surface sup- 
port through contact with some more vitally endowed 
tissue, is the indication which naturally suggests itself, 
and which might well have been fulfilled at the time 
when John Hunter showed the possibility of grafting 
living tissue upon a denuded surface, when he trans- 
planted the cock’s spur upon the stump of its comb. It 
was, however, reserved for Reverdin, only a few years 
since, first to put into practice his method of skin-graft- 
ing. However productive of the best results this method 
has often proved to be, yet, it must be confessed that 
skin-grafting is neither agreeable, expeditious, nor al- 
ways available. The application of sponge-grafting, on 
the contrary, as a ready means of cure—for the material 
is always at hand and can be easily prepared—presents 
an interesting subject of contemplation to the histologist 
as well as to the pathologist in the mode by which it ac- 
complishes this end. 

It is well known that a living tissue may take root, 
become nourished, grow, and cover an abraded surface 
with which it is retained in contact; but the interest at- 
tached to the sponge in this connection is of a very differ- 
ent nature, for we are here making use of a material which 
is neither organized nor living. The question arises, in 
what way does such a material promote rather than, as 
a foreign body, impede, cicatrization ? Looking critically 
into this subject, in order to offer a demonstrative ex- 
planation of the agency of the sponge in securing, main- 
taining, and assisting in such a process, we must first con- 
sider the mode in which organization takes place in a 
blood-clot. 

It was formerly believed by most physiologists that the 
coagulation of blood was a proof of its vitality. The 
clotting of fibrin and its subsequent fibrillation was sup- 
posed to be a spontaneous assumption of structure, since 
there is a felt-like, matted arrangement of decussating 


613 


Sponge-Graf ting. 
Squill. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


fibres, wholly unlike the granular and homogeneous par- 
ticles of coagulated albumen, through and among which 
blood-vessels appeared to be developed de novo. But a 
closer examination has shown the fallacy of this view. 
The clotting of fibrin is now known to be an evidence of 
the death, not of the life, of the blood. Within the inter- 
spaces of this fibrillated stratum loops of blood-vessels 
are projected from the deeper-seated structures, while 
leucocytes and blood-corpuscles are entangled within its 
meshes ; whatever vitality these corpuscles at first possess 
is very soon lost ; degenerated and destroyed, they finally 
disappear with such few blood-disks as may at first be 
found in the clot. The underlying, distended, and tort- 
uous blood-vessels are displaced and pushed out farther 
into the clot, carrying with them connective-tissue cor- 
puscles which, proliferating, insinuate themselves as 
broods of cells into the interfibrillar spaces. The fibri- 
nous network now contracts, expresses all of the serum 
therein contained, begins to fall to pieces, and finally it- 
self disappears ; and all of this is coincidently connected 
with the destruction, through fatty or granular change, of 
both orders of blood-cells. There seems, therefore, to be 
no evidence to support the views of Cohnheim and oth- 
ers, that a blood-leucocyte is converted into fibrous tissue. 
The subsequent cicatricial or fibrous tissue owes its ori- 
gin, notto these corpuscles which disappear, nor again to 
the original fibrin-clot, which also is sooner or later re- 
moved ; for itis known that the fibrous tissue ultimately 
formed into cicatricial structure, is not that first seen in 
the blood-clot—the original fibrinous material which the 
extravasated blood furnished—but newly-formed fibrous 
tissue evolved through the morphological changes of the 
connective-tissue corpuscles. So far, then, as the original 
clot was concerned, it may be said to have been perfectly 
passive, having, through its elastic and porous arrange- 
ment of fibres, served the purpose of a trellis-work, sup- 
porting the growing cicatricial tissue. The embryonal 
cells may actually be seen to elongate into spindle-cells 
that are slowly transformed into the fibrous tissue which 
forms the cicatrix. 

Another point of interest and worthy of careful study, 
is the mode by which the vascularization of the new tis- 
sue is established. According to many writers, this is 
accomplished by the actual development of newly-formed 
blood-channels, but, notwithstanding the scientific au- 
thorities who support this view, Professor Hamilton has 
never been able to verify the production of new vessels ; 
in no instance did he discover anything but loops of 
ready-formed vessels, the convex side of these being in- 
variably directed toward the distal or peripheral parts, 
the concave toward the proximal; and he detected none 
of these vessels ending in free extremities. There was 
always a complete afferent and efferent vessel. ‘‘ When 
such a loop reached the sponge framework,” he says, ‘‘it 
was pushed into it, often some distance in advance of the 
cicatricial elements which usually surrounded these ves- 
sels. It still, however, maintained the character of a 
complete capillary loop, and I was unable to detect any- 
thing like a free, newly-formed, and pointed offshoot on 
examining other portions of these vessels for any evi- 
dence of sprouts from their sides ; I must say I could not 
detect anything of the kind, Another curious 
point—if these vessels were newly formed—was that the 
stems leading up to the capillary loops at the edge of the 
cicatricial layer possessed, in many cases, a completély 
formed adventitious coat the appearance of 
fully developed capillaries, without any evidence of off- 
shoots branching from them.” 

From this investigation of nature’s method of organi- 
zation of the blood-clot, we learn that the fibrin fulfils 
the passive purpose of a framework for the support of 
vessels, not of new formation, but of such as are forced 
into it from subjacent parts, surrounded by connective- 
tissue corpuscles, whose polynucleation and subsequent 
germination eventuate in a progeny of new cells, migra- 
ting into every interspace, aggregated into clusters which 
press destructively upon each and every fibrillar shred of 
the network, and finally constitute themselves the pro- 
genitors of the incipient cicatricial tissue. 


614 


Now, let us compare this process in the blood-clot with 
that taking place in the sponge, when used in the manner 
which we shall describe. Sponge closely resembles in its 
porous nature the trellis-work of a fibrillated blood coag- 
ulum, when through the proper method of preparation 
it has been converted into fine layers or sheets of extra- 
ordinary delicacy. If such a piece of sponge, properly 
prepared and rendered aseptic, be adjusted to an ulcerated 
surface, the feeble granulation loops of which need sup- 
port, we can readily imagine that the subjacent capil- 
laries will push themselves into its interstices, just as we 
see them do in a blood-clot. This organic connection, 
which the sponge contracts with adjacent and easily de- 
nuded surfaces, has indeed often been seen, and some- 
times seriously realized, when, for example, a sponge- 
tent has been incautiously left too long imprisoned 
within the cervix uteri. Who has not met with diffi- 
culty in its removal, which has only been accomplished 
at the expense of a laceration of vessels that have pene- 
trated the very meshes of the sponge, and which often is 
accompanied with considerable hemorrhage ? 

These capillaries are under no restraining influence 
upon denuded surfaces, and are naturally forced out-into 
loop-like processes under the constant blood-pressure de- 
rived from each propulsive action of the heart, to such 
an extent indeed, in all granulating wounds, that they 
often must be compressed or ‘‘ kept under” by remedial 
agents daily applied to such exuberant granulations. It 
sometimes happens that these blood-vessels grow to such 
lengths that they fall over, their circulation becomes ob- 
structed, and thus they fail to fulfil their purpose in 
wound repair. If, in such a case, the wicker-work of a 


' sponge be placed so as to support the loops, they may then 


climb to the surface and establish a degree of vascular- 
ization which carries with it connective-tissue corpuscles 
from neighboring parts, out of which in time a true ci- 
catricial structure may be formed. It is thus that sponge- 
grafting has been discovered to supplement, as it were, 
a natural process, and, on microscopical examination, is 
seen to bear the relation to neighboring parts which we 
have endeavored to demonstrate. It is needless to state 
that, as cicatrization advances, the new elements of re- 
construction are found to press upon the meshes of the 
sponge, which, like the fibres of a clot, slowly disin- 
tegrate and are removed. During’the entire progress of 
the changes that are seen in parts thus undergoing ad- 
vancing cicatrization, the sponge texture becomes so in- 
filtrated with tissue-corpuscles and filled to repletion 
with reticulated, convoluted, and looped vessels—in other 
words, so thoroughly vascularized—that it appears to 
the unaided eye to be actually organized; and it even 
bleeds at the touch, or when it is pricked by the finest 
pointed needle. Holding, as it were, upon a scaffold 
the elements of repair, while they are actually being 
converted into veritable tissue, the sponge seems to ful- 
fil another important purpose, for it certainly thus pre- 
vents, or at least diminishes, the subsequent shrivelling 
of the cicatrix. This was well seen in the case above 
cited. 

It only remains to state that this sponge must be ren- 
dered aseptic, and should, of course, be first deprived of 
all extraneous particles. It should be immersed in some 
weak acid to destroy every particle of inorganic material, 
after which it must be washed in liquor potasse, per- 
fectly cleansed again in distilled water; it is to remain 
for some days in a strong solution of carbolic acid, then 
dried, when it can be cut with a section-cutter into deli- 
cate layers, which may be kept ready for use, wrapped 
in oil-silk. 

Middleton Michel. 


SPRING LAKE MAGNETIC SPRING. Location and 
Post-office, Spring Lake, Ottawa County, Mich. 

Accrss.—From Chicago by the West Michigan Rail- 
road to Ferrysburg, less than a mile from Spring Lake ; 
or by boat to Grand Haven, thence by Detroit, Grand 
Haven & Milwaukee Railway to Spring Lake ; from De- 
ae by the Detroit, Grand Haven & Milwaukee Rail- 
road, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


ANALYsis.—(Professor C. G. Wheeler). One gallon 
contains (50° F.): 

Grains. 

Chloride oh pacesslimercrerss css cidasccicises clase salect 4.2880 
QHIOTINe OinsOUUIL rae ce areieiete's © oe sare sisieve aie'ers are 405.5330 
Ohiloridooicalcinip seek fee celta lenceckiee eles 115.4200 
CHIOvIdeOLWMACHESIUTI ee cree sc toss selected eines 36.2000 
GHIGHIGEfOmBOUIIIO eee aren ete elais cie'eeieicis’ spare elects asa 0.9537 
BicaroonarerotoalenliMers tet couacset aces te cnet 0.1808 
Bicarbonaterwoiivomeesee ccs ton cases cicace weve o's oars 1.0060 
Bicarbonate of magnesium. ............csce-ceees 0.0640 
Bicarbonate of manganese-s. Sk... dececcccssnes 0.0647 
Bromide Ol Bones... ce. cicisle be cccwese cece 2.1700 
Simi pMacaramsoulitd merce sere ntcistelstre ait arc cle-scis c's, <.0 ots 46.7000 
SUMAN er ee eee eth cero ciers Leniure alchere ois ee nce hia.e ole 0.5030 
TAMAS aera ere aa eteecee reiiere Sooke tis civiciaraie bie weweecs traces 
NPRVIVLOVA GIR oats eacy eters sare atsve © 2 be "eaies.'9 04,6. 60 0.0158 
G@LOAMIGHMALteiene err tcl sue citi aisiciee Wajcle casts ss ene 18.2702 

TGU GURL Cee oie ies seats rede xs aire Siac esac Sek bok traces 

EP ODE MEP 3 cictd Datla ee abslar ate claei aie istuieveie lei s.0 score. op 629.5692 


THERAPEUTIC PROPERTIES.—This is a valuable saline 
water, containing an appreciable quantity of the bromide 
of magnesium. The claim to magnetism, which this and 
other springs in Michigan boast of, is not borne out by 
scientific investigation. This property is found to be due 
to, and to reside in, the iron tubing. ; 

The waters are employed as a cathartic in diseases of 
the liver and digestive organs. 

This spring is located in the town of Spring Lake 
(1,500 inhabitants), on a beautiful sheet of water of the 
same name. It is three miles east of Grand Haven, on 
Lake Michigan. The lake empties into Grand River, 
which forms the harbor of Grand Haven, and affords 
delightful boating and excellent fishing. There are sev- 
eral good hotels, provided with all the modern improve- 
ments necessary for comfort. ‘There are also good facili- 
ties for bathing. GeBAr, 


SPUNK (Fungus Chirurgorum, Ph. G.; Agarie de 
Chéne, Codex Med. ; Amadou, etc.). A preparation made 
from Polyporus fomentarius, or P. igniarius Fries; Order, 
Basidiomycetes (Fungt). 

Both the above fungi are parasitic upon the trunks of 
forest-trees, especially of oaks and beeches. They are 
attached by broad bases and expand horizontally in large, 
rounded, hoof-shaped masses of corky texture, and red- 
dish- or grayish-brown color ; the upper surface is convex 
and marked by a series of distinct concentric rings, each 
of which indicates a year’s growth. The underside (hy- 
menium) is flat. P. cgniarius is a little flatter, rather 
smaller, and in an early stage more velvety upon the 
surface than the other; otherwise they are very similar. 
Both the above species are collected, as well as a few 
others, for making surgeons’ styptic fungus or amadou ; 
but P. fomentarius is said to yield the best quality. 

For surgical use the middle portion only is taken, the 
top and bottom layers being cut away, and, after being 
softened in water, it is beaten with a wooden mallet into 
a tough, flexible, buckskin-like sheet, and dried. In this 
condition it will absorb more than twice its weight of 
water. It was formerly used to stop bleeding, by being 
packed or bound over the bleeding surface. 

Spunk, properly so called, or tinder, consists of this 
‘‘amadou,” prepared as above and soaked in a solution 
of nitre or chlorate of potassium. It is very inflammable, 
burning without flame, but scintillating now and then, 
and holding fire for a long time. This, which is some- 
times kept in the shops, can be prepared for surgical use 
by dissolving out the saltpetre in water, and drying. 
The blood-stanching action of amadou is entirely me- 
chanical, and it is almost completely superseded by the 
excellent preparations of absorbent or styptic cotton, or 
by lint, ‘‘spongio-pilin,” etc., with which the market is 
supplied. 

ALLIED PLANTS, ETC.—See AGARIC, PURGING. 

ALLIED SUBSTANCES. — Cotton, lint, charpie, and 
sponge are used now for the purposes for which amadou 
was formerly valued. See also Matico, W. P. Bolles. 


SQUILL (Sciiia, U. 8. Ph., Br. Ph. ; Bulbus Scilla, Ph. 
G. ; Scille, Codex Med.). The bulb of Urginea maritima 
Baker (Scilla maritima, Linn.); Order, Liliacee; a per- 


Sponge-Grafting. 
Squill, 


ennial herb with an onion-like bulb, liliaceous leaves, and 
a long spike of regular, small, hexamerous flowers. 


Fia. 3690.—Scilla Maritima ; bulb and leaves. 


(Baillon.) 


The bulb is large, four or five inches long, globular, 
covered with two or three dry reddish or gray papery 
scales, and made up within of numerous thick fleshy ones. 
The greenish-white flowers appear in the fall upon a 
scape one or two feet long, and form a spike nearly as 
long as the scape; perianth, six-parted ; stamens, six ; 
ovary, three-celled; seeds, fifteen or twenty, winged ; 
leaves, vernal, narrowly lanceolate, one or two feet long. 

Squill grows mostly, as its name indicates, not far 
from the sea-shore in dry, sandy places. It is native 
to nearly the whole Mediterranean coast, and is especially 
common in Spain. There are two varieties, the white 
and red, distinguished by the color of the outer tunics of 
the bulbs. 


615 


Squill. 
Stammering. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Onions and their relatives are members of the same 
Group. 

The Order Liliacee is a very large one, furnishing 
many beautiful garden and greenhouse flowers, and a 
few useful food-plants. It is in general, however, poi- 
‘sonous or suspicious. 


For medicinal use the bulbs are collected in the latter 
part of summer, the outer scales peeled, and the rest 
sliced transversely in slices from an eighth to a quarter 
of an inch thick, and dried in the sun. 

It is then in quadrangular strips, two sides of which 
are covered with cuticle, the remaining two being sec- 

tions ; the strips 


but hygroscopic 
and generally 
somewhat  flexi- 
ble, nearly odor- 
less, and having 
a mucilaginous 
taste, becoming 
bitter and acrid. 
It consists of a 
simple parenchy- 
matous tissue 
loaded with mu- 
cilage containing 
numerous oxalate 
of lime crystals, 
and traversed by 
occasional vascular 
dles. 

Few medicines outrank 
Squill in antiquity; it is 
mentioned by nearly all 
writers upon medicine, from 
the earliest down. 

Composition. — Besides 
the mucilage and some sugar 
and the oxalic salts, Squill 
contains a dextrin-like sub- 
stance called Sinistrin, of 
no active properties. The 
principal ingredients are, a 
bitter, active principle, Sczi- 
litoxin, amorphous, light- 
brown, soluble in alcohol, 
not in ether or water, a car- 
diac poison resembling digi- 
talis ; Scillipikrin, a yellow- 
ish white, amorphous, hy- 
groscopic powder, similar 
to the above but less active ; 
and finally Sczlin, of no 
medicinal qualities. 

AcTION AND UsgE.—Squill 
has in a measure the heart- 
slowing and diuretic action 
of digitalis, for which it is 
occasionally substituted — 
with which it is more fre- 
quently given as an adju- 
vant. Asaslightly depress- 
ing expectorant it is a com- 
mon ingredient .of cough- 
preparations. Large doses 
(from 6 to 12 grains) occa- 
sion vomiting and purging. 
ADMINISTRATION.—Squill 
Fie, 8691.—Scilla Maritima; Inflor- is difficult to powder, apt to 

escence. (Baillon.) cake up when powdered,and 
seldom given in substance. 

The following preparations are officinal : Fluid Extract 
(Hetractum Scille Fluidum, strength, +), dose, one to two 
minims; Tincture (7inctura Scill@, strength, 7%5), 8 to 
24 minims ; Vinegar Acetwm Scilla, strength, ;';), 15 to 60 
minims; Syrup of Squills (Syrupus Scille), dose, 4-8 c.c. 
(3 j.—3ij.). The Compound Syrup (Syrupus Scilla Com- 
positus) is rather a preparation of antimony than of Squill. 

ALLIED PLANTS.—The Genera Allium, Scilla, Drismia, 
etc., are closely related to Squill and some of their 
species are sometimes substituted for it. 


bun- 


616 


JOOSDCSTO000COD 3000000 
Ae ae a aise aeuetacss Pe ae qaeer 
shrivelled, of a Wy FLERE PEC FY Dra we 
sigs Se EN We ge-s oi = Seen, 
whitish color, CO LA ose 
brittle if very dry, ron. se AL 


3) 2. 


Desa SSS SSS SS SOS OSS OO SS SoS DOSS SO S00 SS 0S0s5eo5Soqog5R0u052 
Fic, 38692.—Squill; transverse section of a Scale, magnified. (Baillon.) 


The following are the most important medicines pro- 
duced by this Order : . 


Alvuar-sativwum Tape Bh eee eee Garlic. 

ALOE, EPR Var SR 4 ne ote . os eye Aloes 

Veratrum viride .....cecee American Hellebore. 

Schoenocaulon officinale (Asagrea) ....Sabadilla. 

Colchicum autumnale Linn ......... Colchicum. 
Etc., etc. 


W. P. Bolles, 


STAMMERING. Synonyms: Lalling, Dysarthria Ii- 
teralis, Stammeln, Balbutiement. Stammering is defined 
as imperfect articulation of the vowel or consonant 
sounds, due to malformation of the organs of speech, or 
to imperfect innervation of the muscles employed in ar- 
ticulation. 

Articulate speech is formed by a column of air set in 
vibration by means of the vocal cords in the larynx, and 
interrupted and varied in pitch and quality by the mouth 
and nasal cavity. In order to bring about these varia- 
tions the tongue, lips, and palate are moved, so as alter- 


nately to open and close the passages, and in this way a 


very large number of sounds may be produced, which 
are represented by letters and called vowels and conso- 
nants. Only asmall proportion of the possible sounds is 
used in any one language. 

A continuous sound made with the air-passage open is 
called a vowel. The particular vowel produced depends 
on the position and degree of approximation of the parts 
during phonation. 

Consonants are made with the passages more or less 
closed. Some of them are capable of indefinite prolon- 
gation, the air escaping either through the nose, as with 
mand n, or between the tongue and palate, as with J, 7, 
and s. The explosives ), d, g, k, p, and t, cannot be pro- 
longed, but there is a preliminary sound called a burr 
while the air is passing into the pharynx and mouth, and 
then the passage is opened with a flap, and takes the po- 
sition of the following vowel. 

No sharp line can be drawn between the two classes. 
The consonants w and y are made in the same way as the 
vowels o and é, with only a little closer approximation 
respectively of the lips, and of the tongue and hard pal- 
ate. 

Consonants are joined with the preceding and follow- 
ing vowel sounds. Stammering has nothing to do with 
the joining together of sounds, but is the inability to ren- 
der them properly, even when given alone. The terms 
stammering and stuttering are confused, always in the 
older writings, often in more recent ones. The differ- 
ence between them was discovered early in the present 


REFERENCE HANDBOOK OF 


century. Stuttering, as we shall see, is characterized by 
attacks of spasm varying in severity, but always of the 
same nature. Thestutterer can render the separate sounds 
perfectly under favorable conditions. His trouble is only 
occasional, and brought on usually by the attempt to pro- 
nounce one of the explosives mentioned above. 

On the other hand, stammering must be distinguished 
from aphasia. That has to do with neither the produc- 
tion nor the joining together of sounds, but with the con- 
struction of syllables and words as a whole. It is caused 
by the disabling of those parts of the cerebral cortex 
which contain the sensory or motor speech memories, or 
of the fibres connecting these with other parts of the ner- 
vous system. 

The highest point in the cerebrum at which a lesion 
can cause a purely literal defect, is at the level of the 
corpora striata.! Disease above this causes impairment 
of the power of perception or construction of words or 
syllables. 

Aside from occasional faulty pronunciation, to which 
everyone is more or less liable, there are many cases of 
stammering in which the trouble is due to sheer careless- 
ness and inattention, fixed by habit. These cases are im- 
portant as well from a diagnostic as from an educational 
standpoint, as they may be mistaken for cases of acquired 
speech defect, especially when organic brain disease coex- 
ists with them. 

The capability of pronouncing different sounds is a 
matter largely of race and training. Everyone stammers 
in a foreign language, if he undertakes to learn its new 
sounds after his habits of speech are formed. Thus the 
German ch, French nasals, and Italian 7 are seldom per- 
fectly acquired by an adult. But, according to Kuss- 
maul, ‘‘the most choking guttural of a Swiss throat 
modestly retires before the vomiting throat-sounds of an 
Arabian.” 

We may divide our subject into stammering from: 1. 
Habit or carelessness. 2. Organic defect of the organs 
of speech. 38. Disease of the nerve-centres. The speech 
defects in all these cases may be identical, and in order 
to distinguish them one from the other a careful exami- 
nation and attention to the history are often necessary. 
A complete list of sounds which may be mispronounced 
is not possible. It will be sufficient to indicate a few of 
the more common ones. 

The mispronunciation of the letter 7 is called Rhota- 
cism or Burring. This letter has the same general sound, 
but is produced in various ways by different nations. In 
English-speaking countries it is formed by approximat- 
ing the sides of the tongue to the roof of the mouth, but 
in certain localities is often slurred. Its place is then 
taken by az or @ sound. In southern England it is pro- 
duced by the tip of the reverted tongue. In Italy it is 
made by a rather prolonged and rapid vibration of the 
tip of the direct tongue against the palate. The Italian 
nobility profess to be unable to produce this sound, and 
use the English 7. In Northern Germany it is made by 
the uvula, in Sweden by the glottis. It is evident that 
correct speech in one country is stammering in another ; 
é.g., the use of the uvula in pronouncing the English or 
Italian 7. Again, the ordinary sound may be replaced 
by an entirely different one. In this case / or w is usu- 
ally employed. This is regularly done by children, who 
acquire the 7 sound among the last. 

L is often mispronounced—7, d, t, y, etc., being used 
instead. This is called Lambdacism. JZ should be made 
by placing the tip of the tongue against the hard palate, 
and then phonating so as to make a continuous sound, 
the air escaping at the sides of the tongue. If the air 
does not escape, the explosive d is produced instead ; if 
the tongue does not touch the palate, the half-vowel y is 
made, and so on. 

Lisping, or Sigmatism, is the most common form of 
stammering. It consists in giving s a wrong sound, usu- 
ally that of th, by carrying the tip of the tongue too far 
forward, so as to touch the upper teeth. In this way 
both the hard and soft sounds of s are replaced. This 
occurs even among the Germans, who have no ti sound 
in their language. 


THE MEDICAL SCIENCES. stake 


~ - 


Gammacism is the mispronunciation of the letter g. 
It is sometimes hardened into k, sometimes changed to 
d, especially by children. 

Examples of the mispronunciation of consonants might 
be multiplied indefinitely. Whole classes of them are 
changed in definite ways by different nations in learning 
foreign languages, so as sometimes to constitute a dia- 
lect, ¢.g., the Scotch and Irish brogues; and, in fact, we 
may bring under this head many provincialisms, among 
them the cockney misplacing of the aspirate. 

Stammering of vowel sounds consists in slurring them, 
so that they lose more or less of their individual charac- 
ter. A certain degree of this isin conformity with the 
spirit of the English language ; in fact, many of our dif- 
ferent vowels are, under certain circumstances, rendered 
in exactly the same way, ¢.g., in bird, burn, and father, 


-and in bun and monkey. When carried beyond the de- 


gree sanctioned by general usage, this is stammering. 

Hesitating speech with interpolation of a & sound is 
popularly called stammering, but usually is simply a de- 
vice for gaining time. 

1. All the above varieties, although they may be pro- 
duced by organic causes, are often simply the result of 
habit. Examination then shows that the patient has al- 
ways spoken in the same way, and reveals absence of 
other symptoms of disease; but it should be borne in 
mind that stammering may coexist with any disease 
which is compatible with speech. 

Treatment here is simply an education. The patient 
should be carefully shown how properly to place his ar- 
ticulating apparatus so as to produce the required sound. 
Sometimes it will be found that he can readily do this 
when shown how. It is then only necessary to insist 
that he take the requisite amount of trouble every time 
he speaks. Other patients, especially adults, have the 
greatest difficulty in accustoming themselves to the 
change. The great point is to begin early. The ac- 
quiring of a new sound in his own or a foreign lan- 
guage is to an adult often an impossibility. 

2. Organic defects of the organs of speech may be con- 
genital or acquired, and lead to the same vices of articu- 
lation mentioned above, but often in a much higher 
degree ; at the same time the voice may be changed in 
quality, acquire a nasal twang,:etc. Here the produc- 
tion of the normal sounds is an impossibility, even if the 
patient is instructed how to do it. 

Hare-lip interferes especially with the pronunciation ~ 
of the labials; cleft palate, and congenital defect of the 
soft palate and uvula, with the gutturals, besides giving 
a nasal twang to all sounds. 

The tongue may be bound down to the floor of the 
mouth by a short freenum, causing thickness of speech 
and imperfect utterance of the linguals. 

All these conditions must be ascertained by inspection. 
The treatment is surgical, followed at an appropriate in- 
terval by instruction in speaking. 

Excision of the tongue for cancer interferes less with 
articulation than might be expected ; d, ¢, and / are the 
only sounds which are lost, and the patient is able in a 
little while after the operation to make himself under- 
stood. 

The larynx has little to do with articulation. Disease 
there causes aphonia. Even after its total extirpation 
patients have acquired the power to speak, setting in 
vibration the column of air contained in the pharynx. 

3. Nervous diseases may cause literal as well as other 
defects of speech. The diagnosis must be based on a 
careful review of all the symptoms. The mode of 
development of the stammer is of the greatest impor- 
tance. 

Most characteristic in this respect is the defect in bul- 
bar paralysis. In this disease the ganglion cells in the 
medulla oblongata are destroycd one after the other. 
The process usually begins in the nucleus of the hypo- 
glossal nerve, and extends to the facial, spinal accessory, 
and glosso-pharyngeal. Wherever it extends it is ac- 
companied by a paralysis of the muscles supplied by the 
affected ganglion cells; and as the tongue, lips, and 
palate are successively involved, the sounds formed by 


617 


Stammering. 
Starch. 


these parts become indistinct, and finally disappear. In 
this way the patient loses the power to form the linguals ; 
paresis of the lips causes at first disappearance of o and 
uw, later of the explosives b, p, andd, when the disease 
extends to the uvula the nasal cavity is not properly shut 
off, and, besides the nasal quality which is given to it, 
the voice becomes much weaker from the large quantity 
of air which cscapes through the nose. At the same 
time the lips, tongue, and palate are paralyzed for ordi- 
nary movements to a corresponding degree ; whistling is 
impossible, swallowing difficult, and there is marked 
atrophy of the muscles with reaction of degeneration 
(Erb). There is no true aphasia nor amnesia, but speech 
may finally be entirely lost by the successive elimination 
of its component sounds. These changes are eminently 
progressive in character, and usually slow. The pro- 
cess is then one of sclerosis. But the same symptoms 
may appear rapidly, from hemorrhage or embolism. 
During the prodromic stage, with heaviness of speech 
and occasional difficulty of articulation, diagnosis is not 
easy. 

In paretic dementia the symptoms are more com- 
plicated. The disease-process is scattered through the 
greater part of the nervous system. If the medulla is 
involved there may be much the same defects of articu- 
lation as in bulbar palsy, but they never reach so high a 
degree. At the same time there is apt to be marked 
tremor of the face and tongue, elision of syllables, loss 
and misapplication of words, and weakening of the logi- 
cal powers. Ina typical case it may be possible to make 
the diagnosis from the speech alone. It should be re- 
membered, however, that stammering and stuttering may 
coexist with congenital mental defect and simulate this 
condition closely. The occurrence of delusions of gran- 
deur and the somatic symptoms will then decide. 

Multiple sclerosis may or may not cause disturbances of 
speech, according to the location of the areas of indura- 
tion. When the cerebrum is affected it is apt to be soin 
the subcortical portion, and the fibres coming from the left 
third frontal convolution may be involved. If they are 
involved, they may be cut across, and aphasia will then 
result. Usually they persist, altered more or less by the 
sclerosed tissue around them, motor impulses are trans- 
mitted through them with difficulty, and speech becomes 
measured and slow. This is called scanning. At the 
same time there is irregularity in the force with which 
syllables are brought out. The voice is monotonous and 
ona high key. But areas of sclerosis may occur below 
the basal ganglia, and cause true stammering. 

In ordinary right-sided hemiplegia speech may suffer 
from implication of the fibres of the knee of the internal 
capsule, and possibly from affection of the basal ganglia, 
though the latter is not proved. Clinically, when aphasia 
of this origin passes off there is generally left an indis- 
tinctness of articulation which coexists with partial par- 
alysis of the tongue and lips. This is not observed with 
aphasia of purely cortical origin. 

The treatment of these forms of stammering is simply 
the treatment of the disease which causes them. 

Functional diseases are not often the cause of a literal 
dysarthria. In chorea, if the lips and tongue are affected, 
speech is irregular or absent during the spasm. This, 
however, is not the result of any disorder of the central 
speech-mechanism. Henry 8S. Upson. 

1 Kussmaul: Stérungen der Sprache. 


STARCH (Amylum, U.S. Ph.; Br. Ph.; Amylé Tritici, 
Ph. G.; Amidon, Codex Med.—also, Fécule de Pomme de 
Terre, Codex). A vegetable assimilation-product, hav- 
ing the composition CeH:.0s, occurring in nearly all 
phenogamous plants, and in some others in the form of 
solid, rounded, or peculiar-shaped, usually laminated, 
microscopic granules. The official starch of the above 
pharmacopeeias is that of wheat only, Triticum vulgare 
Linn.; but, as there are several others of excellent qual- 
ity, prepared on a large scale for domestic and manufact- 
uring purposes, the above restriction, at least in this 
country, is not always heeded. 

Starch is primarily formed, either directly, or, as is 


618 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


more probable, through the medium of some soluble 
hydrocarbon, like sugar, in the chlorophyll corpuscles of 
the leaves and green parts of plants, by the aid of sunlight, 
from the carbon dioxide of the air,and water. It is one 
of the steps in plant-assimilation. ‘The granules first ap- 
pear in these corpuscles as exceedingly minute, trans- 


Fie. 3693.—Section of Seed of Vetch, Vicia Sativa Linn., showing round- 
ed granules of starch in cells otherwise filled with granular nitroge- 
nous substance. 142, 


parent particles ; as they grow they may remain within the 
starch-forming corpuscle, or they may rupture and pro- 
trude from it. The starch does not remain long, nor does 
it become fully developed in size and markings in these 
growing parts of plants, but, becoming changed to a sol- 
uble form (sugar, dextrine, etc.), passes down through the 


Fia. 3694.—Section of Seed of Maize, showing almost solid masses of poly- 
hedral starch-granules completely filling the parenchyma. 


cells and is consumed by the growth of stems, roots, etc. ; 
that which is not wanted for immediate use being again 
transformed to solid granules in some quieter and more 
suitable organs, like pith (sago), rhizome (arrow-root), or 
in specially developed parts designed for storage in large 
quantities, like tubers (potatoes), fruits, and seeds (the 


Fia. 8695. 


Fie. 3696. 


Fies. 3695 and 3696.—Granules of Potato Starch swollen by Boiling; 
those shown in Fig. 5696 afterward shrivelled as they cooled, or they 
may have lost some of their contents. 


cereal grains, buckwheat, etc.). In these more perma- 
nent reservoirs the accumulation may be so dense as to 
crowd out all other cell-contents, or even to make the 
granules ‘angular and polyhedral by pressure against 
each other. Figs. 3693 and 3694, copied, like all the 
others in this article, from Berg’s ‘‘ Atlas zur pharma: 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Stammering, 
Starch. 


ceutischen Waarenkunde,” show the extent to which this 
crowding is carried. 

GENERAL DESCRIPTION AND CHEMISTRY.—With the 
exception of some doubtful substances of scientific in- 
terest only, starch always occurs in granules of micro- 
scopic size, the largest (Canna, Tous les Mois) barely 


Fia. 3697.—Bit of Cellular Tissue from the Potato, showing very numer- 
ous loose starch-grains and very thin-walled parenchyna. > 190. 


visible to the naked eye, the smallest (rice) the ten- 
thousandth of an inch in diameter. The granules are 
hard, highly refracting, of rounded, oblong, or peculiar 
outline, uniform or characteristic in each plant. If large, 
they almost always show a series of concentric lines or 
shades around a spot.called the hilum, which may be 


he woe; f 


POSES 


nsverse Section of Wheat, with closely packed starch- 
granules, cuticular layers, wall of ovary, etc. >< 190. 


central, or more or less excentric. When dry, the hilum 
in many varieties season-splits and presents a variable 
stellate, branching, or single fissure, which, holding air 
when the starch is immersed under the microscope, looks 
black. Under polarized light in the microscope a dark 
cross, formed by two intersecting lines meeting at the 


eas 


Fic. 3699.—Portion of Transverse Section of Barley ; pai, husk (? spe- 
lye); gl, gluten-cells; 2, pericarp; 7, seed-coat. > 190. 


hilum, gives starch a very characteristic appearance. 
Cold water has little effect upon starch, further than to 
make its ruge a little-less prominent, unless the granules 
have been triturated with sand to cut them to pieces, 


when a little is dissolved by it ; but when heated in water 
to, say, 140° or 150°, the granules swell, lose their charac- 
teristic outline, and become less refracting to light; if 
the heat is carried still further the action upon polarized 
light is lost, and before the boiling point is reached they 
burst and form an opalescent granular mass (starch paste) 
in which some 
shreds of sac and 
tissue can usually 
be seen. 

Starch of all 
plants has essen- 
tially the same 
chemical compo- 
sition and. reac- 
tion (C.sHi.05 or 
Cs6H620n1, accord- 
ing to Nageli). It 
is white, odorless, 
or nearly so, taste- 
less, becoming 
finally sweetish in 
the mouth from 
partial change ; insoluble in alcohol and ether: boiled 
with about ten parts of water it gives a moderately stiff, 
bluish, translucent jelly or mucilage. Treated with a 
minute quantity of iodine, it is turned to an intensely blue 
color, which can be discharged by heat, returning again 
upon cooling. 

Starch is not a homogeneous substance, but consists of 
at least two constituent parts, one more soluble than the 
other, called granulose ; the other, which comprises the 
skeleton of the granule, is more like cellulose itself. 
Treated with diluted acids, heat, diastase, or one of a 
number of other vegetable or animal ferments, starch is 
converted into dextrine, a substance in extensive use as 
a mucilage or size; and 
finally into. grape-sugar 
or glucose, which is now 
made from it in great 
quantities, as a substitute 
for sugar in cheap confec- 
tionery, etc. 

PREPARATION, — Figs. 
3693 and 3694, as well as 
Figs. 3697 to 3700, will 
show how closely the 
starch is entangled with cellular structure, and other pro- 
ducts of vegetable growth. ‘The problem is to separate 
it and get it as completely clean as the succeeding figures 
(Figs. 3701 et seq.) show it. 

This is generally accomplished by grinding and wash- 
ing; for arrow-root, for instance, the pulpy rhizomes are 
cleaned with care and ground, then the pulp is washed 
over sieves ; when the starch flows through with the wa- 
ter, it is allowed to settle, and then washed again and 
again until the soluble matters and the tissue are com- 
pletely washed away. Sago pith is treated in essentially 
the same way. Potatoes are ground to a pulp and al- 
lowed to stand until the mucilaginous matters are disin- 
tegrated by decomposition, then 
washed as above. From wheat 
the starch is washed out of the 
glutinous dough, made by mixing 
a coarsely ground meal with a lit- 
tle water; this may be kneaded 
under a stream over a sieve, or 
it may be put in large bags and 


Fig. 3700.—Transverse Section of Oats, show- 
ing composite granules. < 190. 


Fre. 3701.—Wheat Starch. 


_rinsed and pressed until the starch (*¥ 


is all washed out from the gluten. ~~ (Xe 
The processes, of which this is the Ne Wearing ian li cn Sigrent 
merest outline, have considerable 
variety in detail and in the machinery and conveniences 
used, ‘ah 
VARIETIES.—The only certain means of determining 
from what source a given specimen of starch has been 
derived is to examine it microscopically, when the size, 
shape, markings, and other visible peculiarities of the 
granules will generally suffice to make it certain. The 


619 


Starch. 
State Medicine. 


following characteristics of the commoner kinds are 
magnified uniformly three hundred and fifty diameters. 
1. Wheat Starch (Amylum, U. 8. Ph., etc.), ‘In ir- 


Fie. 3703.—Potato Starch. 


regular, angular masses, which are easily reduced to 
powder; white, inodorous, and tasteless; insoluble in 
ether, alcohol, or cold water; under the microscope ap- 
pearing as granules, 
mostly very minute, 
more or less lenticular 
in form, and indis- 
tinetly, concentrically 
striated. Triturated 
with cold water, it 
gives neither an acid 
nor an alkaline reac- 
tion with test-paper. 
When boiled with 
water it yieldsa white 
es 3% jelly, having a bluish 
wy’ tinge which, when 
Fie. 3704.—Arrow-root, cool, acquires a deep 
blue color on the ad- 
dition of test solution of iodine” (U. S. Ph.). The only 
part of this description characteristic of wheat starch 
alone is that which is 
italicized. The gran- 
ules average about 
0.050 millimetre in di- 
ameter. 

2. Maize, or Corn 
Starch, is smaller than 
the preceding, about 
0.030 mm. in diameter, 
of polyhedral form, 
with central hilum. 

3. Rice Starch resem- 
bles maize starch, but 
is very much smaller. 

4, Potato Starch con- 
sists of two classes of 
granules mingled together—fine spherical ones, from 0.01 
to 0.03 mm. in diameter, and large ovoid ones with very 
excentric hilums and very distinct 
ruge, recalling oyster or clam shells, 
from 0.14 to 0.18 mm. long. 

5. Arrow-root is finer than potato 
starch, which it somewhat resembles ; 
the granules are more spherical, with 
blunter, thicker ends, very distinct 
excentric fissures, and less distinct 
ruge. Canna starch, a variety of ar- 
row-root, has enormous granules, 
nearly twice as large as those of po- 
tato. Neither of these varieties has 
the small forms of that from potato. 

6. Sago has medium-sized (0.04 to 0.07 mm.), oblong, 
rather irregular, often faceted, sometimes shoe-shaped 


’ Fie. 3705.—Sago, 


Fra. 3706.—Tapioca. 


620 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, 


granules, with excentric hilum and pretty distinct ruge. 
The sago of commerce is often half-cooked, with many 
of the granules destroyed. | 

%. Tapioca: spherical, medium-sized granules, with 
large facets ; commercial tapio- 
ca is also partly cooked. 

Besides the above are the 
starches of numerous familiar 
grains and roots, which are not 
separated for sale or use, but 
which are of interest in detecting 
adulterations, mixtures, etc., or 
in identifying the powders of 
drugs. ‘The three accompany- 
ing cuts will serve as illustra- 
tions of this large class. 

Medical and Surgical Uses of Siarch.—This substance 
can in no sense be called a medicine, as it is absolutely 
without physiological action. It is the type of crude 
carbonaceous or non-nitrogenous food, and its conversion 
into sugar in the 
mouth and _ intes- 
tine is one of the 
elementary facts 
of digestive physi- 
ology. Asa toilet 
powder the finer 
varieties—rice and 
corn starches—are 
in universal use, ° 
and one or other of ¢ 
these is the foun- ©. 
dation of most of *& 
the proprietary 
powders. 

Boiled starch, 
and especially the flours of starchy substances, are fre- 
quently used as poultices, but they are not so convenient 
and suitable as the mucilaginous flours of linseed and 
slippery elm. 

Starch mucilage is occasionally used for immovable 
bandages, but it is less 
adhesive and less suita- 
ble for this purpose than 
flour- paste, glue, dex- 
trin, silicate of potash, 
or plaster-of-Paris. One 
part dissolved glue, 
as prepared for cabinet- 
makers’ use, and two or 
three of starch mucilage, 
a little thinner than the 
laundress uses it, mixed and applied hot, make a most 
excellent combination for such bandages—light, very 
stiff, and agreeable ih color. 

There are two officinal preparations of starch: the 
Glycerite (Glyceritum Amyli, U. 8. Ph., ten parts of 
starch dissolved in ninety of hot glycerine), is a perma- 
nent translucent jelly, useful in moistening pill masses, 
for emulsions, and similar purposes. Jodized Starch 
(Amylum Iodatum, U. 8. Ph.) is rather a preparation of 
iodine. It is made by triturating five parts of iodine with 
ninety-five of starch, with the aid of a little water. It is 
a blue-black powder, and a suitable preparation to ad- 
minister for free iodine if it is desired to give that drug 
internally. Starch is related, pharmaceutically, to the 
mucilages, chemically to sugar. W. P. Bolles. 


STATE MEDICINE. John Simon, C.B., F.R.S., for 
many years chief officer of the Local Government Board 
of England and Wales, says in a report made in 1874: 
‘“‘In my recent Annual Report the vast amount of in- 
jury which is suffered day by day in this country through 
diseases well known to be preventable, was referred to, 
in regard to the duty it imposes on all who have under- 
taken to serve in the new sanitary organization of the 
country, and ‘I submitted that the Local Government 
Board, viewed as a Central Board of Health, and the 
more than fifteen hundred district authorities which, 


Fie. 3708.—Turmeric Starch. 


Fic. 3709.—Vetch, or Lentil Starch. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


\ 


Starch. 
State | Medicine. 


each with its medical officer of health, locally adminis- 
ter the health laws, may be regarded as having had their 
respective functions assigned to them in special and sys- 
tematic relation to that state of things.” ! 

Professor Loewenthal, of Lausanne, gives as his third 
division of instruction in hygiene: ‘‘ L’enseignement 
particulier pratique, destiné aux médecins qui aspirent 
aux postes d’application de lhygiéne, tels que 
ceux des médecins attachés aux services sanitaires publics 
(municipaux ou de |’Ktat) ;” and a recent American writer 
on the functions of Government says, that ‘‘it is the bus- 
iness of Goverament to do for the mass of individuals 
those things which cannot be done, or cannot be so well 
done, by individual action.” 

In these three quotations we have well set forth, from 
the theoretical, educational, and practical stand-points, 
the comprehensive character of the work which, in those 
countries where the functions of Government have been 
most progressively developed, is included under Public 
Hygiene, or, what is better designated, State Medicine. 
In articles found elsewhere in the HANDBOOK, as Sani- 
tary Inspection, Sewerage, Quarantine, Food Adultera- 
tions, have been discussed some of the principal subjects 
included properly within the scope of State Medicine ; 
quarantine, as generally understood, being a function of 
General Governments ; sewerage and sanitary inspection 
that of Municipal or Local Governments ; while the de- 
tection of food adulterations is usually in part performed 
by General Governments and in part by municipal au- 
thority. 

It is evident that, whatever theory might indicate as to 
the duties peculiar to a General Government, on the one 
hand, and to municipal authorities on the other, the form 
of government—whether it be an autocracy, such as Rus- 
sia, or a democracy, aS Switzerland or the United States 
—will be a primary factor in determining the extent to 
which the term State Medicine will have any distinctive 
meaning or importance. Our personal conception of 
what should properly be included under the term has 
grown out of a practical experience of some years, and is 
derived wholly from the stand-point of results obtained, 
and quite apartfrom any preconceived theories. Whatever 
system is found to save to the State the largest number of 
useful lives (in esse or in posse, €.g., workers or the children 
of our communities), and which further nurtures and matn- 
tains them tn the best possible condition of physical, intellec- 
tual, and moral health ts the best system. 

From this definition it will at once appear that in our 
~ opinion the function of Government is to make such 
enactments as will give ample powers to central authori- 
ties to maintain efficient quarantine systems, both inter- 
nal and external; to endow such institutions as will 
supply the necessary education in practical hygiene to 
medical health officers, sanitary engineers, etc., and to 
establish laboratories wherein those scientific investiga- 
tions which appertain to the discovery of the causes of 
disease, and to the measures to be taken for their limita- 
tion and prevention may be carried on. At the instance 
of the central authority must further be enacted such 
legislation as shall clothe municipal or district authorities 
with ample powers for the isolation of those suffering 
from contagious diseases, and for the institution of such 
works—sewerage systems, public water-supplies, regula- 
tions for the construction of buildings, etc.—as shall con- 
duce to the maintenance of the public health in the high- 
est possible degree. Finally; it comes very naturally 
within the scope of State Medicine to encourage the 
teaching in all schools of those principles which regulate 
the life of the individual, as regards either personal con- 
duct or the regulation of the home, in those matters 
which bear most directly upon the preservation of health, 
and in some instances upon its improvement. 

Having, in general terms, outlined the scope and 
province of State Medicine, we may state, what at once is 
apparent, that climate, aggregations of people, occupa- 
tions, etc., will determine to what extent the functions of 
the State shall be exercised in order to conserve the high- 
est interests of the people. From what has been witnessed 
in the past, it is plain that legislation, at first sight often 


seemingly opposed to some individual interest, may be 
expected to fall, in many respects, short of what the needs 
of the general community demand ; but clear conceptions 
of what is required, and persistent efforts to make the 
public realize wherein their highest interests consist, are 
necessary before legislation is likely to supply the facili- 
ties for real progress in State Medicine. ~~ 

It would be of interest were we to givea history of the 
advances of State Medicine, and the degree in which the 
principles already laid down have been carried into prac- 
tical effect in different countries ; but the still crude con- 
dition of State Medicine in many countries would detract 
very much from any practical value appertaining to such 
a statement, even did space permit. Our purpose will, 
we judge, be equally well served if we indicate the scope 
of State Medicine in those countries where it has reached 
its highest state of development. It is everywhere read- 
ily conceded that in State Medicine, in so far as regards 
its practical application to the ordinary conditions of so- 
ciety, England has, up to the present, been in advance of 
all other countries; and further, that the scope of the 
work of the Local Government (Central) Board is wider, 
and the relations existing between the Central Board and 
Municipal Sanitary Authorities are closer and better de- 
fined, than in any other English-speaking community. 
Since the cholera years 1848-53, there have been framed 
various Public Health Acts, in which have been devel- 
oped to a considerable degree the principles already enun- 
ciated. These Acts are consolidated in the English Pub- 
lic Health Act of 1875. The whole of England and 
Wales is divided into urban and rural sanitary districts, 
governed respectively by urban and rural sanitary au- 
thorities. An Urban district is either a borough under 
the supervision of the mayor, aldermen, and burgesses, 
acting under direction of the Council, or an Improvement 
district under Improvement Commissioners, or a Local 
Government district under its Local Board of Health. 

A Rural Sanitary District is an area not included in 
any of the foregoing, and the guardians of the union 
(Poor Law Guardians) form the rural authority of such a 
district. Over the Local Sanitary Authorities there is 
the Local Government Board, which has supreme control 
in many respects in matters relating to the public health. 
London City does not fall within the operations of the 
General Act. Local Sanitary Authorities are elected by 
the people for terms of three years, and have all neces- 
sary powers to levy rates for necessary sanitary improve- 
ments, and in those cases where continued neglect to pro- 
tect the public is evident, the,Central Board can require 
public works to be undertaken by the municipality. 
Similar central powers to some extent exist in France ; 
but in few countries does this general control by the cen- 
tral authorities extend to matters other than enforcement 
of measures for the control of outbreaks of contagious 
diseases. 

As regards the present position of State Medicine in 
the United States, it may be said that to the American 
Public Health Association, a non-official body, though © 
including most prominent Federal and State sanitary 
officials, is due in large measure such progress as has 
been made during the past fifteen years; and that, asa 
result of its persevering efforts during an epidemic of 
yellow fever of unwonted extent and severity, was estab- 
lished, in 1878, the National Board of Health, a body 
appointed, and supplied with grants, by the Federal 
Government. Since 1882, the money grants which had 
enabled the Board to institute investigations of great in- 
terest and importance regarding the causation of disease, 
etc., have, through political prejudice, been in great part 
withheld, and but little practical work has been done by 
it; but there is réason to suppose that this anomalous 
state of affairs will soon be remedied. In the meantime, 
to the Marine Hospital Service has been committed the 
protection of the country against foreign outbreaks of dis- 
ease, in so far as the Federal Government is concerned. 

A limited amount of experimental work in the field of 
bacteriology is still carried on under the auspices of the 
National Board of Health ; but work such as that done 
by the Governments of England, France, and Germany 


621 


State Medicine. 
Sterility. 


‘is conspicuously limited in amount. The field of conta- 
gious animal diseases is in a much more advanced state, 
controlled as it is by the Bureau of Animal Industries, 
under the Department of Agriculture. 

In keeping with State autonomy the State legislatures 
have done, in some instances, a considerable amount of 
sanitary work. With a few exceptions all the States of 
the Union have State Boards of Health, varying greatly 
in their powers and status. 

In some instances these organizations are crude, with 
limited funds and equally limited powers. Indeed, the 
control which State Boards have over Municipal Health 
Boards is of the most limited character, being little 
more than advisory. The Local Boards, which by some 
State enactments (é.g., those of New York State) are com- 
pulsory, have in a few instances statutory laws compre- 
hensive and uniform in character under which action may 
be taken. Their work is done almost wholly under mu- 
nicipal by-laws, which are naturally of the most varied 
character, as regards both the extent and the thoroughness 
of their execution. In some instances (as in New Jer- 
sey) State Boards have control of animal diseases ; while in 
others (as in Illinois) they are Boards for the Regulation 
of the Practice of Medicine ; and in others, again (as in 
New York), for the registration of births, marriages, and 
deaths. In Massachusetts practical laboratory investiga- 
tions have, to some extent, been carried on from time to 
time by the State Board. The first State to make such 
investigations systematically is the State of Michigan, 
where a hygienic laboratory is being erected at Ann Ar- 
bor, at a cost of $30,000, with an additional $5,000 for its 
equipment. The staff will consist of a professor of hy- 
giene, and an assistant professor. There will be a course 
of lectures by the Professor of Mechanical Engineering 
on ‘‘ Heating and Ventilation,” by the Professor of Civil 
Engineering on ‘‘ Sewerage Systems,” and by the Profes- 
sor of Law on ‘‘ Public Health Laws.” Special labora- 
tories for the various branches of the work will be estab- 
lished. The main object of the laboratory, as stated in 
the memorial asking for its establishment, is to conduct 
original investigations into the causation of disease. This 
new department, added to the very efficient work of the 
State Board in other matters, will place Michigan in the 
van of progress as regards State Medicine. 

In Canada, State Medicine is in a position which com- 
pares favorably with that in the United States. With 
two exceptions all the provinces have some form of 
State organization, while the Federal Government, by 
the Act of Confederation, has charge of quarantine, vital 
statistics, and food adulterations. In many respects the 
provincial statutes are modelled after English Public 
Health Acts. For instance, in the Province of Ontario, 
the most advanced in State Medicine, there is a Central or 
Provincial Board, whose duties and powers are defined 
by statute, and to it are given powers for investigating 
matters bearing upon the public health, and very com- 
plete facilities for acting promptly and effectively in 
threatened or actual outbreaks of contagious disease, 
whether occurring as a danger from without or from 
within. The Provincial Board has ample power, in 
accordance with statutory by-laws, to compel action to 
be taken by Local Boards, whose organization is com- 
pulsory, when contagious disease occurs in their muni- 
cipality. It also requires the submission to it of all 
schemes for the establishment of public systems of sew- 
erage and water-supply. So far very little experimental 
sanitary work has been done in Ontario, there being no 
special facilities enabling the Board to undertake such 
work. A special staff of medical health officers and 
sanitary police, under the direct control of the Provin- 
cial Board, has, in time of need, been organized to limit 
and suppress epidemics of disease likely to get beyond 
the control of individual municipalities. In other Prov- 
inces larger districts are assigned to medical officers, 
who act during epidemics, while elsewhere, as in many 
States, municipal councils have powers as health officers 
assigned to them. 

That part of State Medicine which deals with practical 
instruction in this science has, in Europe, been prosecuted 


622 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


in varying degrees in different countries. Tosuch work 
as that carried on by Parkes, Klein, Creighton, Sander- 
son, Baxter, Smith, and others in England; to the investi- 
gations of Pasteur, Chauveau, Duclaux, Chamberland, 
and others in France, and to the bacteriological investi- 
gations of Koch, and the chemical studies of Pettenkofer 
in Germany, are we to attribute the present position of 
practical knowledge of hygiene. In some countries the 
instruction in public hygiene is of a limited character, 
being confined to a course of hygiene in some medical 
school. In others there are institutes of hygiene on the 
most extended scale, as, for instance, at Munich, Leipzig, 
and Copenhagen. In Hungary the province of instruc- 
tion in State Medicine is of an extended character. M. 
Trefort, the Hungarian Minister of Education, expresses 
the view that hygiene should be taught in all secondary 
or high schools, and that it can only be properly done by 
medically trained hygienists. He has, therefore, created 
in the medical faculties a special course of instruction for 
physicians aspiring to the position of professors of hy- 
giene for secondary schools. At Pavia and Turin, in 
Italy, and at Charcow and Moscow, in Russia, are impor- 
tant hygienic laboratories ; and Stockholm has an excel- 
lent institute of hygiene, established at a cost of 20,000 
francs. 

The reader will perceive, from the illustrations here 
given, that these State organizations were originally 
started with the object of limiting outbreaks of conta- 
gious disease. They employed first, of course, the crude 
methods then in use, but have gradually improved upon 
themasa result of much scientific and experimental work. 
State Medicine was a creation of necessity in times of 
public danger, but its future development will be in pro- 
portion to the scientific character of its work, and to the 
appreciation on the part of the public of the economic 
and beneficent results of such work. 

Peter H. Bryce. 


STAVESACRE (Staphisagria, U. 8. Ph.; Staphisaigre, 
Codex Med.). The seed of Delphinium Staphisagria 
Linn. ; Order Ranunculacee. This is a showy annual 
or biennial herb, arising from a stout, tapering root, by 
an upright, branching, hairy stem, about a metre high. 
Leaves alternate, on hairy petioles, and themselves pu- 
bescent or hairy beneath ; the lower long-stemmed, of 
from seven to nine spreading, lanceolate lobes ; the upper 
more and more simple ; those of the inflorescence small, 
sessile, and simply lanceolate. Flowers irregular, large, 
in open racemes or panicles, about two centimetres 
across ; calyx of five petaloid sepals, the three upper 
erect, the middle one spurred at the base, the two lateral 
ones broad, rounded, and spreading. Petals four, the two 
upper narrow, erect, sending spurs into that of the upper 
sepal; the two lower rounder. Stamens numerous ; 
carpels three, ten-, or twelve-ovuled. Sepals and petals 
pink or purple, the former tipped with green. Seeds 
pyramidal, four-sided, slightly curved, about half a cen- 
timetre long; brownish-gray externally, white and oily 
within, odorless, but bitter and acrid. 

This plant is a native of the South European countries, 
Asia Minor, etc., and is also cultivated. The seeds are 
imported from the south of France and Italy. They 
were known to the ancients, and for twenty centuries 
have been used for about the same purpose as at present 
—killing pediculi and similar vermin. 

ComPposITIOoN.—The seeds contain about twenty-five 
per cent. of a non-drying jfived oil, and about one per cent. 
of alkaloids, of which the following have been isolated 
and named: Delphinine, in fine, large crystals; Staphis- 
agriné, amorphous ; Delphinoidine, also amorphous ; and 
Delphisine, in crystalline tufts. Of these, the first is the 
most important and active, the second least so, while the 
third and fourth resemble the first, but are weaker. 

ACTION AND UsE.—Stavesacre is an active and poison- 
ous drug, irritant to the skin and mucous membranes, 
causing itching, stinging, burning, sneezing, etc., as well 
as diarrhoea ‘and vomiting. Of the alkaloids, Delphinine 
best represents it; rubbed into the skin it causes local 
inflammation, on the tongue burning and numbness, in 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


State Medicine. 
Sterility. 


the stomach nausea and distress, and, when absorbed, car- | of the tubes as to prevent the morsus déaboli from coming 


diac and respiratory slowing, diminished spinal irritabil- 
ity, and sometimes mental disturbance. The others re- 
semble delphinine, but are less intense. Delphinine 
reminds one of both aconitine (to which it is botanically 
related) and veratrine. Staphisagrine is somewhat pecu- 
liar ; it is not very active, but appears to resemble curare 
in its action upon striped muscle. 

Neither the crude drug nor its alkaloids are given inter- 
nally, so its exact action has but little practical bearing. 
It has from a remote time been employed, either by itself 
or in ointments or other vehicles, solely for the purpose 
of killing pediculi, and related animal parasites, on man 
and animals. At the present time it is mostly consumed 
in veterinary practice, kerosene or petroleum, petrola- 
tum, sulphur, and unguentum hydrargyri taking its place 
in human medicine. An ointment can be made with 
twenty per cent. or so of the powdered seeds, or with 
from one-half to one per cent. of the alkaloid. 

ALLIED PLANtTs.—The beautiful genus contains the 
Larkspurs, many varieties, and is closely related to the 
equally beautiful Aconites. For the order, see ACONITE. 

ALLIED SuBSTANCES.—Sabadilla is another time-hon- 
ored parasiticide of very similar properties to the above, 
and is used in the same way. Kerosene and petrolatum 
are put to the same uses. W. P. Bolles, 


STERILITY IN THE FEMALE. Synonyms: Barren- 
ness, infertility ; Lat., sterilitas matrimonii; Fr., stéri- 
lité; Ger., Unfruchtbarkeit. 

Sterility in the female implies an inability to bring 
forth a living child. It involves two points for consid- 
eration : First, her inability to conceive at all; and sec- 
ond, her inability to complete successfully the period of 
gestation. Many women never conceive at all. Many 
other women conceive, but are unable to complete the 
period of gestation. 

Women who never conceive are said to be absolutely 
sterile. Women who have borne one or two children and 
do not conceive thereafter are said to be relatively sterile. 

ErTroLoGy.—Several organs are involved in the process 
of genesis in the female. The essential element of this 
process is the ovum, which is supplied by the ovary. 
The ovum is conveyed from the ovary through the Fal- 
lopian tube to the uterus, where it meets the spermato- 
zoa, and genesis follows. The semen reaches the uterus 
through the vagina. Consequently, the question of ster- 
ility involves the investigation of the condition of, 1st, 
_the ovaries ; 2d, the oviducts; 3d, the uterus; and, 4th, 
the vagina. In addition, upon the general condition of 
the patient alone non-conception often depends. Under 
this head may be classed the extreme gouty vice, the 
syphilitic taint, anemia, great obesity, chronic alcohol- 
ism, and spasmodic dysmenorrhea. 

The Ovaries.—1. The investigation of the ovaries in 
sterility includes inquiry into the possibility of the ab- 
sence or of the imperfect development of these organs, 
conditions rarely met with excepting when the other sex- 
ual organs are anomalous. 

2. Inflammation, chronic or acute, of the ovaries may 
result in such adhesions of the organs that the ovum is 
totally prevented from entering the oviducts. It may 
lead to arrest of function, so that the ovum can no longer 
be matured. The ovary may become so embedded in in- 
flammatory deposit that extrusion of the ovum from its 
capsule is no longer possible. 

3. Structural degenerations of the ovary may exist, 
é.g., cystic, carcinomatous, and sarcomatous, and are 
generally attended with sterility. 

4. Displacement of the ovary, often attended with 
chronic inflammation, may place it beyond the reach of 
the fimbriated extremity of the Fallopian tube so com- 
pletely that the ovum cannot be transmitted to the uterus. 

The Fallopian Tubes.—1. Absence or defective devel- 
opment of the oviducts is usually associated with other 
abnormalities of the sexual system, and causes hopeless 
sterility. 

2. Inflammation of the oviducts is a cause of sterility. 
It may affect the serous coat, resulting in such fixation 


in contact with the ovary, or in constricting bands that 
occlude the calibre of the tube. It may attack the mu- 
cous lining of the canal, and result in the production of 
secretions which are destructive to the spermatozoa or 
the ova, or it may result in permanent occlusion of the 
opening of the tube, whence may follow collections of 
blood, pus, or serum. In either case the ovum is pre- 
ae from descending to the uterus, and sterility fol- 
OWS. 

8. Degeneration of the tubal structures produces a 
hopeless occlusion of the canal, and thus causes sterility. 

The Uterus.—Defective development of the uterus as: 
sumes various forms, such as its total absence, its under. 
size, or its abnormal lateral growth into either a uni- 
cornus or a bicornus uterus. Conoidal cervix, with the 
commonly attendant stenosis of the os, may be classed as 
one of the variations of defective development. The last: 
mentioned condition constitutes one of the most frequent: 
ly removable causes of sterility. 

Degenerations : 1. Myomata often cause infecundity, 
but they are not always a barrier to conception. The co- 
existence of this degeneration and of pregnancy consti- 
tutes one of the most serious conditions encountered by 
the obstetrician. . 

2. Sarcomata seem always to prevent pregnancy. 

3. Carcinomata, if extensive enough, cause sterility. 
In their early stage conception is often possible, and is 
now and then encountered. 

Abnormalities of involution: An excessive involution 
(hyperinvolution) or a deficient involution (subinvolu- 
tion) often constitutes a barrier to conception. The 
writer recently saw a healthy patient, aged twenty-seven, 
who bore a child at twenty-one years of age, and had not 
menstruated since that event. The uterus measured but 
one and one-fourth inch in depth. The organ may be 
still further decreased in size, even to a quarter of an 
inch. 

Subinvolution of the uterus is often accompanied with 
an inflammatory state, completely preventing the occur- 
rence of pregnancy. 

Inflammation of the uterus or the circumjacent tissues 
is a very common cause of sterility. The morbid pro- 
cess, according to its seat, may be endocervicitis, endo- 
metritis, metritis including cervicitis, parametritis, or 
perimetritis. Often two or more of these conditions co- 
exist, and render the cure very tedious. Endometritis 
may be accompanied by abnormal secretions destructive 
to the spermatozoa, there may be a dilated uterine cav- 
ity, the lining membrane of the uterus may be made so 
unhealthy that it becomes impossible for a fertilized 
ovum to secure a lodgement thereon, or the inflammation 
may cause more or less occlusion of the uterine orifices. 

Displacements: Malpositions of the uterus include 
prolapse, flexions (retroflexion, anteflexion, and latero- 
flexion), and versions (anteversion and retroversion). 

Anteversion and antetlexion exist most frequently in 
nullipare. Retroversion and retroflexion exist most fre- 
quently in those who have borne children. Lateroversion 
and lateroflexion are present when an inflammation has 
existed in either broad ligament, resulting in shortening 
of the ligament, or when some foreign growth or an in- 
flammatory deposit exists on the side of the pelvis opposite 
to the displacement, crowding the uterus away from its 
normal condition. 

The Vagina.—This organ may be so injured or may be- 
come the seat of discharges so fatal to the semen that it 
becomes a source of sterility. 

Malformations: The vagina may be absent congeni- 
tally. Its occlusion is very rare. A severe vaginitis has 
been the cause of an almost total occlusion by the agglu- 
tination of the vaginal walls. The hymen is sometimes 
so hypertrophied that it becomes a barrier to copulation. 
Unnatural shortness of the vagina renders it incapable of 
retaining the semen a suitable length of time. E 

Inflammation: Vaginitis nearly always produces dis- 
charges fatal to the semen. It is occasionally productive 
of that condition of spasm called vaginismus, but this 
may also be caused by other conditions. 


623 


Sterility. 
Sternutatories. 


Injuries: Extensive perineal lacerations often become 
causes of sterility. Fistule may also prevent conception. 

Degererations: Elephantiasis labiorum prevents col- 
tus, and thus becomes a barrier to insemination. Exten- 
sive urethral caruncle often interferes with successful 
intercourse. 

General State of the Patient’s Health.—An indefinable 
something in the patient’s general condition is oftentimes 
the apparent cause of a sterility. The proof of this state- 
ment consists in the fact that women, sterile when in 
poor health, often conceive when their general condition 
has been improved by remedies, by change of climate, or 
by travel. Some women are sterile because of the pres- 
ence of discharges from the genital tract which have their 
origin in a systemic taint. The lithemic state, for ex- 
ample, may give rise to such discharges, which cease 
when an anti-lithic course of treatment has been followed, 
and conception thereafter may follow. Many cases of 
sterility of this form have been wholly removed by a 
course of treatment at suitable mineral springs. 

Under this head may be also mentioned that variety of 
sterility which is dependent upon some obscure incompat- 
ibility of the parties, illustrations of which every physi- 
cian of experience has encountered. A woman, sterile in 
many years of married life, who has been, for this reason, 
abandoned by her husband, eventually secures a divorce, 
is married to a second husband, and bears a number of 
children. The old illustrations of Augustus and Livia, 
and of Napoleon and Josephine, are quoted by writers 
on sterility. 

Diaenosis.—It is not always that only one of the fore- 
going obstacles to conception is present. Very often two 
or more of them coexist. When the causes of sterility are 
manifold in the same patient, it is obvious that the skill 
of the gynecologist will often be taxed in recognizing and 
removing them. A complete diagnosis can be arrived at 
only by an exhaustive examination. It is always a safe 
plan for the physician to endeavor to find all the possible 
causes of sterility in each patient. 

It must be confessed that only too often does it occur 
that, after every discoverable removable obstacle to con- 
ception has been corrected, sterility will still exist. 

ProGnosis.—In no condition is the prognosis more un- 
certain. In a general way, it may be stated that imper- 
fect development or marked malformations constitute an 
absolute bar to conception. 

In the same manner, it may be stated that removable 
obstacles to conception, as inflammations, flexions, ver- 
sions, stenosis, some vaginal occlusion, or fistule, may 
be treated with a fair prospect of fruitful results. The 
apparently complete removal of these obstacles, however, 
only too often fails to render the woman fruitful. 

TREATMENT.—A successful treatment of sterility in the 
female is secured by removal of all the obstacles to con- 
ception. Such treatment does not include that of steril- 
ity in the male, although many gynecologists investigate 
the male first, since about one case in ten of infecundity 
in marriages has its origin in the male. With this branch 
of ie subject, however, the present article has nothing 
to do. 

After the physician has discovered as many obstacles 
to conception as he can find, he must set about removing 
them. Insufficient treatment nearly always results in 
failure. In no department of gynecology is more per- 
sistence in treatment demanded. 

Urethral caruncles, vulvar vegetations, and other sensi- 
tive excrescences must be removed or destroyed. 

Vaginal stenosis or contraction must be stretched and 
the canal must be kept patulous. 

Cervical stenosis must be overcome by sea-tangle or 
tupelo tents, or by stretching with dilators, Division of 
the cervix by the hysterotome has been much practised 
successfully in the past, but is at present falling into dis- 
use, forcible dilatation being preferred. 

Uterine deviations must be corrected. Versions can 
often be rectified by suitable pessaries. It has been sug- 
gested that anteversion may be corrected by allowing the 
bladder to become distended with urine, thus pushing 
the fundus uteri backward and throwing the cervix suf- 


624 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


ficiently forward to place the os in a direct line with 
the seminal ejaculation, thus facilitating the entrance of 
semen into the cervical canal. Similarly, retroversion, 
it is alleged, may be temporarily corrected by allowing 
the rectum to become distended with feces, whereby the 
fundus uteri may be crowded forward. 

Flexions demand the use of the intrauterine stem-pes- 
sary. 

Hyperinvolution may be treated with the galvanic in- 
tra-uterine stem-pessary. Similarly, attempts may be 
made to stimulate the growth of an imperfectly developed 
uterus. 

Inflammations must be treated secundum artem. Vari- 
ous antiphlogistic methods of treatment are in vogue. 
Cauterizing applications, hot-water douches, glycerine 
tampons, the dry treatment of Englemann, etc., each has 
its adherents. 

Morbid growths on the endometrium must be removed 
or destroyed. 

Quite exceptionally, the method of introducing semen 
into the uterus by means of a syringe and a tube has been 
used, it is alleged, successfully. 

In the treatment of all cases of sterility the physician 
must never ignore the general condition of the patient. 
Systemic vices must be eradicated as far as possible. 
Many cases of sterility can be cured by general treat- 
ment. Repeated abortions indicate the possibility of the 
syphilitic taint. The existence of this vice in a marked 
degree is an almost certain obstacle to the chances of ges- 
tation being completed, and it must, therefore, receive 
continuous and persistent treatment for a period of at 
least two years. J. H. Htheridge. 


STERILITY IN THE MALE, This term, in its accepted 
sense, implies inability to impregnate the female, from 
other causes than that of impotence or loss of the power 
of copulation (see Impotence). ‘‘ Sterility not only does 
not include impotence, but is met with in subjects who 
are vigorous in intercourse, and who may ejaculate a 
fluid which, in the absence of minute examination, pre- 
sents all the properties of normal semen. Sterility in- 
cludes, first, azodspermism, or the condition in which 
either no semen whatever, or unproductive semen, is se- 
creted ; secondly, aspermatism, in which spermatic fluid 
is not ejaculated ; and, thirdly, misemission, or the fail- 
ure to deposit fertile semen in the upper portion of the 
vagina. In the first variety intercourse and ejaculation 
are natural, but the essential anatomical elements are ab- 
sent or dead, either because they are not formed, or are 
imprisoned behind an obstacle seated in the epididymes 
or vasa deferentia, or because they are unable to live in 
the medium in which they are suspended. In the second 
variety the ability to copulate is unimpaired, but the 
power to ejaculate is prevented by an impediment situ- 
ated between the seminal vesicles and the urinary meatus 
In the third variety coition and emission are perfect, but 
fruitful semen fails to reach its proper destination in con- 
sequence of congenital deficiencies of the urethra, or of 
fistulous openings in that canal, resulting from inflamma- 
tion, or of abnormal positions of the meatus” (S. W. 
Gross, ‘‘ On Impotence, Sterility, and Allied Disorders of 
the Male Sexual Organs.” Philadelphia, H. C. Lea’s Son 
& Co., 1883). 

1. Azodspermism may be due: a. To congenital bilat- 
eral absence of the testes, or congenital bilateral deficiency 
of the epididymes or vasa deferentia. Such absence of 
the testes likewise results in impotence and may here be 
dismissed. Such deficiency of the excretory apparatus 
of the testes need not result in impotence, but prevents 
all escape of spermatozoa. 

6. To non-descent of the testes into the scrotum. In- 
dividuals thus affected are potent; they are usually ster- 
ile, but may, in exceptional cases, be fruitful (S. W. 
Gross). 

c. To affections of the testes. Bilateral atrophy, from 
whatever cause, always diminishes, and sometimes pre- 
vents, the formation of spermatozoa. Simple parenchym- 
atous orchitis results in absolute azoédspermism. Par- 
tial destruction, by malignant or other new-growths, does 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sterility. 
Sternutatories, 


not necessarily result thus. After syphilitic orchitis sper- 
matozoa may return under proper treatment. 

d. To bilateral obliteration of the epididymis and vas 
deferens, thus preventing the escape of spermatozoa from 
the testes. This is by far the most frequent cause of 
azodspermism, and in the great majority of cases is due 
to gonorrhceal epididymitis. It may also be due to tu- 
bercular, malignant, or syphilitic disease of these organs. 
It is held by some good authorities that epididymitis of 
one side may abolish the function of the opposite gland. 

e. To nervous exhaustion or neurasthenia, attended 
with abnormal seminal and prostatic discharges, and with 
various degrees of impotence, all of which is usually 
brought about by onanism, venereal excesses, or ungrati- 
fied desire. As a resuit of impaired nutrition induced 
by perverted innervation, the secretory activity of the 
testes is interfered with, and either the evolution of the 
spermatozoa is arrested, or their number and activity are 
diminished (8S. W. Gross). 

The diagnosis of azodspermism must be made by re- 
peated examinations of the ejaculated fluid, if such there 
be, under the microscope. 

The treatment is in many cases evidently nz. In ad- 
vancing atrophy of the testicles, galvanism gives some 
promise of good. In syphilitic orchitis or epididymitis, 
prompt and persistent treatment may avert the calamity 
or restore fertility. In bilateral epididymitis from other 
causes, early and vigorous antiphlogistic treatment ‘will 
often prevent occlusion. . But even if this exist, it may 
sometimes be overcome by iodide of potassium, bichlo- 
ride of mercury, and the local use of mercurial ointment 
or oleate of mercury. 

2. Aspermatism, or the failure to ejaculate semen dur- 
ing copulation, may be due to the following causes : 

a. Organic lesions preventing the discharge of seminal 
fluid into the urethra,or preventing its ejaculation through 
the meatus. Congenital occlusion, absence or deviations 
of the ejaculatory ducts, have occasionally been met with. 
Stricture of these ducts and deviation of their orifices, 
due to inflammation or injury, are more frequent. This 
may follow gonorrhea, blows on the perineum, or the 
operation of lithotomy. 


Semen having been delivered in the urethra may fail | 


_to be discharged properly, owing to some obstruction 
anterior to the prostate gland. If this obstacle is in the 
posterior portion of the canal, the fluid will pass back- 
ward into the bladder ; if near its orifice, the semen will 
flow out after erection has ceased. Stricture of the ure- 
thra is the most common of these obstacles. <A stricture 
which permits the flow of urine when the penis is flaccid 
may prevent the escape of semen during erection. More- 
over, according to Gross (loc. cit.): ‘‘ In these cases the 
fault is to be ascribed less to the organic contraction than 
to the spasm of the muscular walls of the urethra be- 
neath the sensitive mucous membrane, through which the 
opening is temporarily occluded.” 

The escape of semen is occasionally prevented by a 
tight phimosis. Finally, it may be due to induration of 
the corpora cavernosa, which sometimes results from in- 
juries, and sometimes seems to be associated with the 
gouty diathesis. 

ob. Aspermatism may exist in cases where there are no 
such organic defects or obstacles as are mentioned above, 
and no external anesthesia. This is attributed by Rosen- 
thal and others to the ‘‘absence of excitability in the 
lumbar reflex ejaculatory centre.” 

Such subjects commonly give the general symptoms 
of neurasthenia and a history of masturbation, sexual 
excesses, repeated attacks of gonorrhea, etc. 8S. W. 
Gross is of the opinion that in many of them there will 
be found inflammation and hypereesthesia of the pro- 
static urethra, with accompanying lesions, which main- 
tain, and are probably the cause of, the diminished ex- 
citability of the lumbar ejaculatory centres. This is im- 
portant, as indicating possible cure by the use of steel 
bougies and other appropriate treatment. 

c. Ansesthesia, or insensibility, of the glans penis is an 
occasional, though rare, cause of aspermatism, and a case 
is reported by Curling, in his work on ‘‘ Diseases of the 


Vou. VI.—40 


Testis,” in which he relieved the difficulty by applying 
the acetum cantharidis to the gland. 

d. Mental causes, such as disgust, anxiety, etc., may 
sometimes interfere with ejaculation, just as they often 
prevent erection. 

Diagnosis.—The fact that semen is not ejaculated dur- 
ing intercourse is apparent to the patient himself, and 
will probably be the reason of his consulting the physi- 
cian. The diagnosis as between the various forms, or 
causal conditions, depends on the history of the case, a 
careful examination of the genital organs, the question 
of whether semen escapes with the urine or from the 
urethra after intercourse, and on the consideration of 
other points which have been mentioned in the descrip- 
tion of the different varieties. 

Treatment.—A number of the organic lesions which 
cause aspermatism are plainly beyond the reach of treat- 
ment. In case of phimosis circumcision should be per- 
formed ; strictures should be dilated or divided. In the 
atonic variety, if the insensibility of the lumbar nerve- 
centres is associated with inflammation and hyperesthesia 
of the prostatic urethra, this should be treated by the 
systematic introduction of the conical steel sound. If 
granular patches in the urethra fail to yield to this 
method, astringents, as solutions of nitrate of silver of 
from ten to thirty grains to the ounce, may be carried to 
the part by some of the catheter syringes or other appli- 
cators in vogue. If, on the contrary, the prostatic ure- 
thra is not sensitive and no stricture exist, tonics are in- 
dicated, as iron, quinine, strychnine, cold sitz-baths, and 
perhaps galvanism. In anesthetic aspermatism the fa- 
radic brush to the penis or vesication of its surface, as in 
Curling’s case, may succeed. 

3. Misemission.—In this form of sterility fertile semen 
may be secreted and ejaculated, but for some reason it 
fails to be so deposited in the female organs as to come 
in contact with the ovum and impregnate it. This is 
usually due to malformations of the urethra, as hypo- 
spadias, epispadias, or fistulous openings in the urethra 
following injury or stricture. The subjects of these de- 
formities are not always sterile, inasmuch as semen de- 
posited at the mouth of the vagina may find its way into 
the uterus. Congenital or acquired shortening of the 
freenum may so displace the meatus as to direct it down- 
ward or backward, a fault which may be remedied by 
division of the frenum. Hdward W. Schauffler. 


STERNUTAT ORIES,or errhines, are substances which, 
when applied to the nasal mucous membrane, cause 
sneezing and increased secretion. Properly speaking, 
there is a distinction between the two terms, errhine be- 
ing used to denote an agent which increases the nasal 
secretions, while a sternutatory causes sneezing only. 
But as the act of sneezing is almost always accompanied 
by increased secretion, the distinction between the two 
classes of remedies is practically without a difference. 

In former times sternutatories were much more com- 
monly employed than they are at present, and older 
writers were wont to lay great stress on the efficacy of 
these agents in the treatment of many apparently dissim- 
ilar conditions. Their use was recommended (1) to re- 
store suspended respiration ; (2) to effect the expulsion of 
foreign bodies from the air-passages ; (8) to increase the 
secretion of the nasal mucus or of the tears, or to expel 
accumulated mucus from the sinuses ; (4) to awaken the 
action of the encephalon, restore sensibility, or excite 
uterine action. At the present time, remedies ofthis 
class are out of fashion, and the only applications to 
which they are put are to excite sneezing for the sake of 
the pleasurable sensations that it causes, to increase the 
nasal secretions in the dry stage of coryza, and to clear 
the nasal passages and the adjacent sinuses of accumu- 
lated mucus. It is possible, however, if the present ten- 
dency of attributing many and diverse morbid conditions 
to the score of nasal reflexes should prevail, that future 
generations will restore the sternutatories to their ancient 
rank among the most prized of therapeutic agents. 

The list of substances which have been employed at 
one time or another for the purposes above enumerated is 


625 


Sternutatories. 
Stethoscopes. 


as long as the moral law, and embraces nearly every drug 
which can be reduced to a fine powder, and even many 
gases, such as ammonia. To enumerate only a few of 
them, we have rosemary, lavender, peppermint, spear- 
mint, white and black hellebore, stavesacre, mustard, 
euphorbium, betonica, ginger, iris, the peppers, calomel, 
bismuth, the alkaline carbonates, ipecac, tobacco, sweet 
marjoram, and a host of others. At present this list is 
practically restricted to half a dozen substances, the chief 
of which are tobacco, ipecac, veratrum album, quinine, 
camphor, and cubebs. Tobacco snuff is seldom em- 
ployed now, except as a luxury, but the others just men- 
tioned enter, one or all, in varying proportions, into the 
composition of the different catarrh snuffs prescribed by 
physicians or sold as proprietary remedies. 

The following are some formule for catarrh snuffs 
which may serve a useful purpose in the early, dry stage 
of a coryza, or later when there is an abundant secretion 
of tenacious mucus which is dislodged with difficulty : 
R.. Quin. sulphatis, gr. xx. (1.3); potassii chloratis, 3 j. 
(4.0); amyli, 3j. (30.0). M. &. Pulv. ipecac., gr. v. 
(0.3) ; quin. sulphatis, 3 ss. (2.0); pulv. camphoris, % ss. 
(15.0); sacchari albi, % jss. (45.0) M. 8. Acidi sa- 
licylici, gr. x. (0.6); pulv. camphoris, 3j. (4.0); pulv. 
acacie, 3 ij. (8.0); pulv. cubebee, %ss. (15.0). M. B. 
Morphine sulphatis, gr. 2 (0.12); bismuthi subnitratis, 
3 vj. (23.0); pulv. acacie, 3 ij. (8.0). M. This powder, 
as all others containing morphine, must be used with 
some caution, 3 ij.-iij. (8.0-12.0) being as large a quan- 
tity as can be safely given to an adult in the twenty-four 
hours. An errhine which formerly enjoyed much re- 
pute was the cephalic snuff—pulvis asari compositus— 
composed of powdered lavender leaves, one part, sweet 
marjoram (origanum majorana), one part, 
and asarum, three parts. 

In cases of suspended respiration tick- 
ling the interior of the nose-with a feather 
will sometimes cause a deep inspiratory 
effort, followed by a sneeze, and thus re- 
store the breathing. This is sometimes 
even more efficacious than cold affusions, 
slapping the body, and other means com- 
monly employed; for the Schneiderian 
mucous membrane is among the last of 
the parts to lose its sensibility in cases of 
unconsciousness, and will often respond 
to this stimulus after the integument has 
become insensible. 

Thomas L. Stedman. 


STETHOSCOPES. Hisroricau 
SxetTcH.—The credit of having invented 
the stethoscope has been variously attri- 
buted to Hippocrates, Bayle, Hook, Laén- 
nec, and others. It is certain, however, 
that Laénnec was the first to make the idea 
practically useful. He hit upon it acci- 
dentally, by using a roll of paper which he 
was holding in hishand. His first instru- 
ment was a cylinder of paper compactly 
rolled and kept in shape by paste. The 
stethoscope subsequently adopted was a 
cylinder of wood an inch and a half in di- 
ameter and a foot long, per- 
forated longitudinally by a 
bore three lines wide, and 
hollowed out into a funnel 
shape at one end to the depth 
of an inch and a half. A 
plug of wood fitted into this 

‘ hollowed extremity with a 

d perforation through it of the 
sn. Same diameter as that of the 

a eon eeeeHe! rest of the tube. This was 


i 


Fre. 3711. — 


ae o, eng s used in auscultating heart Plug erie 

c, sections ; d, , 2 < s nec’s etno- 

anreleteamity: sounds. It was discarded in Bédpe! 
stethoscopes made at a later 

date. The instrument was made in two sections for con- 


venience of carrying. Piorry introduced a more slender 


626 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


instrument, with ivory cap, and later this was altered and 
made of wood only. An instrument in which the pecto- 
ral end was trumpet-shaped, was devised by Dr. Williams, 
of London, about 1848. Since then a large number of 
monaural stethoscopes have been devised, and descrip- 
tions of them are to be found 
scattered through various 
medical publications. They 
have been made of metal, 
wood, hard rubber, papier- 
maché, and other materials, 
used either alone or in combi- 
nation. Most of these stetho- 
scopes are hollow, the bore 
of the tube being pretty uni- 
form throughout, except at 
the pectoral extremity, where 
it is expanded and bell-shaped. 
Solid wooden _ stethoscopes 
have also been devised, but 
these are more especially use- 
ful in conveying percussion sounds when the method of 
auscultatory percussion is practised. The monaural in- 
struments do not differ from one another in any important 
particular. A few are combination instruments, having 


Fig. 3712.—Diameter of Laén- 
nec’s Stethoscope. 


WAZARD.HAZARD.&CO.W.F.FORD 


AZARD.HAZARD&CO, 
w.F.FORD 


Fie. 3713. Fra. 3714. Fie. 8715. 
Fies. 3718, 8714, and 3715.—Monaural Stethoscopes. 
a percussor and pleximeter attached, or a clinical ther- 
mometer, a female catheter, etc., hidden away in them. 
Among others who have devised monaural stethoscopes 
may be mentioned Quain, Stokes, Arnold, Barclay, Elli- 
ottson, Dobell, Loomis, Burrow, Clark, 
Cammann, and Ferguson. V2 
M. Landouzy, of Paris, in 1850, con- 
structed a stethoscope with a bell-shaped 
chest-piece, with a number of flexible tubes 
attached, by which several observers at 
once could austultate. A single tube was 
designed for each person, but by the use of 
two tubes it became a binaural instrument. 
It was necessary to hold the tubes in the 
ears by the hands, and it was not found to 
be of much practical use. Many years 
previously Dr. Williams, of London, had 
been accustomed to use a binaural stetho- 
scope made of two metal tubes attached to | 
the bell of an ordinary stethoscope, and NNW 
with flat ear-pieces. This conveyed sound | 
with increased intensity, but was inflexible, ; 
clumsy, and awkward of application, The Fie. 3716. — In- 
double stethoscope of Dr. Leared, shown erry tet a 
in the Great International Exhibition of scope. 
1851, was a great improvement. Itismade 
entirely of gutta-percha. The two tubes are attached at 
one extremity to a bell-shaped chest-piece, and at the other 
to ear-pieces similar to those of the monaural stethoscope. ° 
These tubes being separated and applied to the ears, ex- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sternutatories, 
Stethoscopes. 


— 


erted a certain amount of pressure by their own elasticity. 
To use this instrument ordinarily in practice, however, 
would require three hands, one fxn 

for each ear-piece, and another 
to manage the pectoral end. In 
1851 Dr. Marsh, of Cincinnati, 
patented a double stethoscope. 
This had a membrane stretching 
over its objective end, and two 
gum-elastic tubes. leading from 
the chest-piece to the ears. In 
this instrument the ear-pieces 
were inconvenient, and the sounds 
conveyed were muffled and con- 
fused. These circumstances ren- 
dered it of little value. 

Dr. G. P. Cammann devised a 
binaural stethoscope which, after 
considerable labor and expense, 
was perfected in 1852. He was 
familiar with the instruments of 
Landouzy and Marsh, and _ his 
stethoscope, therefore, was not a 
new invention, but was, and is 
now, the best instrument of the 
kind devised. It is light, dura- 
ble, easily carried, and a good 
conductor of sound. The attach- 
ment of.a rim of soft rubber to 
the chest-piece, as devised by Dr. 
Snelling, is of advantage in some 
cases in applying it more closely 
to the inequalities of the chest. 
Oval chest-pieces are also made, 
which enable. the end of the 
stethoscope to be pressed into the 
intercostal spaces. In most of 
the instruments now made the = 
rubber band which served to draw F14. 8717.—Cammann’s Bin- 
the two tubes together is replaced mares vet oreo pe 
by a spring. In the latest im- 
provement the spring is placed 
in the screw which binds the 
tubes together (Fig. 8721). <A 
considerable variety of flexible 
stethoscopes are now in use. 
The credit of having firstused 
one is probably due to Dr, 
Pennock, of Philadelphia. 
They may be generally de- 
scribed «as consisting of a 
chest-piece, long flexible rub- 
ber tubes, and round ear- 
pieces. The ear-pieces are 
held in place either by being 
firmly pressed into the meatus, 
or by a spring passing over 
the head or under the chin. 
A. flexible stethoscope was de- 
vised by Mr. Brown, in which 
the ear-pieces are oval. When 
placed in the ear, with the 
long diameter vertical, they 
are said to remain readily 
in position. The differential 
stethoscope of Scott Alison is 
similar in mechanism to Cam- 
mann’s, but has two chest- 
pieces, one for each ear, enab- 
ling the sounds from different 
regions of the chest to be con- 
veyed to the two ears at the 
same time. The hydrophone 
z is another instrument devised 

— r by Alison. It consists of an 
Fia. 3718.—Scott Alison’s Differ- india-rubber bag, about the 
Pee) Brethorocne: size of a large watch, and filled 
with water. Another inventor had previously construct- 
ed a wooden instrument filled with water, but it was not 


(SS 
SSEeEE=oa 


i 


-binaural stethoscope, and is held 


| edge, be for- 


practically useful. Alison found that when water was 
interposed between two conducting media, sound was 
conveyed to the ear with increased intensity. The hy- 
drophone may be employed as an instrument by itself, 
or in aid of the stethoscope. 

Dr. McBride has devised for use in auscultatory per- 
cussion a solid binaural stethoscope of hard rubber, with 

mi chest-piece sufficiently small to fit in 

(> the intercostal spaces. Dr. Constan- 
*s- tin Paul devised a stethoscope with 
two flexible tubes leading to the ears, 
and a hollow chamber in the chest- 
piece connected with a rubber bulb 
by along flexible tube. If the air in 
the hollow chamber is exhausted the 
instrument is held firmly against the 
chest. A modification of the chest- 
piece of Cammann’s 
binaural stethoscope, 
which can be screwed 
on in place of the usual 
chest-piece, has. been de- 
vised by the writer. In 
the pectoral end is an 
air-chamber, which is 
completely closed by 
pressure against the 
chest. Connected with 
this chamber by a small 
tubular opening is a rub- 
ber bulb, through which 
the sound - conducting 
tube passes. By press- 
ure upon this bulb, when 
the instrument is held 
in position, the air is ex- 
hausted in the hollow chamber and the stethoscope is 
held firmly to the chest-wall. 

Dr. Heineman, of New York, has devised an attach- 
ment to the binaural instrument, in which, by an admi- 
rably arranged piece of mechanism, the stethoscope is held 
firmly against the chest by means of a metal rod extend- 
ing from the chest-piece to the chin, and both hands are 
left free. 

Dr. D. M. Cammann devised a binaural hydrophone 
with the two tubes made of hard rubber, and thin hard- 
rubber caps at the aural extremities. The pectoral ex- 
tremity is covered by a dia- 
phragm of soft rubber, and the 
instrument is filled with water by 
means of a faucet. The chest- 
piece has been already described 
as a modification of the ordinary 


Fia. 8719.—Alison’s Hydrophone. 


firmly against the chest, leaving 
both hands free. It is intended 
for use in practising auscultatory 
percussion, 
CONSTRUCTION OF 
SCOPES. — 
The rules for 
the proper 
construction 
of stetho- 
scopes can- 
not, in the 
present state 
of our knowl- 


STETHO- 


Fia, 3720.—Cammann’s Modified Chest-piece. A, Rub- 
ber bulb; B, pectoral end; C, air-chamber closed by 
pressure against the chest; D, outerrim; &, inner rim, 


mulated with 
scientific ex- 
actness ; nev- 
ertheless, a knowledge of the laws of acoustics and of the 
results of the experiments of others, will aid us 1n con- 
structing instruments less faulty than many of those now 
in use. In selecting a material, one should be chosen 
that, as far as possible, is light, durable, and a good con- 
ductor of sound. For the monaural stethoscope nothing 
has been found better than a light, firm, vibrating wood 


627 


Stethoscopes. 
Stomach. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


like cedar. 
length of the stethoscope. Mahogany, deal, and lime- 
wood answer well, but the heavier woods, as oak, beech, 
lignum vite, and boxwood, are inferior and deaden the 
sonorous vibrations of the bodies upon which they are 
applied. The quality that makes wood desirable is the 
same that applies in its use in violins, in sounding-boards 
for churches, and in the walls of concert-rooms. Other 
materials, although inferior, are good conductors of 
sound. -Ebonite, a preparation of india-rubber, has the 
advantage of being light and durable, and easily mould- 
ed into shape. The metals, horn, papier-maché, gutta- 
percha, and ivory are good conductors, and have all been 
used for this purpose. Hollow stethoscopes are most de- 
sirable, as some sounds are conducted best through the 
solid walls, while others are transmitted most perfectly 
through the enclosed column of air. The latter is the 

= case with the aérial sounds 
of the chest, the solid wall 
of the stethoscope acting as 
a sounding-board, receiving 
\\ and transmitting the weak- 
WH est vibrations. In the prac- 
tice of auscultatory _ per- 
cussion, a solid wooden 
stethoscope or the binaural 
hydrophone is most useful, 
as sounds produced in solids 
are best conducted through 
homogeneous media; but 
even in this case the ordinary 
hollow instrument will usu- 
ally be found to convey 
sound with sufficient inten- 
sity for all practical purposes. 
The bore of the stethoscope 
and the hollow in the chest 
end should not be too large, 
else there will be caused a 
confused reverberation of 
sound ; nor should the wall 
of the stethoscope be of great 
thickness, both on account of 
superfluous weight and _ be- 
cause the weaker vibrations 
are thereby checked. It is 
best that the stethoscope 
should be of one material 
throughout and in a solid 
block. This is not essential, 


instrument is not possible. 
Theoretically the breaking 
of continuity, by having it in 
several pieces, would impair 
the conducting power ; but 
practically the difference is 
found not to be as great as 
might be expected. Flexible 
stethoscopes, in which the 
tubes are of soft rubber, or of wire covered with some 
pliable material, are useful in some cases, but the sounds 
are modified by reverberation, especially when the tubes 
are long and with large hollows. The length recom- 
mended by Laénnec was one foot divided in two for 
convenience of carrying. This is unnecessarily long, 
and six inches is now the usual length. The length of 
the binaural instrument, from ear to chest-piece, varies 
from ten or twelve to sixteen or seventeen inches. Most 
of the binaural instruments have two chest-pieces, one 
small and narrow, the other trumpet-shaped, which can 
be screwed on at pleasure. The modified chest-piece 
may also be used, and can be screwed on in the same 
way. ‘The smaller end can localize sounds best, and is 
easier of application to the chest ; the larger is more use- 
ful in examining the chest rapidly. The edges should 
not be too sharp, but rounded off both toward the cir- 
cumference and toward the centre. The ear-piece of the 
monaural stethoscope ought to be large enough to cover 


Fie, 3721. — Cammann’s Binaural 
Hydrophone. 


628 


The fibres should run in the direction of the | 


the concha and to close the external meatus. It may be 
flat, but the most convenient form is with a depression 
between the circumference and the centre, the latter be- 
ing considerably elevated. The binaural instruments 
have small circular knobs, which should not be too large 
nor too small. If too large, they do not fit closely and 
allow externa] sounds to enter; if too small, they cause 
discomfort by pressure. No instrument will suit all ears, 
and a stethoscope should be fitted to the ear as a shoe is 
to the foot. 

VALUE OF THE STETHOSCOPE. —-In considering the value 
of the stethoscope it is taken for granted that the instru- 
ment used is reliable, and that the auscultator knows how 
to use it. Some skilful auscultators advocate its contin- 
ual use; others, equally skilful, advise that it be used 
only occasionally. The cause of this difference of opin- 
ion probably lies partly in difference in the acuteness of 
hearing and the extent of the training of different observ- 
ers, and partly isa matter of habit. That the habitual 
use of the stethoscope does after a time render the sense 
of hearing less acute to the sounds heard over the chest, 
in immediate auscultation, is, I think, an undoubted fact. 
Yet the stethoscope is a valuable instrument, and although 
it is not always needed, often we cannot attain to a full 
knowledge of a case without making use both of mediate 
and immediate auscultation. Often a doubtful or half- 
heard sound has been clearly brought out and appreciated 
by the use of the stethoscope; but still oftener, I think, 
has a sound scarcely suspected with the stethoscope been 
made evident by the immediate application of the ear. 
It requires some practice to become accustomed to its 
use, especially to that of the binaural instrument. In 
the latter some sounds are exaggerated, while others are 
impaired, and there are not the distinctness and simplic- 
ity that there are when we use the ear or the monaural 
instrument. It is an acoustic fact that sounds are better 
heard with two ears than with one, and virtually the 


| double stethoscope enables us to place two ears on the 


chest at the same time. The modified instrument increases 
the intensity of sounds both by bringing the pectoral end 
into the closest possible contact with the chest, and b 
both the hollow air-chamber and the rubber bulb acting 
as resonators. It also leaves both hands of the ausculta- 
tor free. Alison’s hydrophone may be used either by it- 
self or placed between the end of the stethoscope and the 
chest, thereby increasing the contact and the conducting 
power when it is difficult to bring the inflexible end of 
the instrument into close apposition with the chest-wall. 
The value of the stethoscope for purposes of modesty, 


| cleanliness, and convenience, and for examining the su- 
however, and in the binaural | 


praclavicular and axillary regions which cannot readily 
be reached by the ear, are obvious, and need only to be 
mentioned to be appreciated. 


REFERENCES. 
New York, 


London, 1861. 


Laénnec: Diseases of the Chest. 
1830. 

Alison, Scott: The Physical Examination of the Chest. 

Walshe: Diseases of the Lungs. London, 1871. 

Aitken: Pract. Med. Edited by Clymer. New York. 

Constantin, Paul: Diseases of the Heart. New York, 1884. 

Cammann, G. P.: N. Y. Med. Times, January, 1855, 

Pollock: Lancet, April 12, 1856. 

Hyde, Salter: Brit. Med. Journ., 1863, pp. 106, 133. 

Flint: N. Y. Med. Record, 1870, p. 235. 

Williams: Lancet, November 8, 18738. 

Brown: Lancet, March 3, 1877. 

Cammann, D.M.: N. Y. Med. Journ., January 3, 1885, and February 27, 
1886. 

McBride: Archives of Medicine, December, 1880. 


Donald M. Cammann. 


Translated by Forbes. 


STOMACH. The stomach is a dilatation of the intes- 
tinal tube, and forms the connection between the cesoph- 
agus and the duodenum. In the adult it is a pyriform 
sac, concave on its upper border (lesser curvature), and 
convex on its lower (greater curvature). The esophagus 
enters its upper part at the distance of about one-fourth 
or one-fifth of its long diameter from the left extremity 
(cardiac orifice). The portion to the left of the cardiac 
orifice is called the fundus. From the cardiac orifice the 
stomach tapers until it merges into the duodenum. The 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


outlet of the stomach is marked externally by a constric- 
tion (pylorus). A short distance from the pylorus is a 
narrowing, more marked above than below, which indi- 
cates the boundary of the antrum pyloricum. 

Occasionally a second constriction is found near the 
middle of the stomach. 

The cardia lies behind the sixth and seventh right cos- 
to-sternal articulations ; the pylorus between the tip of 
the ensiform cartilage 
and the edge of the 
ribs. The lesser cur- 
vature lies along the 
left edge of the ver- 
tebral column, The 
greater curvature, be- 
ginning a little to the 
left of the sixth costo- 
sternal articulation, 
rises to the fourth in- 
tercostal space, lying 
at this point above the 
apex of the heart; 
thence it goes down- 
ward and to the left 
in a nearly circular di- 
rection until it reaches 
the lower border of 
the seventh rib, then 
continues its course 
to the right until it 
reaches the middle of 
the epigastrium, and 
finally rises to the 
edge of the floating 
ribs, on a level with 
the tip of the ensiform 
cartilage. The dia- 
phragm rests upon 
the greater part of the 
left segment of the 
stomach. The fundus touches the spleen and left kid- 
ney. The pancreas, with only the omentum and splenic 
artery and vein intervening, rests against the lesser cur- 
vature and the body. Behind this again is the great solar 
plexus of nerves and the celiac axis. The pyloric end 


Fie. 3722.—View of the Abdominal Organs 


from in Front, (From Ranney, after 
Luschka.) The numerals are placed upon 
the respective ribs: I., the stomach; II., 
duodenum; III., ileum; IV., colon; V., 
sigmoid flexure, 


of the stomach is covered by the liver ; the greater part 
of the lower border of the greater curvature rests upon 
the transverse colon (Fig. 3722). 
In infancy the stomach is more fusiform in shape, and 
its direction is more perpendicular, than in adult life. 
The position is said to change when the stomach is dis- 


Fic. 3723.—Outline of the Stomach, showing Constriction of Antrum 
Pyloricum and Direction of Muscular Fibres, R, Circular muscular 
layer; L, longitudinal muscular layer; Oe, radiation of oesophageal 
fibres; K, saddle-like bundles. 


tended, the greater curvature being carried forward and 
upward, the anterior surface being raised and the poste- 
rior depressed. This change in position has, however, 
been denied by some. 

When full, the stomach is from ten to twelve inches in 


Stethoscopes. 
Stomach. 


length, and at the boundary of the fundus, the broadest 
part, it is from three to four inches in breadth. From 


this point it diminishes 
until it is only one inch in 
diameter at the pylorus. 


UA al BRA 
, b, °3) oy O/')' 
yA 7 gi) 


dia; of the remain- 


Its capacity is from five to 
eleven pints (Henle). The 
thickness of the walls, 
which increases toward the 


FA 
iris 


Hil 4K 
Matt 4 


pylorus, varies according VN ip RN 1 
to the degree of muscular BE Mig iy 
tonus, the average being ey) eee tre 
from 9 to 8 mm. (as to 4 DC ga rH (Hani 


inch). The weight is about 
four and a half ounces in 
the male ; it is less in the 
female. 

It is composed of four 
layers : serous, muscular, Fia. 3724.—Mammillated Appearance 
submucous And muCoUsL “gas Cehe mei Than 

The serous, outer, layer 
was derived originally from the peritoneum. A double 
layer passes from the liver to the lesser curvature of the 
stomach (the gastro-hepatic or lesser 
omentum). At the stomach it splits, 
and one layer passes in front and the 
other behind. At the greater curva- 
ture these layers unite again, to form 
the great omentum. To the left of 
the cardia, a fold similar to the lesser 
Fra. 8725.—Epithelium Omentum passes between the dia- 


of the Mucous Mem- = 
ne ER Sipe POSE phragm and stomach (the gastro 


fresh. (Heidenhain.) phrenic ligament). 
The muscular coat, of smooth mus- 


cular fibre, consists of thrée layers—longitudinal, circu- 
lar, and oblique. 

The longitudinal fibres are in direct continuity with 
those of the cesopha- 
gus. Some of the Z 
cesophageal fibres % \ 
are lost at the car- NE " 


eG ah ke Ny 
Ng SLA hiv 


Stomach. 


der a thick layer 
passes along the 
lesser curvature to 
the pylorus, another 
bundle of fibres pass- 
es along the greater 
curvature, and 
others radiate from 
the cardia. Two 
‘* saddle-like collec- 
tions of fibres,” one 
to the right of the 
cesophagus and radi- 
ating to the left, 
the other to the 
left of the ceso- 
phagus, radiat- 
ing to the right, 
form a sort of 
sphincter around 
the orifice; the 
latter bundle, the /ifqiik 
thicker, reaching! 
as far as the an- |ijiiiil! 
L trum pyloricum. 
The circular is 
the most complete 


wav 


ns 


he 
il 
AS 


ie 


\ 
ay 


LY 
4 
esen 
a 
Bese TE a 


nae 
aro 
My 


a 
Mf 


hy 


oy 


= 


SW 
SSG} 
© j 


layer. At the py- 
lorus it is thickened Aa \ : 
into a sharp ring, HM i IN 
. . os Y Cy ' Hey q AN WS 
which forms the py / HI NNR EZ 


loric sphincter. 

The inner, ob- 
lique, layer is the 
continuation of the inner circular fibres of the esophagus. 
It spreads over the interior of the stomach to the left of 
the cardia, in a direction to form an oblique angle with 


629 


6.—Glands ‘of the Stomach, From 
the neighborhood of the pylorus. (Ebstein.) 


Stomach, 
Stomach. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the axis, to the pylorus, and gradually loses itself on the | the infant it is pink, but becomes reddish-gray and gray 


two sides (Fig. 3728). 
The submucous layer is composed of loose connective 
tissue, and serves as a bed for the net-work of blood-ves- 


Fie. 3727.—Longitudinal Section of a Cardiac Gland of Man. m, Mus- 
cular fibres. (Stéhr.) 
\ 
sels and lymphatics which supply the mucous mem- 
brane. 

The mucous membrane is soft and pulpy, and is in 
marked contrast with the shining membrane of the 
cesophagus, from which it is separated at the cardia by a 
sharp zigzag line. 

The color varies with the age of the individual. In 


630 


as age advances. 

When the stomach is empty the contraction of the 
muscularis mucose throws the mucous membrane into 
folds (rwg@) which lie, for the most part, in a longitudi- 
nal direction. The ruge are obliterated when the stom- 
ach is distended. 

Between the rugee run minute furrows, which divide 
the surface into rounded eminences flattened at the top 

‘(mammillations) ; they are from two to three mm. (;); to 
+ inch) in diameter (Fig. 3724). 

Besides the mammillations there are also elevations 
caused by the presence of the agminated glands. 

The stomach is very vascular. The arteries are de- 
rived from the cceliac axis, 
branches passing to each end 
of both the upper and lower 
curvatures. Here they pene- 
trate beneath the peritoneum 
and anastomose, to form two 
vessels which run the length 
of the curvatures, one above 
and the other below. These 
vessels divide the organ into 
equal halves. 

The veins accompany the 
arteries and have essentially 
the same course, but they 
are of larger calibre, fewer 
in number, and less com- 
plex. 

The lymphatics also follow 
the course of the blood-ves- 
sels, to form a plexus in the 
submucous connective tissue 
from which the lymphatic 
capillaries arise. 

Lymphatic glands are 
found in the course of the 
lymphatic vessels along the 
two curvatures. 

HistoLoey. — The serous 
layer is 0.03 mm. 
in thickness, and 
resembles the per- 
itoneum in micro- 
scopic character. 

The muscular 
layer is composed 
of smooth muscu- 
lar fibre. 

The submucous 
layer is composed 
of loose connective 
tissue, with a few 
fat-cells. 

The mucous mem- 
brane, however, is 


he layer of i 

Fies. 3728 and 3729.—Longitudinal and Trans- . ay , 5 ae 
verse Sections of a Gland from the Fundus of !1terest, DO 1S- 
the Human Stomach. The transverse section tologically and 
is made near the base of the gland. 7, Lumen; physiolo icall A 

v, vacuole; del, delomorphous, and adel, ade- I ane en a 1 ye 
lomorphous parietal glands; b, prolongations P 'p Cular SeC- 
of the delomorphous cells. (Stéhr.) 600. tlon shows _ the 
membrane to con- 


sist of an epithelial layer separated by a basement mem- 
brane from a muscular layer (muscularis mucose). 

The epithelium is of the columnar variety, and presents 
a Sharp contrast to the flat epithelium of the cesophagus. 
The cells are long and slender, and are filled with gran- 
ules. They contain near their centre a large, oval nu- 
cleus. ‘‘ Goblet-cells” are sometimes found. Scattered 
among these are rounded cells, sometimes in nests (Fig. 
3725). 

The surface epithelium dips down at short intervals to 
form the mouths of the gastric glands. These glands 
begin at the cardia and extend to the pylorus. They lie 
so thickly together that, in a transverse section, the mu- 
cous membrane appears striated, and seems to be wholly 


Fie. 3728. 


Fie. 38729. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Stomach. 
Stomach. 


composed of them. They extend through the membrane 
and rest upon the muscular layer beneath. The glands, 
at first sight apparently all alike, are, upon closer exami- 
nation, found to be of two classes : those found near the 
pylorus (pyloric glands), and those found near the cardia 
(cardiac glands). 

The cardiac glands, formerly called peptic glands, are 
longer and more complicated than the pyloric. They 
consist of a cylindrical tube, which gives off at its lower 
extremity three or four branches. 

The upper and broader tube is lined by cells which re- 
semble the cells of the mucous membrane, except that 
they are perhaps a trifle smaller. Lower down in the tube 
the cells become shorter and slightly broader, and at the 
point where the branches are given off they are, in a longi- 
tudinal section, nearly square (cubical cells). From this 
point they broaden, and toward the bottom of the gland 
become irregular in 
outline. Lying next 
the basement mem- 
brane, and covered 
by the irregular cells, 
is a fourth variety of 
cell—the parietal cell 
—sometimes called 
peptic cell. These 
cells are ovoid in 


shape and much 
darker than the 
others. When swol- 


len they nearly touch 
one another. Two 
to four are usually 
seen in a section of 
the gland parallel to 
the surface of the 
stomach. The _ net- 
work described by 
some observers in 
these cells has not 
been demonstrated. 

The pyloric glands 
resemble the cardiac 
glands in general ap- 
pearance, but their 
upper portion is 
broader, and the 
branches at the bot- 
tom are shorter and 
fewer in number. 
They contain only 
the first and second 
varieties of cells. 
The two kinds of 
glands shade grad- 
ually one into the 
other. 

The number of 
glands in a square 
millimetre (5 inch) 
is about one hundred. In the whole stomach there are 
about forty-nine thousand (Henle) (Figs. 3726, 3727, 3728, 
3729). The depth of the first part of the glands ‘‘ in the 
normal stomach is, at the cardia, about 0.2 mm. (.0079 
inch), but toward the pylorus it increases in a marked 
degree. The transverse diameter, including the epitheli- 
um, is about 0.07 to 0.10 mm. (.0028 to .004 inch), of 
which about 0.05 mm. (.002 inch) is included in the 
height of the epithelium. The height of the epithelium 
is 0.025 mm. (0.001 inch). The passages average 0.02 
mm. (0.008 inch) in breadth ; exceptionally they are 0.06 
mm. (.024 inch)” (Henle). 

The basement membrane bounds the epithelium of the 
stomach and its glands. It is a membrane composed of 
flattened cells, which send out prolongations among the 
epithelial cells of the mucosa and of the glands. 

The muscularis mucose is better developed in many of 
the lower animals than in man. It consists of two layers 
of smooth muscular fibre, an outer circular, and an in- 


Fie. 3730.—Glands of the Stomach, from 
the Neighborhood of the Pylorus, showing 
the Changes occurring during Digestion. 
(Ebstein. ) 


ner longitudinal, layer. From the inner layer prolonga- 
tions are sent up among the glands. 

A use for these prolongations in emptying the glands 
of secretion during digestion can be imagined. 

The mucous membrane and glands present different 
appearances at different times. The cells of the mucous 
membrane in the intervals of digestion are slightly larger 
at the top than at the bot- 
tom, and are filled with a 
clear, muco - albuminous 
substance (mucigin, Sché- 


Re Yr : 

r)i rig DN GCG Sg gh, 
e ) in which the granules ae ay td a 
are suspended. Conse- La] PALL ears 
quently the tops of the IFAC Wages ssc 


cells appear more trans- 
parent and less granular 
than the bottom. During 
digestion the mucigin is 
discharged, carrying with 
it a considerable number. 
of granules. After diges- 
tion, therefore, the cells 
become shorter and more 
opaque. During digestion 
the glands of both kinds 
discharge granules. The 
parietal cells of the cardiac 
glands at this time swell to 

nearly double their size ; Fic. 37381.—Plan of Blood-vessels of 
they resume their original TeStemech. a, Arteries: rings 
appearance after digestion ¢, veins. (Quain.) 

is completed (Fig. 3730). 

At the pyloric orifice is a ring of racemose glands which 
resemble the duodenal glands. 

Papilie also begin to appear in the neighborhood of 
the pylorus, which are the beginnings of the papille 
of the small intestine and resemble them in structure. 
“These plice villose are about 0.05 mm. in height” 
(Henle). They are sometimes absent. 

The blood-vessels of the stomach are arranged in a man- 
ner which differs from that in any other organ, except 
the colon. The arteries form a net-work in the submu- 
cous connective tissue. From this net-work large capil- 


a. 


=¥ 


— 


Cann rt a 


Fig. 3732.—Lymphatics from Human Gastric Mucous Membrane; in- 
jected. The tubules are faintly indicated. @, Muscularis mucose ; 
b, plexus of fine vessels at base of the glands; c, plexus of larger valved 
lymphatics in submucosa, (Lovén.) 


laries or arterioles arise, which pass upward between the 
glands, giving off in their course two or more branches 
which connect with the other upright arterioles, and 
form a mesh-work around each gland. At the upper part 
of the glands they empty into veins, which form rings 
around the mouths of the glands. They are of consider- 
ably larger diameter than the capillaries. They are con- 


631 


Stomach. 
Stomach. 


nected together in a network which empties into a large 
vein perpendicular to the surface. 

In the submucous tissue, these veins empty into an- 
other venous plexus which conveys the blood away from 
the organ (Fig. 3781). 

The lymphatics are also peculiar. A lymphatic plexus 
in the submucous connective tissue sends up branches 
which, as is usual with lymphatics, are very irregular in 
size and length. In the main they run upward, inoscu- 
late with other branches, and end apparently in a blind 
tube (Fig. 37382). 

Lymphatic structures resembling the so-called solitary 
glands of the small intestine are found scattered through- 
out the stomach. These are less perfectly separated from 
the other structures than are the solitary glands. They 
consist of a reticular structure filled with lymphoid cells, 
Toward the periphery the reticulum becomes coarser, 
the cells are fewer, and finally disappear without any 
line of demarcation. These structures are most abun- 
dant in childhood, after which they become fewer, and 
finally disappear after middle life. 

The nerves form gangliated plexuses similar to those of 
the small intestine. In the muscular layer is a plexus 
similar to Auerbach’s plexus. In the submucous layer is 
one similar to Meissner’s plexus. The termination of the 
nerves is unknown. Lester Curtis. 


STOMACH, ORGANIC DISEASES OF THE. Gas- 
TRITIS.—Although there is no distinct dividing line, as 
regards morbid anatomical changes, between subacute and 
acute inflammation of the stomach, it is necessary to dis- 
tinguish clinically between these two grades of gastric 


disease, because they differ essentially, in symptomatol-: 


ogy, in prognosis, and in treatment; while typical cases 
also present decided points of diversity in their respective 
pathological anatomical conditions. The writer, there- 
fore, proposes to describe under their combined titles, 
first, the milder, and then the graver types of gastritis, be- 
lieving that their juxtaposition will render more apparent 
both their resemblances and their points of dissimilarity. 

I. SusacuTtE AND AcuTE Gastritis. Htiology. — 
The causes of these diseases are predisposing and excit- 
ing. 

(a) Predisposing Causes.—The predisposing, or indirect 
causes are so similar for both subacute and acute gastri- 
tis that a separate enumeration for each disease seems 
unnecessary, While the exciting, or direct causes differ 
rather in degree than in kind. The predisposing causes 
are all conditions, whether general or local, which tem- 
porarily impair the vitality of the gastric tissues, thus 
reducing their power of resisting irritation, and their ca- 
pacity for the performance of their respective functions. 
The constitutional conditions favoring subacute and 
acute gastritis are, thus, transient anemia and asthenia 
from whatever source. We accordingly see a predispo- 
sition to these diseases in febrile affections, such as 
typhoid and typhus fevers, diphtheria, the eruptive and 
malarial fevers, acute rheumatism and gout; while in 
those persons who are naturally weak, even slighter ail- 
ments, such as bronchitis, pharyngitis, or influenza may 
predispose to these diseases. The predisposing influence 
of these febrile conditions is readily accounted for by the 
accompanying diminution in the secretion of saliva and 
gastric juice, and by the consequent retardation and per- 
version of digestion. If, in these febrile states, food be 
administered in such quantity or be of such a quality as 
to overtax the digestive powers of the stomach, fermen- 
tation will ensue and lead to the production of irritating 
acids and gases. Besides exerting a harmful chemical ac- 
tion upon the gastric mucous membrane, the gases over- 
distend the organ, thus still further enfeebling its muscles, 
the contractile power of which has already been impaired 
by pre-existing systemic weakness. The decomposing 
mass thus remains, for an indefinite period, in contact 
with the mucous membrane, constituting one of the ex- 
citing causes of gastritis to be presently enumerated. 

The use of certain drugs, in disease or in health, may 
strongly predispose to gastritis, by diminishing the secre- 
tion of the digestive fluids and by retarding the peristole 


632 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


of the stomach. Among these medicines may be men- 
tioned opium and its derivatives, belladonna, stramoni- 
um, hyoscyamus and cocaine. Chloral, the bromides and 
other spinal depressants probably exert a similar influ- 
ence. Local diseased conditions of the stomach and of 
other organs likewise favor the development of gastritis. 
To this class of causes belong gastrectasia, whether ob- 
structive or atonic, ulcer, new-growths in the stomach 
and congestion. Venous congestion of the stomach is 


‘ produced by obstruction to the portal circulation from 


many causes, among which the most obvious are weak- 
ened heart action, pulmonary and pleuritic diseases ob- 
structing the pulmonary circulation and hepatic diseases 
preventing the normal discharge of blood from the portal 
vein. Repeated attacks of gastritis predispose to relapses 
of the disease by their deleterious influence upon the vi- 
tality of the mucous membrane and, perhaps, by impair- 
ing the tone of the gastric vessels. 

Children are more susceptible than adults to the action 
of comparatively feeble gastric irritants, because of the 
inherent sensitiveness of their mucous membranes. Old 
people, convalescents, and anzmic patients are likewise 
particularly predisposed, because of their low vitality 
and of the consequent slight resisting power of their 
tissues. Asthenia and anemia from chronic diseases, 
on account of their more lasting influence, rather pre- 
dispose to chronic than to subacute and acute gastritis. 
These chronic diseases will, accordingly, be mentioned 
under the etiology of chronic gastritis. It is, however, 
to be remembered that these disorders may, in their in- 
ception, lead to transient attacks of subacute and of 
acute gastritis, which diseases may also be invited by the 
imposition of unusual digestive tasks upon a stomach 
ordinarily accustomed to a simple and restricted diet. 

(b) Haciting Causes.—The exciting causes of subacute 
and acute gastritis are thermal, mechanical, or chemical 
irritants. To the first class belong ice-cold, as well as 
overheated fluids and solids. Mechanical irritation of 
the stomach may be produced by abdominal contusions, 
the careless or frequent introduction of hard-rubber 
stomach-tubes, and the ingestion of sharp, rough, or in- 
digestible solids, or of coarse, uncooked, or superfluous 
foods. Among the most important chemical irritants are 
the gases and acids resulting from putrefactive and other 
fermentative processes in the stomach, too highly sea- 
soned and too acid foods, undiluted alcoholic beverages, 
as spirits and cordials, drastic cathartics, other irritating 
drugs, urea and carbonate of ammonia eliminated by the 
stomach in Bright’s disease, and various corrosive poisons, 
as mercury, arsenic, zinc, nitric acid, sulphuric acid and 
oxalicacid. Alcohol and the corrosive poisous are chiefly 
responsible for the most severe cases of acute gastritis, 
but any of the above-named irritants may act as efficient 
exciting causes of the disease in an organ already predis- 
posed to inflammation. Most authors mention exposure 
to cold as a possible exciting cause of gastritis, but re- 
gard its etiological influence as problematical. Violent 
physical exercises, powerful intellectual efforts, or strong 
emotions, may act as exciting causes of subacute gastritis 
by arresting digestion, and thus favoring fermentation. 
In these cases the arrest of secretion may be the effect 
either of nervous inhibition, or of diversion of blood into 
other channels, or of both these conditions combined. 

Morbid Anatomy.—Opportunities for the post-mortem 
observation of the pathological anatomical changes in 
subacute gastritis are rare, because the disease tends, 
almost invariably, to recovery, and such examinations, 
when obtained, are necessarily misleading because vascu- 
lar contractions, occurring after death, may quite oblit- 
erate the traces of the inflammatory process. On the 
other hand, post-mortem injection and softening of the 
mucous membrane, or auto-digestion of the gastric walls, 
may confuse the pathologist. The recorded cases of 
subacute and acute gastritis in which ¢ntra-vitam obser- 
vations have been made upon men and animals, therefore, 
possess a peculiar importance, and the classical case of 
Alexis St. Martin, minutely studied by Beaumont, is 
regarded as the most valuable and. reliable source of in- 
formation in regard to this subject. The gastric mucous 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


membrane of St. Martin, when moderately inflamed by 
alcohol or other irritants, presented, according to Beau- 
mont, a mottled appearance, pale areas intervening be- 
tween small and irregularly shaped spots of a red or 
bluish-red color. Otherspots, white, apparently elevated 
above the surrounding membrane and resembling patches 
of false membrane, were sometimes present. The gastric 
juice was notably diminished in quantity, while the 
mucus was increased ; and when the inflammation was 
more severe, pus was also abundantly produced. Small 
venous hemorrhages occasionally took place from the 
congested areas, and ecchymoses were also observed. 

In acute gastritis autopsies are more frequently made 
and the pathological conditions are consequently better 
understood than in subacute gastritis. In these cases 
the mucous membrane, particularly that of the pyloric 
region, is more opaque than in health, and may present 
alternating red and pale areas. Sometimes, however, the 
whole surface is pale, and again, it may be uniformly 
congested. The membrane is softened, thickened, some- 
times ecchymotic, often ulcerated and covered with thick, 
adhesive mucus or muco-pus, which is sometimes stained 
with blood, and contains desquamated cylindrical epi- 
thelial cells. The ecchymoses and ulcerations are most 
frequently seen at the apices of the folds in the mucous 
membrane. The submucous tissues are sometimes swol- 
len and either red or pale. The microscope shows the 
capillaries of the reddened areas in the mucous membrane 
to be distended with blood, and this is especially true of 
the vessels in close proximity to the orifices of the gastric 
tubules. The ecchymoses present the usual microscopic 
appearances. The base of the ulcers is sometimes com- 
posed of extravasated blood, and sometimes of the sub- 
mucous tissues. Ecchymoses are also found between 
the tubules, besides serum, either limpid or blood-stained, 
and pus. The submucous tissues may be infiltrated with 
serum and pus. The gastric solitary follicles are, when 
present, occasionally hypertrophied, and sometimes nu- 
merically increased. The lining cells of the mucous mem- 
brane are swollen and their desquamation is probably 
abnormally increased. Great interest centres about the 
pathological changes in the secreting cells of the gastric 
tubules. These may remain normal, but they often un- 
dergo parenchymatous, and subsequently fatty, degenera- 
tion, being thickened, in these respective conditions, by 
abundant albuminous or fatty granules, and presenting a 
whitish, opaque appearance. Thetubules are sometimes 
partly filled by cells of this description, and sometimes 
with amorphous and granular matter. In the most acute 
forms of gastritis, such as are produced by corrosive poi- 
sons, false membranes may be developed in the mucous 
membrane, and sloughing of this membrane and of the 
deeper tissues may ensue, leading to perforation of the 
stomach. Many of the above-mentioned morbid anatom- 
ical changes are often simultaneously found in the stom- 
ach and the duodenum, the disease being then known as 
gastro-enteritis. 

Clinical History. (a) Constitutional Symptoms.—Sub- 
acute gastritis presents the familiar train of symptoms col- 
lectively known as acute indigestion, by French authors 
as embarras gastrique, and in popular parlance as a 
‘‘pilious attack.” The symptoms naturally vary within 
wide limits, in accordance with the severity of the inflam- 
mation. The following description aims at reproducing 
the clinical picture presented by a case of medium 
severity. In such a case there is loss of appetite, gener- 
ally repugnance to food, often nausea, sometimes emesis, 
and occasionally a longing for highly seasoned foods and 
for condiments or spices. The vomited matter contains 
the offending material which caused the attack, unless 
this has already passed into the intestine, mucus, some- 
times bile and, more rarely, a little blood. The bowels 
are generally constipated, but sometimes are relaxed. If 
diarrhea is present, enteritis probably exists. Eructa- 
tions and flatulence arecommon. The urine is scanty, 
high-colored, charged with urates, and sometimes contains 
oxalate of lime, leucine, and tyrosine. Headache is a 
frequent, but not a constant, symptom ; occasionally it is 
very intense and may then be due to auto-infection with 


Stomach, 
Stomach, 


septic materials resulting from fermentation in the stom- 
ach. In this connection it is interesting to recall the 
cases reported by Litten, in which he observed, besides 
headache, nervous restlessness, great muscular weakness, 
and finally, marked somnolency. In these cases the ex- 
pired air had a decidedly fruity odor and the urine 
showed the reaction now usually referred to the pres- 
ence of diacetic acid, viz., a bright red-color upon the 
addition of a solution of the chloride of iron. In 
some cases the eructations have the odor of sulphuretted 
hydrogen, but often they are odorless. The mental 
energy is impaired, the spirits are depressed, and there is 
ordinarily a sense of physical fatigue or of prostration 
out of all proportion to the real loss of power. There 
may also be vertigo and partial aphasia, tinnitus aurium, 
faintness and dyspnea. The pulse is generally quick- 
ened and the temperature raised, but not commonly above 
100° or 1003° F. Exacerbations of fever may occur to- 
ward evening and after the ingestion of food. In milder 
cases there is sometimes no febrile movement, the pulse 
remaining infrequent and feeble, and the surface cold. 
Chilly sensations and even chills may occur. 

(b) Local Symptoms.—The mouth is dry, the breath 
foul, the tongue coated at first, and, later, sometimes red 
or glazed. There is epigastric tenderness and promi- 
nence, generally accompanied with a constant dull pain 
and a sensation of tension in the stomach. This feeling 
of repletion is sometimes relieved by emesis or by eructa- 
tions. The above-named sensations are all intensified by 
the introduction of food, unless it be cool and liquid. 
The gastric muscles being relaxed or paretic from over- 
stretching, the food remains undigested in the stomach 


for a long time, unless removed by vomiting or catheter- 


ization. Intermittent, acute pains, resembling those of 
intestinal colic, often occur, while pyrosis and gastric 
tympanites are notuncommon. Patients frequently com- 
plain of a bitter taste inthe mouth. Slight icterus some- 
times appears, as a sign of gastro-duodenitis. Labial 
herpes and urticaria are occasional symptoms. Mild 
cases of subacute gastritis are usually of only a few days’ 
duration. In more severe cases the inflammation may 
persist for one, two, or even three weeks. If the disease 
be still more protracted, it is regarded as constituting 
chronic gastritis (quod vide). When subacute gastritis 
develops in conjunction with gastric dilatation, the symp- 
toms are more likely to be severe and protracted than in 
subacute inflammation of a previously healthy stomach. 
The contents of the stomach are retained for a greater 
length of time, and fermentation ensues with greater 
rapidity. The cerebral symptoms are correspondingly 
intensified, whether from reflex irritation or from auto- 
infection by means of ptomaines. Gastric tympanites 
and epigastric tenderness are apt to be more marked than 
in healthy stomachs, but paroxysmal pain is less frequent 
on account of the flaccidity of the dilated organ. Obsti- 
nate constipation is the rule, because the gastric contents 
pass through the pylorus in very small quantities and 
their fluid parts are completely absorbed in the small in- 
testine. Prostration is sometimes extreme in these cases. 
In young children subacute gastritis causes more intense 
febrile movement, more marked depression, and more 
serious symptoms, in general, than in adults. It is diffi- 
cult to elicit exact information from the little patients 
regarding their subjective symptoms, but the objective 
phenomena and physical signs are essentially the same 
as in grown people. Entero-colitis is likely to associate 
itself with the gastritis in young children, particularly 
in hot weather, thus constituting the disease popularly 
known as ‘‘ cholera infantum,” for a description ot which 
the reader is referred to the article in this HANDBOOK 
treating of that subject. 

In acute gastritis—which term is here applied to that 
serious form of gastric inflammation ordinarily caused 
by immoderate indulgence in alcoholic drinks, or by the 
action of corrosive poisons—the symptoms and signs are 
striking, characteristic, and, in serious cases, truly appall- 
ing. The first symptom, in cases of great severity, 1s 
generally intense burning epigastric pain, accompanied 
by great tenderness on pressure, and by rigidity of the 


633 


Stomach. 
Stomach, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


abdominal walls. Even the respiratory diaphragmatic 
movements augment this pain. If the attack is occa- 
sioned by caustic substances, there is also pain and burn- 
ing in the mouth, pharynx, and csophagus, dysphagia 
and sometimes aphonia. Nausea, with violent and very 
painful acts of emesis, soon follows, the matter rejected 
from the stomach containing portions of the poisonous ma- 
terial, saliva, and often either liquid or grumous blood. 
The stomach is so irritable that any substance, no matter 
how bland or how small in volume, is instantly rejected. 
Even cool water, in teaspoonful doses, is not retained. 
The thirst is intense and the bowels are constipated, un- 
less some violent irritant has entered the intestine, when 
there may be active and painful purging. The urine 
is almost or quite suppressed. There is often violent 
headache, but the intellect is unimpaired. The face is 
haggard and expresses fright or apprehension. In the 
advanced stages of fatal cases the eyes are sunken, the 
features pinched, and the color ashen. The pulse is fre- 
quent and compressible. The temperature is at first ele- 
vated, sometimes to a point between 102° and 103° F., but 
is, later, depressed. The respirations are frequent, super- 
ficial and irregular. The surface is at first hot and dry, 
andlateriscold. Sometimes there is icterus from involve- 
ment of the duodenum. In cases ending in recovery, 
gradual amelioration of all these symptoms occurs. In 
fatal cases asthenia ensues, ending in collapse, which 
quickly closes the scene. If perforation of the stomach 
occurs, fatal shock follows, or, if the patient survive the 
shock, peritonitis causes a lethal issue. 

Differential Diagnosis.—T he diagnosis is generally easily 
made. Remittent or typhoid fever of slight severity 
may be mistaken for subacute gastritis, but the reverse 
error is more likely to occur, particularly in the case of 
children. 
ease which arrests the secretions and invites fermenta- 
tion. Under these circumstances, care must be exercised 
lest one or the other ailment be overlooked. An exam- 
ination of the spleen and of the blood, and the use of the 
thermometer, may decide the question by revealing the 
absence or presence of conditions characteristic of ma- 
larial or of typhoid fever. Leube considers the presence 
of herpetic vesicles as quite characteristic of gastritis. 

Chronic meningitis may simulate subacute gastritis, 
especially in young subjects, being attended with fre- 
quent vomiting, which is, however, explosive and not 
accompanied by nausea, or by epigastric tenderness. 
There is, moreover, obstinate constipation in meningitis, 
while gastritis in children is usually complicated by en- 
teritis, which causes diarrhcea. In the early stages of 
meningitis the pulse is rather diminished in frequency 
than accelerated, while the reverse obtains in gastritis. 
In meningitis there are jactitation and intolerance of 
light and sounds. 

Prognosis.—Subacute gastritis almost invariably ends 
in recovery, or at most, in badly managed cases, may 
terminate in chronic gastritis. Acute gastritis, from cor- 
rosive poisons, iscommonly fatal from collapse or shock. 
Alcohol in excessive quantities often produces the same 
result, particularly in cases attended with asthenia from 
repeated debauches. 

Various complications of acute gastritis may contribute 
to the fatal issue. Chief among these are peritonitis from 
gastric perforation ; the effect on the nervous system, inde- 
pendent of their local action, of some corrosive poisons, 
like arsenic ; cedema glottidis, and enteritis. Assequele, 
may be mentioned gastrectasia, from fibroid constriction 
following ulceration of the pyloric orifice, and cesopha- 
geal obstruction from the same cause. 

Treatment. — The indications for treatment, in sub- 
acute gastritis, are to remove irritating substances from 
the stomach and to prevent the ingestion of such arti- 
cles; to allay the irritation of the mucous membrane, 
and to temporarily procure for the organ partial or 
complete relief from the performance of its functions. 
The measures adapted to meet these indications will vary 
with the severity of the gastric inflammation. In the 
mildest cases, nothing is required beyond a reduction of 
the diet to the minimum quantity consistent with ade- 


634 


Gastritis is often produced by any febrile dis- | 


| 


quate support of the patient, and the exclusion of all 
irritating foods. Peptonised milk, or milk and Vichy 
water, in equal parts, with toast or toasted crackers, may 
be given, in six- or eight- ounce doses, at intervals of three 
hours. The writer is in the habit of prescribing a pow- 
der containing from three to eight grains of sodium bi- 
carbonate and from ten to thirty grains of bismuth sub- 
carbonate, before each drink of milk and Vichy water, or 
of peptonised milk. The former ingredient is intended 
to neutralize abnormal acids which may have been 
formed in the stomach as the result of fermentations, and 
the latter to soothe the irritated mucous membrane. If 
there be physical evidences of prolonged retention of 
food in the stomach, an unirritating laxative, as Hun- 
yadi Janos water, citrate of magnesia, or a seidlitz pow- 
der, may be administered at the outset. If there be jaun- 
dice, a few grains of calomel may be given and followed, 
in a few hours, by the saline laxative. In subacute gas- 
tritis complicating gastrectasia, the writer has had good 
results from the gentle use of the soft syphon-tube, ac- 
cording to the method described in the section which 
treats of Gastrectasia. By lavage, irritating matters are 
at once withdrawn, and the proper dietetic measures are, 
subsequently, doubly efficacious. Daily laxative enemata 
are also to be recommended, besides demulcent drinks, in 
small quantities, between the doses of milk. 

In more acute gastritis, attended by considerable vom- 
iting and febrile disturbance, the ingestion of aliment is 
to be still farther restricted, or even suspended, for a few 
hours or days. In these cases nature has generally ful- 
filled the first indication for treatment, viz., the removal 
of irritating substances, as is proven by the rejection of 
simple mucus or of bile, occasionally mingled with blood. 
Here no evacuant is necessary, and neither emetics nor 
the syphon-tube are permissible. In acute gastritis com- 
plicating atonic gastrectasia, however, the tube may still 
be employed, as the dilated stomach can be quickly re- 
lieved of its irritating contents by this means alone, and 
enteritis from decomposed foods is, also, thus avoided. 
The first duty of the physician, in these cases, is to allay 
gastric irritability, which may generally be effected by 
placing the patient in bed, withholding all food and 
drink, applying a sinapism or blister to the epigastrium, 
and by administering morphia, in doses of one-eighth or 
one-fourth grain, either dry upon the tongue, or dis- 
solved in a teaspoonful of water. Ifthis be rejected, the 
vomiting may be controlled by a moderate dose of mor- 
phia, given hypodermatically or by the rectum. In all 
but the most severe cases, small bits of ice, given every 
few minutes, are very grateful to the patient, mitigating 
his thirst and cooling the inflamed stomach. Sponging 
the surface of the body with tepid water also allays thirst 
and fever. If, however, even the ice-water be not re- 
tained, urgent thirst may be relieved by rectal injections 
of lukewarm water, preceded by alaxativeenema. Laud- 
anum, given in the water by rectum, obtunds the sensi- 
bility of that viscus, thus favoring the retention of the 
water, and also controls the gastric tenesmus, the pain, 
and the emesis. This method of administering the opi+ 
ate is to be strongly recommended whenever the hypo- 
dermatic use of an opiate is objectionable. "When the 
vomiting has been so far ‘controlled that cracked ice is 
tolerated and may be relied upon to assuage the thirst, 
or before this time, if the patient be in urgent need of 
nourishment and support, nutritive enemata may be giv- 
en instead of those composed of pure water, or of water 
and opium. It is under these circumstances that rectal 
alimentation renders its most striking and signal services. 
The enemata are not to exceed five ounces in quantity, and 
are to be given every four or six hours. Peptonised milk 
is, in the writer’s opinion, the aliment best adapted for 
administration by the rectum, as it is practically digested 
and need only be absorbed by the bowel. Leube’s meat 
solution, as modified by Rosenthal, and defibrinated blood, 
and Rudische’s beef peptonoids, are also of great value. 
Even sweet milk, to which the white of an egg has been 
added, given with pepsin and pancreatic extract, is of 
undoubted service. A few drops of laudanum, added to 
each enema, prevent the development of rectal tenesmus 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Stomach, 
Stomach, 


and exert a desirable tranquillizing influence. Alcohol 
may be added, if necessary, for purposes of support, and 
is particularly useful in asthenic cases of alcoholic gas- 
tritis. Laxative enemata are required, once or twice a 
day, to clear the bowel of undigested matters. When the 
stomach will tolerate food, the peptonised milk, or the 
milk and Vichy water, are to be given in small quantities, 
tentatively, next the carbo-hydrates and fats, and finally, 
after some days, the solid proteids. 

The treatment of toxic gastritis, due to corrosive poi- 
sons, has been considered under the heading Poisons, 
Corrosive, and claims only a passing notice in this place. 
The first therapeutic measure indicated in these cases, is 
the prompt administration of such antidotes as are in- 
dicated, and, next, the expulsion from the stomach of 
the poisons. The poisons may be best removed by the 
soft stomach-tube, to which the stomach-pump may be 
attached in case of necessity. After the withdrawal of 
the toxic substances, appropriate emollients and sedatives 
are in order. The subsequent treatment is identical with 
that of ordinary acute gastritis. During convalescence 
from subacute or acute gastritis, great care should be 
taken to adapt the foods to the capacity of the enfeebled 
stomach, lest chronic gastritis or atonic gastrectasia be 
developed. The early use of tonics and of stimulants is 
contra-indicated on account of their irritating action. 
The appetite will generally be restored by nature, pari 
passu with the ability to digest substantial nourishment, 
but a feeble digestion may well be assisted by five grains 
of pepsin, and fifteen or twenty drops of dilute hydro- 
chloric acid, given in water, an hour after each meal. 

II. CHronic Gastritis. Ltiology.—Most cases of 
chronic gastritis have their origin in antecedent subacute 
or acute gastritis, their causes being essentially the same 
as those of the latter forms of gastric disease. Some of 
the etiological agents of gastritis are, however, more 
prone than others to occasion chronic gastritis, because 
their influence is more protracted. This is true of all 
chronic, wasting diseases, and of all sources of chronic 
malnutrition which, by occasioning anzemia, gastric atony 
and, probably, degeneration of the gastric vessels, inter- 
fere with the normal secretion of the gastric juice, enfee- 
ble the muscular coats of the stomach, and thus invite 
_ inflammation. In this category belong phthisis, cancer, 
gout, chronic nephritis, syphilis, rheumatism, chronic 
malarial disease, neurasthenia, rigid dieting, long fasting 
and old age. All causes of protracted obstruction to the 
portal circulation tend to produce chronic gastritis, by 
maintaining a venous congestion of the stomach. This 
group of causes, in which all diseases obstructing the 
pulmonary circulation are prominent members, has been 
sufficiently considered under the etiology of subacute and 
acute gastritis. Men suffer more frequently than women 
from chronic gastritis. Fenwick and Striimpell believe 
in the existence of a hereditary tendency to chronic gas- 
tritis. Among the exciting causes of chronic gastritis are 
to be particularly emphasized repeated over-indulgence 
in foods, whether digestible or comparatively indigesti- 
ble, the habitual use of over-stimulating aliments, imper- 
fect mastication, and alcoholic excesses, or even the use 
of moderate quantities of alcohol when the stomach is 
empty. Even perfectly simple food, in proper quantities, 
may cause chronic gastritis in an enfeebled stomach, or 
in one still feeling the effects of antecedent inflammation. 
Another exciting cause is the abuse of irritating drugs, 
such as cathartics and tonics, or of medicinal substances 
which diminish the secretions and retard gastric peristole, 
as opium and cocaine. Many gastric diseases either pre- 
dispose to chronic gastritis or excite it. Among these 
diseases are gastrectasia, suppurative gastritis, cancer 
and ulcer. 

Morbid Anatomy.—The stomach, when affected by 
chronic inflammation, may be either normal in size, di- 
lated, or smaller than in health. The pyloric region of 
the stomach is generally the seat of the most marked 
pathological changes. The mucous membrane is com- 
monly abnormally vascular, and covered with a deposit 
of thick tenacious mucus, or of thinner muco-pus con- 
taining epithelial cells. The membrane may be thickened 


or thinned, In the earlier stages, there is more frequently 
general thickening and opacity, while diffuse thinning 
and transparency correspond to the atrophic changes of 
a later period in the disease. Thickening and thinning 
often, however, coexist, producing, by their combination, 
alternating prominences and depressions in the mucous 
membrane. This is the condition to which the name 
état mamelonné was given by Louis, Diffuse thickening 
of the pyloric mucous membrane may occasion stenosis 
of the pylorus, followed by gastrectasia. Small cysts, 
produced by the distention of obstructed gastric follicles 
with a clear fluid, are often observed, and, more rarely, 
polypi composed of hypertrophied connective tissue and 
hyperplasia of the gastric tubules. The consistency of 
the mucous membrane is, in some cases, increased, and in 
others diminished. The membrane is rough when thick- 
ening coexists with thinning, but it may be smooth when 
extensive atrophy exists alone. The color of the mucous 
membrane may be white, ashen, red, reddish-blue, slate- 
colored, reddish-brown, or black. Ecchymoses and so- 
called hemorrhagic erosions are not rare, and many of 
the above-mentioned variegated tints are produced by 
the more or less complete reabsorption of hemoglobin. 
Little points of a darker hue than the surrounding mem- 
brane are found, on microscopic examination, to consist 
of pigment particles, either free or inclosed in cells, be- 
tween or within the tubules. The microscope generally 
shows, in the thickened parts of the mucous membrane, 
dilatation of the vessels, proliferation of connective tis- 
sue, sometimes hypertrophy of the submucous and mus- 
cular coats, and enlargement with distention of the gastric 
tubules, from parenchymatous and fatty degeneration of 
their epithelium. In the thinner portions of the mucous 
membrane the vessels are of small calibre. Some of the 
tubules are diminished in size, being filled with granular 
detritus resulting from degeneration of the epithelium, 
and others are quite obliterated by the pressure of sur- 
rounding, new-formed connective tissue. The cysts al- 
luded to above are also due to partial obstruction of the 
tubules by connective tissue and their consequent disten- 
tion with their perverted secretion. W. Fox has observed 
fatty degeneration of the connective tissue in some cases 
of chronic gastritis. The gastric solitary glands, when 
present, are often hypertrophied. 

Clinical History. — Given the morbid anatomical 
changes of chronic gastritis, the symptoms of the dis- 
ease are referable to certain perversions in the functional 
activity of the stomach. Chief among these is the inter- 
ference with the normal secretion of gastric juice. The 
effects of the diminution of this fluid are the retardation 
of digestion and the occurrence of butyric, lactic, acetic, 
or alcoholic fermentation. These fermentations do not 
occur in a healthy stomach, because the normal gastric 
juice is capable of destroying the living ferments which 
cause these retrograde changes in the food. The acids 
generated by these fermentative processes, being them- 
selves irritating, add to the existing inflammation, while 
the gaseous products of the fermentations overdistend 
the stomach, and retard the peristaltic movements of that 
organ by inducing atony of the muscular coats. The 
free acid of the gastric juice is, moreover, held, by many 
writers, to be an essential stimulus to the gastric peristole, 
and the absence of the normal quantity of this acid may, 
accordingly, be unfavorable to the production of natural 
gastric contractions. Since successive contact of the 
food with all parts of the mucous membrane is essential 
to the due stimulation of glandular activity, the delayed 
peristole itself further indirectly reduces the amount of 
gastric juice, which is already diminished by glandular 
degeneration and atrophy. Another bad result of the 
impaired contractile power is the prolonged retention of 
the undigested contents of the stomach, by which fuller 
opportunities for decomposition are afforded. The gastric 
mucus, which, in chronic gastritis, is secreted in abnor- 
mally large quantities, hinders digestion mechanically, 
by coating the food with a comparatively impenetrable 
material, and chemically, since its alkalinity partly neu- 
tralizes the acid of the gastric juice. It is well known 
that the bulk of peptones elaborated in the stomach are, 


635 


Stomach. 
Stomach, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


under physiological conditions, directly absorbed from 
that viscus. Chronic gastritis greatly impairs absorption 
by causing inefficient muscular contractions, and, prob- 
ably, by leading to degenerative changes in the gastric 
absorbent vessels. It has, moreover, been demonstrated 
that the presence of unabsorbed peptones directly retards 
the further transformation of proteids into peptones. The 
individual symptoms of chronic gastritis will be better 
understood and more readily interpreted, if these devi- 
ations from the regular course of physiological gastric 
digestion be constantly borne in mind. 

The morbid phenomena of chronic gastritis may be 
classified as subjective and objective. 

(a) Subjective Symptoms. A prominent subjective 
symptom is the loss or the perversion of appetite. Usu- 
ally there is indifference and often absolute repugnance 
to food. Sometimes, however, there is a morbid craving 
for stimulating foods and beverages. When the inflam- 
mation is of a comparatively low grade, there may even 
be a moderate appetite, which, however, is succeeded by 
a sense of repletion after the ingestion of a small quan- 
tity of food or drink. Thirst is an almost constant symp- 
tom, and is, usually, most troublesome in the evening. 
Patients commonly complain of a bad taste in the mouth 
and of dryness of the buccal mucous membrane. There 
is, generally, persistent epigastric discomfort, burning, 
or oppression, which is accompanied by tenderness, is 
most marked after meals, particularly if the food be 
stimulating, and may at times be replaced by more or 
less acute pain. Eructations, either acid or tasteless, py- 
rosis, nausea, and vomiting are common, taking place, 
most frequently, soon after meals. In mild cases vomit- 
ing does not often occur, and it is an unusual symptom 
in chronic gastritis complicating atonic gastrectasia. 
With habitual drinkers, morning vomiting is common, 
and is known to the laity as water brash. Headache is a 
prominent symptom. Itis generally frontal or temporal, 
and of a dull character. At times it becomes acute, lan- 
cinating, and even excruciatingly severe. The other lead- 
ing subjective symptoms are vertigo, fatigue, disinclina- 
tion for either physical or mental labor, and generally 
great depression of spirits, sometimes amounting to hypo- 
chondriasis. These nervous symptoms are all probably 
the joint effect of anemic neurasthenia and of auto-infec- 
tion with ptomaines. The bowels are constipated, unless 
there be coexistent entero-colitis, in which case there may 
be diarrhcea. Flatulence is common. Heemorrhoids are 
caused by the constipation. The sleep is disturbed by 
restlessness and by distressing dreams. The urine is 
scanty and high-colored, or the reverse in cases of long 
standing. There may be cardiac palpitation and so-called 
‘‘hot flashes,” from temporary facial and cerebral con- 
gestion. This symptom chiefly occurs in women. Dys- 
pnoea may be occasioned by the encroachment of a tym- 
panitic stomach upon the thoracic space. 

(0) Objective Symptoms. The patients are, as a rule, 
more or less emaciated and anemic, their muscles being 
atrophic and their expression apathetic or melancholy. 
The skin is dry and of a grayish tint, unless there be 
icterus from concomitant duodenitis, which is not rare. 
The tongue is commonly pale, flabby, and covered with a 
whitish or a brownish-white coat, through which en- 
larged papille may sometimes be seen. The tongue is 
occasionally red and glazed. The borders of the tongue 
sometimes bear the impress of the teeth. Salivation is 
common. The gums are pale and swollen, the breath 
fetid. The pulse is normal in frequency or slightly 
quickened. In old people, the pulse may be remarkably 
slow and feeble. It is generally small and compressible ; 
it may be irregular and intermittent. There is often 
slight fever, particularly during the exacerbations of the 
symptoms corresponding to intercurrent attacks of more 
acute gastritis. The urine is, ordinarily, of a high spe- 
cific gravity and of dark color, and is frequently laden 
with amorphous urates. Uric acid and oxalate of lime 
are common urinary deposits, and the mucus is often 
abnormally abundant. On the other hand, the urine 
may, in cases of long standing, be of low specific gravity 
and of a pale color, its reaction being neutral or alkaline, 


636 


and its sediment containing amorphous and crystalline 
phosphates. The epigastrium is generally sensitive to 
pressure, and is often distended. A succussion sound 
may sometimes be obtained, even in an undilated stom- 
ach. Caries of the teeth has been noted by some authors. 
Considerable interest attaches to the character of the 
matters spontaneously rejected, or artificially withdrawn 
from the stomach. The microscope shows these matters 
to consist chiefly of mucus, gastric epithelium, and rem- 
nants of undigested food, with the occasional admixture 
of blood, saccharomyces, sarcine ventriculi. and various 
bacteria. The reaction of the contents of the stomach is 
generally acid, from the presence of either hydrochloric, 
butyric, acetic, or lactic acid. The existence of hamor- 
rhagic erosion may be suspected if much blood be vomit- 
ed. The presence of lactic acid may be demonstrated by 
means of a test-liquid composed of ten cubic centimetres 
of a four per cent. solution of carbolic acid, twenty cubic 
centimetres of distilled water, and a drop of liquor ferri 
perchloridi. The blue color of this mixture is changed 
to yellow by free lactic acid. Striimpell recommends a 
solution of methyl violet as a test for hydrochloric acid, 
which turns this reagent blue, and the same author 
makes favorable mention of Uffelmann’s test, which con- 
sists of the pigment derived from the common blueberry 
or huckleberry. This pigment is turned a bright-red by 
free hydrochloric acid. The so-called ‘‘ water-brash,” re- 
jected by habitual drinkers, is usually alkaline, and prob- 
ably partly consists of saliva swallowed during sleep. In 
the chronic gastritis secondary to Bright’s disease, traces 
of ammonium carbonate are found in the vomited matter. 
If it be deemed essential that the physician obtain definite 
data regarding the time consumed in digestion and the 
presence of the products of fermentation in the stomach, 
the gastric contents may be removed by a soft-rubber tube 
in the manner described in the section on Gastrectasia, 
six or seven hours after the ingestion of food. If undi- 
gested remnants of food are obtained, it is safe to assume 
the existence of impaired digestion, and diminished mus- 
cular power on the part of the stomach. By means of 
the tests given above, approximately accurate data relat- 
ing to the relative amounts of hydrochloric and of lactic 
acid may be otained. 

Differential Diagnosis.—Ulcer, cancer, dilatation of the 
stomach, and atonic dyspepsia may be mistaken for 
chronic gastritis. The differential points between the first 
three diseases and chronic gastritis will be found in the 
articles devoted to these subjects. Atonic dyspepsia 
presents few of the symptoms of irritation and none of 
the signs of inflammation characteristic of chronic gas- 
tritis. In dyspepsia there is hardly any febrile move- 
ment. In gastritis this occurs more frequently. In 
dyspepsia there is less often nausea and vomiting than 
in gastritis. Indyspepsia there is little thirst, in gastritis 
often tormenting thirst. In dyspepsia the tongue is 
often clean, in chronic gastritis almost always coated. 
In dyspepsia the appetite is generally good, and often 
ravenous, while anorexia is common in gastritis. In 
dyspepsia stimulating foods are best tolerated, in gas- 
tritis bland ones. In dyspepsia there is less gastric 
pain, tenderness, and burning than in gastritis. In dys- 
pepsia the urine is generally normal, in chronic gastritis 
abnormal, containing urates, uric acid, and oxalates. In 
dyspepsia there is often no loss of weight, while emacia- 
tion is the rule in chronic gastritis. 

Prognosis.—The duration of chronic gastritis, even 
when due to causes susceptible of removal, is long, par- 
ticularly if the disease be wrongly treated or neglected. 
Relapses are common after apparent cures, and alternate 
with attacks of more acute gastric inflammation. Chronic 
gastritis dependent upon incurable diseases of other 
organs, as of the heart, lungs, or liver, is naturally not 
amenable to curative measures. Chronic gastritis is not 
in itself directly fatal, but, if protracted, may induce 
such a degree of asthenia as to incapacitate the patient 
for resisting intercurrent acute diseases, and may eventu- 
ally lead'to atonic or obstructive gastrectasia. 

Treatment.—The treatment of chronic gastritis resolves 
itself into (a) the prophylactic, and (+) the curative treat- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Stomach. 
Stomach, 


ment. While the former has for its object the prevention 
of gastritis, the latter aims at fulfilling existing casual and 
symptomatic indications. 

(a) Prophylaxis. The aggregate suffering caused by 
chronic gastritis is enormous, and preventive medicine 
finds in this disease one of its widest and most fruitful 
fields. It is the physician’s duty to instruct the heads of 
the families intrusted to his care how to avoid all pre- 
ventable causes of chronic gastritis, and these are enum- 
erated in the writer’s remarks concerning the etiology of 
this affection. Since recurrent attacks of subacute and 
acute gastritis strongly predispose to chronic gastritis, 
these should be carefully avoided. All remediable condi- 
tions causing anemia and malnutrition must be removed, 
while incurable chronic diseases should receive appropri- 
ate palliative treatment. This remark is particularly ap- 
plicable to diseases causing portal obstruction and con- 
sequent venous congestion of the stomach. Nearly all 
the exciting causes of chronic gastritis are avoidable if 
the patient only has sufficient moral force to control the 
cravings of appetite. The physician should, therefore, 
insist upon moderation in eating and in the use of alco- 
holic drinks, upon thorough cooking, upon the banish- 
ment of the elaborate products of the French cuzsine, and 
upon the avoidance of drugs which irritate the stomach 
or check either its movements or its secretion. 

(6) Curative Treatment. The indications for the cura- 
tive treatment are causal and symptomatic. 
predisposing and exciting causes are, if possible, to be re- 
moved, and physiological rest provided for the stomach. 
Thus, diseases of the heart, lungs, and liver, which lead 
to secondary gastritis, are to be relieved, and the labor of 
digestion reduced toa minimum. Even in a mild case it 
is desirable to adopt simple measures for cleansing the 
stomach of mucus and of undigested food. This may 
generally be efficiently accomplished by the use of a large 
glass of warm or cool water on retiring, and again in the 
morning, as long as possible before the first meal. The 
benefit resulting from this measure is referred to the 
cleansing and quieting effect of the water, which carries 
away much of the accumulated mucus and any residue 
of undigested food into the intestine. Sometimes laxa- 
tive enemata, with water taken as above suggested, suffice 
to produce efficient alvine evacuations. <A seidlitz powder 
may, however, be given, at first every morning or every 
second morning, to clear the intestine of undigested food 
and of accumulated mucus. Should this not prove 
sufficient, two grains of calomel triturated with milk- 
sugar may be administered every second evening. Care- 
ful and explicit dietetic rules must be framed for each 
patient in accordance with his personal necessities, for 
while the principles directing the treatment of all cases 
are the same, allowance must be made for individual 
idiosyncrasies and for varying physical conditions. All 
irritating foods and drinks are to be absolutely forbidden. 
This rule excludes very hot or very cold articles, alcohol, 
spices, condiments, and decided acids, which are chemi- 
cally irritating, and all bulky, rough, or indigestible ali- 
ments, which mechanically excite the inflamed mucous 
membrane. All readily fermentable foods are, at first, 
to be withheld. In this category must be placed the 
sugars, starches, and fats, whether alone or in the form 
of cakes and pastry, where they are found in proverbially 
fatal combinations. Cooked fats seem particularly indi- 
gestible, while small quantities of cream and butter are 
sometimes well tolerated, Even uncooked fats, however, 
impede gastric digestion by encasing other foods ina 
covering more or less impenetrable to the watery gastric 
juice. The best food for the great majority of cases is 
milk. Sweet milk may be given undiluted, or diluted 
with pure water or with Vichy water, the proper pro- 
portions of each being determined by experiment. The 
writer commonly begins with one-fourth Vichy water 
and three-fourths milk, gradually decreasing the propor- 
tion of Vichy water. If sweet milk is not well toler- 
ated, it may be peptonised, or butter-milk may be tenta- 
tively employed. Whichever variety of milk is selected 
ought, in the writer’s opinion, to be persistently employed 
until the subsidence of the graver symptoms betokens 


Existing 


relief of the inflammation. The quantity of milk should 
be about two quarts in the twenty-four hours, and the 
intervals at which it is taken may vary from two to four 
hours. Should milk, in any form, be so repulsive to the 
patient that his repugnance cannot be overcome, Leube- 
Rosenthal’s meat solution may be substituted. In the 
intervals between the feedings thirst may be allayed by 
frequent sips of cool water or of carbonated water. 
When nausea, thirst, and fever have disappeared, more 
solid foods are gradually to be added to the menu. Those 
most likely to be tolerated are soft-boiled eggs, cold roast 
mutton, and stale bread well toasted. With these solids 
small quantities of weak tea or of weak percolated coffee, 
without sugar, may be used as beverages. The quantity 
of solid food at first employed must be smaller, and the 
meals more frequent, than in health. The patient should 
be impressed with the absolute necessity of very slow 
and thorough mastication. At a more advanced stage 
of convalescence other meats, such as roasted, broiled, 
or boiled mutton, tender broiled beefsteak, as well as 
broiled oysters and tender chicken, may be used. Rare 
roast beef may, finally, be taken in small quantities, 
preferably finely scraped and seasoned only with salt. A 
little rice, well boiled, may next alternate with the toast, 
and, finally, other vegetables may be tried. The best 
vegetables are well-boiled rice, baked potatoes, tender 
carrots, very young pease and tender asparagus. The 
length of time during which this treatment must. be car- 
ried out can only be determined by experiment in each 
case. The least symptom of a relapse, during the use of 
solid food, should serve as a warning that the milk diet 
is to be resumed for a season. 

Few drugs are necessary in the treatment of this dis- 
ease. Since the gastric juice is deficient in chronic gastri- 
tis, it may well be replaced by pepsine and hydrochloric 
acid. The former may be exhibited in five-grain doses, 
after each meal. The acid is best administered in doses of 
from five to ten drops, from one-half to one hour after 
food. If there be notable acidity of the stomach, as 
proven by cardialgia and acid eructations, a few grains 
of sodium bicarbonate may be given before each drink of 
milk, or before each solid meal. Should the stomach be 
unusually sensitive to pressure, twenty or thirty grains 
of the subcarbonate of bismuth may be combined with 
the soda. If epigastric sensitiveness be extreme, emesis 
common, or pain severe, small doses of hydrocyanic acid, 
cocaine, codeia, morphia, or hyoscyamus may be exhib- 
ited. In all cases counter-irritation of the epigastrium 
is good, and, in obstinate cases, even moderate vesication. 
Constipation is to be relieved by small doses of calomel 
triturated with sugar, given every second evening, and 
followed the next morning, if necessary, by a small dose of 
Hunyadi Janos water, or by a seidlitz powder. The sa- 
line laxatives act best on an empty stomach, and their 
effect is more speedy and complete if they are given 
warm. Should there be marked gastric tympanites, 
thirty-grain doses of pure willow charcoal will be found 
useful as an absorbent of the gases. It is, however, more 
rational to prevent the fermentations causing gaseous ac- 
cumulations by decreasing the amount of food and by 
increasing the pepsin and hydrochloricacid. Antiseptics 
are rarely necessary, but naphthaline, in five-grain doses, 
has, in the writer’s experience, quickly relieved gastric 
tympanites not readily controlled by other means. Sali- 
cylic acid and the sulphites have been found equally 
efficient, but more irritating. Intestinal tympanites is 
commonly easily overcome by salol, in doses of from two 
and a half to five grains, administered at intervals of 
from two to four hours. The bad taste in the mouth is 
greatly diminished by thoroughly cleansing the tongue 
with a soft rag or brush, and by lotions containing a few 
drops of the tincture of myrrh, or a few grains of car- 
bolic acid to the ounce. When epigastric tenderness has. 
quite disappeared, a bitter tonic, preferably the tincture 
of nux vomica, or the infusion of gentian, may be spar- 
ingly used to restore tone to the weakened stomach. 
Anemia is to be combated by the mildest ferruginous 
preparations. After complete subsidence of the gastric 
symptoms, habitual constipation may be relieved by 


637 


Stomach, 
Stomach. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


small doses. of aloes and rhubarb in combination, or by a 
pill composed of aloin, 4 grain ; strychnine, 74> grain ; and 
extract of belladonna, 4 grain. Great attention should 
be also paid to general hygiene, all patients being con- 
strained to keep early hours, to lead lives so far as possi- 
ble free from excitement, and, above all, to exercise mod- 
erately in the open air. The clothing should be warm, 
and the functions of the skin should be maintained by cool 
sponge-baths. In obstinate cases, washing the stomach 
is a measure of inestimable value. By this method the 
stomach is at once relieved of accumulated mucus, undi- 
gested aliment, acids and gas. The use of hot or cold 
water and of cathartics is thus, in a large measure, obvi- 
ated, and the bowels may be relieved by enemata. The 
writer’s method of employing lavage is given in the sec- 
tion on Gastrectasia. Lavage is, at first, best performed 
every morning, an hour before breakfast. After a short 
time the washing may be done every second morning, 
and then, at lengthening intervals, until convalescence 
is established. In cases requiring the use of the tube, the 
other therapeutic measures are, in general, identical with 
those already described as applicable to less severe cases 
of chronic gastritis. In the most refractory and chronic 
cases it may be necessary to temporarily resort to rectal ali- 
mentation, in the manner recommended under the cap- 
tion Acute Gastritis. The efficacy of the above treatment, 
systematically followed, is generally quickly manifest in 
the relief of symptoms, in the augmentation of weight 
and in the increase of mental and of bodily energy. 

SUPPURATIVE GASTRITIS. Definition. — Primary or 
secondary suppurative inflammation of the stomach, usu- 
ally affecting the submucous tissues, but sometimes in- 
volving other coats of the organ. 

Etiology.—The causes of primary suppurative gastritis, 
which is very rare, are not well known. — The disease af- 
fects men more often than women, and middle-aged 
persons rather than the young or the aged. It has been 
referred to traumatism, gastric ulcer, the abuse of alco- 
hol and to dietetic indiscretions. Silcock reports a case 
following gastrostomy. In many cases no adequate 
cause has been ascertained. Secondary, or metastatic, 
suppurative gastritis, which is more frequent than the 
primary form, occurs as a complication of acute infec- 
tious diseases, especially of puerperal septicemia and py- 
zemia, 

Morbid Anatomy.—The suppuration may be either cir- 
cumscribed or diffuse. The former variety is known as 
abscess of the stomach, which may be single or multiple. 
It is less rare than diffuse suppurative gastritis. In gas- 
tric abscess the pus first collects in the submucous tis- 
sues, whence it sometimes makes its way between the 
muscular layers and into the subserous tissue, or may 
even perforate the mucous and serous layers, pus being 
then evacuated into the stomach or into the peritoneal 
cavity. The abscess is sometimes, however, confined to 
its original seat in the submucous tissues. If the serous 
coat is involved, general peritonitis may follow. Ex- 
ceptionally the abscess cavity may close after the escape 
of its contents, and cicatrization, occurring, may lead to 
gastric stenosis. In diffuse suppurative gastritis the pus 
is also first formed in the tunica submucosa, whence it 
may invade the intermuscular connective tissue, the sub- 
serous structures, the mucous membrane, and the se- 
rous coat. In rare instances the inflammatory process is, 
however, confined to the submucosa. The suppuration 
commonly involves only a part of the gastric parietes, 
but it may be coextensive with them, and may even in- 
vade the duodenum and the cesophagus. Diffuse and 
circumscribed purulent gastritis sometimes coexist. The 
parts of the stomach affected are swollen, and the mu- 
cous membrane over the seats of purulent collection is 
cedematous and spongy, or perforated and ulcerating. 
The ulcers may be single or multiple. There may be 
evidences of pre-existing chronic gastritis or of fibroid 
gastritis. The serous coat frequently becomes inflamed, 
and general peritonitis may be the result. Thrombi some- 
times form in the veins of the stomach, and parts of the 
thrombi, becoming detached, produce metastatic abscesses 
of the liver and of the lungs. The microscopical ex- 


638 


~marked at the pylorus. 


amination of the purulent matter often shows numerous 
streptococci and other bacteria. 

Clinical History.—Primary suppurative gastritis may be 
acute or chronic. In either case the symptoms are the 
same, except in their duration. The initial symptom is 
generally a chill, which may or may not be repeated at 
irregular intervals. Fever follows, with a rapid compres- 
sible pulse and a high temperature, scanty urine, torment- 
ing thirst, headache and anorexia. There is generally 
much nausea and vomiting, as well as great epigastric 
pain and tenderness, with meteorism, although these feat- 
ures are not invariably present. The vomited matter 
sometimes contains pus, but ordinarily only mucus, gas- 
tric juice, or bile. Sometimes a tumor, corresponding to 
an abscess, may be felt in the wall of the stomach. If 
the abscess ruptures into the stomach, large quantities 
of pus may be vomited. If perforation occurs into the 
peritoneal cavity, symptoms of shock appear and are fol- 
lowed by those of acute peritonitis, if the patient survives 
a sufficient length of time. Jaundice is sometimes pres- 
ent, and there may be either diarrhoea or constipation. 
Asthenia appears early in the disease and deepens into 
collapse, death being commonly preceded by delirium and 
coma. Secondary suppurative gastritis presents essen- 
tially the same symptoms, but they are generally com- 
pletely masked by those of the primary complaint (v7de 
article Septiceemia and Pyemia, in this HANDBOOK). 

Callow’s case, recited by Leube, presented no symp- 
toms up to the day of its fatal termination, when rupture 
of the gastric abscess took place, emesis occurred, and 
speedy collapse followed. 

Diagnosis.—The diagnosis can rarely be made during 
life, although the disease may be strongly suspected 
when, coincidently with the existence of the above symp- 
toms, a soft gastric tumor is felt, which suddenly disap- 
pears simultaneously with the vomiting of a large quan- 
tity of pus. Circumscribed suppurative peritonitis might, 
however, present almost identical symptoms. 

Prognosis.—This, although very grave, is not absolutely 
desperate, as some apparently authentic cases of recov- 
ery have been reported. Death usually ensues in about 
a week, but life may, in cases eventually fatal, be pro- 
longed three weeks or longer. : 

Treatment. — The treatment is purely symptomatic. 
Pain and emesis are to be relieved by the hypodermic 
use of morphine, rest of the stomach secured by rectal 
alimentation, and the strength sustained by fearless 
stimulation. Some authors recommend the persistent 
application of ice to the epigastrium, and the administra- 
tion of small ice-pellets by mouth. In secondary sup- 
purative gastritis the primary disease naturally claims 
appropriate treatment, 

CHRONIC INTERSTITIAL GASTRITIS AND HYPERTROPH- 
1c Pytoric Stenosis. Definition.—Thickening of the 
stomach, either general or limited to the pyloric region, 
due chiefly to the development of new connective tissue, 
with which hyperplasia of the muscular coat is usually 
associated. 

Hiiology.—Cases of this disease are so rare that few 
opportunities have been afforded for the discovery of its 
causes. It affects middle-aged men most frequently, but 
has been observed in young men, in women, and, very 
rarely, in children. Chronic interstitial gastritis is of- 
ten associated with simple chronic gastritis, but there is 
no proof that it is produced by the latter disease. The 
abuse of alcohol is regarded as an exciting cause by the 
majority of authors, but the circumstances under which 
alcohol leads to this form of gastric inflammation, rather 
than to chronic gastritis, are not definitely known. 
Welch observed a case in which there were syphilitic 
gummata of the liver, and Snellen reported a case in 
which the disease followed an injury to the epigastrium. 
Many cases of hypertrophic pyloric stenosis are believed 
to owe their origin to the cicatrization of a gastric ulcer. 
Others are without evident cause. 

Morbid Anatomy.—The pathological changes may af- 
fect the whole stomach equally, or they may be most 
When the whole stomach is in- 
volved, the organ is generally heavier and smaller than 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. . 


normal. ‘The capacity of the stomach may be reduced 
to a few ounces, and its size to that of a small pear, which 
fruit it somewhat resembles in shape. The gastric wall 
has, in some recorded cases, been more than an inch 
thick. The dimensions of the stomach may, however, 
be either normal or abnormally large. Upon section 
the stomach sometimes does not collapse as in health, 
owing to the thickness and firmness of its walls, the con- 
sistency of which often resembles that of cartilage. The 
minute examination of the tunics of the stomach shows 
all the coats of the organ to be structurally altered by 
that growth of new connective tissue which is character- 
istic of the disease. The submucous tissues are usually 
most involved, and the submucosa thus stands out upon 
cross-section as a broad, firm, whitish layer. The mu- 
cous membrane sometimes escapes alteration, but gen- 
erally the microscope shows the gastric tubules to be 
compressed, or even obliterated, by hyperplasia of the 
intertubular connective tissue. In this case, the cellular 
elements present the same microscopical changes found 
in simple chronic gastritis (guod vide). The muscular 
layer is often greatly thickened, particularly in its trans- 
verse fibres, by hyperplasia of the muscular fibres and of 
the interfibrillary connective tissue. The subserous and 
serous coats are similarly thickened, the latter being 
opaque and of a milky-white color. The entire peri- 
toneum may, rarely, present a similar thickening, or only 
the visceral layer may be affected. Welch states that 
adhesions frequently exist between the stomach and sur- 
rounding organs. When the above-described interstitial 
changes involve only the pyloric region, hypertrophic 
stenosis of the pylorus is said to exist. The result of 
these localized pathological processes is, as the above 
name implies, a more or less complete occlusion of the 
pyloric orifice. Owing to the obstacle opposed to the es- 
cape of the gastric contents, the latter accumulate, and, 
overdistending the stomach, produce gastrectasia, to 
which is added hypertrophy of the muscular coat. 

Clinical History.—The symptoms of chronic interstitial 

gastritis are variable and ambiguous. In some cases there 
have been no symptoms, or these have been of so trivial 
a character that they have been referred to functional 
dyspepsia. Ina case reported by Nothnagel the disease 
presented the characteristic features of pernicious ane- 
“mia. If the disease involves the entire stomach, one 
somewhat characteristic symptom, at a late stage of the 
malady, may be inability on the part of the patient to 
take more than a very limited amount of food or drink 
without a disagreeable sensation of distention referred 
to the epigastrium. At this advanced period of the dis- 
ease the hardened and contracted stomach may be recog- 
nized by abdominal palpation, presenting the peculiar 
form and outline of the normal organ. In such a case 
the exact capacity of the stomach may be ascertained by 
first removing all the gastric contents with the soft tube, 
and then introducing water from a graduated receptacle 
until a sensation of discomfort is perceived. Before the 
development of the symptoms mentioned there may be 
those of a protracted chronic gastritis—vomiting, emacia- 
tion, and asthenia being particularly prominent clinical 
features, while pain is almost or quite absent. Some- 
times there is, however, violent gastralgia. In that form 
of chronic interstitial gastritis known as hypertrophic 
stenosis of the pylorus, the clinical history corresponds 
to that of obstructive gastric dilatation, to which the 
reader is referred. The symptoms of dilatation are 
sometimes preceded by those of chronic gastritis. The 
hypertrophic pylorus can occasionally be made out by 
abdominal palpation, and is apt to be mistaken for a car- 
cinomatous tumor. 

Differential Diagnosis. —Diffuse chronic interstitial gas- 
tritis is to be distinguished from simple chronic gastritis. 
The distinction can only be made with an approach to 
certainty when, in the later stages of the disease, a con- 
tracted and hardened tumor, presenting the contours of 
the stomach, can be mapped out. 

Hypertrophic stenosis of the pylorus may be mistaken 
for atonic dilatation of the stomach and for cancer. The 
differential points between hypertrophic stenosis of the 


Stomach, 
Stomach, 


pylorus and atonic dilatation are stated in the section on 
Gastrectasia. Cancer can, generally, be excluded by at- 
tention to the following points: Patients with carcinoma 
have almost always passed middle life, while stenosis of 
the pylorus may affect the young. In cancer there is 
often a family history pointing to that disease. In hy- 
pertrophic stenosis this is not true. In cancer the dura- 
tion of the disease is short, usually under two years; in 
hypertrophic stenosis it may be long. In cancer there is 
commonly much pain ; in stenosis there is generally lit- 
tle or none. In cancer haematemesis is common, but it 
is rare in simple stenosis. In cancer there is a peculiar 
cachexia, which is absent in hypertrophic stenosis. In 
cancer there may be secondary hepatic carcinomata, 
while metastasis does not, of course, occur in stenosis. 
In cancer the tumor is tender on pressure, while in hy- 
pertrophic stenosis it is not so. 

The prognosis of chronic interstitial gastritis, of either 
form, is serious, the patients ordinarily succumbing to 
inanition and asthenia, 

The treatment of chronic interstitial gastritis, when 
diffuse, embraces the exclusion of all irritating ingesta, 
the use of bland, and, if necessary, of predigested foods, 
given in small quantities and at frequent intervals, and 
the employment of rectal alimentation. In cases of hy- 
pertrophic stenosis of the pylorus the treatment is the 
same as that recommended in the following section.on 
Gastrectasia. : 

DILATATION OF THE STOMACH (GASTRECTASIA). De- 
jinition.—That condition of the stomach in which the 
organ is both abnormally capacious and inadequate to 
the performance of its functions, 7.¢., the digestion and 
absorption of some foods and the propulsion of other ali- 
mentary materials into the intestine. Two forms of gas- 
trectasia are recognized, namely, hypertrophic dilatation, 
in which the gastrectasia is preceded or accompanied by 
muscular hypertrophy, and atonic dilatation, in which 
no compensating hypertrophy occurs. 

Htiology.—The classification of the causes producing 
gastrectasia, suggested by Professor William H. Welch 
(Pepper’s ‘‘ System of Medicine,” vol. ii., p. 591, edition 
1885), is so clear and comprehensive that the writer in- 
troduces it in this place. The three causative conditions 
recognized in Professor Welch’s classification are: L., 
Stenosis of the pylorus and of the duodenum; II., ab- 
normalities in the contents of the stomach ; and III., im- 
pairment of the muscular force of the stomach. These 
general causative conditions may be again subdivided 
into the following tabulated classes. It will be noticed 
that causes belonging to Class I. occasion dilatation with 
hypertrophy, while those of Classes II. and III. lead to 
atonic dilatation. 

I. Stenosis of the Pylorus or of the Duodenum. 1, 
Cancerous; 2, cicatricial; 8, hypertrophic (of pylorus) ; 
4, from external pressure; 5, congenital (of pylorus) (?) ; 
6, from torsion of duodenum. 

II. Abnormalities in the Contents of the Stomach. 1. 
Ingesta: (a) Excessive; (0) imperfectly masticated ; (c) 
indigestible. 2. Stagnation and fermentation in conse- 
quence of chemical insufficiency of the stomach, as in 
chronic catarrhal gastritis and functional dyspepsia. 

Ill. Impairment of the Muscular Force of the Stom- 
ach. 1. Organic changes in muscular coat: (a) Partial 
destruction by ulcers and cancers; ()) inflammation, as 
in chronic catarrhal gastritis and peritonitis ; (c) degen- 
erations (fatty, colloid, amyloid); (d) cedema (?); (e) 
cirrhosis of stomach. 2. Mechanical restraint: (a) By 
adhesions ; (0) by weight of hernie. 3. Impaired nutri- 
tion and general muscular weakness, adynamic dilata- 
tion from typhoid fever, tuberculosis, aneemia, ete. 4. 
Paresis from neuropathic causes (?). 

Obstruction at the pylorus, or near that orifice, in the 
duodenum, is the most important cause of gastrectasia, 
which is, generally, of the hypertrophic variety, ¢.¢., ac- 
companied by hypertrophy of the gastric muscles. Hy- 
pertrophy of these muscles may, however, sometimes 
quite compensate the obstructive lesion, in which case 
gastrectasia does not ensue. In almost all cases of hy- 
pertrophic gastrectasia the order of events is as follows : 


639 


‘ Stomach. 


Stomach, 


First, obstruction, then compensatory hypertrophy with- 
out dilatation, and, finally, hypertrophic dilatation in 
which the dilatation eventually preponderates. 

I. Stenosis of the Pylorus or of the Duodenum. Py- 
loric stenosis is more frequently due to cancer than 
to any other morbid condition, and the next most fre- 
quent cause is contraction of cicatrices resulting from 
pyloric gastric ulcers. Duodenal stenosis, leading to dil- 
atation of the stomach, may also be brought about by 
cicatrices and tumors of that part of the intestine or by 
external pressure. Under the caption Chronic Interstitial 
Gastritis it has been stated that this disease, when limited 
to the region of the pylorus, may cause obstruction of 
that orifice, and stenosis may, very rarely, be caused by 
sarcomata, myomata, fibromata and other benign tumors. 
The most common causes of stenosis from external press- 
ure are tumors, such as hepatic carcinomata, and con- 
tracting cicatricial bands resulting from circumscribed 
peritoneal inflammation. The question of the existence 
of congenital pyloric stenosis is still swb gudice, Landerer 
reported ten cases of supposed congenital stenosis of the 
pylorus, but his conclusions regarding their congenital 
character have not been generally accepted. Torsion of 
the pylorus or of the duodenum, or traction upon these 
parts by complete inguinal hernias, particularly by those 
containing the transverse colon or the omentum, may lead 
to stenosis of the intestine, and to secondary gastrectasia. 

II. Abnormalities in the Contents of the Stomach. 
These abnormalities relate either to the character of the 
gastric contents or to unnatural fermentations in the 
food. Ingesta may be abnormal in quantity, in quality, 
or in their preparation. Vegetable foods, if relied upon 
to the exclusion of animal diet, may induce dilatation 
because of the large volume of aliment required, and 
liquids, as ice-water or beer, may act in the same way, 
when ingested in considerable quantities. Foods which 
are difficult of digestion, either because not easily penc- 
trated by the gastric juice or because readily fermentable, 
may cause atonic dilatation ; and the same is true of raw 
and of imperfectly cooked aliments, and of those not 
thoroughly masticated and insalivated. It is possible that 
the long continued abuse of drugs which diminish the 
secretions of the stomach, or which inhibit its peristole, 
may also contribute to the development of atonic gas- 
trectasia. Atonic dilatation is, moreover, often brought 
about by repeated attacks of indigestion and of gastritis, 
which favor the retention and decomposition of the con- 
tents of the stomach. In these cases both the secretion 
and the peristaltic movements are inhibited, and abnor- 
mal fermentation is the inevitable result. Fermentation 
leads to the evolution of gases which distend the stomach, 
and of acids—chiefly acetic, butyric, lactic and hydro- 
sulphuric acids—which by their irritating character ag- 
gravate the pre-existing inflammation. 

Ill. Impairment of the Muscular Force of the Stom- 
ach. Diminution in the muscular power of the stom- 
ach may be due to the various organic lesions of the 
gastric parietes enumerated in the above table. The 
weakening effect of chronic gastritis and of peritonitis 
has been already alluded to. Ulceration, whether simple 
or carcinomatous, and of varying depth, may diminish 
the stomach’s contractile power, as well as amyloid, col- 
loid and fatty degeneration of the gastric muscles, and 
the changes incident to chronic interstitial gastritis. 
Among the remaining tabulated causes of atonic dil- 
atation should be emphasized the general weakness and 
atony of all the bodily tissues, resulting from anemia, 
acute febrile diseases and chronic wasting affections. 
Fenwick refers to a case, reported by Willis, in which 
primary paralysis of the stomach followed an injury to 
the splanchnic nerve. It is often quite impossible to as- 
sign a single definite cause for the occurrence of dilata- 
tion in an individual case, as several etiological agents 
are almost certain to co-operate in its production. This 
is particularly true of gastritis, muscular insufficiency, 
and fermentation, which most frequently go hand in 
hand, and which are, to a large extent, interdependent. 
Diabetic patients suffer from gastrectasia on account of 
the polyphagia characteristic of their primary disease, and 


640 


- REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


a sedentary life, combined with a generous diet, has the 
same result. Hypertrophic dilatation of the stomach is 
most frequent after middle life, because cancer, the chief 
cause of this variety of gastrectasia, develops at that age. 
Atonic dilatation is most common in middle life, but may 
occur at any age. When occurring in childhood it par- 
ticularly affects rachitic children. 

Morbid Anatomy.—While the post-mortem recognition 
of largely dilated stomachs presents hardly any difficulty, 
that of slightly and of moderately dilated stomachs may 
be impossible, because of the wide limits within which 
the size of the normal organ varies. If a reliable history 
can be obtained, the clinical test of gastrectasia, viz., in- 
ability of the stomach to empty itself, may be utilized in 
making a post-mortem diagnosis. Even when the stom- 
ach reaches below the umbilicus, it is not necessarily di- 
lated. Perfectly normal stomachs, which are of a looped 
shape, or which occupy a vertical position such as exists 
in fetal life, may extend considerably below the navel. 
A. Flint, Sr., states that tight-lacing may depress the 
stomach to a notable extent. The size of a dilated stom- 
ach may, on the one hand, be so small that the clinical 
test of insufficiency is necessary to render the diagnosis 
at all certain, or, on the other hand, may be such that the 
stomach contains gallons of liquid, occupies nearly the 
whole abdomen, and reaches nearly or quite to the iliac 
bone. Cases have been reported in which the dilated 
organ descended even into the true pelvis, or into the sac 
of a complete inguinal hernia. Stomachs which are the 
seat of hypertrophic dilatation from obstruction are gen- 
erally of larger dimensions than those affected by atonic 
dilatation. The fundus becomes first dilated, and al-- 
though the entire organ may subsequently be involved, 
the fundus remains more largely dilated than the cardiac 
and the pyloric extremities. The increased weight of the 
dilated stomach generally causes it to be displaced down- 
ward, the pylorus occupying a lower plane than normal 
and dragging the duodenum downward from its natural 
position. The stomach thus sometimes comes to assume 
a more vertical position than that of health. If, how- 
ever, the pylorus be fixed, as in cancer, the long axis of 
the organ is more nearly transverse than normal, owing 
to the predominant dilatation of the fundus. In the early 
stages of gastrectasia from obstruction, the walls of the 
stomach are generally notably thickened, especially at 
the pylorus, by hyperplasia of the muscular coat. Ata 
later period of the disease the gastric parietes may be 
found normal in thickness, or even decidedly thinned 
In non-obstructive gastrectasia the muscular coat ma 
be hypertrophied, but it is commonly atrophied. In both 
varieties of gastrectasia fatty degeneration of the mus- 
cular fibres, and a pathological condition described by 
Maier as colloid degeneration of these fibres, is not very 
rare. ‘The mucous and other coats of the stomach ordi- 
narily present in dilatation the changes already described 
as characteristic of chronic gastritis. In addition to the 
morbid anatomical changes peculiar to dilatation, those 
of the primary disease, which has occasioned gastrectasia, 
will be observed. These primary pathological conditions 
are enumerated in the preceding etiological table. If the 
gastrectasia be caused by duodenal obstruction, this part 
of the bowel will be likewise dilated. The cesophagus is 
often dilated in pronounced cases of gastrectasia. The 
liver, spleen, intestine, diaphragm and heart are some- 
times displaced by the enlarged stomach. The spleen, 
liver and pancreas are frequently atrophied. Many 
writers refer these atrophic changes to the pressure of 
the stomach, but they are, more probably, merely subor- 
dinate features of the general emaciation resulting from 
gastrectasia. The pressure of indigestible foreign bodies, 
such as coins or bits of wood, is said by Leube, when long 
continued, to have occasionally produced circumscribed 
or sacculated dilatation of the stomach. 

Clinical History.—The symptoms presented by patients 
suffering from gastrectasia are referable partly to the 
original causative conditions of the disease, and, partly, to 
the dilatation proper. The symptoms due to the causes 
which eventually produce gastrectasia, may exist for a 
long time before the supervention of those denoting dila- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Stomach, 
Stomach, 


tation, and, if properly interpreted, may thus afford an 
indication for the adoption of preventive treatment. 
The symptoms, which are to a certain extent premon- 
itory, as well as concomitant, are usually those of car- 
cinoma or of ulcer in cases of hypertrophic gastrectasia, 
and of chronic gastritis in the early stages of atonic dila- 
tation. These symptoms need not be enumerated in this 
place, as they are given in this article under their respec- 
tive headings. Ationg the symptoms properly referred 
to dilatation, but which do not occur in hypertrophic 
gastrectasia so long as compensation is complete, the 
most prominent is copious vomiting at irregular intervals. 
This symptom is almost constant in dilatation from ob- 
struction of the pylorus or of the duodenum, and is also 
frequent in the earlier stages of atonic gastrectasia. 
When, in either class of cases, the gastric nerves and mus- 
cles have partly sacrificed their functional powers, owing 
to compression, atrophy, or degeneration, emesis becomes 
less frequent and may entirely cease. The most charac- 
teristic features of this vomiting are its copiousness and 
its tendency to a more or less periodical recurrence. 
The volume of vomited matter often far transcends the 
normal capacity of the stomach, sometimes amounting to 
several quarts. The length of time intervening between 
successive acts of emesis varies with the irritability of 
the stomach and with the amount ingested. Two, or 
even more days, however, generally intervene between 
the paroxysms of vomiting, but the interval may be of 
only a few hours’ duration. The emesis commonly oc- 
curs several hours after meals, and is frequently explosive, 
being unaccompanied by notable straining. The vomit- 
ing does not completely empty the stomach, which is 
often found still largely distended after the emesis has 
ceased. The vomited matters consist largely of undi- 
gested food, which fact may be ascertained by macro- 
scopical inspection. In some instances portions of 
aliment taken days before their rejection may be recog- 
nized. Their odor is that of putrefaction. Their re- 
action is acid, from the presence of lactic, acetic, and 
butyric acids, or, rarely, from that of gastric juice. 
Their color varies with their composition. When the 
diet has been a mixed one, the color is generally yellow- 
ish, or brownish-red. Sometimes it is almost black or 
gray, with interspersed clumps of a blackish color. The 
upper layers of the vomited matters are often white and 
frothy. Strings and shreds, apparently of muco-pus, 
are dependent from this layer, reaching for some distance 
below the surface. At the bottom of the vessel are seen 
irregular masses of solid material. 

Microscopically examined, the vomited matter is found 
to contain food particles, either undigested or but partly 
digested, bacilli and other bacteria, sarcine ventricull, 
torule cerevisiz, and other fungi or their spores, crys- 
tals of fatty acids, flat epithelium from the stomach and 
cesophagus, mucus, pus, and occasionally blood-corpus- 
cles. Sometimes hematin is detected by chemical tests, 
when no blood-corpuscles can be recognized, and _ bile 
may be present in sufficient quantity to furnish its char- 
acteristic chemical reactions. Blood is more frequently 
found in cases of gastrectasia from cancer than in simple 
atonic dilatation, while bile is more often present in atonic 
gastrectasia, Various gases are held in solution in the 
vomited matters. Chief among these gases are oxygen 
and nitrogen, in about the same proportions as in the 
atmosphere ; sulphuretted hydrogen, hydrogen and car- 
bonic dioxide. In a case observed at Frerich’s clinic, 
olefiant gas and some undetermined gaseous hydrocar- 
bons were present. In this case the gases burned with 
a yellow flame. In other, comparatively rare, instances, 
the gas burns with a whitish flame. The gases in ques- 

tion mostly result from the abnormal fermentations in 
the stomach, but the nitrogen and oxygen may be swal- 
lowed with the food. Acetic, butyric, lactic and hydro- 
chloric acids are at times present. These, with the ex- 
ception of the last, result from fermentative processes. 
The clinical test of gastrectasia consists in the habitual 
discovery, among matters rejected from the stomach by 
vomiting, or withdrawn by the stomach-tube, of food 
taken on the preceding day, or even earlier, Subacute or 


Vou. VI.—41 


chronic gastritis may cause the retention of food for an 
equal length of time; but, if this test be habitually suc- 
cessful, the existence of gastrectasia may be confidently 
assumed. The error is sometimes committed of consid- 
ering stomachs of unusually large size, as shown by phys- 
ical examination, to be dilated. The weight of authority 
is, however, in favor of regarding only those stomachs 
as dilated which, independently of their capacity, are 
inadequate to the performance of their digestive and pro- 
pulsive functions, 

Physical Signs.—Inspection of the abdomen sometimes 
reveals unusual prominence of the epigastric, of the left 
hypochondriac, and sometimes of other abdominal re- 
gions. If the abdominal walls are thin and relaxed, the 
outlines of the dilated stomach may be distinguished and 
the peristaltic gastric movements studied. This peristole 
may occur spontaneously, or may require to be excited 
by percussion and pressure. The movements begin at 
the cardiac extremity of the organ and slowly pass to- 
ward the pylorus. Rarely they alternately progress in 
either direction. These peristaltic movements are com- 
monly indicative of hypertrophic dilatation, but that they 
are not characteristic of gastrectasia alone is shown by 
their occasional occurrence in healthy stomachs, Kuss- 
maul refers such visible movements, occurring indepen- 
dently of gastrectasia, to a neurosis of the stomach, 
Similar vermiform movements in the intestine may simu- 
late those of the stomach. If, while the abdominal pro- 
tuberance is under observation, about thirty grains of 
sodium bicarbonate and fifteen grains of tartaric acid, in 
separate solutions, be drunk in quick succession, as rec- 
ommended by Frerichs, sufficient carbonic dioxide may 
be generated to more fully distend the stomach, and thus 
to render its outline more clearly apparent. In widely 
dilated stomachs a much larger quantity of these re- 
agents may be necessary to efficiently distend the stom- 
ach. This method of distending the organ is not uni- 
formly successful, inasmuch as the gas may sometimes 
escape into the intestine, through a relaxed pylorus, al- 
most as rapidly as it is generated. The method has, be- 
sides, the disadvantage of occasionally distending the 
stomach to such an extent as to cause severe pain. In 
such an emergency the prompt introduction of the stom- 
ach-tube is indicated, and quickly affords relief. Some 
authors advocate the employment of distention with gas, 
when the stomach is empty, to demonstrate the extent of 
the dilatation, but the method is open to so many objec- 
tions that its usefulness is problematical. Even a healthy 
stomach may be distended to a misleading extent through 
the rapid generation of gas by the method in question, 
and in an organ the walls of which are relaxed by dis- 
ease, the results would be still less reliable. “Were the 
supposed gastrectasia due to malignant disease, the fri- 
ability of the gastric walls might be such that rupture 
would occur from overdistention with the gas. 

Palpation may sometimes enable the examiner to out- 
line the borders of a dilated stomach, to obtain fluctuation 
and to perceive the peristaltic gastric movements. If the 
stomach be not overdistended with liquid, palpation may 
also elicit a splashing sound in the organ, which is, how- 
ever, generally more readily produced by gentle succus- 
sion of the entire abdomen. If succussion be resorted to, 
the patient is requested to lie upon his back and to relax 
his abdominal muscles. The physician then grasps the 
iliac bone and the lumbar region with either hand, the 
thumbs being directed forward, and imparts a quick, lat- 


. eral, vibratory motion to the body, simultaneously apply- 


ing his ear to the epigastrium. ‘This succussion sound is 
only diagnostic of gastrectasia when obtained six or eight 
hours after a meal, or from three to four hours after the 
ingestion of liquids, as it is often heard, under other cir- 
cumstances, in perfectly healthy stomachs. Some persons 
can produce it at will, by rapid movements of the dia- 
phragm, by holding the breath and quickly contracting 
the abdominal muscles, or by simply changing their posi- 
tion. The gastric succussion sound may be almost per- 
fectly simulated by a like splashing sound in the trans- 
verse colon, An accessory diagnostic measure, suggested 
by Leube, consists in feeling, through the abdominal 


641 


Stomach, 
Stomach. 


wall, the end of a hard stomach-tube introduced into the 
stomach. If the tube be felt far below the umbilicus, di- 
latation is, according to Leube, probably present. This 
method is, however, not to be recommended, since the 
hard tube may inflict injury upon the gastric wall, and, 
even when introduced, cannot always be recognized with 
certainty. Oser objects to Leube’s method because the 


sound may slip along the greater curvature, and, bending ~ 


upward, may even reach the pylorus, so that its point will 
be felt far above the most dependent part of the stomach. 
Palpation may show upward displacement of the heart, 
and cardiac arhythmia if the stomach is greatly distended 
‘with gas. 

Auscultation, besides aiding in the detection of the 
gastric succussion sound, may reveal the presence, in the 
stomach, of fine crackling or hissing sounds, produced by 
the bursting of minute bubbles of gas upon the surface 
of the liquid contents of the stomach. This gas, as al- 
ready explained, owes its origin to abnormal fermenta- 
tions. 

Percussion often affords great assistance in mapping 
out a dilated stomach, but, in other cases, the information 
it conveys is negative or misleading, from the fact that in- 
testinal tympanites may displace the greater curvature 
upward or may overlap the stomach to a variable extent. 
Over a stomach which is considerably dilated, and con- 
tains liquid and gas, there is, when the patient is erect, a 
tympanitic percussion note above the level of the liquid. 
The line of flatness is changed, when the patient assumes 
the dorsal or the lateral decubitus, to that part of the vis- 
cus which is the most dependent, while the tympanitic 
resonance is heard over the highest point of the stomach. 
The most rational method of ascertaining the existence 
and the extent of dilatation is, in the writer’s opinion, 
that referred by Welch to Penzoldt. This method con- 
sists in withdrawing all fluids from the stomach by the 
tube, whereupon the pre-existing flatness disappears. If, 
now, a moderate quantity of liquid, from a pint to a quart, 
be introduced through the tube, flatness will reappear. 
If the flatness extends below the umbilicus, dilatation ex- 
ists, and the extent of the gastrectasia may be approxi- 
mately ascertained by noting the lowest level reached by 
the liquid. 

General Symptoms.—The bowels of patients suffering 
from gastrectasia are generally obstinately constipated, 
because a comparatively small amount of aliment gains 
access to the intestine within a given time, and the fecal 
matter is soon deprived of its fluid constituents by the 
intestinal absorbents. The bile and the intestinal juice 
are also reduced to a minimum, and intestinal peristole 
is consequently retarded. Sometimes diarrhcea alter- 
nates with constipation, and is best explained by the as- 
sumption that occasional relaxation of the pylorus al- 
lows the entrance of a large volume of undigested and 
fermenting matter into the bowel. The tongue may be 
either coated or clean. A‘coating speaks for the existence 
of gastritis. The urine is usually acid, scanty, high 
colored, and of high specific gravity, either from retention 
of liquids in the stomach or as a result of coincident gas- 
tritis. The urinary sediment is often abundant, and con- 
tains, chiefly, amorphous urates and oxalate of lime. In 
gastrectasia uncomplicated by gastritis, the specific grav- 
ity may be low and the reaction neutral or alkaline. In 
this case, amorphous phosphates and crystalline phosphates 
of lime and magnesia may be precipitated. Quantitative 
analysis has revealed a relatively small quantity of urea 
and a large amount of phosphates in many of the writer’s 
cases. The pulse is apt to be slow and feeble, the sur- 
face cool and dry, or clammy, and the temperature nor- 
mal. Owing to the lowered vitality, the temperature 
may be subnormal during the early morning hours, In- 
tercurrent attacks of subacute or of acute gastritis may 
reverse these conditions, and the pulse may sometimes 
become irregular, fluttering, frequent, and intermittent 
from disturbed cardiac action due to the pressure upon 
the thoracic viscera of a stomach distended with gas. 
Gastric tympanites may also induce temporary dyspneea. 
Patients are more or less emaciated, in proportion to the 
extent of their gastrectasia and to the nature of its cause. 


642 


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They are ordinarily anemic, nervous, hypochondriacal, 
sleepless, and sometimes apathetic. They suffer from 
headache and nausea, perhaps referable to auto-infection 
with toxic ptomaines, and sometimes persisting for a 
number of days. ‘The appetite is generally diminished, 
and often lost. If, however, there be no gastritis, the ap- 
petite may be good and even ravenous, because of the 
small amount of nourishment assimilated. There is often 
constant and tormenting thirst, only aggravated by the 
ingestion of liquids, because they augment the gastric 
dilatation and still further retard absorption. There is, 
ordinarily, a sensation of gastric oppression and disten- 
tion, at least until the dilatation has progressed so far as 
to paralyze the gastric sensory nerves. This oppression 
is temporarily relieved by emesis. During the earlier 
stages of dilatation there is often acute gastralgia, prob- 
ably due to advancing distention, and generally occurring 
after meals. This pain may be entirely relieved by the 
prompt and efficient use of the stomach-tube. Pyrosis 
and the eructation of badly smelling and tasting gases 
and liquids are frequent symptoms. ‘True epileptic 
convulsions and tetanic spasms may occur in the latest 
stages of gastrectasia, as was first stated by Kussmaul. 
This author holds that they are due to abnormal dryness 
of the tissues from continuous abstraction of fluids, and 
are, hence, analogous to the convulsions in the asphyxia 
of cholera. Kussmaul supports this view by the fact 
that the spasms generally occur after emesis, or lavage 
of the stomach. It is, however, possible that the con- 
vulsions are due to cerebral and spinal anemia, to 
toxseemia from the absorption of ptomaines, or to imper- 
fect elimination of urea. The tetanic spasms involve 
by preference the abdominal muscles, the flexors of the. 
hands and forearms, and the calves of the legs, but 
sometimes affect the muscles of the neck and face. The 
pupils are sometimes contracted, and nystagmus has been 
observed. Consciousness is commonly retained, but oc- 
casionally it is lost. Coma may follow the spasms or be 
developed independently of them. The convulsions may 
be momentary, or they may continue for hours or days. 
They are followed by great asthenia and by tenderness 
over the affected muscles. The spasms are not, in them- 
selves, fatal. 

Diagnosis.— Chronic gastritis may be mistaken for 
slight grades of gastrectasia, but may be differentiated by 
the application of the clinical test for dilatation already 
alluded to, @.e., by ascertaining, with the syphon, wheth- 
er the stomach habitually contains remnants of food. in 
the morning, when the patient rises. If food be thus 
found, dilatation exists. Ascites may be mistaken for 
gastrectasia, but not if moderate caution be observed. In 
hydroperitoneum, flatness exists in the lowest abdominal 
regions when the patient is erect ; the reverse obtains 
in gastrectasia. In simple hydroperitoneum there is no 
succussion sound. In hydroperitoneum the withdrawal 
of fluid from the stomach, by means of the tube, does 
not affect the size of the abdomen nor the area of dul- 
ness. Hydatids of the liver, ovarian tumors, distention of 
the urinary bladder, and pregnancy are said to have been 
mistaken for gastrectasia, but such errors need never oc- 
cur, even to tyros in physical diagnosis. 

Prognosis.—The best prognosis is afforded by cases of 
atonic dilatation without pyloric or duodenal obstruction. 
In these cases, if the dilatation be moderate in degree, a 
cure may be reasonably expected from proper treatment 
persistently pursued. In cases of marked atonic gastrec- 
tasia a complete cure is only rarely effected, and it must 
be admitted that the treatment is usually only palliative. 
Still, even in these cases, marked relief is often obtained, 
the patients gaining in weight and strength sufficiently 
to pursue their ordinary avocations for an indefinite pe- 
riod. <A larger proportion of recoveries would, doubt- 
less, be reported were it not for the fact that patients, 
encouraged by their notable improvement, and presuming 
too much upon their powers of digestion, frequently as- 
sign to the stomach tasks far beyond its capacity to per- 
form, and wilfully violate fundamental dietetic laws. 
The prognosis, in dilatation secondary to obstructions 
which are not cancerous, is less favorable than that of 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


atonic gastrectasia, although life may be considerably 
prolonged and suffering be much relieved by proper ther- 
apeutic measures. In a few cases of cicatricial stenosis 
following ulcer, resection of the pylorus has permanently 
cured when all other means were unavailing. In dila- 
tation from carcinomatous obstruction, the prognosis is 
hopeless. Gastrectasia, when fatal, usually causes death 
from inanition, very rarely by rupture of the stomach. 

| Treatment.—The treatment of gastrectasia embraces 
prophylactic and curative measures. The former are, in 
_ general, deplorably neglected, perhaps because the causes 
of dilatation are not fully understood. Prophylaxis is 
naturally powerless to avert certain obstructive lesions, 
such as carcinoma, but the timely and persistent treat- 
ment of subacute and chronic gastritis, as well as of as- 
thenia and anzemia from various removable causes, might 
often avert atonic dilatation. It is the imperative duty 
of the physician to carefully follow cases of gastritis un- 
til the danger of gastrectasia is averted. Parents and 
guardians of the young should be made to understand 
the far-reaching and disastrous effects of overfeeding, 
and of disregarding so-called dyspeptic ailments of ap- 
parently trivial import. Young persons should be re- 
peatedly warned against improper foods, immoderate 
indulgence and insufficient mastication. The curative 
treatment should aim to fulfil three indications: First, 
to empty and cleanse the stomach, and to prevent the re- 
currence of overdistention ; second, to relieve coexistent 
gastritis ; third, to improve the general condition of the 
patient. The objects accomplished by meeting these in- 
dications are the following: Thorough evacuation and 
cleansing of the stomach relieves tension of the gastric 
walls, placing them in a more favorable condition for re- 
gaining their normal resiliency and contractility. The 
peristole of the stomach is thus, in favorable cases, meas- 
urably strengthened, the secretion of the gastric juice re- 
stored, absorption facilitated and stagnation prevented. 
The removal of tenacious mucus and of irritating fer- 
menting matters diminishes the dangers of auto-infection 
from ptomaines, checks morbid fermentations and sub- 
dues gastritis. The curative efficacy of these measures 
is most plainly manifest in moderate atonic dilatation, 
but even in incurable obstructive gastrectasia they are of 
‘inestimable value in palliating distressing symptoms. 
The relief of gastritis controls the hypersecretion of mu- 
cus, and aids the re-establishment of the normal gastric 
secretion, while improvement of the patient’s general 
condition can but react favorably upon the local morbid 
_ conditions. In cases of moderate dilatation, particularly 
if the patients be women or children, heroic measures for 
the evacuation of the contents of the stomach are unnec- 
essary. Mild cathartics, preferably hot salines, as Karls- 
bad salts, Hunyadi Janos, or citrate of magnesia, em- 
ployed every second day, two hours before the morning 
meal, will usually suffice. In cases of marked gastreeta- 
sia, and in any instance where a speedy result of treat- 
ment is the first consideration, recourse should be had to 
the siphon-tube or to the stomach-pump. The medical 
world is indebted to Kussmaul for first advocating, in 
1867, the systematic employment of these efficient means 
of emptying and cleansing the stomach. The instru- 
ments necessary for the mechanical cleansing of the 
stomach are, respectively, the ordinary stomach-pump, 
with its stiff gum-elastic tube, and a soft elastic stomach- 
tube, or catheter, to which a funnel is adapted, and which 
acts upon the principle of the siphon. The tubes gen- 
erally employed in this country are made of perfectly 
elastic, reddish-brown rubber. Their diameter varies 
from one-fourth to one-half an inch, and their length 
from twenty-four to thirty inches. The writer prefers a 
tube about one-third of an inch in diameter. The so- 
called Faucher tube, much used in Europe, is six feet 
long, and the funnel is directly attached to its proximal 
extremity. The tube should always be new and strong, 
lest a portion be torn away and retained in the stom- 
ach, and it should be provided with two sunken, so-called 
velvet eyes, in order that the friction may be reduced 
to a minimum, and that one eye may remain pervious if 
its fellow becomes obstructed. The catheter proper is 


Stomach. 
Stomach. 


generally connected, by means of a small piece of stout 
glass tubing, with a piece of elastic tubing of about the 
same calibre as the catheter, which, when the tube is in- 
troduced into the stomach, constitutes the long arm of 
the siphon. The elastic tubing should be long enough 
to nearly reach the floor when the patient isseated. The 
use of the stomach-pump is so generally understood that 
any explanation is unnecessary. The pump should, in 
the writer’s opinion, never be used when the soft tube will 
accomplish the object proposed, for the reason that its 
rigid tube is more disagreeable to the patient, and far 
more irritating to the cesophagus and the stomach than 
the elastic catheter. There is, moreover, danger that 
aspiration may be performed with such violence, by 
means of the pump, as to separate portions of the gastric 
mucous membrane. This accident has frequently oc- 
curred, and, although not serious, is still to be deprecated. 
In some instances better results are attained by the pump 
than by the soft tube. This is particularly true when 
a stomach containing large pieces of alimentary matter 
is to be cleansed. . In such a case the eyes 
of the soft tube often become occluded by 
solid masses of food, and the aspirating 
power of the siphon is inadequate to their 
removal. The method of employing the 


' siphon-tube is as follows : 
The patient should as- 
sume the sitting posture, 
throwing his head back- 
ward and holding his 
mouth open. The tube, 
having been lubricated 
with vaseline or oil, is 
introduced into the 
pharynx, and the patient 
is instructed to make re- 
peated movements of deg- 
lutition. The physician 
may hasten the progress 
of the tube and prevent 
its rejection by making moderate pressure upon the 
proximal extremity. The tube, having been introduced 
to the depth of about twenty-six inches, is intrusted to 
an assistant, or to the patient himself, care being taken 
that it be held immovably in one position. This pre- 
caution is necessary, as movements of the tube often in- 
duce nausea and excite reversed cesophageal peristaltic 
movements. The funnel is now attached to the elastic 
tubing, filled with the liquid selected for irrigation, from 
a graduated glass, and elevated a short distance above 
the patient’s head, as shown in Fig. 3733. In propor- 
tion as the liquid escapes from the funnel it is replen- 
ished, until about a pint has been allowed to flow into 
the stomach. Then, before all-the liquid has escaped 
from the funnel, the latter is lowered to a point some feet 
below the stomach, as shown in Fig. 3784, and the con- 
tents of that organ evacuated by the action of the siphon. 
The elastic tube, to which the funnel is attached, should 
be longer than it is represented in the cut. It will be ob- 
served that the tube here shown is the long, continuous 
Faucher tube, often employed in Europe, but little used 
in the United States. When the current ceases to flow 
from the stomach, more liquid is introduced, and the pro- 
cess is continued until the liquid returns as clear as when 


643 


Fre. 3733. 


Stomach. 
Stomach. 


it enters. The tube is then gently withdrawn, its upper 
end being compressed between the fingers to prevent the 
escape of the contained liquid. The liquid best adapted 
to the majority of cases is lukewarm water. Various 
medicaments may be added to the water to meet existing 
indications. If there be much acidity of the stomach 
from morbid processes of fermentation, one-half drachm 
of sodium bicarbonate may be added to each pint of wa- 
ter used. It is held by many that adhesive mucus is 
more easily detached by such an alkaline solution. If 
active fermentation is taking place in the stomach, anti- 
septics may be employed, the best being carbolic acid, 
salicylic acid and resorcin, in one per cent. solutions, 
these solutions being followed by a few measures of pure 
water. In cases characterized by great gastric irritability 
the writer has employed water at a temperature of about 
102° F., with much success. The hot water appears to 
exert a decided sedative action upon the gastric mucous 
membrane, and to cleanse its surface more quickly and 
thoroughly than cool or lukewarm liquids. Certain dif- 
ficulties may attend 
the simple operation 
of lavage. One of 
these relates to the 
introduction of the 
tube. This may be 
rendered very diffi- 
cult by pharyngeal 
or esophageal 
spasm, A _ certain 
amount of pharyn- 
geal spasm generally 
occurs at the first 
introduction. This 
may often be obvi- 
ated by spraying the 
throat, for a few 
minutes, with a two 
per cent. solution of 
hydrochlorate of co- 
caine. Should the 


Fie. 3734, 


spasm prove protracted, the operation may be post- 
poned, ora tube sufficiently stiff to resist the muscular 
pressure may be introduced. After a few introduc- 
tions this is usually unnecessary. Some patients com- 
plain of a sensation of oppression and of dyspnoea 
when the tube is in position. This discomfort is relieved 
by repeated deep inspirations, the air being allowed to 
enter through both mouth and nose. The current of 
liquid may be interrupted by various conditions. One 
of these is occlusion of the eyes of the catheter by food 
or mucus, The obstacle may sometimes be removed by 
voluntary straining efforts made by the patient, the 
breath being held and the abdominal muscles called into 
action, or by forced coughing. The obstruction may be 
temporarily removed by allowing more water to pass 
through the tube into the stomach, and the offending ob- 
ject will then occasionally present its shorter diameter 
to the eye and be expelled. Should all efforts at remov- 
ing the obstruction fail, the tube may be removed, cleaned, 
and reintroduced, or, in the event of recurrent occlusion, 
the stomach-pump may be used. The current occasion- 
ally ceases because the tube has not been introduced to 
a sufficient depth and its eyes are above the level of the 
liquid contents of the stomach. On the other hand, the 
pliable tube, if introduced too deeply, may impinge upon 
the greater curvature of the stomach, or, passing into the 
pyloric region, may bend upon itself, thus checking the 
current. These difficulties are respectively obviated by 


644 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


withdrawing the tube or by introducing it to a greater 
depth. Paroxysms of coughing interrupt the current, 
the continuity of which is re-established by the introduc- 
tion of more liquid. The liquid introduced should always 
be measured and compared with the amount withdrawn, 
in order that no accumulation shall take place. Cases 
have been reported by Jackson and Leube, in which the 
entire tube was swallowed and subsequently rejected by 
vomiting. This accident may be prevented by attaching 
a string to the upper extremity of the tube before its in- 
troduction. The leading contraindications to the use of 
the tube are aneurism of the aorta, recent gastrorrhagia, 
most cases of gastric ulcer, cancer of the cesophagus or 
of the cardiac orifice and marked asthenia. The passage 
of the tube sometimes produces such violent vomiting 
and cesophageal spasm as to cause syncope, in which case 
the simpler methods of cleansing the stomach must be 
relied on. Authorities do not agree regarding the best 
time of day for the operation of lavage. The majority 
are, however, in favor of performing the operation be- 
fore breakfast. The writer prefers this time, because the 
stomach has then had the fullest possible opportunity for 
the digestion and absorption of food. Less chyme is 
thus lost than when lavage is done later in the day. 
Again, the food, having been reduced to a pultaceous 
mass, does not obstruct the tube, and the operation is 
thus accomplished with greater certainty and despatch. 
The stomach should be washed every day at the begin- 
ning of the treatment. Later, if progress be satisfactory, 
it may be washed every second or third day. The fre- 
quency of the operation is, however, to be entirely goy- 
erned by the symptoms in each case. The use of the soft 
tube may be safely left to the patient, after a few lessons. 
The use of the tube should not be continued after the 
stomach is restored to health, and patients should be 
cautioned not to allow the consciousness that relief from 
suffering can be quickly obtained by a resort to the tube 
to betray them into dietetic indiscretions. 

The dietetic treatment of gastrectasia is even more im- 
portant than the mechanical. The objects to be accom- 
plished by regulation of the diet are the prevention of 
fermentation, of overdistention and of irritation. The 
foods selected should, therefore, be mostly solid, small in 
volume, unstimulating, not easily fermentable and not 
hot. They should be taken at intervals of two or three 
hours, in small quantities. Liquids should be taken spar- 
ingly, thirst being relieved by small swallows of water, 
rather than by large volumes taken at one time. Nitrog- 
enous foods are, in general, preferable to the carbo-hy- 
drates and fats, because the former are small in bulk, and 
since the latter, not being acted on by the gastric juice, 
tend to more rapid decomposition and fermentation. Ac- 
cording to this principle, fresh mutton and beef, eggs, 
oysters and tender chicken are ordinarily best tolerated, 
tender cold mutton usually proving the most digestible 
of all these foods. ‘Toasted bread, with a little fresh 
butter, may soon be added to the menu, and weak tea, or 
weak percolated coffee, without sugar, may be sparingly 
used with the meals. If the case progresses favorably, 
other vegetable foods may be tentatively added to the bill 
of fare, and baked apples, with sweet cream, may be used 
asa dessert. All spices and condiments, save a moderate 
quantity of salt, and all alcoholic beverages, are to be rig- 
idly withheld, unless at times of great exposure or of 
marked exhaustion, when pure whiskéy, well diluted, 
may be sparingly taken. Opium, cocaine, and other 
drugs which diminish gastric peristole, are to be for- 
bidden, unless required to meet special indications. In 
the first days of the treatment the writer has often suc- 
cessfully employed a diet composed exclusively of pre- 
digested aliment, in the form of peptonised milk. A 
large part of the milk, being quickly transformed into 
peptones, is absorbed, and the objection usually urged 
against fluid foods—namely, their large bulk—is thus re- 
moved. When this plan is adopted, two or three quarts 
of peptonised milk are given daily, in divided doses, the 
intervals of drinking being from two to three hours. 
Leube-Rosenthal’s beef solution and the so-called beef 
peptonoids of Rudisch are often of great value when milk 


* 


, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


in any form is not well borne. When hardly any food is 
absorbed from the stomach, as in advanced hypertrophic 
gastrectasia, rectal alimentation may prolong life for 
some time. The medicinal treatment of gastric dilatation 
is not complicated. Digestion may be materially assisted 
by the judicious use of pepsin and dilute hydrochloric 
acid, given an hour after meals. Three grains of pepsin 
and five drops of the acid are fair average doses. The 
acid should be well diluted and gradually sipped, rather 
than taken all at once, if the patient’s time will allow. 
Nux vomica or strychnine may be used if a tonic is indi- 
cated, and, aside from meeting this indication, it may 
render some service in increasing the contractility of the 
gastric muscles. Faradic electricity is also useful for the 
same purpose. It may be employed every day for five 
or ten minutes, both poles being applied to the epigas- 
trium, or one pole to that region and the other to the 
lower dorsal region of the spine. If there be notable 
gastric acidity, with eructations, bicarbonate of sodium 
should be taken in twenty-grain doses, with water, ten 
minutes before meals. Constipation may be relieved by 
laxative enemata, or by a pill containing aloin, bella- 
donna and strychnine. Ergotin, hypodermatically admin- 
istered, has been recommended to stimulate gastric peris- 
tole, and an abdominal bandage, if not uncomfortably 
tight, may be useful in supporting the distended stom- 
ach. Abdominal massage improves the tone of the gas- 
tric and of the intestinal muscles. The constitutional 
condition of the patient claims attention. It will gener- 
ally improve par? passu with the stomach. Mild prep- 
arations of iron, such as the carbonate, if well tolerated, 
may be used for anemia. Patients should guard them- 
selves against exposure, since their vitality is lowered and 
their powers of resistance impaired. ‘They should be 
urged to exercise moderately in the open air, always 
within the bounds of slight fatigue, and should sleep 
seven or eight hours at night in well-ventilated rooms, 
resting, as much as possible, upon the right side. This 
position favors the emptying of the stomach, by allowing 
the contents of the organ to gravitate toward the pylorus. 

ACUTE DILATATION OF THE STOMACH.—This term has 
been applied to rapid overdistention of the stomach, sup- 
posed to be due to sudden paralysis of the gastric mus- 
cles and the consequent retention of all fluids and solids 
introduced into the stomach. The chief causes to which 
the overdistention has been referred are abdominal in- 
juries, acute gastritis, acute peritonitis, fevers and bouli- 
mia. It is not certain that true paralysis of the stomach 
~ exists in these cases, nor has it been proved that chronic 


gastrectasia has not preceded the development of sup- _ 


posed acute dilatation. The symptoms usually stated to 
be characteristic of sudden overdistention of the stom- 
ach are severe gastric pain, gastric tympanites, cerebral 
anemia, and the absence of emesis, or its cessation if it 
existed before the occurrence of acute overdistention of the 
stomach. The treatment of overdistention, whether sud- 
denly or slowly developed, embraces lavage, as described 
in the section on gastrectasia, the use of foods both small 
in bulk and easily digestible, the employment of pepsin 
and of hydrochloric acid and the adoption of measures 
calculated to restore vigor to the atonic stomach. 

ULCER OF THE SToOMACH.—Synonyms.: Perforating, 
chronic, round, peptic or digestive, eroding and simple 
gastric ulcer. Theterms perforating, chronic, and round 
are not always appropriate, as many ulcers do not pos- 
sess the characteristics described by these adjectives. 

Frequency.—Gastric ulcer occurs very frequently, and, 
according to many authorities, is found, either open or 
cicatrized, in five per cent. of all autopsies. 

Htiology.——Women between the ages of twenty and 
thirty are particularly liable to ulcer, and, in general, 
females are more often attacked than males, the pro- 
portion being, according to Brinton, as three to two. 
Men between thirty and forty are more liable to the 
disease than at other ages, while children are rarely af- 
fected. Ulcer is more common in anemic, chlorotic, 
and enfeebled subjects than in strong and plethoric per- 
sons, and is more frequent in England and France than 
in the United States. Occupations which engender irri- 


Stomach. 
Stomach, 


tation of the stomach may predispose to gastric ulcer. 
Thus, cooks and knife-grinders, who swallow irritating 
substances, are said to lend a large contingent to: the 
victims of the disease. Injuries of various kinds may 
constitute predisposing or exciting causes of ulcer, as 
will be explained under the heading Pathogenesis. U1- 
cers due to traumatism possess, as was shown by the 
experiments of Cohnheim, an unexplained tendency to 
ready healing, which does not belong to ulcers from other 
causes. 

Pathogenesis.—Nearly all authors agree in regarding 
gastric ulcer as resulting from localized auto-digestion 
of the stomach-walls, and refer this auto-digestion to 
impaired circulation and nutrition in those areas which 
are the seats of the ulcerative processes. There are many 
divergent views regarding the nature and cause of the 
circulatory disturbance in the gastric vessels which is 
assumed to produce ulceration. Virchow holds embo- 
lism or thrombosis of the gastric arteries responsible for 
the vascular disturbances, but his view is not supported 
by anatomical evidence, as has been shown by Cohnheim, 
who, however, together with Panum, produced gastric 
hemorrhagic infarction and ulcers, in dogs, by artificial 
embolic occlusion of the small gastric arteries. Klebs 
believes local spastic contraction of the arterioles to be 
the causative vascular condition. Other writers attribute 
the assumed circulatory disturbances to diseases of the 
gastric arteries, such as amyloid, fatty and atheromatous 
degenerations, to venous thrombosis, to vaso-motor neu- 
rosis and to excessive acidity of the gastric juice. Rind- 
fleisch advanced the theory that the chief vascular dis- 
turbance leading to ulceration was generally heemor- 
rhagic infarction or venous hemorrhage, the ulcer being 
produced, according to this theory, in essentially the 
same way as hemorrhagic erosions. Rindfleisch’s view, 
which has met with general favor, is supported by the 
experiments of L. Miller, who produced gastric hemor- 
rhages, hemorrhagic erosions and ulcers, in rabbits, by 
obstructing the portal vein and the larger gastric veins. 
Various conditions may lead to the venous hemorrhages 
supposed by Rindfleisch to cause ulcer, chief among them 
being spasm of the gastric muscles, by which the thin- 
walled veins are compressed and overdistended (Axel 
Key), varicose veins, passive congestion, and injuries, 
whether mechanical, chemical, or thermal. The nature 
of the changes in the mucous membrane dependent upon 
the above-named disturbances of the circulation, by 
which the membrane is rendered vulnerable to the at- 
tacks of the gastric juice, has also been the subject of 
long controversy. Pavy first formulated the theory that 
auto-digestion was prevented, during life, by the alka- 
linity of the blood coursing through the vessels of the 
gastric mucous membrane, by which the acid gastric juice 
was neutralized. In accordance with this view, impair- 
ment of the circulation would diminish the supply of 
alkaline blood, and the gastric juice would then be free 
to act upon the defenceless tissues. Pavy’s theory is 
widely accepted, although not susceptible of absolute 
demonstration. It is, however, quite possible that some 
unknown vital property of the healthy gastric mucous 
membrane prevents auto-digestion, rather than the alka- 
linity of its contained blood, and that the loss of this 
property, from impairment of the circulation, facilitates 
the action of the gastric juice upon the enfeebled gastric 
tissues. . 

Pathological Anatomy.—Peptic ulcers are produced and 
extended by non-inflammatory, molecular necrosis, which, 
beginning in the mucous membrane, may involve only 
this and the submucosa, or may erode all the coats of the 
stomach. Peptic ulcers are situated in those parts of the 
digestive tract which are accessible to the gastric juice. 
Their favorite seat is in the pyloric region of the stomach, 
on the posterior wall, at or near the lesser curvature. 
Less frequently ulcers are seated in other regions, on the 
anterior wall, or at the greater curvature. They have 
been often found in the cardiac extremity and, rarely, in 
the cesophagus and in the duodenum. Welch analyzed 
a series of 793 gastric ulcers with reference to their seat, 
and found the ulcer at the lesser curvature in 288 cases, 


645 


Stomach. 
Stomach, 


on the posterior wall in 235, at the pylorus in 95, on the 
anterior wall in 69, at the cardiac orifice in 50, at the 
fundus in 29, and at the greater curvature'in 27 cases. 
Usually there is but one ulcer, but two or more ulcers are 
found, according to Brinton’s statistics, in twenty-one per 
cent. of all cases. The size of the ulcer varies from that of 
a pin-prick to a diameter of several inches. Delafield and 
Prudden give six inches as the maximum size. Cruveil- 
hier described an ulcer six and one-half inches in length 
and three and one-half inches in breadth. The average size 
is that of a quarter of adollar. The shape of the ulcer is 
‘commonly round, oval, or elongated, rarely annular, some- 
times irregular, from the coalescence of neighboring ul- 
cers. The loss of substance in the mucous membrane is 
ordinarily greater than in the deeper gastric tissues, so 
that a typical ulcer is of a peculiar funnel-shape, which 
is not, however, constant, particularly in old ulcers. The 
aperture in the mucous membrane is sharply defined in 
recent ulcers, as if a portion of the membrane had been 
removed by a punch. The various deeper layers can 
sometimes be distinguished by the varying extent to 
which they are eroded. Occasionally, however, the walls 
of the ulcer are both vertical, instead of being sloping, 
and sometimes they are swollen and infiltrated with 
blood. Virchow states that the most characteristic ar- 
rangement of the ulcer’s walls consists in one side be- 
ing vertical and the other sloping or terrace-like. Orth 
called attention to the direction of the axis of the ulcer, 
which is often not perpendicular to the mucous surface, 
but obliquely directed, as are the gastric arteries. The 
base of the ulcer is composed of one or the other coat of 
the stomach, unless complete perforation has occurred. 
In this case the base may be formed by the liver, by the 
pancreas, or by some other organ. The base of recent 
ulcers may be smooth and firm, soft, irregular, or hem- 
orrhagic, generally presenting no pus and being devoid 
of granulations. In old ulcers the base is often anemic, 
even, and indurated, the edges being hard and elevated, 
from the development of new connective tissue. The 
tissues in immediate proximity to recent ulcers contain 
granular detritus, composed largely of amorphous rem- 
nants of connective-tissue fibres, of disintegrated red 
blood-corpuscles and of fatty granules. The tubules are 
often compressed and separated from each other by this 
granular matter. Some of the blood-vessels contain 
thrombi. Around the margins of the granular detritus is 
occasionally found a band of tissue infiltrated with lym- 
phoid cells. The blood-vessels*in the newly developed 
connective tissue have their walls thickened by endarteri- 
tis or by atheroma. They sometimes contain thrombi. 
The new tissue may develop in the mucous membrane, 
around the ulcer for a considerable distance, compressing 
or obliterating the gastric tubules, and causing inflam- 
mation and atrophy of the nerve-filaments. The ulcer 
frequently erodes blood-vessels in its wall or on its base, 
causing hemorrhages which, according to the size of the 
vessels, may be trivial, dangerous, or even fatal. Serious 
hemorrhages occur in only about one-third of the cases, 
and generally proceed from the splenic, the pyloric, the 
coronary, the gastro-epiploic, or the gastro-duodenalis 
vessels. Sometimes, however, grave hemorrhage may 
come from erosion of the hepatic, pancreatic and mesen- 
teric arteries and veins, or from varicose gastric veins. 
Peptic ulcers often heal spontaneously, leaving a cicatrix 
which is ordinarily stellate, and which often, in contract- 
ing, produces deformities of the organ or obstruction of 
the pylorus. In the former case the stomach may be di- 
vided into two unequal parts, and in the latter gastrecta- 
sia may result from the obstruction. Ulcers may coexist 
with cancer, and are often complicated by chronic gastri- 
tis. If.an ulcer perforates all the layers of the gastric 
parietes, which occurs most frequently when the ulcer is 
situated on the anterior wall, the contents of the stomach 
may escape into the peritoneal cavity, producing rapidly 
fatal peritonitis ; or if the perforation takes place slowly, 
local peritonitis is developed, and causes adhesions be- 
tween the stomach and other organs which then form the 
floor of the ulcer. Under these circumstances the proc- 
ess of ulceration may invade these organs, especially the 


646 


_ creases, but, rarely, mitigates the pain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ‘ 


liver, producing irregular cavities and, occasionally, ab- 
scesses. The pancreas is not often deeply eroded. The 
ulcer may open into the pleura, the large or small intes- 
tine, the mediastinum, the pericardium, the left ventricle, 
the left bronchus, the common bile-duct, the pancreatic 
duct, the gall-bladder, the lung, on the surface, or into 
the portal vein. When perforation of this vein occurs, 
pylephlebitis is commonly the result. When the stomach 
communicates with the cavities of hollow viscera, or with 
the cutaneous surface, the channels of communication 
are called gastric fistulae. Typhoid and tuberculous ul- 
cers are rarely found in the stomach, but cases have been 
recorded in which they caused perforation and hematem- 
esis. Necrotic gastric ulcers also sometimes occur in diph- 
theria, pyemia and phlegmonous gastritis. 

Clinical History.—In many cases gastric ulcers remain 
entirely latent throughout their course, as is proved by 
the post-mortem discovery of open or of healed ulcers in 
patients who have never presented any symptoms of the 
disease and have died of other complaints. Less fre- 
quently there are no symptoms until perforation sud- 
denly occurs and induces fatal peritonitis or shock. In 
still another class of cases there are distinct symptoms, 
which are, however, not peculiar to ulcer, such as vom- 
iting, eructations, anorexia and pyrosis. Generally, 
however, certain diagnostic symptoms are present, the 
leading ones being pain, localized tenderness and hama- 
temesis. Pain is the most constant symptom of ulcer. 
The pain may be either continuous or intermittent, dull 
and gnawing, or lancinating, confined to one spot or 
radiating into various organs and members. The diffuse 
pains are not characteristic of ulcer, as they may be ex- 
cited by gastritis or by various other causes. The kind 
of pain which, when present, is most characteristic of 
ulcer is circumscribed, gnawing or boring, generally epi- 
gastric or dorsal, or both, appearing soon after the inges- 
tion of food, and generally ceasing when the food has 
been expelled into the duodenum or has been rejected by 
vomiting. This pain is therefore probably due to the 
chemical and mechanical irritation of the food and of the 
gastric juice. It is usually intensified by stimulating ar- 
ticles of diet, and by fermentations producing abnormal 
acids in the stomach, being lessened by bland aliments 
and by the neutralization of the abnormal acids with 
alkalies. When, as occasionally happens, the circum- 
scribed pain persists after the expulsion of the gastric 
contents, it is probably due to localized peritonitis, to 
abscesses in neighboring organs or, in some cases, to 
an abnormal secretion of hydrochloric acid. The pain 
may sometimes be modified by position, the dorsal decu- 
bitus commonly affording relief when the ulcer is on 
the anterior gastric wall, and the prone position when 
the ulcer is located posteriorly. Pressure ordinarily in- 
It is to be borne 
in mind that this pain may sometimes be entirely ab- 
sent in cases of gastric ulcer. Circumscribed tenderness 
on pressure, corresponding to the seat of the ulcer, is. 
a valuable and quite constant symptom. Pressure should, 
however, be carefully employed, as it has been known 
to cause perforation. Vomiting is another cardinal and 
fairly constant symptom, varying greatly, however, as 
to frequency, in different cases. Vomiting may be due 
to coexisting gastritis or to irritation by the ulcer. It 
may occur after cicatrization of an ulcer, from irritation 
of the stomach or from obstructive gastrectasia. Some- 
times it occurs several times daily, and sometimes only 
once or twice a week. When present, emesis usually 
takes place soon after the ingestion of food, particularly 
if the latter be hot or possess irritating mechanical and 
chemical properties, and is preceded by pain. Occasion- 
ally vomiting occurs independently of eating and without 
premonitory discomfort. The act of emesis, although 
generally not violent, results in the complete evacuation 
of the gastric contents and in the relief or marked allevi- 
ation of the pain. The vomited matter contains portions 
of food, mucus, bacteria, sarcinze, occasionally bile and 
sometimes blood. Hematemesis occurs in about twenty- 
five per cent. of all cases. This percentage does not ac- 
curately represent the frequency of. gastrorrhagia, be- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


cause slight hemorrhages often occasion no vomiting, 
and the blood, being digested, does not appear in the 
dejections. Even when large hemorrhages occur, there 
may be no vomiting, but merely more or less marked 
melena. If hamatemesis occurs after a moderate gas- 
trorrhagia, the blood is generally acid, coagulated, and 
resembles coffee-grounds or tar. This appearance is due 
to the action of the gastric juice upon the coloring mat- 
ter of the red corpuscles and upon the proteids of the 
plasma. If the hemorrhage be very profuse, the vom- 
ited blood may be arterial in color, uncoagulated and of 
alkaline reaction. Several pints of such blood may be 
rejected at once. In about four per cent. of all cases the 
hemorrhage is sufficiently profuse to induce fatal col- 
lapse. In such cases all the blood may, sometimes, be 
retained in the stomach, or only a small part of it may be 
vomited. The gross appearance of vomited matters which 
contain blood is ordinarily quite characteristic. In cases 
of doubt, the microscope or the spectroscope may be called 
into requisition. After hamatemesis meleena may persist 
for several days. Perforation of the ulcer into the peri- 
toneal cavity occurs in about six and a half per cent. of 
all cases, and is generally rapidly fatal either from shock 
or from acute peritonitis. Perforation is, in certain rare 
cases, the first and only symptom of an ulcer. Perfora- 
tion occurs most frequently in females between the ages 
of fifteen and thirty years, the proportion of cases occur- 
ring in females and males being, respectively, as three to 
one. Ulcers on the anterior wall of the stomach cause 
perforation more frequently than those in other locations. 
When gases escape from a perforated stomach the liver, 
unless adherent, may be pressed backward and the nor- 
mal hepatic flatness replaced by tympanitic resonance. 
If the perforation is small, it may cause localized peri- 
tonitis with adhesions to, and abscesses in, the various 
organs invaded, and generally proves lethal by exhaus- 
tion. In this way sub-diaphragmatic abscesses, simulat- 
ing pneumo-pyothorax, may occur, or, adhesions between 
the stomach, the diaphragm and the pleura having taken 
place, the pleura and lung may be perforated and pul- 
monary abscess and gangrene excited, or pleuritis and 
pneumo-pyothorax induced. If the perforation occurs 
into the colon, feeces may be vomited. Rarely, the peri- 
cardium is invaded, and pericarditis results, or the portal 
vein is penetrated, and pylephlebitis with pyzmia fol- 
lows. Perforation is usually caused by some sudden 
exertion, as lifting, coughing and vomiting, or by over- 
distention of the stomach with gas or food. The general 
_symptoms in progressive ulcers are chiefly those of in- 
digestion and the consequent malnutrition. The patients 
lose weight and strength, and, if hemorrhage occurs, be- 
come more or less anemic and cedematous. After large 
hemorrhages this anemia may become acute.. The 
symptoms of chronic gastritis are commonly present. 
The bowels are ordinarily constipated and amenorrhcea 
is frequent. In some cases, however, there is hardly any 
interference with the general condition, and even the 
presence of large ulcers may not be incompatible with 
fairly good health. The cicatrization of ulcers may 
cause gastralgia, from traction upon the peritoneum, or 
it may lead to gastrectasia. Relapses, after apparent re- 
covery from ulcer, are not rare. 

Diagnosis.—Many gastric ulctrs, presenting no diag- 
nostic symptoms, necessarily escape observation. None 
of the cardinal symptoms of ulcer is absolutely pathogno- 
monic, but, when associated, they usually render the diag- 

nosis sufficiently clear to justify the adoption of measures 
adapted to the cure of ulcers. The characteristic features 
of the pain of ulcer are its localization, its aggravation by 
eating and by pressure, and its relief by evacuation of the 
stomach and by changes of posture. Heematemesis is the 
most important symptom of ulcer, and in young people 
should always excite suspicion of its existence. 

The differential diagnosis lies between ulcer, gastralgia, 
chronic gastritis, cancer, hematemesis without ulcer and 
so-called biliary colic. 

Gastralgia is not accompanied by tenderness, being 
rather relieved by pressure, and is paroxysmal, while the 
pain of ulcer is often continuous, and is aggravated by 


Stomach, 
Stomach, 


pressure. Eating does not usually excite simple gastral- 
gia, but mitigates it. Vomiting is not so constant in sim- 
ple gastralgia as in ulcer, and does not relieve the pain. 

Hematemesis is not a symptom of gastralgia. The 
general health is often but little impaired in gastralgia, 
which often coexists with neuralgias in other organs. 
Chronic gastritis may be confounded with ulcer and, in- 
deed, generally complicates the latter. Existing alone, 
it may even have all the cardinal symptoms of ulcer, but 
toaless degree. Thus, hamatemesis is more rare, vomit- 
ing less common, and the pain less severe, more dissemi- 
nated, and not paroxysmal. The results of treatment are 
less marked and speedy in chronic gastritis than in ulcer. 
The differential points between ulcer and cancer will be 
found in the remarks upon the diagnosis of cancer in 
the section on that subject. Hamatemesis from various 
causes other than ulcer is to be excluded by careful at- 
tention to the history of each case (wide article Hema- 
temesis in this HANDBOOK). So-called biliary colic, from 
the passage of biliary calculi, has some symptoms in 
common with ulcer, but the pain is situated in the right 
hypochondrium, and sometimes radiates to the right 
shoulder. The pain begins and ends abruptly, without 
reference to the ingestion of food. There is no epigastric 
tenderness. Jaundice is usually present. Biliary calculi 
are sometimes found in the dejections, after an attack. 
Sometimes the liver and the gall-bladder are enlarged in 
cases of biliary colic. : 

Prognosis.—It is estimated that about fifteen per cent. 
of all gastric ulcers end in recovery by cicatrization, the 
prospect for this desirable termination being good in pro- 
portion as the ulcer is superficial and recent, the patient’s 
general condition good, and the treatment judicious. The 
causes of death are chiefly perforation, which ends fatally, 
according to Welch, in about six and a half per cent. of 
all cases ; hemorrhage, which is fatal in about four per 
cent. of all cases; and inanition, which is mainly respon- 
sible for the high average rate of mortality. Perforation, 
which is most common with ulcers on the anterior wall 
of the stomach, causes death by shock, by general peri- 
tonitis, or by localized inflammations. Yet some cases 
of slight perforation recover by the gradual subsidence 
of the resulting inflammatory complications, or by evac- 
uation of abscesses. A profuse hemorrhage is of bad 
prognostic import, betokening deep ulceration and caus- 
ing anzemia, which itself predisposes to the development 
of new ulcers. Continuous pain, irrespective of the in- 
troduction of food, is an unfavorable symptom, pointing, 
together with a rise of temperature, to extra-gastric in- 
flammation. Ulcers may be indirectly fatal even after 
their cicatrization, by causing gastrectasia, sacculation of 
the stomach, or, very rarely, rupture at the seat of the 
cicatrix. The duration of the disease is most uncertain, 
varying from a few days to many years. Brinton reports 
a case in which the ulcer continued open for thirty-five 
years, and several cases the duration of which was thirty, 
twenty, and fifteen years, respectively. The prognosis 
for a cure of old ulcers is naturally less favorable than 
for recent ones, since the fibroid thickening in the bor- 
ders of the ulcers retards the progress of cicatrization. 
Relapses, after apparent complete cicatrization, are quite 
common, and carcinoma may develop from the floor of 
the cicatrix. 

Treatment.— Whenever the symptoms are such as to 
render the existence of gastric ulcer even probable, ap- 
propriate treatment should be at once begun and persist- 
ently carried out. The objects of the treatment are to 
secure as absolute rest as is possible for the stomach, to 
prevent all chemical and mechanical irritation of the ul- 
cer, to relieve pain, to prevent vomiting, and to check 
hemorrhage, if these symptoms exist, to sustain the pa- 
tient’s strength, and to overcome his anemia. The first 
two indications are best fulfilled by keeping the patient 
in bed, in that position which gives him the greatest com- 
fort, and by withholding all food from the stomach. In 
some recent cases, the patients possessing a fair amount 
of strength, rectal alimentation may be exclusively em- 
ployed for some weeks, and, in every case, it 1s desirable 
that no food be taken by mouth for at least several days. 


647 


Stomach, 
Stomaeh, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Persistent vomiting and gastrorrhagia, at any period of 
the treatment, also naturally constitute urgent indications 
for rectal alimentation. The methods of preparing and 
of using nourishing rectal enemata, in cases of ulcer, are 
the same as those described under the treatment of gas- 
tritis, to which the reader is referred. The best materials 
for alimentary injections are Leube-Rosenthal’s beef so- 
lution, Rudisch’s beef peptonoids and peptonised milk. 
The last is prepared by means of Fairchild and Foster’s 
peptonising tubes, to be obtained of any druggist. The 
quantity of these substances which the rectum will toler- 
ate, and the length of the intervals between the enemata, 
can be best ascertained by trial. In general, from four 
to six ounces of fluid may be injected every three or four 
hours, a simple cleansing enema being also daily em- 
ployed, and a few drops of the tincture of opium being 
added to each nutritive enema, for the purpose of ob- 
tunding the sensibility of the rectum and facilitating the 
retention of the enema. It would be advantageous to 
continue rectal alimentation until the evidences of com- 
plete cicatrization were obtained. In practice, however, 
this method is often objectionable, on account of aversion 
on the patient’s part, and because it does not adequately 
sustain the vital forces. So soon, therefore, as these ob- 
stacles are encountered, rectal alimentation is to be sup- 
plemented or superseded by stomach-alimentation, unless 
pain and hemorrhage absolutely contra-indicate feeding 
by the mouth. The foods recommended for rectal injec- 
tion are also the best for use under these circumstances, 
and the writer gives the preference to peptonised milk. 
The food selected should be taken at intervals of two or 
three hours, and in small quantities. Urgent thirst may 
be quenched by cracked ice, in small pieces, dissolved 
slowly in the mouth. If none of the above-named foods 
be obtainable, sweet milk is the next best article of diet. 
Of this about two quarts should be given daily, and no 
other aliment employed for at least two weeks, unless 
there be considerable loss of weight and strength. Should 
emesis and pain return under this regimen, recourse 
must again be had to rectal alimentation. At the end of 
two weeks, or sooner, if the general condition of the pa- 
tient demand more nourishment and there be no contra- 
indications, other articles of food may be experimentally 
employed. The qualities most desirable in these foods 
are blandness, concentration, softness and freedom from 
a tendency to fermentation. At first, raw eggs may be 
added to the milk and taken soft-boiled or poached ; then 
well-toasted bread, soaked in the milk, thoroughly boiled 
rice, or soda biscuits. Should a diet strictly limited to 
these articles be well borne, rare beefsteak, finely scraped, 
tender mutton-chop, thoroughly minced, stewed sweet- 
breads, cold roast mutton, raw or slightly cooked oysters, 
and the breast of chicken may be alternately used, in 
small quantities. Baked potatoes with fresh butter, corn- 
starch, sago, and tapioca cooked with eggs and milk, 
may also be allowed. All cooked fats, strong acids, 
spices and condiments, cheese, pickles, pastry, coarse 
and irritating foods such as cabbage and oatmeal, liquors, 
wines, and fruits, are to be carefully avoided. Violent 
exercise should not be taken. All these foods should be 
taken moderately warm, and should be eaclustvely used 
until cicatrization is believed to be complete, when the 
patient may gradually add any easily digestible foods to 
his menu. He should, however, ever after his attack, 
rigidly exclude all coarse, irritating, and indigestible ali- 
ments from his diet. A relapse should be the signal for 
an immediate return to the simplest foods or to rectal 
alimentation. Comparatively little can be accomplished 
by medicinal agents for the cure of ulcer. Great benefit 
is, however, often derived from the use of antacid reme- 
dies for the relief of pain due to the presence of abnor- 
mal acids, or of excessively acid gastric juice. The bi- 
carbonate of soda fulfils this indication admirably when 
given in twenty-grain doses, before eating, or whenever 
the pain is felt. Bismuth subnitrate, in one-half-drachm 
doses, has rendered good services in some of the writer’s 
cases, and seems especially beneficial in cases of ulcer 
complicated with chronic gastritis. These cases are most 
easily amenable to /avage, which, cautiously performed 


648 


with the soft tube, can hardly do harm unless contra-in- 
dicated by great gastric irritability or by hematemesis. 
If lavage be employed, only about eight ounces of water 
should be slowly introduced at one time, and at once 
withdrawn, care being taken to secure the return of all 
the liquid. Ziemssen advocates the use of Carlsbad salts 
for the relief of the gastritis complicating ulcer. One or 
two drachms of the salts are to be dissolved in one-half 
pint or a whole pint of water at a temperature of 95° F., 
and one-fourth of this solution is to be drunk at inter- 
vals of ten minutes, the last dose being taken one hour 
before breakfast. Should the above quantity of salts not 
produce a loose movement after two or three hours, the 
quantity should be cautiously increased on the following 
days, until the desired result is obtained. Laxative en- 
emata and the use of the soft tube are, perhaps, better 
adapted to cases of severe chronic gastritis, while the 
salts do well in milder cases. The pain of ulcer is best 
controlled by careful regulation of the diet and the use 
of alkalies according to the rules already given, or by 
temporary rectal alimentation. Gastralgia may be so se- 
vere as to require opiates, best given hypodermatically or 
by the rectum, which must, however, be withdrawn so 
soon as practicable, lest the opium-habit be engendered. 
Counter-irritation of the epigastrium is also useful. If 
constant pain, with fever, points to perigastritis or to 
local peritonitis, ice-bags may be applied. Vomiting is, 
likewise, most easily subdued by rest, mild diet, or, fail- 
ing these, by rectal alimentation and opiates. 

Hematemesis calls for rectal alimentation, rest, ice- 
bags to the epigastrium, and ergotin in solution, by the 
rectum or hypodermatically. For hypodermic use the 
following solution is appropriate : 


R. Ergotin, vel Squibb’s ext. ergote.... gr. xlviii. 
Aque, 
GlY Cerne. Geto vagy eres wsvhe haere St aa fl 3 j. 

M. Sig.—m. 20 = gr. j. 


Twenty minims of this solution may be injected several 
times, at intervals of a few hours. Twice the quantity 
may be given in warm water, at the same intervals, by the 
rectum. Morphine, hypodermatically administered, is 
also indicated. Ifthe hemorrhage be so profuse as to 
cause dangerous cerebral anemia, brandy and ether may 
be given subcutaneously, ammonia inhaled, and trans- 
fusion performed. In the event of perforation, rectal 
alimentation, morphine, and warm fomentations are indi- 
cated, and, although not curative, serve to mitigate suffer- 
ing and thus to promote euthanasia. Rydygier recom- 
mends laparotomy for perforation, and closing the ulcer 
with sutures. The same operator and Van Kleef and 
Czerny each successfully performed extirpation of a cica- 
trix which was producing pyloric stenosis and gastrec- 
tasia. Most physicians will, however, be content to treat 
gastrectasia by the method recommended in the section on 
that subject. The chronic anemia resulting from ulcer 
is to be met with mild ferruginous preparations, well di- 
luted, which should, however, be withheld until after 
complete cicatrization of the ulcer. 

CANCER OF THE STOMACH. Pathogenesis.—Nothing is 
definitely known about the essential cause of cancer in 
general, and this statement of course applies with equal 
force to the origin of gastric carcinoma. Virchow ad- 
vanced the theory that cancer results from long-continued 


‘normal or pathological irritation, and adduced the fact 


that the orifices of the stomach which are subjected to. 
the greatest amount of friction are most frequently at- 
tacked, in support of his doctrine. Cohnheim’s theory 
refers the origin of carcinoma to abnormalities in cellular 
development, and particularly to the persistence of embry- 
onic cells. In accordance with this theory, pyloric cancer 
is most common on account of the complex development 
of that part of the stomach. 

Frequency.—The stomach is, after the uterus, the most 
frequent seat of primary cancer. Many authors place 
gastric carcinoma first in point of frequency, but the 
carefully collated statistics of Welch show that one-third 
of all primary cancers are uterine and one-fifth gastric. 
According to Virchow, 34.9 per cent: of all cancers are 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Stomach. 
Stomach, 


gastric, and 1.9 per cent. of deaths from all causes are 
due to this disease. 

Etiology.—No occupation, injury, previous general dis- 
ease, or mental condition has any etiological relation to 
gastric cancer. Age exerts a well-recognized causative 
influence. 
the ages of forty and seventy years, the largest number 
taking place between the ages of fifty and sixty. Gastric 
carcinoma is exceedingly rare in childhood, and infre- 
quent after the seventieth year. Lebert concludes that 
hardly one per cent. of the cases occur before the thirtieth 
year, 16.3 per cent. between the sixtieth and the seventieth 
year, and 4.4 per cent. after the seventieth year. The cases 
are about equally distributed between the sexes, males 
being apparently rather more frequently attacked than 
females. Heredity exerts a causative influence. Welch 
states that in about fourteen per cent. of all cases it can 
be ascertained that relatives of the patient have suffered 
from the disease. Gastric cancer occasionally develops 
from a gastric ulcer, either open or cicatrized, which fact 
is of considerable practical importance. Cancer is said 
by Griesinger to be unknown in Egypt, and is also said 
to be rare in other tropical couutries. 

Morbid Anatomy.—A gastric cancer is most commonly 
situated at or near the pylorus, and generally on the 
posterior surface or at the lesser curvature. Welch ana- 
lyzed 1,300 cases, with reference to the situation of the 
tumors, with the following results: Pyloric region, 60.8 
per cent.; lesser curvature, 11.4 per cent. ; cardiac extrem- 
ity, 8 per cent.; posterior wall, 5.2 per cent.; the whole 
or the greater part of the stomach, 4.7 per cent.; multiple 
tumors, 38.5 per cent.; greater curvature, 2.6 per cent. ; 
fundus, 1.5 per cent. Gastric carcinomata are usually 
primary, very rarely secondary. The varieties of gastric 
cancer are the cylindrical-celled, the scirrhous, the medul- 
lary and the colloid or alveolar. Combinations of these 
varieties often occur. Colloid cancer is the least common, 
and the cylindrical-celled the most frequent variety. 
The alveoli of cylindrical-celled carcinomata resemble the 
- structure and arrangement of normal gastric tubules, 
the cells lining the alveoli being of cylindrical form. 
The consistency of this variety of cancer is soft. Scir- 
rhous cancer is largely composed of a fibrous stroma, the 
alveoli being comparatively small. Scirrhus may be 
either nodular or diffuse, grows rather slowly, and does 
not so readily ulcerate as the other forms of cancer. 
Medullary cancer grows rapidly and readily occasions 
metastases. Itsalveolar structure predominates quantita- 
tively over the fibrous stroma, and it is consequentl 
soft. It grows rapidly and ulcerates readily. Colloid 
cancer is either nodular, infiltrated, orannular. Itis soft, 
the alveoli containing a clear, jelly-like substance, but it 
does not so readily ulcerate as the other varieties of car- 
cinoma. According to Waldeyer, the origin of gastric 
cancer is in the mucous membrane, whence it extends to 
~ the submucosa and to the other tunics of the stomach. 
Sometimes the neoplasm is apparently seated in the sub- 
mucosa, but careful search will show the tubules to be 
involved, connecting bands extending between these and 
the submucosa. 

Ulceration occurs in three-fifths of all cases; most 
frequently, according to Lebert, in medullary, and least 
frequently in colloid, cancers. The ulcers vary in size, 
may be irregular or crater-like in form, and often show 
eroded or obstructed vessels in their base. Partial cica- 
trization of the ulcers sometimes occurs. Ulceration may 
reduce the size of cancerous tumors, and thus prevent or 
remove pyloric stenosis. If stenosis of the pylorus per- 
sist, gastrectasia ensues. Chronic gastritis usually ac- 
companies carcinoma. Sometimes cancer causes atrophy 
of the stomach by obstructing its cardiac orifice. Pro- 
gressive carcinomatous ulceration may perforate the stom- 
ach, causing hemorrhage from erosion of the vessels, 
chronic adhesive peritonitis, or, more rarely, diffuse peri- 
tonitis. Violent gastrorrhagia and peritonitis from per- 
foration are, however, less common with cancer than with 
ulcer. The ulcer may invade the pancreas, the liver, 
the diaphragm, the pleura, the pericardium, the spleen, 
etc., or it may establish fistulous communications be- 


Three-fourths of all the cases occur between: 


tween the stomach and the pleural, the peritoneal, or the 
pericardial cavities, and with the colon. Gastric cancer 
may also extend by metastasis through the lymphatics or 
the blood-vessels. The secondary growths are usually 
identical in structure with the primary neoplasm. The 
lymphatic glands near the stomach constitute the most 
frequent site of metastatic deposits, and next to these 
the liver, the peritoneum, the pancreas and the lungs, in 
the order named. 

Clinical History.—As in gastric ulcer, so in cancer, 
particularly if it be secondary, there are sometimes no 
symptoms, death being due to intercurrent diseases. 
This rarely occurs, but shows that the duration of car- 
cinoma cannot always be accurately estimated from the 
first unmistakable symptoms. In other instances local 
symptoms ae signs referable to the stomach are trifling 
or absent, while emaciation, anzemia, and exhaustion are 
rapidly progressive. These cases are sometimes mistaken 
for phthisis, for Bright’s disease, or for pernicious ane- 
mia. In typical cases, however, there are symptoms and 
signs which are collectively diagnostic, namely, diges- 
tive disturbances, pain, emesis, heematemesis and a gas- 
tric tumor. Digestive disturbances, due to the neoplasm 
or to coexisting gastritis, are often the first symptoms. 
The appetite is impaired, perverted, or lost more fre- 
quently than in gastric ulcer. Sometimes, particularly 
if the cancer be at the cardiac orifice of the stomach, 
there is no loss of appetite. There are often epigastric 
discomfort, eructation, pyrosis, and nausea before the 
appearance of actual pain or emesis. Sooner or later, 
however, pain almost always becomes a prominent symp- 
tom. Brinton estimates that pain occurs in ninety-two 
per cent., and Lebert in seventy-five per cent., of all 
cases. It is probably most apt to be absent when the 
cancerous growths do not involve the orifices of the stom- 
ach. The pain may be either dull or lancinating, con- 
stant or paroxysmal. It is generally referred to the epi- 
gastrium, but often to the hypochondria, the loins, the 
mediastinum, the back, and even to more remote regions. 
The location of the pain does not, therefore, afford great 
assistance in exactly locating the cancerous tumor. When 
intermittent, the pain is frequently excited, and, when 
constant, is aggravated, by the ingestion of food. Pain 
is ordinarily more constant in the later stages of the dis- 
ease, when ulceration has occurred, than at earlier periods 
of the malady. Vomiting occurs, according to Lebert, 
in eighty per cent. of all cases, appearing most constantly 
when either the pylorus or the cardiac orifice is diseased. 
In many instances emesis is rare, or absent, in the earlier 
stages, but begins or increases in frequency and violence 
as the disease advances. When the cancer is situated at 
the cardiac orifice, vomiting often, but not invariably, 
immediately follows the ingestion of food. In this case 
the food may not enter the stomach, but, encountering 
the cancerous obstruction at the cardiac orifice, is returned 
by reversed peristaltic movements of the cesophagus. In 
pyloric cancer vomiting usually occurs later than in car- 
cinoma of the cardiac orifice, generally an hour or more 
after meals, but this rule has frequent exceptions. It is 
thus evident that the time when emesis occurs does not 
afford material assistance in locating gastric cancer. If 
gastrectasia has followed malignant pyloric stenosis, the 
vomiting naturally takes place after much longer inter- 
vals and is more copious, as is.the rule in obstructive 
dilatation. The vomited matters consist, at first, of undi- 
gested food mingled with mucus and epithelium. Later, 
sarcine, torule, abnormal acids and gases are present, 
and in forty-two per cent. of the cases, according to 
Brinton, blood, which having been acted on by the gas- 
tric juice presents the familiar coffee-ground or choco- 
late-like appearance. In the majority of cases gastror- 
rhagia from cancerous ulceration is not profuse, the 
blood escaping from capillaries eroded by the process of 
ulceration. Commonly, however, the blood is present in 
sufficient quantities to be recognized by the naked eye, 
but in some cases an appeal to the microscope or the 
spectroscope may be necessary to decide the question. 
The spectrum produced by alkaline solutions of hematin ~ 
shows an absorption band between C and D, which some- 


649 


Stomach. 
Stomach. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


times extends beyond D. The microscopic test for he- 
min is made as follows: An excess of glacial acetic acid 
and a few grains of sodium chloride are added to the 
suspected liquid, and boiled in a test-tube. If blood-pig- 
ment is present, microscopic crystals of hzemin will be 
deposited by the cooled liquid, and may be recognized 
by their rhombic form and dark-brown color. Profuse 
hemorrhages occur, according to Lebert, in only twelve 
per cent. of all cases of gastric cancer, men being more 
liable to them than women. Copious hematemesis is 
most often caused by soft cancers seated at the pylorus 
or on the lesser curvature, and generally takes place at a 
late stage of the disease. Gastrorrhagia may sometimes 
be fatal, and may even cause death, without occasion- 
ing hematemesis. Rosenbach recognized, in three cancer 
cases, fragments of cancerous structures in matters with- 
drawn from the stomach by the tube, and similar frag- 
ments have, very rarely, been seen by other observers. 

Van der Velden claims that free hydrochloric acid is 
habitually absent in cases of gastrectasia from cancerous 
pyloric obstruction, but Seaman and others have detected 
hydrochloric acid in stomachs dilated by this cause, and 
the relative frequency with which this acid is absent in 
gastric cancer unaccompanied by dilatation remains to 
be ascertained. The view at present held by the majority 
of the profession, regarding this question, is apparently 
to the effect that habitual presence of hydrochloric acid 
in fluids taken from a dilated stomach renders the exist- 
ence of cancer improbable. The absence of the acid can- 
not, however, be regarded as diagnostic of carcinoma, 
since it also occurs in chronic gastritis, in fevers and in 
other diseases. Rough clinical tests for free hydrochloric 
acid have been described under the treatment of chronic 
gastritis. There are, however, many sources of error in 
applying the more reliable and complicated tests for the 
detection of the acid, and it is therefore to be recom- 
mended that physicians employ competent chemists to 
make the necessary tests. The digestive power of the 
gastric juice is usually notably impaired in cancer cases, 
which naturally follows from the absence of hydrochloric 
acid. Riegel states that the gastric juice from a cancerous 
stomach, if added to normal gastric juice, even notably 
retards the action of the latter. The digestive power of 
gastric juice may be tested by suspending, in the filtered 
gastric fluids, a piece of fibrin, the temperature of the 
filtrate being maintained at about 100° F. If free hydro- 
chloric acid is present the proteid will soon begin to dis- 
solve. The most important sign of cancer in the stomach 
is a gastric tumor. This sign is never perceptible in the 
earlier stages, but can be discovered in about eighty per 
cent. of all cases at some period of the disease. Tumors 
placed at the cardiac orifice, at the fundus, on the pos- 
terior wall, or at the lesser curvature, near the pylorus, 
may escape observation, because hidden beneath the liver 
or behind the border of the ribs. If the neoplasm grows 
chiefly into the lumen of the stomach, it may likewise 
escape detection. In diffuse cancerous infiltration of the 
‘ gastric walls no localized tumor is perceived, but a pecu- 
liar resistance and induration, corresponding to the seat 
of the stomach, may sometimes be appreciated: Pyloric 
tumors are felt more often than others. This is true 
partly because, even if a pyloric neoplasm be at first 
covered by the liver, it may later become palpable by 
displacing the pylorus downward. The tumor is. ordi- 
narily felt in the epigastrium, sometimes to the right and 
sometimes to the left of the median line, but may, owing 
to downward displacement of the stomach, be found in 
various other abdominal regions. In some instances the 
tumor is movable, changing its position according to the 
varying distention of the stomach and of the colon. 
When adhesions exist between the cancer and the liver 
or the diaphragm, the tumor follows the respiratory dia- 
phragmatic movements. More frequently, however, the 
cancer is immovable, being fixed by adhesions. The tu- 
mor is generally small and nodular, occasionally smooth. 
Ulceration often causes perceptible diminution in the 
size of a tumor. 

Percussion over the tumor occasionally yields a flat 
note, commonly, however, a dull one. The urine often 


650 


has an abnormally small amount of urea and contains 
albumin, indican, and, according to V. Jacksch, diacetic 
acid, to which coma, occasionally observed at the end 
of cancer cases, is attributed by some authors. The 
bowels are ordinarily constipated, but often constipation 
alternates with diarrhea. The temperature is often nor- 
mal during the entire course of the disease. Sometimes, 
however, there are slight chills, followed by elevation 
of temperature. As death approaches, the temperature 
may become subnormal. Cancer of the stomach causes 
marked anemia, extreme emaciation and great asthenia, 
and imparts a more or less characteristic color to the skin. 
This cachectic appearance is not pathognomonic of car- 
cinoma, as it may occur in non-cancerous pyloric stenosis 
and in ulcer. Thromboses of the veins of the thigh and 
leg are common, but hydreemic cedema of the feet and 
legs may occur independently of this. Dysphagia occurs 
in many cases, chiefly when the cancer involves the car- 
diac region of the stomach. The patient’s mental pow- 
ers are generally not impaired by the disease, but he is 
usually depressed and melancholy. Gastric cancer may 
perforate the stomach, causing peritonitis or any of the 
inflammatory complications and fistulous communica- 
tions mentioned as possible results of perforation by an 
ulcer. Gastro-colic fistula is more common with cancer 
than with ulcer. Perforation of the stomach occurs much 
more rarely with cancer than from ulcer. Fatal gastror- 
rhagia from erosion of blood-vessels occurs in only about 
one per cent. of all cases of gastric cancer. The symp- 
toms due to metastatic cancerous tumors of the liver, of 
the peritoneum, of the lymphatic glands, of the pancreas 
and of the lungs are to be sought in the articles in this 
HANDBOOK devoted to these respective subjects. 
Differential Diagnosis.—This involves the exclusion of 
other gastric diseases and of tumors not connected with 
the stomach. The gastric diseases most likely to be mis- 
taken for cancer are ulcer, simple chronic gastritis, 
chronic interstitial gastritis, gastrectasia from non-malig- 
nant pyloric stenosis, gastralgia, and other gastric neo- 
plasms. The chief points of distinction between gastric 
cancer and ulcer are the following: The age of patients 
with ulcer is under forty in about one-half the cases, 
while cancer is rare until after the fortieth year. In can- 
cer, vomiting is less frequent than in ulcer, and com- 
monly occurs later after the ingestion of food. Gastror- 
rhagia is more frequent in cancer, but less profuse. In 
cancer the vomited matters may contain cancerous frag- 
ments and be devoid of hydrochloric acid. The pain of 
cancer is more constant, is less affected by eating, is more 
diffuse, and is less relieved by emesis than that of ulcer. 
A gastric tumor is present in eighty per cent. of cancers 
of the stomach, but a tumor is rare with ulcer. The 
maximum duration of cancer is about a year and a half ; 
that of ulcer may be much longer. Appropriate treat- 
ment commonly relieves the symptoms of ulcer, but not 
those of cancer. The cachexia of carcinoma is more 
marked, and not so directly referable to the gastric symp- 
toms. Secondary growths are often found in other or- 
gans with cancer, but not with ulcer. The fact is to be 
constantly borne in mind that a cancer may develop from 
the margins or from the cicatrix of an ulcer, in which 
case the clinical history of the latter gradually merges 
into that of the former. In simple chronic gastritis the 
vomited matters frequently contain hydrochloric acid and 
never cancerous fragments ; gastrorrhagia is rare, and the 
pain is both less severe and less localized than in cancer. 
Gastritis occurs at all ages indifferently, has no tumor, 
and may continue indefinitely, but is more readily con- 
trolled by treatment than is cancer. Gastritis produces 
no marked cachexia, and is not attended by secondary 
growths. Chronic interstitial gastritis sometimes pre- 
sents a smooth, resisting tumor, possessing the shape and 
outlines of the stomach, but can hardly be differentiated 
from diffuse gastric cancer. It generally tends to di- 
minish the size of the stomach, is of longer duration, and 
is usually not accompanied by gastrorrhagia or by severe 
pain. Simple gastralgia generally has none of the symp- 
toms of carcinoma except the pain. Gastrectasia follow- 
ing non-malignant pyloric obstructions is ordinarily due 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Stomach, 
Stomach, 


to antecedent ulcer, the history of which may be obtained. 
It also commonly occurs before forty rather than after 
that age. The other gastric neoplasms are so rare that 
they are clinical curiosities, and their differential diagno- 
ses need not be, discussed. If they are so situated as to 
cause pyloric stenosis, they can hardly be distinguished 
from cancer. The tumors of other organs most likely to 
be mistaken for gastric cancer are those of the liver, the 
pancreas, the peritoneum, the aorta, the intestine, the 
retroperitoneal lymphatic glands and the omentum. 
Even renal and splenic tumors may be included in this 
category. For the differential diagnosis of these neo- 
plasms the reader is referred to the writer’s article on 
Abdominal Tumors, in the first volume of this Hanp- 
BooK. The diagnostician should always bear in mind 
the possibility that secondary cancerous tumors, devel- 
oping in any of these organs, may quite obscure the 
original gastric carcinoma. It is usually impossible to 
diagnosticate the variety of cancer existing in a given 
case, nor is it especially useful to make the distinction. 
In very rare cases the variety of cancer may perhaps be 
ascertained by an examination of the carcinomatous frag- 
ments found in the fluids withdrawn from the stomach. 

Prognosis and Duration.—There is no authentic record 
of recovery from gastric cancer. Billroth successfully 
performed pylorectomy for gastric carcinoma in 1881, 
and the operation has been successfully done several 
times since then. In the majority of the cases, however, 
the operation has been fatal, and in no case has an ulti- 
mate cure been effected, although life has undoubtedly 
been considerably prolonged by this surgical interference. 
It is possible that a radical cure may sometimes be at- 
tained by early pylorectomy in favorable cases, but the 
diagnosis is so frequently in doubt until secondary depos- 
its have occurred that there is little probability of a de- 
cided reduction in the mortality of gastric cancer by oper- 
ative treatment. The duration of gastric carcinoma can 
often only be approximately estimated, because the dis- 
ease frequently remains latent for a long time. On the 
other hand, in cancers developing from ulcers the carci- 
noma may be regarded as the original disease, and a cor- 
respondingly long duration be ascribed to it. Lebert 
estimates the average duration at fifteen months, and the 
maximum duration at four years. Brinton places the 
average duration at twelve and a half, and the maximum 
duration at thirty-six months. 

Treatment.—There is no known specific for gastric 
cancer, and all treatment must consequently be symp- 
tomatic. 
tritis by bland aliment, to relieve pain, to check emesis 
and to control haematemesis; to sustain the patient’s 
strength, and to meet other symptomatic indications as 
they arise. The most suitable articles of diet are those 
recommended under the treatment of gastric ulcer. Pain 
is to be relieved by morphia, preferably given hypoder- 
matically. Vomiting is to be checked by opium, counter- 
irritants, a regulated diet, and, if otherwise uncontrol- 
lable, by rectal alimentation. Hemorrhage, if profuse, 
and perforation require the same treatment suggested for 
pain and gastrorrhagia from gastric ulcer. The same re- 
mark applies to inflammatory complications of abdominal 
or thoracic organs. Constipation calls for laxative enem- 
ata, and diarrhcea for opium and bismuth, or for starch 
and laudanum enemata. For pyrosis, alkalies are valua- 
ble. Lavage, by means of the soft tube, unless contra- 
indicated by profuse gastrorrhagia, or by great asthenia, 
is useful in relieving gastritis and in preventing the de- 
velopment of gastrectasia. Operative interference, to be 
of avail, must be undertaken early, before glandular in- 
filtration has occurred. If an early and reasonably cer- 
tain diagnosis of cancer is made, it is justifiable to per- 
form laparotomy, in order to decide upon the propriety 
and necessity of an operation. In the hands of experienced 
surgeons this laparotomy is devoid of serious dangers. 

OTHER GaAsTRIC NEOPLASMS.—The most common non- 
malignant gastric new-growths are mucous or submucous 
adenomata and myomata. Fibromata, lipomata, cystom- 
ata and miliary aneurisms are rarely observed.  Pri- 
mary or secondary sarcomata and myo-sarcomata are also 


The indications are, as in ulcer, to prevent gas- » 


infrequent. These neoplasms have little clinical signifi- 
cance, owing to their rarity and to their ordinarily small 
size. The differential diagnosis between carcinoma and 
these new-growths cannot ordinarily be made with any 
certainty, and their treatment, when recognized, is the 
same as that recommended for cancer. 

ATROPHY OF THE STOMACH AND DEGENERATION OF 
THE Gastric TuBEs.—Atrophy of the entire stomach, 
from disuse, may follow stenosis of the esophagus or of 
the cardiac orifice. The general atrophy of marasmus 
and of senility may also involve the stomach. The gas- 
tric tubules frequently undergo parenchymatous and 
fatty degeneration in the acute infectious diseases, such 
as typhus and typhoid fevers, yellow fever, septiczemia, 
and the eruptive fevers, and in poisoning with phos- 
phorus, arsenic, mercury and the mineral acids. The 
tubules are gradually restored to their natural condition 
after the subsidence of these febrile disorders or the 
elimination of the poisons causing the degenerations. It 
is reasonable to assume that the digestive disturbances ob- 
served in cases of the above maladies are in large meas- 
ure due to failure in the functional activity of the gastric 
secreting cells. Allusion has been already made, in the 
appropriate sections, to the degenerative and atrophic 
changes in the tubules accompanying chronic gastritis, 
interstitial gastritis, phlegmonous gastritis, ulcer and 
carcinoma, As early as 1860, Dr. A. Flint, Sr., advanced 
the opinion that degeneration of the gastric tubules 
would prove to be the anatomical basis of certain cases 
classed as pernicious anemia. ‘The subsequent investi- 
gations of Fenwick, Quincke, Brabazon and others sup- 
port this view. In some of the recorded cases the atro- 
phy has been attended by increase of the interstitial 
gastric connective tissue, but in other cases this was want- 
ing. The absolute demonstration of the existence of pri- 
mary atrophy of the tubules has, however, in the writer’s 
opinion, not yet been furnished. The general symptoms 
which have been referred to atrophy of the gastric tu- 
bules are those of pernicious anzemia, the digestive symp- 
toms being anorexia with occasional vomiting, eructa- 
tion and epigastric pain. It is exceedingly difficult, in 
these cases, to decide whether the anemia may not-have 
caused sufficient disturbance of nutrition to produce the 
local atrophy, rather than that the reverse conditions ob- 
tained. This is one of the problems now engaging gen- 
eral attention on the part of the profession, and which it 
is to be hoped may eventually meet with a satisfactory 
solution. 

RUPTURE OF THE SToMAcH.—Perforation of the stom- 
ach may occur, as has been stated in the appropriate sec- 
tions, from diseases affecting its parietes, such as ulcer, 
cancer, toxic gastritis and suppurative gastritis. Rupt- 
ure of a healthy stomach may occur from severe abdom- 
inal injuries, with or without perforation of the abdom- 
inal walls. Thus, heavy weights falling from a height, 
the wheel of a heavy vehicle—or the buffers between rail- 
way carriages—being brought violently in contact with 
the abdomen, may rupture the stomach in common with 
other viscera, or, in rare cases, the stomach alone. There 
are no satisfactory records of spontaneous rupture occur- 
ring in a stomach with healthy walls, although many 
cases of supposed spontaneous rupture have been re- 
ported. Inthe majority of these cases the pathological 
anatomical conditions were not carefully investigated, 
and it is probable that pre-existing lesions were responsi- 
ble for the accidents. Leube performed experiments 
upon the cadaver in order to test the resisting capacity 
of the stomach, and found that enormous distention of the 
organ could be produced by hydraulic pressure without 
occasioning rupture. In these experiments the mucous 
membrane and the serosa yielded to the pressure, while 
the muscular coat remained intact. The writer has seen 
a case of atonic gastrectasia in which the distention of 
the stomach was such as to cause intense suffering, with 
extreme tenderness over the organ, which reached to 
the iliac crest. In this case the pain and the other 
symptoms were such that rupture was regarded as immi- 
nent, and the tube was at once introduced. After the 
escape of an immense amount of gas the pain at once 


651 


Stomach. 
Stomatitis. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


subsided, whereupon nearly three gallons of liquids and 
solids were withdrawn by the siphon. The symptoms 
of rupture of the stomach are identical with those of per- 
foration, already described. The prognosis is fatal, and 
the treatment must consist in the free administration of 
morphine hypodermatically, with a view to promoting 
euthanasia. 
BIBLIOGRAPHICAL REFERENCES. 


Structural Diseases of the Stomach in General. 


Flint: Practice of Medicine, p. 421, sixth edition, 1856. 

Welch, William H.: Pepper’s System of Medicine, vol. ii., p. 480. 

Strampell’s Lehrbuch d, Spec. Pathologie u. Therapie, vol. i., p. 562. 
1885. 

Oser: Eulenbure’s Real-Encyclop. d. Gesammt. Heilkunde, vol. xii., p. 
409, 1887. 

Luton: Jaccoud’s Nouv. Dict. de Méd. et de Chir., vol. xiv., p. 220, 
1871. 

Fenwick: Quain’s Dictionary of Medicine, p. 1523. 1884. 

Leube: Ziemssen’s Cyclopedia of the Practice of Medicine, vol. vii., p. 
309. ‘1876. 

BHichhorst: Hdb. d. Spec. Path. u. Th., ii., pp. 75-180. 1887. 

Ewald: Zur Diag. u. Therap. d, Magenkrank., Berlin. klin. Wochensch., 
1886, xxiii., pp. 33, 50. 

Delafield and Prudden: Handbook of Pathological Anatomy and Histol- 
ogy, p. 802. 1885. 

Ebstein : Ueber die Verand., etc., Virchow’s Archiy, vol. lv., p. 469. 

Fox, Wilson: The Diseases of the Stomach. 1872. 

Fenwick, S.: The Morbid States of the Stomach and Duodenum. Lon- 
don, 1868. : 

Klebs, Ed. : Die All. Path., I. Theil. 1887. 

Brinton: On Diseases of the Stomach. London, 1865. 

Index Medicus : Geo, 8. Davis, Boston and Detroit ; all the volumes. 


Gastritis, Acute and Subacute. 


Krause : Ueber d. Submuciés. Magenentz. Diss. Berlin, 1872. 

Ebstein : Ueber d. Verand., etc., Virchow’s Archiv, 1872, lv., p. 467. 

Bohm : Toxis. Gast., Ziemssen’s Hab. d. Spec. Path., xv. 

Cotter, S. K.: Acute and Chronic Gastritis of Hot Climates, Indian 
Medical Gazette, 1884, pp. 279-282. Calcutta, 


Gastritis, Chronic, 


Wilks and Moxon: Path. Anat., p. 3881. 
Delafield : Chronic Catarrhal Gastritis, Medical Record, New York, 1886, 
Volo xxx NowhG 
Lene : Beitraige z. Diag. d. Magenk., Deutsch. Archiv f. klin. Med., xxx., 
p. 
Gastritis, Suppurative. 
Silcock: Transactions of the London Pathological Society, 1883, p. 90. 
Grainger Stewart : Edinburgh Medical Journal, February, 1868. 
Derniger: Deutsch. Archiv f. kiin. Med., xxiii.; Jahresb. v. Virchow- 
Hirsch., i.,.p. 177, 1579. 
Gelax: Ueber Gast, Phleg., Berlin. klin. Wochensch., 1879, No. 38. 
Fagge: Transactions of the London Pathological Society, 1875, p. 81. 


Gastritis, Chronic Interstitial. 
Nothnagel: Deutsch. Archiv f. klin. Med., xxiv., p. 353. 
Brinton ;: The Diseases of the Stomach. 
Marcy and Griffith: American Journal of the Medical Sciences, July, 
1884, p. 182. 
Kahlden : Centralbl. f. klin. Med., 1887, No. 16. 
Hanot and Gambault: Archives de Phys. norm. et path., 1882, ii., p. 


418. 
Snellen; Canstatt’s Jahresbericht, iii., p. 802. 1856. 


Gastrectasia. 


Kussmaul: Volkmann’s Samml. Klin. Vort., 181. 

Welch : Pepper’s System of Medicine, vol. ii., p. 588. 1885. 

Mossé: Gazette heb. d. Sci. méd., de Montpellier, 1884, vi., pp. 586-438. 
Fogt : Aerztl. Intelligenzbl., 1884, No. 26. 

Rosenbach : Volkmann’s Sammi. Klin. Vort., 153. 

Maier: Deutsch. Archiv f. klin. Med., vol. vi., p. 480, 

Nogaro; Courrier Méd., 1886, xxxvi., pp. 133-142. Paris. 
Dreyfus-Brysac: Gaz, hebd, de Méd. et Chir., 1885, No. 27. 

Sonligoux: De la Dil. de ’Estomac. Paris, 1883. 

Riegel: Deutsche Med. Wochenschr., 1886, xii., pp. 634-636. Berlin. 
Penzoldt: Magenerweiterung. 1875. 

Ewald: Reichert u. Du Bois-Reymond’s Archiv, 1874, p, 222. 

Ebstein : Volkmann's Samml. Klin. Vortrige, 155. 1878. 

Laprevotte: Thése, Paris. 1884. 

Herc S.: The Morbid States of the Stomach and Duodenum. London, 


Loretta: The Lancet, April 26, 1884. 
Platt: Maryland Medical Journal, March 8, 1884, 
Kussmaul: Deutsch. Archiv f. kl. Med., vi., p. 455. 


Acute Dilatation, 
Poensgen: Die Mat. Verricht. des Mensch. Magens, p. 95. 1882, 
Bennett, Hughes: Practice of Medicine, p, 275, 
Fagge: Guy’s Hospital Reports, xviii., p. 1. 


Ulcer. 
Mackenzie, S.: Lancet, 1885, ii., p. 1048. London. 
Cohnheim: Untersuch. iiber embol. Processe. 1872, 
Hauser; Das Chron. Magengesch., 1883, p. 61. 
Waldeyer: Virchow’s Archiv, vol. xli. 
Moore: Transactions of the London Pathological Society, 1880, p. 110. 
Cohnheim: Lehrb, d. allgem. Path., ii., p. 54. 1881. 


652 


Welch: Pepper’s System of Medicine, ii., p. 480. 1885. 

Cerenville: Revue Méd. de la Suisse Romande, September, 1885. 

Pavy: On Gastric Erosions, 1868; Guy’s Hospital Reports, xiii., 1867; 
Philosophical Transactions, p. 161. 1863. 

Leube: Ziemssen’s Cyclopeedia, vii., p. 192; Deutsch. Archiv f. kl, Med., 
December 18, 1878. 

Fox, Wilson : The Diseases of the Stomach, p. 146; 1872. 

Brinton : The Diseases of the Stomach. 2. 

Boéttcher: Dorpat Med. Zeitsch., 1874, v., Heft 2, p. 148. 

Janeway: Transactions of the New York Pathological Society, ii., p. 1. 

Oser: Wien. Med. Blat., 1880, No. 52. 

Korte: Dissert., 1875. 

Dalton: Transactions of the New York Pathological Society, i., p. 263. 

Gerhardt: Wien. Med. Presse, 1868, No. 1. 

Cancer. 


Van der Velden: Deutsch. Archiv f. klin. Med., xxiii., £69. 
Lebert: Deutsch. Archiv f. klin. Med., 1877, vol. xix., p. 545. 
Welch: Pepper’s System of Medicine, ii., p. 530. 

Honigmann and Noorden: Zeitsch. f. klin. Med., 1887, No. 13. 
Waldeyer: Virchow’s Archiv, xli. 

Brinton: British and Foreign Medico-Chirurgical Review, 1857. 
Lebert: Die Krank. d. Magens. Tubingen, 1878. 

Hardy: Gaz. d. Hop., 1884, lvii., p. 1169. Paris, 

Deschamps: Thése, Paris. Le Mans, 1884. 

Ewald: Berlin. klin. Wochensch., 1885, xxii., p, 137. 

Thiersch: Munch. Med. Wochensch., 1886, xxiii., p. 221. 
Ripley: Transactions of the New York Pathological Society, iv., p. 121. 
Mathieu: Du Cancer précoce de l’Estomac, Paris, 1884, 

Von Jaksch; Wien. Med. Wochenschr., 1888, pp. 473, 512. 
Ebstein: Volkmann’s Samml, klin. Vort., No. 155 and No. 87. 


Leube: Ziemssen’s Handb. d. spec. Path. u. Therap., vii., p. 184. 1878. 


Atrophy. 


Flint, A.: American Medical Times, 1860; New York Medical Journal, 
March, 1871; Practice of Medicine, p. 438. 1886. 

Fenwick: On Atrophy of the Stomach. London, 1880, 

Kinnicutt: American Journal of the Medical Sciences, October, 1887, p. 
419, 

Fenwick: The Lancet, July 7, 187%. London. 

Quincke: Volkmann’s Samml, klin. Vort., No. 100. 

Henry and Osler: American Journal of the Medical Sciences, April, 1886, 
p. 498. 

Nothnagel : Deutsch. Archiy f. klin. Med., 1879, vol. xxiv., p. 353. 

Hanot and Gambault: Archives de Phys, norm. et path., 1882, ii. 


William H, Flint. 


STOMATITIS. This word, which from its derivation 
signifies inflammation of the mouth, is held to include 
inflammatory affections of the cavity of the mouth as far 
back as the soft palate. Any abnormal condition of an 
inflammatory character which involves the gums, the 
tongue, or the inner surface of the cheeks, is included, 
therefore, under the designation of stomatitis. Experi- 
ence shows that there is little tendency toward limitation 
to any one of these structures—usually the entire cavity 
of the mouth partakes of the diseased condition. 

The affections included under this name are, in great 
part, limited to the age of childhood. Adults are never 
the subjects of certain forms of the disease, and seldom 
suffer from any variety of it, save as part of some other 
morbid condition. Not infrequently, however, stoma- 
titis is nothing more than a part of such general condi- 
tion. Diphtheria sometimes involves the mouth as well 
as the tonsils, pharynx, and palate; inflammation, with 
pustulation in the mouth, may occur in small-pox, vari- 
oloid, and varicella; facial erysipelas often presents an 
inflamed condition of the mouth; measles, R6theln, and 
syphilis are accompanied by characteristic mouth affec- 
tions; and many drugs, such as mercury and iodine, in 
addition to the mineral and other stronger acids, produce 
an abnormal condition. 

These various conditions do not come within the prov- 
ince of the present article, and for their consideration the 
reader is referred to the articles treating of the various 
diseases mentioned. 

What may be called primary stomatitis, as distin- 
guished from the above-mentioned conditions, being prac- 
tically a distinct disease, is encountered in the following 
varieties : 

I. Simple, catarrhal, or erythematous. 

II. Membranous, or ulcero-membranous. 

III. Ulcerative. 

IV. Gangrenous. 

I. CATARRHAL SToOMATITIS.—By this we mean that 
form which does not present exudation or ulceration. It 
is seen occasionally as a result of taking cold, being part 
of a general inflammation of the respiratory mucous 
membrane ; it is sometimes associated with chronic alco- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


holism ; it may be caused by excessive eating of acid 
fruits and highly seasoned articles of food ; and in chil- 
dren it is frequently an attendant upon difficult denti- 
tion. . 

Its symptoms are: Redness and capillary injection of 
the mucous membrane ; swelling of the tongue, cheeks, 
gums, and lips; dryness of the cavity of the mouth, es- 
pecially at first, and Jater sometimes increased flow of 
saliva and mucus, especially in the case of teething chil- 
dren. If the swelling, which is flabby, be marked, the 
impression of the teeth may be seen on the tongue and 
cheeks. The sense of taste is often diminished, and is 
sometimes perverted—patients stating that meats, etc., 
have a putrid flavor. The amount of pain is not great in 
this variety of the disease, and is often entirely absent, 
particularly in the chronic stomatitis of excessive drink- 
ers. Occasionally the salivation is a source of annoy- 
ance, as in the stomatitis of difficult dentition. 

As to treatment, over and above that addressed to the 
causative agency, the means to be used are the moisten- 
ing of the mouth with cold water, the administration of 
chlorate of potassium, and often the application of astrin- 
gent washes, such as a weak solution of sulphate of zinc 
or copper. 

Il. MEMBRANOUS, OR ULCERO-MEMBRANOUS STOMA- 
T1T1s. —Diphtheritic membrane may involve the anterior 
aspect of the soft palate, and sometimes spreads forward 
over the cheeks and tongue. Thrush, which is charac- 
terized by the formation of a white pellicle or membrane 
in patches, is most frequently visible on the tongue. 
Both these diseases are certainly membranous forms of 
stomatitis, but the term is here employed to indicate an 
affection distinct from these, and local in its nature. 
Diphtheria and thrush are described elsewhere in this 
work. 

Ulcero-membranous stomatitis, in this restricted sense, 
is a disease characterized by the production of discrete 
patches of thick, yellowish, pseudo-membrane or exuda- 
tion, which apparently becomes separated from the sub- 
jacent tissues by an ulcerative process, leaving. erosions 
on the surface formerly occupied by the exudation. 

As to causation, it is to be attributed to bad hygienic 
surroundings, to improper and insufficient nourishment, 
and is generally met with in hospital patients, and but 
very rarely among people in more comfortable circum- 
stances. It has clearly an epidemic character, as usually 
a number of cases will be encountered at or near the 
same time; and, on the other hand, long periods will 
elapse without the occurrence of a single case. Conva- 
lescence from acute diseases is thought to be a condition 
predisposing to its occurrence. 

Like other forms of stomatitis, it is in the main an af- 
fection of childhood, though not of infancy ; the usual 
time of its occurrence being between the ages of five and 
ten years. 

The disease generally begins with pain and discomfort 
in the gums, made prominent by the act of mastication. 
The gums are seen to be reddened and swollen, and are 
tender to the touch—in short, a condition of gingivitis is 
present. There is commonly a slight rise of temperature. 
Then a grayish or yellowish exudation makes its appear- 
ance on the gums, which spreads to the adjacent parts of 
the cheeks and inner surface of the lips ; and occasionally 
even involves the palate and pharynx. If this pseudo- 
membrane be detached, the subjacent mucous membrane 
is found to present an excoriated and ulcerated appear- 
ance. 

If the case be a mild one, the area covered by the ex- 
udation is not great, the ulcerations are neither large nor 
deep, the other symptoms are not severe, the course is 
rapid, and complete restoration to the normal condition 
occurs within a few days. ; 

On the other hand, in a severe case the exudation 
spreads widely, the ulcerations become deep, foul, and 
extensive; the breath is offensive, the odor sometimes 
being almost gangrenous; the saliva is greatly increased 
in amount, is offensive in odor, and discolored; the 
salivary and submaxillary glands become enlarged and 
tender, and the swelling, stiffness, and pain in the jaws 


Stomach. 
Stomatitis. 


are marked. Sucha case may be protracted for a month 
or more, and may closely resemble true gangrenous 
stomatitis— possibly may run into that disease. The 
similarity between the two conditions may be very great, 
and the points of difference in the matter of diagnosis 
will be mentioned below, in the description of the latter 
disease. 

The prognosis is favorable, even in the severe form, if 
true gangrene do not supervene. 

The treatment is, in the first place, to be addressed to 
the general condition of ill-health spoken of as having a 
causative relation. Nourishment, of good quality and 
quantity, should be first provided for ; stimulants may be 
necessary ; tonics, as the compound tincture of cinchona 
or the tincture of nux vomica, are usually of consider- 
able assistance ; and the administration of iron is advis- 
able. As to local treatment, the most serviceable drug is 
the chlorate of potassium, which should be given in con- 
siderable quantity—two or three grains every two or three 
hours. In addition to this, local astringent washes, as a 
solution of sulphate of copper (five grains to the ounce), 
or the honey of borax, should be used freely. Chloride 
of lime is highly spoken of as a cleansing agent. 

III. ULCERATIVE INFLAMMATION constitutes an essen- 
tial part of the variety of stomatitis just described, and, 
as will be seen, is also present in the gangrenous form. 
Ulceration occurs also in aphthe, and in children this is 
by far the most frequent form of ulcerative stomatitis. 
Finally, small ulcerations are formed by the breaking of 
herpetic vesicles, which occasionally appear in the mouth 
as well as on the lips. These are popularly known as 
‘‘canker sores,” are always small in size, and remain but 
a short time. To touch them once or twice with solid 
sulphate of copper or nitrate of silver is sufficient to cause 
them to heal readily and quickly. 

IV. GANGRENOUS STOMATITIS. —This grave disease 
has a variety of names, the two in most frequent use be- 
ing cancrum oris and noma; it is occasionally called 
cancer aquaticus, or water cancer. 

Itis atrue gangrene or sphacelation, affecting the jaws 
and cheeks, and sometimes spreading widely and with 
great rapidity. It occurs, like the ulcero-membranous 
form of stomatitis, in children only, and in those in bad 
general condition and living in bad hygienic surround- 
ings ; and, in the great majority of cases, develops during 
convalescence from some one of the acute febrile diseases. 
Of such. antecedent affections measles is the most fre- 
quent; it being estimated that one-half the cases follow 
this disease. Pneumonia, though very often a concomi- 
tant of the gangrenous disease itself, sometimes precedes 
it, and typhus fever is said to be occasionally followed 
by gangrenous stomatitis. It is asserted by some that 
the affection may become developed in severe forms of 
mercurial sore mouth, but such instances must be rare, 
for mercurial ptyalism is usually amenable to treatment. 
Sometimes it is encountered in such a manner as to ap- 
pear to be epidemic; in this bearing some resemblance 
to hospital gangrene. 

It is an affection of childhood, occurring in the period 
of second dentition, and is rarely, if ever, seen in a child 
under one or two years of age, or over ten or eleven. 

The disease is generally unilateral—not extending 
across the middle line of the lips. It is considered by 
many to be independent of thrombosis or embolism of 
the blood-vessels, such as causes gangrene elsewhere, and 
under different conditions. Yet there must be, seem- 
ingly, some circulatory disturbances to account for it, 
since the unilateral character is almost invariable ; from 
which we may reasonably argue that the circulation on 
the unaffected side is maintained in proper degree, while 
the death of tissue on the diseased side is evidently due 
to defective nutrition. Moreover, after death the arte- 
ries are found to contain more or less firm clots, and be- 
fore death hemorrhage does not occur when a vessel is 
opened by erosion. ae: 

Gangrene of the mouth does not begin with active in- 
flammation, and absence of pain is quite characteristic ; 
often the existence of the disease is not suspected until 
the destructive process has become far advanced. If seen 


653 


/ 


Stomatitis. 
Strabismus, 


at the outset, its first appearance is that of a vesicle or 
bleb, which soon breaks, leaving an ulceration on the 
gum or inner surface of the cheek, or frequently at the 
line of junction of the two. Some degree of swelling of 
the face soon shows itself, the breath almost immediately 
becomes fetid, and soon acquires a gangrenous odor. 
With the bad general condition there is but little fever or 
pain, and a pronounced condition of prostration does not 
develop at once. On the contrary, the child usually sits 
up and takes its nourishment quite readily. The foul 
ulceration spreads, often with great rapidity, and soon 
the substance of the cheek presents a circumscribed, 
hard, tense, and shining swelling or infiltration, of a 
dark red color, with one or more bluish spots soon ap- 
pearing—which are in reality dead tissue. Sometimes 
only two or three days are needed for this condition to be 
attained. The saliva is increased in quantity, is blood- 
stained and dark, and most offensive in odor; and the 
submaxillary and salivary glands become enlarged. 
Thirst is constant, and is most distressing to the patient, 
and often an exhausting diarrhea, difficult to control, 
sets in, increasing, of course, the prostration. 

The intelligence remains generally undisturbed, and 
the little patients do not seem to be greatly alarmed, but 
rather apathetic. The temperature and respiration be- 
come influenced principally because of, and in propor- 
tion to, pneumonic inflammation of the lungs, which, as 
stated, is frequently a precedent and concomitant condi- 
tion. This associated pulmonary inflammation is, how- 
ever, never of the sthenic type of simple acute lobar 
pneumonia, 

The appearance of an eschar on the skin of the cheek, 
usually at or near the angle of the mouth, is characteris- 
tic, and is an indication of the extension of the gangrene 
through the thickness of the cheek. This may occur in 
as short a time as two or three days. The eschar con- 
tinues to spread, and may, indeed, advance with such 
rapidity that from three to six days suffice for the de- 
structive process to be complete. Such rapid progress is 
not, however, the rule, and ofdinarily the entire dura- 
tion is from one to two weeks in cases terminating in 
death, which almost always occurs. 

Together with the sphacelation of the soft parts, ne- 
crosis of the maxillary bones takes place. The bone be- 
comes diseased, and presents a worm-eaten appearance, 
and the teeth loosen and can be removed from their sock- 
ets. The tongue, however, remains uninjured. 

Profuse hemorrhage is very rare, though there is al- 
ways some oozing of blood, which discolors the saliva. 
As stated, the arteries are found after death to contain 
clots of considerable firmness. 

When the disease has advanced, the odor of the pa- 
tient’s breath is more than fetid and offensive—it is dis- 
tinctly gangrenous. 

Recovery is a remarkable event, occurring, according 
to most authorities, in about one case in twenty. If the 
characteristic eschar appear on the skin of the cheek, very 
little hope can be entertained. 

Death occurs from asthenia, after a duration of from 
one to two weeks, and is often hastened by the lung in- 
flammation which so frequently occurs. In the few 
cases which recover, the disease is greatly prolonged, and 
after the final healing of the affected part much cicatri- 
zation and disfigurement remain. 

A similar gangrenous disease, in rare instances, in- 
vades the genital region in girls (noma vulvee), and runs 
the same severe course, with generally a fatal termina- 
tion. 

The diagnosis of gangrenous stomatitis is usually not 
difficult. The conditions bearing a resemblance to it are : 
The bad form of ulcero-membranous stomatitis, and se- 
rious and aggravated cases of mercurial sore. mouth. 
From the former, discrimination is to be based on the ab- 
sence of pseudo-membrane, the rapid and deep extension 
of the ulcerative process, the perforation of the cheek, 
and the hard, smooth, dark, and shining swelling. Also, 
in the simpler disease, no necrosis of the jaw nor loosen- 
ing of the teeth occurs. Ulceration from mercurial poi- 
soning has an antecedent stage of salivation, is bilateral, 


654 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


and does not spread rapidly and extensively, nor does it 
perforate the cheek like gangrenous stomatitis. 

The treatment of gangrenous stomatitis, though not 
satisfactory, must yet be energetic. It consists of gen- 
eral and local measures. The former include the carry- 
ing of nutrition to the highest possible point, by urging 
the patient to drink most freely of milk and cream of 
good quality ; to take concentrated fluid preparations 
made from meat; and, if it can be done without inter- 
ference with digestion or discomfort in eating, to take 
bread and farinaceous articles of food. Stimulants are 
almost always admissible from the first, and generally 
have to be given with a free hand. A child five years 
of age can take two teaspoonfuls of brandy every two or 
three hours, and if the prostration be great, a still larger 
quantity. The better plan is to give the liquid nourish- 
ment in stated quantities at intervals of about two hours, 
so that one or two quarts of milk are administered in the 
twenty-four hours. 

The principal part of the local treatment consists in 
the thorough application of cauterizing agents to the dis- 
eased surface. The earlier and the more thoroughly 
this is done, the better is the chance (slight though it is) 
of altering the character of the eroded surface, and con- 
verting it into a simpler form of ulcerative process. 

The agent most frequently used is nitric acid, applied . 
over the entire diseased surface, the surrounding healthy 
tissues being protected by oil or vaseline. The applica- 
tion must be thorough to be of any value, and the ut- 
most care is necessary to prevent injury to the sound 
parts. The mouth should be carefully and copiously 
syringed out with water after the cauterization. Other 
escharotics, aS muriatic and pure carbolic acid, can be 
employed, as well as the actual cautery or galvano-cau- 
tery. Usually authorities advise frequent cauterization 
—sometimes as often as twice a day—but, on the other 
hand, the statement has been made that no greater pro- 
portion of recoveries results among those treated by this 
means than among those in whom it is not resorted to. 
It should, however, be looked upon as a plan of treat- 
ment affording at least a chance of recovery from what is 
almost a hopeless disease. 

In addition, constant antiseptic washing of the mouth 
should be enforced, since a part at least of the asthenic 
condition and prostration can be attributed to septic ab- 
sorption. Simple salt and water, weak solutions of car- 
bolic acid, of bichloride of mercury, or of boracic acid, 
should be liberally used. Chlorate of potassium and the 
tincture of the chloride of iron should also be given. 

The following authorities have been consulted in the 
preparation of this article: 


Meigs and Pepper: Diseases of Children. 

Kustace Smith : Diseases of Children. 

J. Lewis Smith: Diseases of Children. 

Holmes: Surgery. 

Ashhurst: Surgery. 

Agnew : Surgery. 

Erichsen : Surgery. 

Vogel: Article, Diseases of the Mouth, in Ziemssen’s Cyclopedia. 

Squarey : Article, Diseases of the Mouth, in Reynolds’s System of Medi- 
cine. 

Heath : Medical Times and Gazette, 1884. 

Sansom : Medico-Chirurgical Transactions, 1878. 

Hall : Edinburgh Medical and Surgical Journal, vol. xiv. 


Thomas D. Swift. 


STORAX (Siyraz, U. 8. Ph. ; Styrax Preparatus, Br. 
Ph.; Styraw Liquidus, Ph. G.; Styrax liquide, Codex 
Med.). ‘‘ A balsam prepared from the inner bark of Z7- 
quidambar orientalis Miller ; Order, Hamamelacee.” 

This is a bushy, middling-sized tree, resembling a ma- 
ple or plane tree, with smooth, purplish-gray bark, and 
maple-like, lobed, smooth, stipulate leaves. Flowers mi- 
nute, the sterile of numerous stamens only, the fertile of 
a short calyx-tube and two several-ovuled carpels. They 
are arranged in compact globose clusters, which, as they 
ripen, form compound fruits of the coalescing calices and 
pistils. 

This tree is a native of the Southwest districts of Asia 
Minor,, where it forms forests. Its range seems to be 
quite a small one, not extending to the north or to the 
islands of the Levant. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


The name Storax (Styrax) has for many centuries been 
applied to two quite distinct substances : The resin of Sty- 
rax Officinalis Linn., a solid, benzoin-like balsam which 
has become obsolete, and the present complex liquid 
called for distinction Liquid Storax. This is collected 
by removing the outer bark from the tree, then scraping 
off the inner bark and boiling it with water from the sea. 
The resin melted out from the bark separates from the 
watery liquid and is skimmed off. The bark is then 
pressed and a further amount obtained. 

Storax prepared in this way is a soft, resinous compound 


“ Wi) v/ ii 
POSE as: ~ ‘ \\ Ka aif 
<a eae q =: Ry My) 


i wee i 
7 aa ie US 
IS) ne i Vy PTA 
pY f iy 


Fig. 3735.—Storax ; leaves and flowers. 


(Baillon. ) 


of peculiar balsamic, agreeable odor, having a honey-like 


consistence and a pungent, burning taste. It is opaque, 


Stomatitis. 
Strabismus. 


Hamamelis Virginica, Witch-Hazel, belongs to a related 
Genus. 

ALLIED Drues.—Numerous balsams, resins, turpen- 
tines, etc., resemble this in their action; perhaps the 
nearest is Balsam of Peru, q. v. W. P. Boiles. 


STRABISMUS, or SQUINT, is that condition in which | 
the visual axes are not both directed toward the point 
looked at; its peculiar subjective symptom is diplopia, 
and objectively the eyes may be seen to be turned in dif- 
ferent directions. 

Diplopia arising from strabismus is binocular, and is 
noticed only when light from the object looked at falls 
on both eyes and is sufficiently well focussed by both to 
form a sensible image on the retina; when both retinal 
images cause the proper impression on the visual centres ; 

and when these visual centres are so related to each 
other as to possess the power of binocular fusion. If, 
when one eye is excluded from vision by closing it or 
covering it with an opaque object, the double vision 
still remains, it is monocular and has nothing to do 
with strabismus. 

Normally, when a certain point is looked at, or 
fixed, the visual axes of both eyes pass through that 


E> point and in each eye its image falls on the retina at 


the fovea centralis ; and the impressions thus received 
produce in consciousness the idea of a single point. 
When, however, the point looked at makes its im- 
pression on the fovea in one eye, but on some other 
portion of the retina in the other, it generates the 
idea of two distinct points some distance apart, the 
impression on the fovea being referred to a point directly 
in front of the eyes, while the impression on another part 
of the retina is referred in a different direction, giving 
rise to the idea of the duplication of the point looked at, 
called diplopia or double vision. Thus in Fig. 3787, 
representing a case of convergent strabismus, the visual 


of a grayish-brown color, and contains considerable water iF 
entangled in it, to which its opacity isdue. Upon long 
standing or heating the water may be driven off, and a 
_clear yellow or brown resin remains behind. In odor 


it improves with age. It always remains sticky. This 
baisam consists principally of an amorphous substance 
named storesin. It also contains several cinnamic ethers 
and cinnamate of cinnamyl (styracin), which can be pre- 
pared in rectangular prisms, and cinnamic acid and styrol. 

Storax goes principally to the East, very little being 
used in European pharmacy ; in its action it varies very 


Fie. 3736.—Storax; staminate and pistillate clusters enlarged. (Bail- 


lon.) 


little from a number of other resinous substances; inter- 
nally it has been used in bronchitis and similar condi- 
tions with but moderate success. As an ingredient of 
liniments, ointments, etc., itis quite useful. The com- 
pound tincture of benzoin contains eight per cent. of 
storax. Dose of storax, from three to five drops. 
ALLIED PLAntTs.—The Sweet Gum Tree, Liquidam- 
bar Styraciflua Linn., resembles the above species and 
supplies a non-drying sticky resin resembling storax in 
medicinal properties, although not in color or opacity. 


Fre. 3737. 


axis of the eye A being directed to the object O, the vis- 
ual axis of the eye B is directed elsewhere to P. 

In the eye A the impression of the point O will be made 
at the fovea; but in the eye B the light from O, entering 
in the direction of the broken line O m, will make its im- 
pression on the point m, some distance from the fovea. 
Since the impression is made on A at the fovea, it will be 
correctly referred to the object looked at. But in B the 
impression made at m will be referred to a point to one 
side of the object looked at; its position relative to O be- 
ing in the direction mF, which makes the same angle 
with the visual axis of A as O m makes with the visual 
axis of B. The image of the point received on A, and re- 
ferred to its true position O, is called the true image. 
The image received at m, and referred to F, in the direc- 
tion 7 F, is called the false image. 

In Fig. 3738, representing what occurs in divergent 
squint, the eye A, turned toward the object O, receives 
on its fovea the true image, which is referred to its proper 
source; and the eye B receives at m the false image, 
which, with reference to the true image, is referred in 
the direction n F to F. : ; 

In either case, when the deviating or squinting eye 1s 
turned to the right, the false image appears to belong to 
an object to the left of that which causes the true image ; 


655 


Strabismus, 
Strabismus. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


and when the deviating eye turns to the left, the false im- 
age seems to be to the right of the object. When an eye 
deviates upward its false image appears below ; and when 
it deviates downward the false image appears above. In 
general, in whichever direction the squinting eye deviates, 
its false image appears to be situated to the opposite side 

of the true one. When the image on the right side be- 
’ longs to the right eye, it is called homonymous diplopia. 
It occurs when the visual axes are crossed as in Fig. 
3737. When the image on the right side belongs to the 
left eye, and the image seen to the left belongs to the 
right eye, it is crossed diplopia. This is represented in 
Fig. 3788, and occurs in divergent squint. To determine 


ee 


a 
es 
— —, 


Fie. 3738. 


which image belongs to the right eye, and which to the 
left, cover one eye and the image belonging to it will in- 
stantly disappear. Another method of identifying the 
images is to place before one eye a piece of colored glass, 
when the image belonging to that eye will instantly ap- 
pear colored, In making these tests for diplopia a candle 
or lamp flame is an excellent object to have the patient 
look at. . 

Objective Symptoms.—If the squint be well marked, in- 
spection, sometimes the most casual, will reveal the de- 
fect, and show which eye it is that deviates. But even 
in what may seem to be an unmistakable case there is a 
possibility of error. We judge of the direction of the 
visual axis by the direction of the centre of the cornea ; 
and usually the visual axis pierces the cornea near its 
centre, or a very little to the nasal side of the centre. 
But sometimes the visual axis deviates considerably from 
its usual direction, so that, when it is properly directed 
toward the object fixed, the centre of the cornea will be 
turned considerably to one side, and the eye will appear 
to squint. Or the centre of the cornea will be turned ap- 
parently in the right direction, and the visual axis will 
really deviate considerably from the object looked at. 

To determine whether the eye really does squint, di- 
rect the patient to gaze steadily at a certain object in 
front of him, and cover first one-eye and then the other. 
If both eyes are properly directed toward the object, 
there will be no change of position when either one is 
covered. If one eye have its visual axis turned elsewhere, 
covering it will not cause any change of position ; but 
covering the eye which has been really directed toward 
the object will cause the eyes or head to be turned, so 
that the eye which had looked elsewhere may now fix on 
the object. If, however, both eyes have been fixed on 
the object, but only by an undue effort, the covered eye 
will deviate and take such position as can be preserved 
without the undue effort. The objective test of covering 
the eyes alternately while fixed upon some point and 
watching their behavior should be repeated until the ob- 
server is satisfied as to the presence or absence of squint. 
Having ascertained that squint is actually present, the 
first point to be settled is whether it is concomitant or 
paralytic. 

CoNCOMITANT STRABISMUS is a wrong, and usually va- 
riable, co-ordination of the movements of the eyes with 
reference to each other, without marked limitation of 
these movements in any particular direction. In general, 
it is to be noticed whatever the direction of the object 
looked at, but its amount may vary from time to time, 
and is often greater the nearer the object is to the eye. 


656 


It commonly appears in early childhood, but may exist 
from birth, and more rarely begins during adult life. 

Convergent squint is the most common form of concomi- 
tant strabismus. Init the visual axes, instead of converg- 
ing to the point looked at, converge to and cross at a 
point nearer the eye, as in Fig. 3787. In it the diplopia 
is homonymous, and on covering the eye which is fixed 
on the object it turns in toward the nose, while the other 
turns from the nose and fixes the object. 

Divergent squint comes next to the convergent in fre- 
quency. In this form the visual axes do not converge 
enough, either meeting at some point beyond the. object 
looked at, or remaining parallel or even divergent; the 
diplopia is crossed, and when the fixing eye is covered it 
turns out toward the temple, diverges, and the other eye 
turns toward the nose and fixes the object. When the 
visual axes remain always divergent, no matter how 
great an effort is made to turn them in, the squint is said 
to be absolutely divergent. When the visual axes can be 
made to converge, but not to converge enough for the 
visual axes both to pass through the point looked at, as 
in Fig. 3788, the squint is said to he relatively divergent. 
Parallel squint is the name formerly applied to those 
cases of relative divergence in which the visual axes re- 
main parallel when they should converge toward a near 
object. 

Vertical squint, in which one visual axis is directed 
more upward or more downward than the other, is ex- 
ceedingly rare, except as complicating one of the other 
forms of concomitant squint. It is quite common in di- 
vergent squint to find the eye which habitually deviates 


to be turned upward, as well as outward; and, as this 


condition is frequently associated with drooping of the 
upper lid, it has been regarded as an effort of nature to 
exclude the deviating eye from vision and thus avoid © 
diplopia. 

Constant squint, as its name implies, is always present, 
the visual axes never assuming normal relations. Op- 
posed to it is pertodic or intermittent squint, which is only 
present part of the time, the relations of the visual axes 
being at other times entirely normal. The periodicity 
may be looked upon as being an exaggeration of those 
variations in degree which constant squint usually pre- 
sents ; and it is irregular, not cyclical, unless dependent — 
on some cyclical variation in the general nervous system, 
like that which attends menstruation. 

Periodic squint is apt to be most marked when the 
general tone of the nervous system is low, or at times 
of great excitement, or when the eyes are particularly 
taxed; a form of convergent squint, appearing only dur- 
ing strong effort of the accommodation, being called ae- 
commodative squint. Squint occurring during violent dis- 
order of the general nervous system would not be spoken 
of as periodic, but as convulsive squint. Closely allied to 
periodic and convulsive, perhaps standing rather between 


- them, is hysterical squint. 


Monotateral or monocular squint is the form in which it 
is always the same eye that fixes on the object looked at, 
while the other eye always deviates. Ifthe fixing eye 
be covered it will deviate, while the ordinarily deviating 
eye fixes; but, upon uncovering, the deviation is soon 
transferred back to the eye which habitually presents it. 
The large majority of cases of concomitant strabismus are 
in this sense monolateral. But it must not be supposed 
that only the deviating eye is at fault. The squint isa 
faulty co-ordination of the motions of the two eyes, and 
the reason that it is always one eye that deviates is sim- 
ply that the fixing eye has better vision, or is more easily 
used, as in hyperopia of differing degrees the use of the 
eye with the lower degree entails less exertion of the 
power of accommodation. 

Alternating squint is the variety in which the deviation 
is sometimes presented by one eye, and sometimes by the 
other ; either of them becoming the fixing eye when the 
other is covered, and continuing to fix after the other is 
again allowed to participate in the act of vision. Cases 
which are frequently at their outset, to some extent, al- 
ternating, may after a time become quite monolateral. 
Such cases, however, show from the start a disposition. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Strabismus. 
Strabismus. 


to let one eye deviate more than the other; and true al- 
ternating strabismus may exist many years without tend- 
ing to become monolateral, the determining factor being 
the equality or inequality of the two eyes as to acuteness 
of vision and ease with which they can be used. 

Absence of Binocular Fusion.—In speaking of diplopia 
we have already given the conditions necessary for its 
production ; and since, in the large majority of cases of 
concomitant squint, some of these conditions are lacking, 
most persons with squint do not experience double vision. 
In some cases it is quite obvious why there is no diplopia, 
as where corneal opacity, or a high degree of ametropia, 
prevents the formation of a retinal image in the deviating 
eye. In another class of cases the reason is less obvious, 
yet not hard to understand ; as where, although the de- 
viating eye presents no abnormal appearance either to 
external inspection or with the ophthalmoscope, when 
the ametropia is not excessive, yet the acuteness of vision 
is very low. Here amblyopia, probably indicating some 
defect of development, prevents the deviating eye from 
any considerable participation in the act of seeing. But 
there is still another class of cases in which, although 
each eye, when tested alone, shows good power of vision, 
and in which there can be no doubt that both eyes are 
usefully employed by their possessor, yet with marked 
squint there is no diplopia. 

This state of affairs must be looked upon as a reversion 
to a type of visual act, common to most of the lower ani- 
mals, in which, though they have two eyes, nothing like 
our binocular vision can be assumed to exist ; the power 
of what has been called binocular fusion is lacking. It 
is quite conceivable that this power may now and then 
be lacking as a congenital anomaly ; it may perhaps be 
always lacking at birth, and in all cases be a matter of 
individual development. Certainly it varies greatly in 
extent of development among those who undoubtedly 
possess it. The power is most developed and longest re- 
tained with reference to images formed on the macula 
lutea, if, indeed, it be not wholly confined to these. One 
who lacks entirely this power cannot have binocular di- 
plopia, and cannot judge any better of the distance of un- 
familiar objects with both eyes open than when one is 
shut. 

— Amblyopia with Squint.—Allusion has already been 
made to the large number of cases of squint in which there 
is great defect of vision, without any gross change to 
account for it. This amblyopia was formerly known as 
amblyopia ex anopsia, or amblyopia from disuse. It was 
supposed that squinting eyes presenting no lesion sufli- 
cient to account for their amblyopia had originally pos- 
sessed good vision, that when they began to squint it 
caused diplopia, that to avoid diplopia the image formed 
in the deviating eye was actively ‘‘suppressed,” exclud- 
ed in some way from producing its proper effect on con- 
sciousness ; and, further, it was supposed that this ‘‘sup- 
pression” or ‘‘ exclusion” reacted injuriously on the sen- 
sibility of the eye subjected to it, causing a permanent 
amblyopia. For atime the frequent occurrence of this 
special form of amblyopia from disuse was scarcely 
questioned ; but recently this series of suppositions has 
been challenged by various observers, most actively by 
Schweigger ; and they have been shown to have no suffi- 
cient foundation in the facts. There is nothing to show 
that in many of these cases diplopia has ever existed. 
Where diplopia does exist in the beginning of a squint, it 
may disappear with the loss of binocular fusion, without 
the least impairment of visual acuteness ; and in cases of 
paralytic squint, which are often seen from the beginning, 
and which sometimes become quite constant and are apt 
to be attended with very annoying diplopia, such a pro- 
cess as that supposed to lead to amblyopia ex anopsia 1s 
quite unknown. i: 

Causes of Concomitant Squint.—The highly specialized 
character of the movements designed to secure binocular 
vision makes it extremely probable that they depend for 
their perfection on individual development. The con- 
trolling influence in such development is binocular fusion. 
Under the head of latent squint, we shall see how many 
cases of squint are kept from consummation by the desire 


Vou. VI.—42 


to avoid diplopia, and it is in every way probable that a 
much larger number of cases are, during the early years 
of life, by this same impulse, led to so use the muscles 
which move the eyeball as to secure their symmetrical 
development and so do away with any tendency to squint. 
When, therefore, binocular fusion is impossible, or the 
tendency to it unusually feeble, as where the vision of 
one or both eyes is very imperfect, or where the faculty 
of fusion itself is not added to good vision of each eye 
alone, the orbital muscles never attain that normal de- 
velopment which enables them, by their elastic tension, 
to keep the visual axes properly directed to the point 
looked at. And while the rudiments of the proper bin- 
ocular movements exist, so that both eyes may turn up- 
ward or downward, or to either side, at the same time, or 
converge somewhat more for near seeing, or somewhat 
less when a distant point is fixed, the perfection of their 
co-ordination, bringing the visual axes always to intersect 
at the point fixed, is not attained, and concomitant stra- 
bismus results. Of course, under this view anything 
which impairs the development of the visual centres or 
the acuteness of vision—as hereditary anomalies, convul- 
sions, prolonged nutritive disorders, injury of the eyeball, 
keratitis, or high ametropia—becomes a cause of squint. 
But ametropia has an especial share in the causation of 
squint, as was first pointed out by Donders, although 
the importance of this factor has often been much ex- 
aggerated. Normally, the exertion of the power-of ac- 
commodation is accompanied by convergence of the vis- 
ual axes ; the full power of the accommodation cannot 
be exerted without strong convergence. Hence in hyper- 
opia, where the accommodation must be exerted more 
strongly to focus the image of the point looked at upon 
the retina, it is reasonable to expect a special tendency 
of the visual axes to converge more than in emmetropia, 
where the accommodation is less taxed. Statistics show 
that convergent strabismus usually occurs in hyperopic 
eyes. Still, asa large majority of all eyes present a low 
degree of hyperopia, it cannot be regarded as proved that 
the association of low hyperopia and squint is, in many 
cases, more than accidental. In the higher degrees of 
hyperopia, the proportion of patients presenting at least 
a periodic squint is too great to be accounted for in this 
way ; and the view that hyperopia is, in some cases, one 
cause of squint, is fully supported by the results of 
treatment directed to the prevention of excessive effort of 
accommodation. 

In myopia not only is it possible that the need for 
complete relaxation of the accommcodation, even when a 
near object is looked at, may lead to deficient conver- 
gence of the visual axes, or divergent squint, but there 
is also an anatomical obstacle to normal binocular move- 
ments, in the shape of the myopiceyeball. The posterior 
segment of the emmetropic eye is spherical, and it rests 
in a spherical socket of orbital fat and connective tissue 
which it fits accurately, no matter in what direction the 
eye is turned. And in cases of hyperopia, even of the 
higher degrees, that are commonly met with, the devia- 
tion from the spherical form is comparatively slight. But 
in myopia, which runs into higher degrees than hyper- 
opia, and of which the higher degrees are more com- 
mon, there is an antero-posterior elongation of the globe 
which is often very marked. This makes the eyeball an 
oval, fitting inan oval socket, in which it cannot be turned 
without changing the shape or direction of the socket, by 
actual displacement of the orbital tissue. Hence conver- 
gence of the myopic eye requires excessive effort, while 
myopia, restricting the range of distinct vision, requires 
that the convergence should be especially great. Often, 
and in the highest degrees of myopia always, the effort at 
convergence is abandoned, and a divergent strabismus 
permitted. This is at first relative and periodic, but, if 
associated with deficiencies of muscular development, is 
very likely to become in time absolute and constant. — 

Treatment of Concomitant Squint.—The preventive 
treatment would include all measures favoring the nor- 
mal development of the general nervous and muscular 
systems, or calculated to improve the acuteness of vision. 
Both to influence the acuteness of vision, and to give 


657 


Strabismus, 
Strabismus, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the normal accommodation and range of distinct vision, 
errors of refraction are to be corrected. In convergent 
squint with hyperopia, the convex lens fully correcting 
the latter should be worn constantly. If the squint is 
commencing in a child too young to wear glasses, it is 
advisable to place the eyes under the influence of a 
mydriatic, as 


Atropine sulphate 2... . vst a erates eee Bry. 
Distilled ‘water’. os, <4 Seco. so ae eee Semel: 


one drop to be placed in each eye three times a day. 
This should be kept up for some time after the squint 
has disappeared, or, when squint continues, at least for 
some weeks, until it is clearly demonstrated that the de- 
viation is not being favorably influenced by it. 

The mydriatic acts by paralyzing the accommodation, 
and so preventing any attempt to use it which may bring 
about excess of convergence. This remedy is worth try- 
ing in any case of commencing convergent squint, 
whether associated with hyperopia or not. Care must 
be taken that the solution used is strong enough, and is 
efficiently applied ; for if only enough of the mydriatic is 
instilled to somewhat weaken the accommodation, the 
effect will be not to prevent, but to increase the accom- 
modative effort, and therefore the accompanying conver- 
gence, é 

In myopia concave lenses, either correcting all of it or 
so much as is necessary to enable the patient to see clearly 
at a distance of some twelve inches, may be used to pre- 
vent divergent squint. Or if the squint is already estab- 
ablished, the use of correcting lenses, by making accom- 
modation necessary for near vision, may bring about 
some convergence. 

As aiding in the proper development of the muscles con- 
cerned, what are called orthoptic or orthopedic exercises are 
recommended. They consist usually in looking through 
some form of stereoscope at lines, letters, or figures, a 
part of each being seen by one eye, and the remainder 
being presented to the other eye; by an effort these are to 
be fused into one harmonious whole. An ingenious at- 
tempt in the same direction, proposed by Cuignet, is made 
by attaching to a firm head-band an arm projecting hor- 
izontally from the centre of the brow, from which are 
suspended the page to be looked at and a ruler placed 
vertically between the page and the eye. The ruler cuts 
off a part of the page from each eye, but by using both 
eyes all parts may be seen; and the reading of each line 
necessitates the alternate use of both eyes. Orthoptic 
exercises are mainly of use to cultivate the faculty of 
binocular fusion where that exists, but is deficient in 
comparison with the obstacles it has to overcome. 

As a palliative of concomitant squint, prisms may be 
worn in rare instances. They are so used as to cause 
the rays to enter the squinting eye in the direction of its 
visual axis and thus avoid diplopia, while the squint re- 
mains unchanged. Or they may be used as a sort of 
orthoptic apparatus, to bring the rays so nearly in the 
direction of the visual axis of the deviating eye that, by 
a little additional effort, the visual axis will be brought 
to coincide with their direction, and the squint thus les- 
sened. In either case the strength of prismatic effect re- 
quired is to be determined by trial, and this secured by 
placing prisms of equal strength before both eyes, with 
the refracting angle or thin edge of the prism in the di- 
rection in which the eyes deviate. Thus, ina case of 
divergent strabismus a prism will be placed before each 
eye, with its edge toward the temple; in convergent 
strabismus, with its edge to the nose; or, if the right eye 
turns upward more than the left, a prism with the edge 
- up before the right eye, or with the edge down before the 
left, will give relief. Because of the weight of strong 
prisms, the dispersion of light which they cause, and the 
apparent distortion of objects seen through them, it is 
scarcely practicable to wear prisms of more than from 
four to six degrees ; and for this reason they are rarely 
useful in cases of actual squint. 

Since in the vast majority of cases of squint it is im- 
possible to so develop the muscles concerned that they 
shall, by their elastic tension and normal contraction, 


658 


* 

keep the visual axes in proper relation one to the other, 
recourse is had to operative measures ;, these are intended 
so to change the connection of these muscles to the eye- 
ball that the visual axes may assume approximately their 
proper positions. These measures are two in number : 
One of them is the severing of the tendon of the muscle 
toward which the cornea is turned, allowing it to retract 
and the eyeball to be turned toward the proper position 
by its opponent, so that it shall attach itself farther back 
upon the sclerotic, and thenceforth have relatively less 
power to turn the eye in its direction; this is called ¢e- 
notomy of the rectus, or strabotomy. The other is advance- 
ment of the tendon of the muscle which has exerted too 
little,influence on the direction of the eye, allowing it to 
acquire a new insertion closer to the cornea, and so ex- 
ert arelatively greater influence in determining the di- 
rection of the visual axis. Since operative procedure 
is only to be resorted to where development cannot be 
expected to accomplish the relief of the deformity, it 
should not be tried until development is so far advanced 
as to leave it clearly indicated. Thus, it should not be 
done before the age of six or eight years in the highest 
degrees of squint, until after puberty for moderate 
amounts, and for low degrees not until adult life is ap- 
proached or reached. Again, it is wise, before operating 
for squint, to determine the refraction of the eyes and 
try the effect of correcting lenses upon the deviation, 
or, at least in the convergent form, to ascertain what ef- 
fect is produced by the use of a mydriatic. Neglect of 
wise caution in this direction is responsible for the not 
rare conversion of convergent into divergent squint. It 
is not rare for squint to occur, sometimes to persist for 
mouths or even years, and then to spontaneously disap- 
pear ; and the premature correction of such a case by 
operation, though perhaps quite satisfactory at the time, 
may in the end bring both operator and operation into 
discredit. 

In determining the operation to be done the amount of 
deviation is to be considered. This may be measured in 
degrees on the arc of a perimeter, by placing the deviat- 
ing eye at the centre of the arc, making the visual axis 
of the fixing eye parallel to the axis of the instrument, 
and noting the number of degrees from the axis of the 
perimeter to the visual axis of the deviating eye. Or, if 
convergent, the number of metre-angles of squint may 
be found by placing at the root of the nose a metre-meas- 
ure graduated to metre-angles (the same as dioptric focal 
lengths), directing the fixing eye to the other end of the 
stick, and subtracting one from the number of metre-an- 
gles indicated for the point at which the visual axis of 
the deviating eye crosses the measure. Or the deviation 
can be measured by placing a scale along the edge of the 
lower lid of the squinting eye, covering the good eye so 
that the other may fix, and then uncovering it and watch- 
ing the deviation. Where the deviation is slight it is 
usually to be corrected by a tenotomy ; where the devia- 
tion is much greater than can be remedied by a single 
tenotomy, it is generally best to do an advancement ; and, 
if this proves insufficient, a subsequent tenotomy may be 
resorted to. Asarule, the inward deviation that can be 
remedied by a tenotomy of the internal rectus is greater 
than the outward deviation that can be overcome by 
a tenotomy of the external rectus; and. the effect of the 
former operation tends to increase for a certain time af- 
ter its performance, while the effect of the latter rather 
tends to diminish. 

To perform tenotomy of one of the recti muscles it is bet- 
ter to have an assistant, although the operation can be 
done without aid by using a spring-stop speculum to keep 
the eye open. The instruments required are a pair of scis- 
sors with fine but slightly blunt points, a pair of strabis- 
mus forceps (a form of fixation forceps with narrow 
toothed jaws), a strabismus hook, and a lid-elevator or 
speculum. A drop of a four per cent. solution of cocaine 
is to be placed over the insertion of the tendon to be cut. 
This is repeated every two minutes for five or ten minutes. 
The lid-elevator or retractor is then introduced beneath 
the upper lid and confided to the assistant, who stands 
behind the patient, steadying the head against his own 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Strabismus. 


breast. The operator then seats himself on the same side 
of the patient as the eye to be operated on, and, with the 
forceps in one hand, seizes a fold of the conjunctiva 
some five mm. back from the margin of the cornea, and 
over the lower part of the tendon to be divided. With the 
scissors in the other hand, this fold in the conjunctiva is 
snipped so as to make an opening which, when stretched 
out, will be from five to eight mm, in length. The for- 
ceps are then allowed to drop the conjunctiva, and are 


introduced through the cut just completed and made to’ 


grasp the subconjunctival tissue. This is also divided 
with the scissors, and while it is still held by the forceps 
the points of the scissors are to be introduced beneath it, 
and, being alternately spread and brought together as 
they are pushed forward, are made to divide the tissue, 
until a free opening is obtained for the introduction of the 
hook. The scissors are then laid down and the hook is 
introduced, care being taken to keep the point in contact 
with the sclerotic, and is pushed back and then upward 
under the upper part of the tendon, which is drawn for- 
ward. The forceps are now removed and the hook de- 
pended upon to fix the eyeball. The points of the scis- 
sors are introduced beneath the conjunctiva, one point 
close to the hook beneath the tendon and close to its in- 
sertion, the other over the tendon and immediately be- 
neath the conjunctiva. The blades being brought to- 
gether, the tendon is divided and the hook can be pushed 
forward without hinderance to the margin of the cornea. 
The point of the hook is then turned downward, and the 
lower part of the tendon taken up and divided in a simi- 
lar manner. When no bands remain to prevent the hook 
from freely slipping forward to the corneal margin, it 
- is removed and the motility of the eye is tested. If mo- 
tion is not decidedly limited in the direction of the cut 
tendon, the hook is to be introduced again and other 
bands searched for, especially at the upper and lower 
margins of the tendon, and these must all be divided, or 
no material effect will be produced by the operation. In 
this connection it is to be remembered that the width of 
the. tendon to be divided is from six to ten mm. The 
effect of the operation can be considerably enhanced by 
freely dividing the subconjunctival tissue around the 
tendon. 
For advancement of the tendon of one of the recti mus- 
- cles, there are required, in addition to the instruments 
used for tenotomy, fine needles and silk sutures, and a 
needle-holder. It is better to have the patient recumbent, 
and, after the use of cocaine, the introduction of the ele- 
vator or speculum, and the tenotomy of the opposing 
‘muscle, an incision is made with the scissors in the con- 
junctiva, parallel to the corneal margin, five mm. from 
it, and extending the whole width of the tendon to be 
advanced, and some distance beyond it on either side. 
The tendon is now to be isolated and raised on the hook. 
A needle armed with the silk should then be passed 
through each margin of the tendon from without inward, 
some distance back from its insertion; and, having been 
drawn through, is to be introduced beneath the conjunc- 
tiva near the corresponding margin of the insertion, car- 
ried around the cornea, and brought out near the extrem- 
ity of its vertical diameter, thus including a good mass 
of tissue. The ends of each suture are now tied together 
and the sutures drawn out of the way. The tendon is 
then severed at its insertion, and a small piece of it may 
be cut off if a decided change of the direction of the eye- 
ball is desired. A third suture, connecting the centre of 
the tendon with the corresponding pericorneal tissue, is 
now introduced, and the sutures are tightened, care being 
taken that the upper and lower margins shall be equally 
drawn upon. The eye is then closed and bandaged. 
The stitches are allowed to remain several days, unless it 
is feared that too great an effect will be produced. 

In a large proportion of cases, the result of operative 
interference is only an approximate correction of the de- 
formity, which may sometimes be improved by the sub- 
sequent use of glasses, or orthoptic training. Only where 
good binocular fusion can be obtained may a perfect re- 
sult be hoped for. 

PARALYTIC SQUINT is a lagging behind of one eye when 


what toward the affected side. 


Strabismus. 


the patient attempts to look in a certain direction ; it is 


due to limitation of the movement of the eye, by partial 
or complete loss of power in the muscle or muscles 
which should turn the eye in that direction. 

Such palsies, like those of other muscles, may arise 
from lesions of the muscle itself, of the centres governing 
its action, or of the connecting nerve-tracts ; usually they 
have the latter origin. Early, in a case of uncomplicated 
paralytic squint, all ocular movements which do not de- 
pend on the muscle or muscles affected may be perfectly 
normal ; and, so long as no demand is made on these mus- 
cles, no diplopia or inconvenience results. But when it 
is attempted to turn the eyes in some direction where 
the action of the affected muscle will be essential, it is 
found that, while one eye responds normally to the im- 
pulse of the will, the other responds imperfectly or not 
at all; and the farther in this direction the sound eye is 
carried, the greater the deviation of the affected eye, and 
the wider the separation of the two images, which in this 
kind of squint are almost always present. Hence the 
squint and diplopia are not constant, but only appear 
when the eyes are turned in a certain direction—which 
sharply separates this from concomitant strabismus. In 
periodic concomitant squint the squint is sometimes ab- 
sent, but when present it is so irrespective of the direc- 
tion of the object fixed; in paralytic strabismus the 
squint, though sometimes absent, is always present when 
the eyes are turned in a certain direction, and always ab- 
sent when they are turned in another. After paralysis 
of one of the muscles has existed for some time, its nu- 
trition is impaired and elastic tension reduced, so that 
it is no longer sufficient to balance the elastic tension of 
its opponent. The latter turns the eye toward itself, so 
that it cannot assume the normal position, even when the 
muscles are relaxed as much as possible. When this oc- 
curs the deviation becomes more or less constant, and if 
some power of voluntary contraction be recovered by the 
paralyzed muscle, after its elastic tension has become 
thus impaired, the case assumes somewhat the character 
of a concomitant strabismus. The form of the squint 
depends on the muscle or muscles involved. It is, for 
practical purposes, convenient to ‘classify paralytic stra- 
bismus by the nervous supply of the muscles involved. 

Paralysis of the abducens nerve, or external rectus mus- 
cle, causes a most frequent and simple form of paralytic 
squint. The distribution of this nerve (the sixth cranial) 
being confined to the one muscle, and the action of this 
muscle being essential only to turning the eye outward 
(toward the temple), especially outward and upward 
(since the superior oblique has some power of turning it 
outward and downward), diplopia and deviation are 
only noticed when the patient tries to look toward the 
side on which the affected muscle is situated. If the 
paralysis be complete, diplopia begins as soon as the ob- 
ject fixed passes the median line; if it be but partial, it 
may not appear until the eyes have been directed some- 
When the case has lasted 
some time, so that the internal rectus has acquired an 
elastic preponderance, the deviation and diplopia involve 
a greater part of the field of vision; but, in any case, the 
deviation and the separation of the double images are 
least when the eyes are directed most toward the sound 
side, and greatest when they are directed most toward 
the affected side. Congenital paralysis of both of the 
abducens nerves, causing a constant convergent squint 
with inability to turn the eyes to either side, without di- 
plopia, and perhaps with excentric fixation, has been oc- 
casionally observed. 

Paralysis of the Patheticus, Fourth Nerve ; the Supervor 
Oblique Muscle.—Here again we have a nerve supplying 
a single muscle, but one whose action is somewhat com- 
plex. Its function is to aid in turning the eye down and 
out, and to rotate it about the antero-posterior axis. The 
deviation and diplopia appear mainly when the eyes are 
turned toward the affected side and rather downward ; 
when the eye is turned to the affected side the false 
image appears so inclined that its upper end is close to 
the upper end of the true image, while the lower deviates 
more widely from it. 


659 


Strabismus, 
Stramonium. 


Oculo-motor Paralysis.—The oculo-motor, or third 
nerve, which is distributed to three of the recti muscles— 
the inferior oblique, the elevator of the lid, and the iris 
and ciliary muscle—may be paralyzed in one or more of 
its branches. With the paralysis of its intra-ocular por- 
tion, causing loss of accommodation and some dilatation 
of the pupil, we are not here concerned. The involve- 
ment of all the extra-ocular branches causes drooping of 
the lid (ptosis), and leaves the-eye unable to move in any 
direction except outward and a little downward, under 
the influence of the external rectus and superior oblique 
muscles. On attempting to look toward the sound side, 
or upward or far downward, deviation and diplopia ap- 
pear, and increase par? passw with the effort to turn the 
visual axes in either of these directions. The same thing 
occurs when any attempt is made to converge for a near 
object. According to the movements attempted does the 
squint assume more the character of a divergent or a ver- 
tical strabismus. 

When the sound eye is excluded from vision there is 
experienced a great uncertainty as to the position of ob- 
jects, which amounts to a kind of vertigo. If the palsy 
has lasted more than a few days, a permanent outward 
deviation of the visual axis is usually established. 
Oculo-motor palsy may involve only a part of the mus- 
cles supplied by the nerve, or may even be limited to a 
single one. Almost always it affects some more severely 
than others ; and quite often, when all have been severe- 
ly involved, some will recover almost completely, while 
others show little or no improvement. Hence, individual 
cases vary greatly as to the nature of the deviation and 
diplopia ; and each must be studied by the light of the 
general principles governing the occurrence of squint ; 
deviation occurs when the eye is turned toward the 
weakened muscle, and the false image is apparently dis- 
placed in the same direction. Several cases have been 
reported of oculo-motor paralysis recurring at consider- 
able intervals, and tending to become fixed and associ- 
ated with other cerebral symptoms; the essential char- 
acter of these paralyses is still unknown. 

_ Ophthalmoplegia externa is the term applied to a paral- 
ysis of all the muscles attached to the eyeball. 

Treatment of Paralytic Squint.—If the paralysis be due 
to some lesion, the location and nature of which are other- 
wise obvious, as a tumor, or ig the result of some trau- 
matism of the orbit, dependence is to be placed on the 
rational surgical treatment of the cause. Where, how- 
ever, the palsy is the most definite or only symptom per- 
ceived, recourse must be had to internal or general medi- 
cation. The largest number of these palsies come from 
some syphilitic new-growth, involving the sheath of the 
nerve or adjoining structures, or from syphilitic disease 
of the nerve itself. A few come from rheumatic disease 
in the course of the nerve-trunk, and a considerable 
number arise from a focus of disease in cerebro-spinal 
or spinal sclerosis. If there be a clear history of rheu- 


matism, or collateral evidence of the rheumatic nature . 


of the attack, anti-rheumatic remedies should be care- 
fully tried. If there is other evidence of commencing 
or progressing sclerosis, we may assume this to be a 
manifestation of the general tendency in that direction. 
But in all other cases it is probably best to assume that 
the lesion is syphilitic, and to treat it with increasing 
doses of potassium iodide. A good way is to prescribe 


POLRSSLI TOL Ore eatin so"... as vse j. 
VOCED. Ae ate pit Select c's lee 4 1 a fe 


each drop of which will contain about a grain of the 
drug. Let this be taken in water or milk, commencing 
with ten drops, three times a day. On the third day be- 
gin giving the same dose four times daily; and after 
that, on each alternate day increase the dose by five 
drops ; and so continue until there is evidence of increase 
of power in the paralyzed muscles, or until symptoms of 
iodism appear. If decided improvement begins we may 
simply continue the administration of the drug without 
further increase of the dose, and if iodism occurs the 
drug must be suspended, or its dose considerably dimin- 
ished. 


660 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


In cases seen within a few days of the commencement 
this treatment generally secures great improvement, and 
not rarely complete recovery. But if many weeks or 
months have elapsed, there is not so much to be hoped 
from it. In very many cases, medical treatment leaves 
the cure far from complete, and certain local measures 
are to be resorted to. 

It is scarcely practicable, on account of their situation, 
to pass through the affected muscles electric currents 
powerful enough to have much effect on them, without 
endangering the optic nerve and retina. 

Prisms and tenotomy are not generally:of any use, be- 
cause the extent of the deviation varies with the direction 
in which it is desired to turn the eye. Where the paral- 
ysis remains absolute and the resulting deformity is very 
great, cosmetic improvement may sometimes be obtained 
by making an advancement of the tendon of the para- 
lyzed muscle and the neighboring portion of the capsule 
of Tenon, with a tenotomy of the opponent muscle. The 
immediate effect, obtained in this way, should always be 
a decided deviation toward the paralyzed muscle, as the 
healthy opponent will, after a time, be sure to greatly 
Jessen this effect. In cases of non-recovery or incom- 
plete recovery from these palsies, passive motion, as pro- 
posed by Michel, has been used with apparent benefit to 
a considerable proportion of the cases subjected to it. 
Cocaine having been applied to the eye, the insertion of 
the paralyzed muscle is seized with the fixation forceps 
and the eyeball dragged back and forth in the direction 
in which the muscle would act, so that the muscle is al- 
ternately stretched and relaxed to its utmost ; and this is 
continued for about two minutes. This manipulation is 
to be repeated every two or three days; but if no im- 
provement is noticed after a few repetitions, none is to 
be hoped for from a further continuation of such treat- 
ment. When the cure of a case of paralytic squint is 
almost complete, orthoptic exercises may be of benefit. 

LATENT OR DyNAmIc SQuint.—A perfectly symmetri- 
cal development of the eye-muscles and their governing 
centres, which secures exactly the proper balance of elas- 
tic tension, contractile power, and motor impulse, that 
makes the co-ordination of binocular movements perfect, 
is perhaps as rare as is mathematically exact emmetropia. 
Binocular fusion is required to make up for its deficiency, 
in a very large proportion of cases, by inducing the slight 
extra, although involuntary, contraction of those muscles 
which without it fail to quite balance their opponents. 
In probably a large majority of persons the withdrawal 
of the influence of binocular fusion leaves a perceptible 
though slight squint. Such squint is called latent or dy- 
namic, or is spoken of as an ¢nsufficiency of the weaker of 
the opposed muscles. It has also been proposed by Ste- 
vens to call it heterophoria, a tending of the visual axes 
toward different points. If not great, the latent deviation 
will cause no trouble to a person with a well-developed 
musculo-nervous system. But in persons of inferior 
muscular development and small reserve of nerve-force, 
even moderate degrees of insufficiency may give rise to 
the symptoms of eye-strain, especially if the eyes are re- 
quired to do large amounts of work, or to work under 
unfavorable conditions. 

Diagnosis of Latent Squint.—When, from the evidence 
of eye-strain, it is suspected that this form of strabismus 
is present, its existence is revealed by rendering impossi- 
ble binocular fusion. For the objective test, binocular vi- 
sion is rendered impossible by holding something opaque, 
as the hand, between one eye and the point fixed. The 
eye thus excluded will then, if there is the tendency to 
squint, be seen to deviate and take the position of equi- 
librium for the muscles that move it. Upon uncovering 
the eye, it quickly assumes again the position in which 
its visual axis will pass through the point fixed. In this 
way, by repeated trials and close watching of the eyes, 
quite low degrees of latent squint can be detected. But 
still more delicate is the subjective test. To make it, 
binocular fusion is prevented by placing before one eye 
a prism of about six degrees, with its base directly up. 
The eyes now being fixed upon some object, as a dot on 
a card across the room, this will appear doubled, the eye 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Strabismus. 
Stramonium, 


with the prism before it seeing a false image below the 
true one. To make the test for a near point it is impor- 
tant to have the eyes accommodating for the point fixed, 
and to secure this the writer uses a single group of four 
fine crossed lines, like those shown in Fig. 3739, drawn 
on a plain card. If no tendency to squint be present, 
and the prism is held with its base directly up, the false 
image will be seen exactly under the true one, as repre- 
sented in A, Fig. 3739; but if there be squint, the images 
will not be in the same vertical line, but in convergent 
squint will part from this position homonymously, and in 
divergent squint will be crossed. Thus, supposing the 
prism to be held 
with its base up be-  ~: oe a 
fore the right eye, 

the lower image 

will belong to the .+ . * a ¢ 
right eye, the up- 

per to ehe left. hes A B 

appearance like B, 
in Fig. 3739, will 
indicate convergent strabismus, the image of the right 
eye being to the right, and the image belonging to the 
left eye to the left. On the other hand, C, in the same 
figure, representing a tendency to crossed diplopia, indi- 
cates latent divergent squint. ‘To determine the presence 
or absence of latent vertical squint, the most satisfactory 
test is the repeated trial of the power to ‘‘ overcome” a 
prism with its base up, held first before one eye, then be- 
fore the other. If any tendency to such deviation exists, 
it will be revealed by ability to overcome a prism with 
its base up before one eye, which cannot be overcome 
when the prism is placed in the same position before the 
other. 

Forms of Latent Squint.—Divergent squint, insuffi- 
ciency of the internal recti muscles, or exophoria, is the 
most common. It was first described in connection with 
myopia, where it is particularly liable to cause trouble, on 
account of the need for unusually strong convergence ; 
but it is even more frequent in persons who are hyper- 
opic and use their eyes much, or under unfavora- 
ble conditions, for close work. 

Convergent latent squint, insufficiency of the 
external recti, or esophoria, is frequently seen in 
hyperopes who tax their eyes. Vertical squint, . 
insufficiency of the superior or inferior recti, or 
hyperphoria, is a very rare condition ; but low 
degrees of it may cause much headache and nervous ten- 
sion, because there is less power of compensatory extra 
contraction in the superior and inferior than in the lateral 
recti. A tendency to vertical deviation of more than from 
two to four degrees is too extensive a squint to be kept 
latent, and one even half as great may severely tax the 
reserve power of the muscles concerned. 

Treatment.— All remedial measures spoken of in con- 
nection with other kinds of squint may be resorted to 
for this. On account of the lesser extent of the deviation 
prisms are particularly available. On the same account 
tenotomy and advancement require more accurate and 
delicate adjustment to the needs of the case, and are to 
be resorted to only after a thorough and rather prolonged 
acquaintance with those needs. But reduction of the 
amount of trying eye-work, and hygienic measures cal- 
culated to improve the condition of the nervous system 
generally, are of the utmost importance in the majority 
of such cases. 

Mixed Forms of Squint.—W hile nearly all cases of stra- 
bismus are readily referred to one or the other of the 
foregoing classes, and while it is of the first importance 
to have clear conceptions as to the special characteristics 
of each class, it should not be forgotten that many cases 
present the peculiar features of more than one class. 
Thus we may have a dynamic divergent squint for dis- 
tant vjsion running into an actual divergent squint for 
near work ; or a case of well-marked concomitant squint 
with an overstretched muscle notably paretic ; and allu- 
sion has already been made to the occurrence of concom- 
itant in the later stages of paralytic squint. In strabis- 
mus, therefore, as elsewhere throughout the domain of 


Fie. 3739, 


medicine, each case is a subject for individual study, a 
most important kind of original investigation. 


BIBLIOGRAPHY. 


Bull, C. S.: Passive Motion in the Treatment of Paralysis of the Ocular 
Muscles, Medical Record, August 6, 1887. 

pene L’Appareil antistrabique, Recueil d’Ophthalmologie, October, 

87, 

Donders, F. C.: The Anomalies of Accommodation and Refraction of 
the Hye. London, 1864. 

Dyer, E.: Asthenopia not Connected with Hypermetropia, Transactions 
of the American Ophthalmological Society, 1865, p. 28. 

Harlan, G. C.: Congenital Paralysis of both Abducens and both Facial 
Nerves, Transactions of the American Ophthalmological Society, 1881, 
p. 216, and 1885, p. 48. 

Landolt : Refraction and Accommodation of the Eye. Translated by C. 
M. Culver. Edinburgh, 1886. 

Noyes. H. D.: A Treatise on Diseases of the Eye. New York, 1881. On 
the Tests for Muscular Asthenopia, and On Insufficiency of the External 
Recti Muscles, Transactions of the Eighth International Medical Con- 
gress, held at Copenhagen, 1884. 

Prince, A. H.: Operation for the Advancement of the Rectus with the 
Capsule, Ophthalmic Review, 1887, p. 249, 

Schweigger ; Handbook of Ophthalmology, Translated by Porter Farley. 
Philadelphia, 1878, Clinical Investigations on Squint, edited by G. 
Hartridge. London, 1887. 

Stevens, G. T.: Terms for the Designation of so-called Muscular Insuf- 
ficiencies, New York Medical Journal, December 8, 1886. 

Theobald, S.: The’ Amblyopia of Squinting Eyes, with Discussion, 
Transactions of the American Ophthalmological Society, 1886, p. 279. 


Edward Jackson. 


STRAMONIUM LEAVES AND SEED (Stramonii-Folva, 
U.S. Ph., Br. Ph.; Stramonit Semen, U. 8. Ph.; Stramo- 
nit Semina, Br. Ph.; Folia Stramonit, Ph. G.; Stramoine 
ou Pomme épineuse, Codex Med.; Jamestown Weed, 


A 
LY 
{J 


Fie. 3740. — Flowering Branch of Datura Stramonium, with Fruit. 
(Baillon. ) 


Thorn-apple, Apple of Peru, Stinkweed, etc.). Datura 
Stramonium Linn.; Order, Solanaceae. 

This well-known weed is a coarse, smooth annual, from 
one to six feet high, with an upright tri- and dicho- 
tomously-branched stem, large ovate, coarsely dentate 
leaves, and long, bell-shaped flowers. The stem is stout, 
smooth, green (or reddish-brown, D. Tatula), more or less 
hollow ; it branches at, say a foot from the ground, in 
three directions, and each of the divisions so formed soon 
forks repeatedly, the whole forming a spreading bushy 
head. Leaves alternate, lateral to the branches, petioled, 
ovate,.pointed, irregularly and deeply dentate, with wavy 
margins. Flowers solitary, terminal, in the forks of the 
branches, short-peduncled. Calyx tubular, five-lobed, 
divisions pointed. Corolla funnel-shaped, three or four 
or more inches long, plicate and convolute in the bud. 
Border five-lobed, lobes pointed, pale pink, purple (in D. 
Tatula), or white. Stamens five, inserted in the tube of 
the corolla. Ovary two-, apparently four-celled ; ovules 


661 


Stramonium. 
Strophanthus. 


numerous. Fruit erect, ovoid, nearly as large as a hen’s 
egg, covered with rigid sharp spines, opening part way 
down by four valves which curl back at the apex ; seeds 
in four divisions, 
very numerous— 

‘*About one-sixth 

of an inch (4 milli- 

i metres) long, reni- 
h form, flattened, pit- 
ted, and wrinkled ; 
testa dull brownish- 
black, hard, inclos- 
ing a cylindrical, 


\ Y 
va f 
SSN Th, 
j Y & AW Ih ‘ 
HHH) Ne \\)), 
| d 
. it i i! 
1 Es ; 
\ | \ i q ( \\ 
\ | 
| 


bedded in a whitish, 
oily albumen; of 
an unpleasant odor 
when bruised, and 
of an oily and bitter 
taste “a ( Tite ere 
The leaves, like 
those of belladonna, 
shrink very much 
in drying, and lose 
their peculiar nau- 
seous odor. They 
are described as fol- 
lows: ‘‘ About six 
inches (15 centime- 
tres) long, petiolate, 
smooth, ovate, 
pointed, unequal at 
the base, coarsely 
and sinuately 
toothed ; after dry- 
ing, thin, brittle, 
and nearly inodor- 
ous; taste unpleas- 
ant, bitter, and nau- 
seous,”’ 
; The original home 
of Stramonium has 
been a puzzling 
question for botan- 
ists, apparently from the rapidity with which it spread 
over the earth in the sixteenth century. Tropical South 
America and the countries around the Caspian Sea are 
thought to be the most probable sources. It is more than 
possible that it is a native of both hemispheres. From 
whatever place it 
came, it has made it- 
self at home every- 
where over the warm- 
er parts of the earth, 
taking most kindly to 
old rich gardens and 
corners, dunghills, 
and door-yards. 
CoMPOSITION.— 
Stramonium contains 
the principal mydria- 
tic alkaloids of the 
family: atropine and 
hyescyamine —or at 
least the latter, and 
an amorphous alka- 
loid considered by 
Planta and others to 
be identical with the H/ 
former, but either not . 
fully proved to be so, FI 3742.—Datura Stramonium ; Ripe Fruit. 
Y (Baillon. ) 
or not yet prepared 
quite clean. Daturine, a name formerly given to the 
Stramonium alkaloids, is now said to be only hyoscya- 
mine. The seeds contain about one-fourth of one per 
cent. of atropine, the leaves not more than one-third as 
much. Besides these the leaves contain a large amount 
of ash (14.5 per cent.), nitre, asparagin, and other unim- 
portant substances. 


Fig. 3741.—Longitudinal Section of Flower of 
Datura Stramonium. (Baillon.) 


662 


curved embryo em-- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


AcTIon AND UsgE.—From the above analysis it will be 
seen that Stramonium has scarcely any difference in ac- 
tion from Hyoscyamus, and but little from Belladonna, 
It is, indeed, capable 
of being used for ex- 
actly the same pur- 
poses, only. it is more 
quieting and hypnotic 
than the latter, prob- 
ably on account of its 
hyoscyamine. Cus- 
tom, perhaps, as much 
as anything, has di- 
rected the leaves of 
this species, instead of 
those of the others. 
named, to be used in 
wo the local antispasmo- 
/ dic treatment of asth- 
ma, for which purpose 
it is almost entirely 
prescribed. The com- 
mon method is to ad- 
minister it by smok- 
ing. The leaves may 
be burnt in a pipe or 
ar on the cover of a hot 
Fie. 3743.—Longitudinal Section of Ovary stove, or they may be 

of Datura Stramonium. (Baillon.) made more inflamma- 

ble by being soaked in 
a strong solution of saltpetre and dried, after which they 
will burn steadily, without flame and without requiring 
any apparatus; prepared in this way and flavored with 
aromatics and balsams, they are the foundation of most 
of the ‘‘asthma cigarettes” and ‘‘ pastilles,” which are 
often better products 
than extemporaneous 
preparations are apt to 
be. The French Codex 
gives directions for mak- 
ing cigarettes of stramo- 
nium, containing one 
gram each of leaves, is 
without any admixture. Fig. 3%744.—Seed Entire and in Section, 
- Se of Datura Stramonium, 

For internal administra- 
tion Stramonium may be considered the same as Hyos- 
cyamus. The following preparations are officinal, all 
made from the seed, the leaves being only used for smok- 
ing (one or two grams): Extract (Hatractum Stramonit), 
strength about +; Fluid Extract (Hatractum Stramonii 
Fluidum), strength, +; Tincture (Tinctura Stramoniz), 
strength, 54; ; and the Ointment (Unguentum Stramonit), 
strength (of the extract), 745. All these have similar prop- 
erties and uses to the corresponding preparations of Hy- 
oscyamus and Belladonna, but are more hypnotic than 
the latter. Dose of Fluid Extract about 0.2 ¢.c. 

ALLIED PLANTS.—Datura, of which the present plant 
is a characteristic species, consists of a dozen, mostly 
large, rank herbs, most of which have similar medical 
properties to the above. D. Tatula, with purple stems 
and flowers, is scarcely distinct from D. Stramonium. 
D. alba, of India, is used for the same purposes. One or 
two other species are cultivated for ornament. For the 
order, see BELLADONNA, 

ALLIED Drues.—Belladonna, Hyoscyamus, Duboisia, 
Tobacco, etc. W. P. Bolles. 


STRAWBERRIES (F7raisier, Codex Med., Rhizome, 
Fruit). Hragaria vesca Linn. ; Order, Rosacew, The 
common garden Strawberry, like every other familiar 
plant, has been put to use as a medicine. Its leaves. 
make by infusion a mild, rather pleasant, astringent tea, 
which is an occasional household prescription. With a 
little aromatic, like vanilla or ginger, a pleasant drink 
for those who cannot drink ordinary tea may be made. 

Strawberry root, the rhizome and rootlets, dried, con- 
taining tannin, a little resin, etc., is an astringent and 
tonic of no great value, but is now and then employed as 
a domestic medicine. 


. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Stramoniumt, 
Strophanthus., 


Strawberries themselves have no medical properties, 
but the syrup made from them is an agreeable flavor for 
‘“‘siphon soda,” and is frequently used by the sick for 
that purpose. 


ALLIED PLANTS, ETC.—See RosgEs. W. P. Bolles. 


STRIBLING SPRINGS. Location and Post-office, Strib- 
ling Springs, Augusta County, Va. 

Accrss.—By the Chesapeake & Ohio Railway to Staun- 
ton, thence by stage thirteen miles to the Springs. 

ANALYsIs (W. K. Tuttle, M.D.).—One pint contains: 


WO lee NG 2a ONO. oO: 
' Grain, | Grains. | Grain. 
Carhnonatewl potassag cori... chest iesscs | 0.044 | 0.093 | 0.095 
WALDONALE OF HOUR At Get. wee tes cals cece i. OLO95 1 OL%80i.1.. 0.198 
Carbonate of magnesia ......... 0.00. cece! 0.1225)" 0-251 0.138 
CarbOnare OF IFONniwe.e etbeeemot sss Sc. eo nals 0.009 | 0.016} 0.014 
Carponate Of limeow. cnet eee sity is iets Sioa wee 0.188 1.204 | 0.104 
Sulpha Lesorumerias erase basis So ce ois cone | 0.028 | 0.156 | 0.886 
MUICTOIAC Cae eee rece a nie reacts oltre dees sakes « | 0.165 ; 0.080 7 0.114 
Chlorides Meaediwme casniiicc. seeasselees coeehl see. OF 0S0N aan 
| 
EDGR Tater Asters ca aslats: s cia cles viele ofa eietata.c | 0.651 | 2.660 | 0.9%4 
| Fl 
: Gas. Cub. in. Cub. in.|Cub. in. 
Carnopign acide dan re yh) stone's sate Mechel Lis cte ctl e (Presse 1.30 Q 
Sulphuretted hydrogem.............0.--0+% ye | 0.08 
No. 4.'] No. 5. | No. 6 
: Grains. | Grains. | Grains, 
Sulphate.ol potassa, ie: wa-cia ac ee sctetls. vielctoe cls | 0.067 | 0.113 | 0.126 
Hulpnste: OBOG A co. acts aeicle we aralate aco ete o's © ole | 0.083 | 0.293 | 0.224 
Sulphate Gl masnesidusdes sass cee tees tale |; 0.066 | 0.048 0.822 
Sulphate of jalumina e220... one. pes cacices oe | 2.086 | 2.244] 4.801 
Up NAGS OL 1VON Ss Actes sioee eee mosses eee ocin es | 1,192 1.6438 1.615 
Sulphare OL MMOt ss salle s oo esis veils Melee seeds isos 2.118 2,389 
Sulpauric acidiree)-unncamcore cece tne } 0.681 iN ae 0.817 
SIGIGL Acid aan sie ener ornare tec aete oe ie S | 0.244) 0.264 | 0.264 
MIA ELEE os cide noi ss Cae tates ta Ss wives op ste AOS oc ae Ay a ae 
PD OC A art eye ccs wie Grae teeetes oo ye terre oe shale | 6.670 | 7.945 | 11.068 


Springs Nos. 1 and 3 are chalybeate, No. 2 sulphur, and 
Nos. 4, 5, and 6 alum. 

THERAPEUTIC PROPERTIES.—The variety and excel- 
lence of these waters render this a favorite resort. The 
alum springs are curative in chronic diarrhea and ¢ca- 
tarrhs generally ; the chalybeate are mild and efficient ; 
-and the sulphur is often needed to meet certain indica- 
tions for which the others are not adapted. 

These springs, sometimes called the Augusta, are lo- 
cated in the mountains of Eastern Virginia, and have 
long been popular, not only on account of the waters, 
but also for their beautiful and salubrious situation. 

Gab 


STROPHANTHUS (Kombé, Arrow Poison, Inée, 
Onaye, etc.). The pods and seeds of several species 
of Strophanthus ; Order, Apocynacee, This is a singu- 
lar genus of tropical plants, mostly climbing shrubs. 
They are usually villous or hairy, although sometimes 
- smooth, opposite-leaved plants with milky or colored 
bitter latex, terminal cymes of regular flowers, and very 
long fruits. Calyx five-pointed, glandular on the inside. 
Corolla funnel- or bell-shaped, gamosepalous, five-lobed, 
with ten scales or appendages; lobes pointed, in most 
species prolonged into Jong filiform or linear processes, 
six or eight times as long as the rest of the flower; these 
processes, whether erect, spreading, or, as sometimes is 
the case, straggling and drooping, serve at once to dis- 
tinguish the genus. Anthers five, short, included in the 
corolla, upon which they are inserted by very short fila- 
ments. Pistil of two carpels, surmounted by one style 
and stigma. Ovules numerous. Fruit consists of two 
separate, diverging follicles, from ten to thirty centime- 
tres long; they are fusiform, pointed, dehiscent ; seeds 
numerous, from one-half to two centimetres long, silky or 
woolly, prolonged at the apex to a long, slender bristle, 
or awn, from five to twenty cm. long, which along its 


upper third, half, or more, becomes a plumose cylindrical 
brush. The genus comprises, according to Bentham and 
Hooker, eighteen species, all but one tropical, and grow- 
ing in equatorial Africa, Southern Asia, or some of the 
Pacific islands; the extra-tropical species growing in 
Souther Africa. The Strophanthus seeds of commerce 
are probably the product of: 1, S. héspidus D. C., with 
hispid branches and leaves, and fine appressed tomentum 
upon the seeds ; or of, 2, 8S. Kombé Oliver, a recently de- 
scribed species, perhaps scarcely distinct from the other, 
with coarsely hairy herbage and woolly seeds. Both 
these species inhabit Central and Western Equatorial Af- 
rica. ‘There are, besides, several other species of the ge- 
nus, with similar very bitter seeds, whose properties are 
probably similar to these, but so far they have not been 
tested. 

DESCRIPTION, — Commercial Strophanthus pods are 
from twenty to thirty centimetres long, and two or three 
or more in breadth, slightly curved, longitudinally wrink- 
led, flattened, tapering to a fine point at the top. Color 
yellowish brown. They have a thin shell, finely grooved 
externally, and of a slightly brighter color inside. 

The seeds are oval, flattened, tapering from near the 
base, about a centimetre long, four millimetres broad, and 
say two in thickness ; a well-marked rib or keel on one 
side runs from the base to the apex ; the awn is about ten 
centimetres long, plumed along the upper half with hairs 
whose length is three or four centimetres (the awn and 
their plumes are absent from the seeds as seen in the 
market). The surface of the seeds is densely silky, with 
shining hairs; it is grayish or greenish-brown, and is 
sometimes somewhat wrinkled lengthwise ; section shows 
a whitish, oily kernel. The odor of Strophanthus seeds 
is bitter, and the taste (principally in the kernel) most 
intensely and disagreeably so. There are about two 
hundred seeds to each pod. All parts of the plant are 
bitter—seeds, pods, leaves, stems, and bark—but the 
seeds are by far the most so, and the most active, so that 
tinctures made of them alone, or of the entire pod, would 
differ much in strength. The hairs are inert. 

Hisrory.—That certain tribes in the interior of Africa 
had efficient arrow poisons, and that some of these— 
inée, kombé, etc.,—were made in whole or partly from a 
paste made by grinding Strophanthus seeds, has been 
known for a number of years, and this poison was inci- 
dentally mentioned or examined by Pelikan, Hilton 
Fagge, and Stephenson in 1865, but the first serious in- 
vestigation of its properties was published by Dr. 
Thomas P. Fraser in the ‘‘ Proceedings of the Royal Soci- 
ety of Edinburgh,” in 1870, who made an elaborate study 
of its action and chemistry, separating an active princi- 
ple, of glucoside character in crystalline form, which he 
named strophanthin. (The strophanthin of the market 
at present is usually amorphous and rather deliquescent. ) 
On account of the scarcity of the supply and other causes 
the investigations were not generally followed up, and 
for fifteen years the article was scarcely heard of, until 
1885, when the same patient investigator read another 
important paper upon it before the British Medical Asso- 
ciation, in which its utility as a medicine was shown by 
a series of cases and heart-tracings. Since this time it 
has been tried by numerous physicians in England and 
America, and so far, at least, with increasing reputation. 

Composition. —The most abundant ingredient is a 
greenish fixed oil, of which about twenty-five per cent. 
can be obtained. This oil is slightly bitter, in cdnse- 
quence of the presence of a little of the bitter principle 
to be mentioned below, but is otherwise not remarkable 
or active. There is also a good deal of albuminous mat- 
ter in the seeds, also inert. The active principle is stroph- 
anthin, a neutral glucoside, generally obtained as a light- 
colored, amorphous, moist powder, which is apt to deli- 
quesce. As prepared by Mr. A. W. Gerrard (Pharm. 
Journ. and Trans., May 14, 1887), it is ‘‘a pale-yellow- 
ish, amorphous substance, easily reduced to powder, but 
having some tendency to readhere. It is freely soluble 
in water and in alcohol, insoluble in pure ether and in 
pure chloroform ; but if the latter liquids contain a trace 
of alcohol, a small portion of strophanthin is dissolved. 


663 


Strophanthus. 
Strychnine. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Strophanthin burns without a residue. It has well- 
marked glucocidal characters. He was unable to obtain 
it in crystals. One-fiftieth of a grain given to a dog 
proved fatal.”’! The crystalline strophanthin of Fraser 
does not appear as yet to be acommercial product. A 
crystalline substance can be obtained from the hairs of 
the seeds, called ‘‘inein ;” it is not active. Gerrard’s 
method of preparing strophanthin is as follows: An al- 
coholic extract of Strophanthus is dissolved in water, 
filtered, and precipitated with tannic acid. The precipi- 
tate is collected, washed with water, and while still 
moist mixed with an excess of basic acetate of lead. The 
mixture is dried, and exhausted with warm alcohol; the 
filtrate is treated with sulphuretted hydrogen, the sul- 
phide of lead removed by filtering again, and the alcoholic 
solution evaporated to dryness. The residue (strophan- 
thin) is dissolved in warm water, and then digested with 
animal charcoal, filtered, and evaporated. 

Action AND Usk.—Dr. Fraser, to whose extremely 
patient and scientific investigations we are indebted for 
the presentation of this new medicine, in his address 
before the section of Pharmacology and Therapeutics of 
the British Medical Society, 1885, says: ‘‘ The pharma- 
cological action of Strophanthus appears to be an ex- 
tremely simple one. It may, I believe, be described in 
the few words that it isa muscle poison. However in- 
troduced into the body, it increases the contractile power 
of all striped muscles, and renders their contractions more 
complete and prolonged. In lethal doses it destroys, be- 
sides, the capacity of the muscle to assume the normal 
state of partial flaccidity, and.causes the rigidity of con- 
traction to become permanent and to pass into the rigor 
of death. Asa result of the action on muscle, the heart 
is early and powerfully affected. It receives a larger 
quantity in a given time than any of the other muscles 
of the body, and therefore it probably is that Strophan- 
thus affects its action more distinctly and powerfully 
than it does that of the other striped muscles. Indeed, 
by regulating the dose, a very distinct pharmacological in- 
fluence may be produced upon the heart, while the other 
muscles remain apparently quite unaffected.” 

In order to ascertain the comparative effect of strophan- 
thin and digitalin upon the heart muscle, Dr. Fraser ex- 
posed the separated heart of the frog to solutions of these 
substances. He found that ‘‘solutions of [Morson’s ?] 
soluble digitalin of one part in a hundred thousand, of 
one in fifty thousand, of one in ten thousand, and of one 
in four thousand, each produced characteristic changes 
in the heart’s action, but were not sufficiently strong to 
kill the heart, at any rate not within two hours. With 
strophanthin, on the other hand, a solution of one part 
in one hundred thousand quickly stopped the heart’s 
action in extreme systole, characteristic changes in the 
heart’s action having previously been produced. I then 
increased the dilution ; and solutions of one part in two 
hundred and fifty thousand, of one in five hundred 
thousand, of one ina million, of one in two million, of 
one in three million, of one in four ‘million and six hun- 
dred thousand, of one in six million, and of one in ten 
million, were each tried, with the result that the heart 
was characteristically affected, and killed by each of 
them. Even the almost inconceivably minute dose 
which was brought into contact with the heart, when a 
solution of one part of strophanthin in six million was 
used, produced complete stoppage of the heart’s contrac- 
tions’in extreme systole in about twenty minutes.” Its 
action upon the blood-vessels, on the other hand, was 
found to ‘be less than one-tenth that of digitalis. Mr. 


Bahadhurji, who experimented with Strophanthus in. 


co-operation with Dr. Langgaard in Berlin, found in 
frogs similar symptoms of heart-poisoning, with death in 
systole. Physiological doses reduced the number of 
beats to one-half, and made them more forcible ; the heart 
filled well and emptied well. 
same thing was observed, the heart finally stopping in 
systole ; the animal was sometimes convulsed_ before 
death. Strophanthus differs from digitalis in having a 
marked central effect upon the vagus. Blood-pressure 
tracings show no appreciable rise. Respirations at first 


664 


In rabbits very much the 


increase, later are slower and weaker. Diuresis is not 
marked in healthy’animals. 

Dr. H. Hochaus, who experimented upon a number of 
persons, both well and suffering from several diseases, 
gives a careful résumé of the results in the Deutsche medt- 
cinische Wochenschrift of last year, of which the following 
is a synopsis, the doses for adults being from six to twelve 
drops of a five per cent. tincture of the seeds, say three 
times a day for several days, other circumstances of diet, 
etc., being the same: 

In five cases of well persons, two showed no result, 
three increase of urine, two slowing of pulse. 

In ten cases of valvular insufficiency, with soft, com- 
pressible, irregular pulse, and marked dyspnoea, two 
showed very great improvement, two moderate improve- 
ment, five no change. One improved remarkably, but 
died suddenly upon getting up. In some of the cases 
where Strophanthus failed digitalis was used with bene- 
fit. 

In eighteen cases of enlarged, weak, myocarditic hearts, 
with diminished urine and weak irregular pulse, ten 
were more or less benefited and eight not improved ; of 
the above ten who were benefited, six had been for sev- 
eral months in the hospital, and most of the different 
heart-strengthening medicines had been tried upon them. 
Digitalis acted best and quickest, next came Strophan- 
thus. 

In nineteen cases of nephritis, five of which were scar- 
latinous, one of these was much, one slightly benefited, 
three not at all. In one it produced diarrheea.. Of six 
cases of granular atrophy three were helped, and three 
were not. The remaining eight were cases of parenchy- 
matous kidneys, with weak hearts, but little urine, and 
abundance of albumen, Of these three were improved 
in all respects, one in respiration only, and four not at 
all. 

In two cases of pericarditis it did no good. 

In two of chlorosis with functional palpitation it was 
beneficial. 

From the above observations it will be seen that this 
drug is a very active one, that its effect upon the diseased 
heart is to strengthen its pulsations, and relieve numer- 
ous discomforts arising from its inefficiency, such as 
dyspnea, palpitation, weakness, cedema, etc. It also in 
most of such cases increases the urine. It does not con- 
tract the vessels as digitalis does, and is said to be less 
likely to disturb the stomach ; it is also not cumulative, 
the dose requiring to be increased after being used a 
while. On the other hand, it is claimed that it is less cer- 
tain than the older remedy. 

ADMINISTRATION.—The dose of Strophanthus cannot 
be considered as fully settled yet, but from one to six 
centigrams (from two-tenths to nine-tenths of a grain) of 
the seeds appears to be the usual range; it is not, how- 
ever, given in substance, but usually as a tincture or a so- 
lution of strophanthin. No preparations are official, nor 
are they all uniform ; therefore the physician should sat- 
isfy himself of their strength before using. Dr. Fraser’s 
early tincture was about twelve per cent., which is stronger 
than is generally employed at present. His later recom- 
mendation is a five per cent. tincture, of which the dose 
is ‘‘from five to ten minims,” and this strength is pretty 
commonly made now in this country. The directions for 
making are: ‘‘Strophanthus seeds, deprived of their co- 
mose appendages, reduced to powder, and dried, one 
ounce or part; ether, freed from spirit and from water, 
ten fluid ounces or ten fluid parts; rectified spirit, a 
sufficiency to obtain one (English) pint, or twenty fluid 
parts” (Fraser). The powder is carefully dried and ex- 
hausted of its fat by maceration and percolation with the 


ether, then redried and the tincture made in the usual 


way, by percolation with alcohol. Tincture of Strophan- 
thus has a very pale straw color, and is intensely and nau- 
seatingly bitter. The dose of strophanthin is variously 
stated at from .0008 to .001 gm. (g}5 grain te zy.) 
ALLIED PLANTs.—The common Oleander (Nerium 
Oleander) of the flower-garden is the, nearest botanical 
relative at all familiar, the pods of the Oleander bear con- 
siderable resemblance to those of Strophanthus, and its 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Strophanthus,. 
Strychnine, 


active principle, oleandrin, is also a heart poison. This 
may probably be said also of many plants in this poison- 
ous order, see Hemp, CANADIAN, (Apocynum Canna- 
binum). 

ALLIED Drues.—First, and most important of all, is 
Digitalis, which in its general usefulness probably ex- 
ceeds Strophanthus, and to which the reader is referred 
(see FoxGLOVE); other heart ‘‘ tonics” are Squills, Ado- 
nis, Lily of the Valley, and Antiaris. 


BIBLIOGRAPHY. 


The literature of Strophanthus is recent, and mostly consists of articles 
in magazines or in the proceedings of societies. The following references 
are to the most important articles : 


Fraser, Thomas R.: First Article, Proceedings Royal Society, Edinburgh, 
1870. 

Fraser, Thomas R.: Journal of Anatomy and Physiology (?), 1870. 

Fraser, Thomas R.: Action and Uses of Digitalis and its Substitutes, 
with special reference to Strophanthus (Hispidus?), British Medical 
Journal, November 14, 1885; also Reprint, London, 1886. 

Fraser, ‘Thomas R.: Note on Tincture of Strophanthus, British Medical 
Journal, 1887, vol. v., p. 151. 

Fraser, Thomas R.: Strophanthus Hispidus (Pharmacological note), Lan- 
cet, 1885, vol. ii., p. 309. 

Porteous: Notes on Strophanthus (Hispidus), British Medical Journal, 
1886, vol. i., p. 198. 

Helbing, H.: Some Notes on Strophanthus, Pharmaceutical Journal and 
Transactions, March 12, 1887. 

Helbing, H.: Pharmaceutische Zeitung, January 15, 1887. 

Purdy, C. W.: Strophanthus Hispidus, its Pharmacology and Therapen- 
tics, Chicago Medical and Surgical Journal and Examiner, i887, vol. 
liv., pp. 213-227, 

Drasche: Ueber die Wirkung des Strophanthus Hispidus auf das Herz, 
Wien. Méd. Blat., 1857, S. 553, 585, 649, 681, 717, 780, 846, 937. 

Bahadhurji, K. N.: Notes on Strophanthus, British Medical Journal, 
1887, vol. ii., p. 620. 

Budd, W.: Strophanthus as a Heart Tonic and Diuretic, Lancet, 1887, 
vol. ii., p. 513. 

Pins, E.: Ueber die Wirkung des Strophanthus Samen in Allgemein, und 
deren Anwendung bei Herz- und Nierenkrankheiten, Therapeut. Mon- 
atsschrift, Berlin, 1887, vol. ii., pp. 209, 261. 

Quinlan, T. F. B.: Notes upon Strophanthus, British Medical Journal, 
1887, vol ii., p. 451. 

Aulde, I.: Strophanthus Hispidus, Medical and Surgical Reporter, Phil- 
adelphia, 1887, vol. lvii. pp. 346-349. 

Mays, T. I.: A New Heart Tonic, Strophanthine, Philadelphia Medical 
News, 1887, vol. ii., p. 472. 

Hochaus, H.: Zur Wiurdigung des Therapeutischen Werthes der Stro- 
phanthustinctur, Deutsche Med. Wochenschrift, 1887, vol. iii., pp. 
909-911, also 937-940. 

Combemale et Grognier: Effets du Strophanthus Hispidus ou Inée sur le 
Coeur, etc., Montpellier Med., 1887, 2e Sér., ix., pp. 462-473, also 505- 
ay 

Combemale et Grognier: Recherches sur l’Action physiologique du 
Strophanthus Hispidus ou Inée, Comptes Rendus Société de Biologie, 
Paris, 1887, 8te Sér., iv., pp. 388, 623. 

Aulde, I.: A Study of Strophanthus, Medical Register, Philadelphia, 
1885, vol. iii., pp. 29-82. 

Durian: Du Strophanthus Hispidus, Bull. Gén. de Thérapentique, Paris. 


—1887, c. iii, pp. 220-271. 
W. P. Bolles. 


1 Proceedings American Pharmaceutical Association, 1887, p. 355. 


STRYCHNINE AND NUX VOMICA, POISONING BY. 
Probably the earliest mention of nux vomica in medical 
literature is that by the younger Serapion, an Arabian, 
who wrote toward the end of the tenth century (Ed. 
Argentorati, 1531, clxiii., p. 115). The earlier European 
writers who treat of the drug recognize its poisonous 
qualities (Wepfer, ‘‘Cic. Aquat.,” Bas., 1679, p. 194; 
Hoffmann, ‘‘Syst. Med.,” 1728, t. i., § vii-ix.). So 
much were the earlier physicians impressed with the 
dangers attending the use of nux vomica that, notwith- 
standing the evidence of Fallopius, Sennert, and others, 
of its medicinal virtues, and its adoption into the Phar- 
macopeeias of London, 1651, and Amsterdam, 1636, the 
opinion of Hoffmann: ‘ Inter medicamenta suspecta et 
quee virus quoddam reconditum alunt, ut ddeo plus dam- 
ni, quam utilitatis aliis expectandum sit, merito nux 
-vomica referri debet” (Ed. Genev., i., p. 226) was that 
generally entertained. 

The earliest medico-legal reference to nux vomica is 
by Valentine (‘‘Corpus Juris Med. Leg.,” 1722, p. 219), 
who in 1680 was called upon to recognize the poisonous 
character of nuces vomice seized upon a prisoner. 

The discovery of strychnine by Pelletier and Caventou, 
in 1818, provided the medical profession with a potent 
remedial agent, but, at the same time, placed a formida- 
ble weapon in the hands of the poisoner and the suicide. 


Several years elapsed, however, before either medicinal 
or criminal use was made of the newly discovered alka- 
loid, although numerous experiments made upon ani- 
mals by its discoverers and others, shortly after its first 
isolation, made clearly manifest the powers of strych- 
nine. 

Christison (second edition, 1832) states that, ‘‘ except 
the hydrocyanic acid, no poison is endowed with such 
destructive energy as the strychnia.” He also describes 
the effects of the alkaloid upon animals, but is completely 
silent concerning its action upon the human subject. 
Richter, in 1834 (Ex. Wibmer, p. 250) relates a case of 
dangerous, though not fatal, poisoning caused by the 
medicinal use of strychnine. Blumhardt (Med. Corr. Bi. 
des Wirt. Ver., 1887, i.) was probably the first to record 
the death of a human being caused by strychnine ; a man, 
aged seventeen, who committed suicide by taking two 
scruples (!) of the alkaloid. Orfila (1852) cites three other 
cases, one suicidal (in 1846), the other two accidental (in 
1849, 1850), by mistake for. salicin and santonin. 

The first instance in which justice was called upon to 
consider strychnine as a cause of death, was the classi- 
cal Palmer case, which occurred in England in 1855, al- 
though it seems probable that the same defendant had 
previously poisoned his mother-in-law in 1848, and his 
wife in 1854, by the same agent. Shortly after the in- 
quest in the Palmer case, and while the secular press was 
discussing the possibility of detecting strychnine, a second 
poisoning occurred in England (case of Dove), which 
affords a striking instance of imitative poisoning, and 
of the ill effects of popular discussions of such a sub- 
yect. 

The meagre statistics concerning deaths by poison in 


.recent years, which are available through board of health 


reports, coroners’ returns, etc., indicate that poisoning by 
strychnine is even now of rare occurrence. A compar- 
ison of reports of criminal trials shows, however, that, 
notwithstanding its intensely bitter taste, strychnine is 
used with homicidal intent more frequently than any poi- 
son, except arsenic. Of 146 cases which were the subjects 
of criminal trials, 47 were by arsenic ; 23 by strychnine; 
14 by hydrocyanic acid ; 10 by mercurials ; 7 by sulphuric 
acid ; and the remainder by other poisons (five cases, or 
less, of each). 

Symproms.—The symptoms of poisoning by strych- 
nine or nux vomica are very characteristic. 

If the dose be relatively small, although capable of 
causing death, there is at first an initiatory stage of ner- 
vous exaltation without any violent symptoms, whose 
duration varies inversely with the magnitude of the dose 
and the rapidity of absorption. The special senses are 
much more acute than normally, the mental functions 
are active, the patient is restless, and experiences a sen- 
sation of itching. 

Soon twitchings of individual groups of muscles oc- 
cur, followed by violent tetanic convulsions. During the 
spasms there is, in the great majority of cases, marked 
opisthotonos. The head is thrown sharply back, the 
body bent backward, the abdominal and thoracic mus- 
cles firmly contracted, the lower extremities rigid, and 
the soles of the feet bent inward and strongly arched. 
The lower jaw is fixed, the eyeballs protruded, the pu- 


- pils dilated, the expression of the countenance distorted, 


the lips cyanotic, the mouth marked with froth—fre- 
quently bloody from the tongue being caught between 
the closing teeth—and the neck swollen. In some excep- 
tional cases emprosthotonos or pleurotonos is observed 
instead of opisthotonos. ' 

The spasm gradually passes off, the muscles relax, the 
eyes and pupils become normal, and respiration is re- 
sumed. The patient speaks, usually calls for air, desires 
to be held, and is in dread of impending death. Indeed, 
consciousness and intellectual activity do not seem to be 
impaired during the spasms. 

After the first convulsion others, similar in character, 
occur, eithef spontaneously or in consequence of very 
slight wneapected excitation. An attempt to move the 
patient, a slight jarring of the floor or bed, a sudden 
noise, a slight draught of air, or even a flash of light, is 


665 


Strychnine. 
Strychnine. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


sufficient to provoke a spasm if the patient do not expect 
it. On the other hand, much more active excitation fails 
to call forth a spasm if the patient be not taken una- 
wares ; and he frequently asks to be rubbed, held down, 
or moved. When the spasm recurs spontaneously, the 
patient usually announces its coming some seconds in 
advance, and asks to be held. 

The number of convulsions varies from three to ten ; 
their duration from thirty seconds to five or even eight 
minutes. The intervals vary in duration from forty-five 
seconds to one hour, or even one and a half hour; usually 
five to fifteen minutes. 

In cases terminating in recovery the interval between 
the spasms increases in length, and the convulsions be- 
come less active and shorter in duration, and finally 
cease, leaving the patient in a condition of great muscu- 
lar fatigue, and with increased reflex irritability. In 
fatal cases death results from one of two causes: ‘In 
some cases death is due to asphyxia by fixation of the 
muscles of respiration during a protracted spasm; in 
others it is due to exhaustion, and occurs during the 
non-tetanic period. In most fatal cases death occurs dur- 
ing or after the fourth or fifth tetanic seizure, although 
cases have occurred in which the patient has succumbed 
at a later period, and others in which life was extin- 
guished during the third, second, and first convulsion. 

Duration.—The rapidity of action of strychnine is 
modified by the form in which it is taken, whether in 
solution or in a hard and difficultly soluble pill, and 
by the length of time which is allowed to elapse before 
treatment is resorted to. 

In 49 cases, in which the time of first appearance of 
the symptoms was noted, the period was ‘‘ directly, or 
very soon,” in 12; from three to thirty minutes in 22; 
from thirty minutes to one hour in 7; from one to two 
hours in 6; and two and a half and three hours in 2. 
The average period of delay is, therefore, within twenty 
minutes. The extremes are ‘‘ directly” and three hours, 

The total duration of strychnine poisoning is also short, 
whether it terminate in death or in recovery. Of 40 fa- 
tal cases of which the duration is stated, 20 died within 
one hour; 8 in from one to two hours; 7 in from two to 
three hours; and 5 in from five to six and a half hours. 
In the majority of these cases the entire duration was 
less than one hour. The extremes were ‘‘ immediately ” 
(from a dose of one and three-fourths grain, combined 
with an equal quantity of nux vomica), and six and half 
hours (from a dose of three grains), both adult males. 

The time elapsing between the beginning of symptoms 
and death has varied in 21 cases as follows: 8 within 
thirty minutes ; 6 in from half an hour to an hour; 4 in 
from one to two hours; 3 in from two to five hours. 
The extremes are five minutes (male, aged twenty-six ; 
dose five grains; symptoms began in fifteen minutes), 
and five and a quarter hours (male adult; dose three 
grains; symptoms began in forty-five minutes). 

In non-fatal cases recovery is usually rapid, the active 
symptoms cease within a few hours, and, after cessation 
of the spasms, the patient’ may be considered as out of 
danger, although in exceptional cases great muscular 
prostration and occasional involuntary muscular contrac- 
tions continue for some days. 

DIFFERENTIAL DriAGNosis.—The disease bearing the 
closest resemblance to strychnine poisoning is tetanus, 
whether traumatic or idiopathic. In poisoning by strych- 
nine the attack is more sudden than in tetanus, and the 
entire history of the case is compassed within a few 
hours, in place of lasting for days. The spasms follow 
each other at shorter intervals, and are of less duration, in 
strychnine poisoning than in tetanus. In the latter, tris- 
mus is one of the earliest and most prominent of the 
characters, while in the former it occurs later, if any suc- 
cession of symptoms be observable, and may be insignifi- 
cant as compared with the violent tetanic contraction of 
the respiratory muscles. During the intervals between 
the convulsions due to strychnine the muscles are usu- 
ally relaxed, while in tetanus they remain more or less 
rigid, particularly those of the lower jaw. The chief 
points of distinction are in the much more rapid progress 


666 


of strychnine poisoning, and, in the great majority of 
cases, in the history of the onset, which, in the poison- 
ing, follows, with very little warning, within two hours 
or less, the ingestion of some bitter substance, but in 
tetanus is gradually developed several hours or days after 
an injury. ‘ 

Uncertainty concerning the diagnosis between epilepsy 
and strychnine poisoning can only occur in the very ex- 
ceptional case of an unknown person dying during a 
single convulsion. In such an event chemical analysis 
would decide the question definitely. In other cases the 
history of the case, the much longer interval between the 
paroxysms in epilepsy, and the more distinctly tonic char- 
acter of the spasms in strychnine poisoning, are sufficient 
to establish the distinction. 

In cases of poisoning of pregnant women by strychnine 
(two such are cited by Wharton and Stillé, pp. 448, 625) 
the distinctions between the effects of the poison and 
puerperal convulsions are of importance. The principal 
diagnostic point is in the fact that in puerperal convul- 
sions the patient is entirely unconscious of what occurs, 
either during or between the convulsions, while in strych- 
nine poisoning consciousness remains unimpaired, except 
immediately before death. The detection or non-detec- 
tion of strychnine in the body would remove all doubts. 

LETHAL Dose.—The smallest amount of strychnine 
which has been known to cause the death of an adult is 
0.016 gram (= } grain), which produced violent symp- 
toms in ten minutes in a female, aged thirty-six, and 
death in one hour and forty-five minutes (Medical Times 
and Gazette, 1854, p. 876). Double this quantity, 0.032 
gram (= 4 grain), caused death in two cases. In one of 
these (case of Dr. Warner) a physician took by mistake 
half a grain of the sulphate, was violently convulsed in 
five minutes, and died in twenty minutes. Less quanti- 
ties have produced dangerous poisoning in adults. Chris- 
tison cites the case of a child of three years, which was 
killed in four hours by 0.004 gram (= 3; grain). 

On the other hand, numerous cases are on record in 
which much larger doses have been taken without caus- 
ing death. Thus Campbell (Lancet, 1856, ii., 695) relates 
a case in which a man, aged thirty, took 0.65 gram (= 10 
grains) of strychnine and recovered. Shaw (American 
Journal of the Medical Sciences, 1856, 547) cites the case 
of an adult female who recovered from the effects of a 
dose of 0.65 to 0.97 gram (= 10 to 15 grains). Tschepke 
(Deut. Klin., 1861, ex ‘‘ Maschka Handb.,” ii., 618) gives. 
a case of a pharmacist. who took from 0.48 to 0.72 gram 
(= 74 to 11 grains) of strychnium nitrate dissolved in 
about 380 grams (= f1%j.) of bitter almond water, and, 
after half an hour, having experienced no symptoms, 
0.6 gram (= 94 grains) of morphium acetate, also dis- 
solved in bitter almond water. Subsequently, being still 
capable of locomotion, he poured chloroform upon his 
pillow and lay with his face upon it. An hour and a 
quarter after taking the first dose he suffered violent 
symptoms of strychnine poisoning, from which he, how- 
ever, recovered under treatment by emetics and tannin. 
Atlee (Medical Times and Gazette, 1871, p. 288, ex Boston 
Medical Journal) cites a case in which the amount taken 
was probably the largest not causing death. The amount 
taken was 1.30 gram (= 20 grains), immediately after a. 
meal, Emesis was provoked very soon after. 

TREATMENT.—The ends to be aimed at are, first, the 
removal of any unabsorbed poison from the stomach, if 
possible, and, second, the prevention or mitigation of the 
paroxysms. For the attainment of the former an emetic 
of zinc sulphate or of apomorphine should be given, if the 
case be seen early, followed by tannin, with the view of 
converting any remaining strychnine into an insoluble 
compound, Chloral should be generously administered, 
followed by inhalations of chloroform sufficient, and suf- 
ficiently prolonged, to control the convulsions until the 
poison shall have been eliminated, as it is with consider- 
able rapidity. In the exceptional cases in which the pa- 
tient is seen before the tetanizing action of the poison has 
been established, the stomach should be washed out as 
expeditiously as possible with a strong infusion of tea, 
or a solution of tannin in some form, or water holding 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


powdered charcoal in suspension. No reliance is to be 
placed upon camphor, albumen, opium, aconite, cannabis 
indica, or tobacco, which have been suggested as so-called 
physiological antidotes. 

Post-MORTEM APPEARANCES.—There are no peculiar- 
ities discoverable, on external or internal examination, 
which are characteristic of this form of poisoning. Rigor 
mortis is more rapidly established and continues for a 
longer period in most cases. According to Wharton and 
Stillé, rigor mortis was very marked in the body of a 
woman exhumed two weeks after death (Medical Juris- 
prudence, ii., 445). Taylor (‘‘ Poisons,” third American 
edition, 676) states that cadaveric rigidity was well marked 
in the body of Cook two months after death. Usually the 
body is relaxed at death and soon stiffens, but in some 
cases the tetanic spasm merges into rigor mortis. But in- 
stances are met with in which cadaveric rigidity has dis- 
appeared in from twenty-four to forty-eight hours. In 
some cases the hands are firmly clenched and the soles 
arched after the other muscles have become relaxed. 
Rigidity is of shorter duration in the bodies of those in 
whom the spasms have been more or less controlled by 
treatment during life, than in those who have died with- 
out medical interference. The surface is usually livid, 
but not in all cases. Sometimes lividity is confined to the 
fingers, and in some cases the inner surfaces of the thighs 
and arms assume a red color. 

The internal appearances are still less characteristic. 
The blood is usually fluid, and dark. The vessels of the 
scalp, the brain and its coverings, and of the spinal cord, 
as well as the lungs, are in most cases congested. The 
heart is usually empty and sometimes firmly contracted, 
the right side being less so than the left, and sometimes 
distended with dark, fluid blood. The bladder is usually 
empty, though in some cases it has been found to be 
nearly full of urine. Occasionally ecchymotic spots or 
patches of congestion are observed in the stomach. 

ANALYsIs.—In cases in which the analysis is not to be 
limited to a search for strychnine, the systematic method 
of Dragendorff for the separation of alkaloids and gluco- 
sides from organic mixtures (see Vol. V., p. 764) should 
be followed. By this method any strychnine which 
-may be present in the substances examined will be found 
in the residues of evaporation of the petroleum-ether and 
benzol extracts from the alkaline aqueous solution. 

In all cases it is advisable to resort to Dragendorft's 
method, even when the history of the case points very 
directly to strychnine, as any question subsequently 
arising as to the presence or absence of another alkaloid- 
ul or glucosidal poison can then be determined. 

In some exceptional chemico-legal cases, and when the 
physician wishes to determine the presence or absence of 
strychnine in the urine during the life of the patient, an 
abridged modification may be used. If the substances to 
be examined be solid, they should be finely divided and 
placed in a flask, to which water, rendered distinctly acid 
with sulphuric acid, is added in sufficient quantity to 
cover the solid. After agitation, the reaction of the 
liquid is to be determined, and if not distinctly acid, it is 
to be rendered so by the addition of dilute sulphuric acid. 
The flask and its contents are then to be placed in an oven 
heated to 40°-50° C. for six or eight hours, after which 
the liquid is to be filtered off. A fresh portion of dilute 
acid is to be added and the extraction repeated four or 
five times. The united acid filtrates, which contain any 
strychnine that may be present in the form of the sul- 
phate, are then evaporated to the consistency of a thin 
syrup over the water-bath. The residue is mixed with 
four volumes of strong alcohol, gradually added during 


stirring, and allowed to macerate twenty-four hours. - 


The alcoholic liquid is filtered off, the residue on the 
filter washed with strong alcohol, and the filtrates and 
washings evaporated over the water-bath until free of al- 
cohol. The residue, thinned with water if necessary, is 
transferred to a stoppered cylinder. The solution should 
not exceed 100 cc. in bulk, and may be less. About 5 cc. 
of benzol (boiling-point not over 85° C.) are then added 
and the cylinder strongly agitated once every five minutes 
for about half an hour. The benzol layer is then removed 


Strychnine. 
Strychnine. | 


by the separatory funnel and a fresh portion added to the 
aqueous liquid, which has been returned to the cylinder. 
This extraction of the acid aqueous liquid is repeated (usu- 
ally four or five times) until the benzol no longer leaves 
a residue on evaporation. The purpose of this extraction 
is to remove pigmentary and other substances, whose 
presence materially interferes with the reactions. The 
aqueous liquid is now rendered distinctly alkaline with 
ammonium hydrate, and again repeatedly extracted with 
benzol as described above, but the benzol layers now 
separated are evaporated in several watch-glasses, and it 
is to the residues so obtained that the tests for strychnine 
are to be applied. 

If the substance to be examined be a liquid, it should 
either be evaporated to dryness, the residue extracted 
with acidulated water, and the filtered aqueous extract 
treated with benzol, the watery solution being first acid, 
then alkaline, as above described ; or, in the case of a 
simple aqueous solution, the treatment with benzol may 
be applied directly, care being had as to the reaction. 

In order that the tests may be relied upon, particularly 
when the alkaloid is present in small amount, as in the 
case of absorbed strychnine, it is essential that foreign 
substances be removed as completely as possible. There- 
fore, if the benzol residue from the alkaline solution be 
colored, it should be purified by dissolving it in a small 
quantity of dilute sulphuric acid, agitating with benzol, 
rendering alkaline, and again extracting with benzol. 

Trests.—1. The crystalline form was formerly much 
relied upon, Strychnine crystallizes from an alcoholic 
solution in small, four-sided, orthorhombic prisms, ter- 
minating in four-sided pyramids; sometimes also in 
small hexagonal plates. Precipitated by ammonia from 
solutions of its salts, it forms slender, needle-like, four- 
sided prisms. As, however, many other substances crys- 
tallize in the same form, and as, when the alkaloid is 
present in very small amount and other substances are 
present, or when the solvent is rapidly evaporated, the 
form of the crystals may be modified, or they may not 
be produced at all, the presence or absence of crystals can 
only be considered as confirmatory evidence. 

2. The taste of strychnine is intensely and persistently 
bitter, with a faintly metallic after-taste. The bitter 
taste is still perceptible in a solution containing only one 
part of strychnine in six hundred thousand of water. The 
value of this quality is simply confirmatory, as there are 
many substances other than strychnine whose taste is bit- 
ter. 

3. Strychnine dissolves in concentrated sulphuric acid, 
forming a colorless solution of the sulphate. If, now, 
nascent oxygen be generated in the solution, a peculiar 
play of colors is produced; at first, and but for an in- 
stant, blue (this is sometimes absent), then violet, which 
gradually changes to red, and then to yellow. 

This test, which is most delicate and characteristic, 
may be applied in a variety of ways. 

The sulphuric-acid solution may be placed upon a 
strip of platinum foil connected with the positive (plat- 
inum) pole of a single Grove cell, and a platinum wire, 
connected with the negative (zinc) pole, brought into con- 
tact with the upper surface of the drop of liquid. The 
nascent oxygen liberated at the foil produces a purple- 
violet blotch. 

The sulphuric-acid solution may be placed in a watch- 
glass upon a white background, and a minute fragment 
of some solid substance capable of yielding oxygen by 
contact with sulphuric acid drawn through it with a stir- 
ring rod. The path of the solid is marked by a streak 
of color passing through the shades above mentioned. 
Either black oxide of manganese, oxide of cerium, per- 
manganate of potassium, dichromate of potassium, ferri- 
cyanide of potassium, or peroxide of lead may be used. 
Black oxide of manganese and dichromate of potassium 
are preferable to the other substances mentioned, and 
both should be used with separate portions of the residue, 
if there be sufficient. The dichromate acts quite rapidly, 
the blue color is not produced, and in solutions contain- 
ing no strychnine only a yellow color is communicated 
to the liquid. The oxide of manganese acts much more 


667 


Strychnine. 
Stuttering. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


slowly by reason of its less solubility, the blue color is 
developed, and, in the absence of strychnine, the liquid 
remains colorless. 

The only substance producing a similar play of colors 
under like treatment is curarine, the alkaloid of the South 
American arrow poison. But the change of colors with 
that alkaloid takes place much more slowly than with 
strychnine. Curarine is, moreover, colored red by sul- 
phuric acid alone, while strychnine forms a colorless so- 
lution with the acid. Any possibility of error is avoided 
if the method of separation above described have been 
followed, because curarine is not extracted from either 
acid or alkaline aqueous solution by petroleum-ether or 
benzol, but remains in the aqueous liquid. 

Aniline also gives a blue-violet color with potassium 
dichromate and dilute sulphuric acid, but this color does 
not change to red and yellow, but to black ; while a pe- 
culiar odor, somewhat resembling that of bitter almonds, 
is given off, which is not observed in the case of strych- 
nine. 

The reaction is interfered with to a greater or less de- 
gree by the presence of sugar, morphine, or other reduc- 
ing agents, brucine, and other substances ; therefore the 
foreign bodies should be removed as completely as possi- 
ble before the test is applied. 

This color reaction is distinct with goto0 grain of 
strychnine. 

4. The physiological test, first suggested by Marshall 
Hall, is also extremely delicate. A small frog is well 
dried and held by the hind legs, the skin of the back 
over the coccyx is raised by a pair of forceps, and a small 
incision made through the skin into the lymph-pouch 
with a pair of pointed scissors. A few drops of the solu- 
tion under examination are then allowed to flow from a 
pipette into the lymph-pouch, and the animal is placed 
under a glass shade. If the liquid contain strychnine 
the animal becomes uneasy in about ten minutes ; the res- 
piration is accelerated; and violent tetanic convulsions 
are provoked by striking upon the table, by blowing upon 
the animal, or by other slight irritations. 

5. A solution of iodic acid in concentrated sulphuric 
acid colors strychnine brick-red, the color changing to 
violet. 

6. Solution of potassium: dichromate causes a yellow, 
crystalline precipitate in solutions of strychnine or of its 
salts. If this precipitate be moistened with sulphuric 
acid, the play of colors described in 3 is produced. 

Other reactions of strychnine are the following : With 
solutions of the alkalies, or alkaline carbonates, a crystal- 
line precipitate of strychnine from moderately concen- 
trated solutions of its salts. With tincture of iodine, or 
solution of iodine in potassium iodide solution, a dark 
red-brown precipitate. With platinic chloride and with 
auric chloride, light-yellow precipitates, gradually be- 
coming crystalline. With potassium-iridium chloride, 
a dark-brown precipitate, which disappears on agitation, 
but gradually reappears in the form of crystals. With 
potassium platinocyanide, a white, crystalline precipitate. 
With potassium-cadmium iodide, a white, flocculent pre- 
cipitate. With potassium iodhydrargyrate, a fine, white 
precipitate. With phosphomolybdic acid, a yellowish- 
white precipitate. With picric acid, a yellow precipitate, 
which gradually becomes crystalline. With tannic acid, 
an abundant, white precipitate. 

FAILURE OF DErEcTION.—The reactions of strychnine 
are clearly defined, and it is difficult to suppose a case of 
death from the effects of this poison in which a properly 
conducted analysis would not reveal the presence of the 
alkaloid in the cadaver. It is unquestionable that death 
may result from the action of certain corrosives and poi- 
sons, without any trace of the substance remaining in 
the body after death. In cases in which a mineral acid 
or alkali destroys life by starvation, weeks or months 
after the corrosive has been taken, and in cases of death 
from digitalis, on the fifth or sixth day, the agent which 
was the remote cause of death has been eliminated be- 
fore the fatal termination, and consequently will not be 
detectable by analysis. The duration of a fatal case of 
strychnine-poisoning is, however, so short (the maximum 


668 


lapse of time being six and a half hours, and the average 
less than one hour from the taking of the poison) that it 
is, to say the least, highly improbable that a person should 
die from the effects of this poison and no trace of it re- 
main in the body. 

Yet cases have occurred in which death has been un- 
doubtedly due to strychnine, and an analysis has never- 
theless failed to reveal the presence of the alkaloid in the 
cadaver. An historical instance is the case of Palmer, 
tried in London in 1856, in which Professor Taylor, who 
made the analysis, did not obtain chemical evidence of 
the presence of strychnine, although the deceased, Cook, 
was seized with violent tetanic convulsions fifty-five min- 
utes after taking the poison, and died in about fifteen 
minutes thereafter. The failure of this analysis (for such 
it must be considered, as complete elimination in so short 
a time is not possible) was the subject of much bitter 
controversy, and seems to have permanently warped the 
mind of Dr. Taylor on the subject of chemico-legal evi- 
dence. It was due to two causes, both avoidable. The 
autopsy was conducted without the commonest precau- 
tions necessary in such cases. The defendant was pres- 
ent, and accidentally (?) caused the loss of the contents of 
the stomach ; and the solid viscera were only obtained 
for analysis at a later date. But the loss of the contents 
of the stomach, although they probably contained strych- 
nine in larger quantity than the tissues, would not have 
caused complete failure of the analysis had the analytical 
processes been properly conducted. In a case of com- 
pound poisoning by arsenic and strychnine, in which the 
analysis was made by the author in conjunction with 
Professor C. A. Doremus, no evidences of the presence 
of the alkaloid were obtained with the residues (by the 
Dragendorff method) first obtained, but on suitably puri- 
fying these residues, positive reactions were observed in 
the contents of the stomach, those of the intestines, and 
in the liver, kidneys, and heart. 

When the amount of strychnine present is large, posi- 
tive reactions may be obtained even in the unpurified 
residues ; but when the amount is small, as it must neces- 
sarily be when absorbed, it is imperative that the alkaloid 
be freed from other substances as completely as possible 
before the tests are applied. 

INFLUENCE OF PUTREFACTION.—Strychnine is one of 
the most stable of the alkaloids, and remains unaltered 
in contact with putrefying animal substances for a long 
time. Cloetta obtained distinct reactions from viscera 
containing strychnine which had been buried three, ‘six, 
and eleven and a half months (Arch. f. Path. Anat., Bd. 
xxv., p. 869). Rieckher (Zettsch. f. Anal. Chem., vii., 
400) demonstrated the presence of strychnine in a mass 
of heart, lung, and liver exposed to the ordinary varia- 
tions of temperature, with which it had been mixed 
eleven years previously. Rh. A. Witthaus. 


STUTTERING. Stuttering is a functional speech de- 
fect, consisting of clonic or tonic spasm of the muscles 
of respiration, phonation, and articulation, induced by 
the attempt to utter articulate sounds. 

The intensity of the spasm varies greatly in different 
cases, from a scarcely noticeable impediment in speak- 
ing, to an attack which renders speech for the moment 
impossible. The disturbance results in closure of the 
air-passages, which is with difficulty overcome by the 
patient, and usually occurs in connection with the explo- 
sive consonants, in producing which there is normally a 
closure either by the lips, by the tongue, or by the soft 
palate. It may, however, occur with the pure open 
sounds, or before a sound has been uttered, in which 
case the spasm originates at the glottis. There may or 
may not be arepetition of the offending sound, but there 
is apt to be when it is one of the explosives. 

The attacks occur irregularly, and are much influenced 
by circumstances, Thus a stutterer may be able to con- 
verse easily with his friends, but be unable to bring out 
a syllable when talking with strangers. Or he may be 
able to carry on an ordinary conversation, but have 
trouble in telling a story, or making any prolonged effort at 
speech, One may stutter only when tired or slightly out 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


of health. Stutterers are usually exempt when whisper- 
ing or singing, but this rule has frequent exceptions. 
Stuttering has been known from the earliest times, but 
has been generally confused with other speech defects, 
so that it is often impossible to tell whether an account 
relates to this, or to aphasia, or to stammering. It dif- 
fers from the latter in origin, is never due to organic de- 
fect, nor entirely to carelessness, is intensified when the 
patient’s attention is directed to his speech, or when he is 
embarrassed, and it is only occasional, while stammering 
isregular. Under favorable circumstances the stutterer’s 
enunciation is perfect. It is evident, then, that it is no 
mere (lefect of articulation, nor of co-ordination, for the 
muscles at times harmonize perfectly in their action. 
Stuttering is mentioned by Hippocrates, Aristotle, and 
Galen, but in a somewhat indefinite way. We are told 
by Plutarch that Demosthenes had a difficulty of enun- 
ciation, which he overcame by declaiming as he walked 
up hill, and by holding pebbles in his mouth as he re- 
hearsed his speeches. The latter plan has points of re- 
semblance with modern devices, as we shall see ; but it 
is not at all certain, from the account, whether the defect 
which it removed was really a stutter, or some form of 
stammer. At any rate, he adopted an excellent form of 
respiratory gymnastics, which are the foundation of most 
of the modern systems of treatment. 
During the Middle Ages, writings on the subject ap- 
peared occasionally, imputing the trouble to malforma- 
tion of the tongue, cerebral disease, etc., but no work of 
importance was done until the beginning of the present 
century. 
Itard (1817) divided stuttering into two classes, con- 
genital and accidental. Under the latter head he in. 
cluded all speech defects due to cerebral lesion or organic 
disease of the tongue. It will be seen that this included 
what is now known as aphasia. In the congenital form 
“he considered weakness of the organs of articulation as 
accompanying, not causing, the difficulty. He recom- 
mends beginning treatment early, and teaching the child 
slowly and carefully the pronunciation of a foreign lan- 
guage, dropping for a time its own. In this way he is 
taught, from the very first, to combine sounds properly, 
and to give prominence to the vowel sounds rather than 
to the consonants. 
In 1825, Mrs. Leigh, of New York, discovered a 
method of treatment which was kept for a long time 
secret. Her observations were made on the daughter of 
a physician in whose house she was governess, and she 
afterward established an institute for the cure of stut- 
terers. She thought the trouble due to a faulty position 
of the tongue, which is spasmodically depressed during 
the attack. To overcome this, she taught her patients to 
voluntarily raise the tip of the tongue, and keep it in this 
position while speaking. Her results were at first sur- 
prisingly good, and attracted a good deal of attention, as 
well throughout Europe as in this country. 
Malebouche bought Mrs. Leigh’s secret, and carried it 
to Europe. He attempted to improve on it, but only 
succeeded in altering it in minor details. He taught the 
system in Brussels, and finally sold it to the Prussian 
Government, who went so far as to appoint a professor 
of it. It was reported on by Magendie in a communica- 
tion to the French Academy. He thought its value only 
temporary. ; 
_ In 1826, McCormack, unable to learn Mrs. Leigh’s 
secret, set to work to discover it for himself. He ar- 
rived, however, at a different conclusion, namely, that 
the trouble is one solely of respiration, and that it is only 
necessary for the stutterer to fill his lungs well with air 
before each sentence. 

M. Serres d’Alais (1829) published a more scientific 
résumé of the subject, in which he divided the cases into 
two classes : 

1. Those due to a stiffness, as if tetanic in character, 
of the muscles of the voice and respiration. 

2. Those due to a chorea of the muscles of articula- 
tion. He recommended in severe cases gymnastic move- 
ments of the arms while speaking; in light cases he 
considered it sufficient to pronounce the syllables in a 


Strychnine. 
Stuttering, 


short and brusque-way, at the same time making the 
movements of articulation as extended as possible. He 
admitted that recovery is never quite complete, differing 
in this respect from most writers of the time, who, skep- 
tical as to the statistics of others, claimed infallible re- 
sults from their own particular method of treatment, 

Chégoin (1880) anticipated by some years the rage for 
operation which was afterward to sweep through Eu- 
rope. He thought the trouble entirely due to malforma- 
tions of the tongue, consisting in either a real shortness 
of the tongue or a faulty position of the fraenum, which 
then binds the tongue too tightly to the floor of the mouth. 
He recommended cutting the frenum, but thought the op- 
eration beneticial only when performed early, soon after 
the child has begun to talk. For shortness of the tongue 
he thought a silver plate on the teeth might be of service. 

Arnolt (1880) ascribed the difficulty to spasmodic clos- 
ure of the glottis. To overcome this he caused his pa- 
tients to make a & sound between the words, so as to 
bind the consonant rather with the preceding than with 
the following vowel sound.. In this way he threw the 
consonant sounds into the background, as one does in 
singing. 

At about this time Colombat, in France, attracted a 
good deal of attention by his brilliant success in treat- 
ment. He claimed to have cured one case in a single sit- 
ting of three hours, but, in a later edition of his work, 
considerably modified this statement, and other authori- 
ties say the case relapsed several times. In fact, so many 
tables of statistics have been compiled from the immedi- 
ate results of treatment, without waiting to see whether 
relapse occurred, that they are almost entirely worthless, 
Colombat gives a classification of cases much like that of 
Serres d’Alais, into: 

1. Repetition of syllables due to convulsive movements 
of the tongue and lips, or labio-choreic form. 

2. Tetanic stiffness of the muscles of respiration, or 
gutturo-tetanic form. For the first form he recommends 
the use of a rhythmical movement of the thumb and 
index-finger during speech, and an instrument for beat- 
ing time, of his own invention, called the muthonome. 
If the case is complicated by gutturo-tetanic spasm, he 
adds ‘‘ lingual and guttural gymnastics, which consist. in 
taking a deep breath before difficult words and phrases, 
and bringing the tongue into the pharynx, at the same 
time raising the point well toward the velum palati.” 
His method is, after all, only a combination of preceding 
ones, but seems to have been effectual in producing, for 
a time at least, very good results. 

The year 1841 is unique in the annals of this affection. 
In that year operation was proposed, hundreds of stut- 
terers were operated on, but before the end of the year 
the surgeons themselves were convinced of the useless- 
ness of operation. The idea was suggested to the mind 
of Dieffenbach, of Berlin, by the frequency with which 
stuttering and strabismus exist in the same patient, and oc- 
curred to him, he says, when a man asked, with a marked 
stutter, to be operated on for strabismus. The operation 
which he usually performed was section of the root of 
the tongue, sometimes with excision of a triangular piece 
throughout its entire length and breadth. This proceed- 
ing was based on the theory that stuttering is a purely 
local affection. The news of these operations soon 
spread to France, but at first without details, and there 
several others were invented, ¢.g., cutting the hyo-glossi, 
genio-glossi, etc., varying with the different theories of 
the surgeons as to the cause of the trouble. At first cases 
were reported as cured by each of these methods. Later, 
relapses were said to have occurred. Then several 
deaths were reported, and operation was soon abandoned 
as useless by common consent. Dieffenbach himself ad- 
mitted the extreme danger of the proceeding. The 
deaths were the result of secondary hemorrhage and 
gangrene. The results attained immediately after opera- 
tion seem to have been due to the impression on the ner- 
vous system of the patient, which wore off as soon as the 
effects of the operation subsided. : 

Since that time there has been a good deal written on 
the subject of stuttering, largely by stutterers them- 


669 


Stuttering. 
Stuttering. 


selves, both in and out of the profession; by Guillaume 
in France, Merkel, Klencke, and Kussmaul in Germany, 
Canon Kingsley and Bristowe in England, Hammond 
and Potter in America, and many others. 

Guillaume lays especial stress on the disturbances of 
respiration. He points out the fact that the ordinary ex- 
piratory act is passive and simply elastic, while in speak- 
ing the inspiratory muscles are innervated during expi- 
ration, so as to allow only so much air to pass out as is 
necessary for phonation. The stutterer often expends 
his whole stock of air in one syllable. His lungs are 
then empty, and a deep inspiration is prevented by 
spasm of the glottis or irregular action of the diaphragm. 
Guillaume recommends a breathing exercise, consisting 
of a deep inspiration, held awhile, and followed by an 
expiration, slow and interrupted as in speech, but with- 
out sound. He also recommends fixation of the tongue 
high, a deep inspiration at the beginning of every clause, 
and the use of an interdental plate. The latter, he says, 
sometimes wonderfully changes a stuttering pronuncia- 
tion. 

Merkel lays especial stress on the fact that the diffi- 
culty lies in combining a consonant with the following 
vowel sound. He locates the trouble, not in the articu- 
lating, but in the vocalizing apparatus, or, farther back 
still, in the nerve-centres which govern that apparatus. 

Gerdts thinks the trouble one of respiration. He says, 
however, that the spasm is induced by the patient using 
the mouth instead of the throat in talking. His idea 
seems to be to make vocalization more, and articulation 
less, prominent. At the same time he pays great atten- 
tion to the breathing, which, he says, has been faulty, 
even when not speaking, in all of the 690 stutterers whom 
he has treated. 

Bristowe likens stuttering to chorea. 

CAUSATION.—Among the many theories which have 
been propounded to account for the symptom under dis- 
cussion, that which ascribes it to malformation or disease 
of the organs of articulation is one of the oldest, and one 
which held its ground longest. It is the foundation of 
all operative interference, and is readily disposed of. In 
many pronounced cases of stuttering the tongue and lips 
execute ordinary movements perfectly. No abnormality 
is noticed except during speech ; and when organic trou- 
ble coexists, its removal does not entirely cure the affec- 
tion. Any conceivable degree of deformity may exist 
and cause nothing but stammering, which is then pro- 
portional to the amount of the lesion. 

Stuttering is not due to a faulty position of the tongue, 
as is shown by the constant relapses which occurred after 
treatment by Mrs. Leigh’s method. It is true that in 
many cases the tongue is pressed against the floor of the 
mouth, and is affected with clonic spasm in this position, 
This is, however, not always the case, and when it ex- 
ists it is a result, not the cause, of the malady. 

The trouble is not a chorea of the muscles of articula- 
tion. The characteristic of choreic spasm is that it is 
irregular and jerky, and occurs during rest. The spasm 
of stuttering occurs only during a voluntary excitation of 
the speech-mechanism. Again, chorea, when it affects 
the lips and tongue, causes marked stammering, never 
stuttering. Chorea of the speech-centre, or coprolalia, 
causes a spasmodic ejaculation of words or phrases in- 
dependently of volition, and the words are perfectly ar- 
ticulated. . 

That the trouble is due to confusion of ideas, or dis- 
proportion of words and ideas, is obviously false. Stut- 
tering occurs in persons of every grade of mental power. 
The greatest disproportion between words and ideas oc- 
curs in acute mania, and leads, not to stuttering, but to a 
chaotic mixture of words and syllables. In most persons 
failure of ideas is marked by a drawl, not a stutter. 

It is not due to a simple ataxia of the muscles used in 
speech. If it were, the patient could at once control the 
irregular movements by ceasing to speak. But when he 
does this, the spasm invariably persists for a short time. 
Again, stuttering is only occasional, and made worse 
when the patient’s attention is directed to his speech ; 
ataxia is constant, and is diminished by attention. 


670 


| often the result of an inherited tendency. 
_ low severe illness, fright, or any shock to the nervous 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


na, 


The theory that it is an inability to combine the con- 
sonant and vowel sounds is inadequate to explain the 
symptoms. The occasion of so combining them is often 
a proximate cause of an attack, somewhat as general con- 
vulsions are caused by teething or other peripheral irri- 
tation. But stuttering may occur on an attempt to utter 
a pure vowel sound entirely apart from a consonant. 

In order to understand the phenomena presented, it 
will be necessary to review briefly the structure and 
physiology of that part of the motor speech-centres 
which serves for the production of articulate sounds. 
The processes which occur in the nerve-centres during 
speech are most of them unconscious, there being pres- 
ent to the mind only the primary volition, which is com- 
paratively simple. The act of speech is based on stored- 
up motor memories of former acts of the same kind, 
which originated in childhood in reflex and accidental 
movements, perceived by the child, and afterward volun- 
tarily executed. The details of these movements are 
carried out by a co-ordinating mechanism which has ac- 
quired its functions gradually, as a result of training. 
The motor impulse travels from the motor speech-centre 
in the left third frontal convolution, downward through 
the knee of the internal capsule, and reaches the me- 
dulla. The nerves carrying it here communicate with 
the articulo-respiratory centre, consisting of the nuclei 
of origin of the facial, pneumo-gastric, spinal accessory, 
and hypo-glossal nerves. These nuclei lie close together, 
and constitute practically one collection of cells bound 
together by fibres running in every direction. Here, and 
possibly also in the cerebellum, is effected the exact de- 
gree of innervation of all the muscles of articulation, so 
as together to produce the vowel and consonant sounds, 
and at the same time to approximate the vocal cords, 
and so regulate the respiration as to cause exactly the 
necessary amount of air to pass through the glottis. 
This exceedingly complex action is entirely apart from 
the conscious act of speech, and is only known to 
the sensorium through the intervention of the sensory 
nerves supplying the mucous membranes and deeper 
parts of the lips, tongue, and palate. It is one of the 
highest reflex actions, and, like most reflexes, is more or 
less under control from the cerebrum. The amount of 
innervation of each muscle is determined by lines of least 
resistance in the connecting fibres, which are formed as 
a result of repeated transmission of motor impulses, and 
are determined to a considerable extent by predisposition.' 
This whole system is probably under the influence of one 
or more controlling centres, which serve to check over- 
action, or the undue diffusion of nerve-force. 

Stuttering is a disturbance of this co-ordinating 
mechanism. It may be due to abnormal excitability of 
the primary system, or to weakness of the inhibiting 
centre, probably the latter. The result is an over-action 
of the muscles innervated, and transmission of the im- 
pulse to other muscles more or less distant, sometimes 
even to those of the arms and trunk ; the attempts of the 
patient to overcome the spasm only serve to intensify it, 
until the controlling centre resumes its function, or the 
patient ceases the effort to speak. 

Several facts tend to show that the troubleis adynamic . 
in origin—e.g., the fact that patients usually stutter 
worst when tired ; that persons sometimes stutter when 
exhausted, or during sickness, who do not otherwise ; 
that stutterers are often, though not always, of weak or 
scrofulous constitution. The inhibiting influence of °* 
strong peripheral impressions, as seen in the results of 
operation on the tongue, is somewhat like the stoppage 


_ of epileptic convulsions by ligature or an encircling blis- 


ter of a limb.’ 
This disturbance of equilibrium between the centres is 
It may fol- 


system. In such cases the trouble may pass off when 
the depressing influence ceases, or may persist for a long 
time, or through life. In any case the intensity of the 
disturbance depends much on the treatment and sur- 
roundings of the patient, anything like ridicule or pun- 
ishment aggravating it tenfold. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ! 


Stuttering. 
Stuttering. 


OcCURRENCE.—Stuttering occurs in all ranks of so- 
ciety, and in most nations. The Chinese are said to be 
exempt, on account of the peculiar intonation of their 
language. It affects men much oftener than women, 
although trustworthy statistics on this point are lacking. 
Some authorities have thought that no women stutter ; 
others place the proportion of women affected as high as 
thirty-five per cent. Kussmaul believes the fact to be 
due to the greater tact and delicacy of women, which 
fits them more readily in every way for their place in 
society. 

SyMPToMs.—These vary much in point of severity and 
mode of sequence of the spasm. In lighter cases, which 
are fairly under control, when one of the explosive con- 
sonants is met with, the organs of articulation remain 
fixed in their closed position for a moment, there is slight 
choking, and tremor of the facial muscles, an effort of 
the will is made, and the parts resume their function. 

In rather more severe cases there may be added a 
good deal of thickening and tremulous movement of the 
tongue, and tonic spasm of the glottis. The breathing 
is then apt to be irregular, and the approximation of the 
vocal cords causes a crowing sound on inspiration, which 
is sometimes utilized for speech. 

When the spasm occurs before speech has actually 
commenced, the trouble begins with tonic spasm of the 
glottis, there is tonic and clonic spasm of the tongue, lips, 
and face, and the diaphragm acts irregularly in its efforts 
to overcome the resistance at the rima glottidis. 

In severe cases the attack may be brought on by any 
sounds, less frequently the open vowel sounds ; the clos- 
ure may be effected by the lips, tongue, or palate ; the 
under jaw is set; there is marked tremor of the facial 
muscles, and sometimes even of the arms; the glottis 
may be closed so as almost or entirely to prevent respi- 
ration, or it may be opened at the same time that there is 
spasm of the respiratory muscles. In the latter case the 
lungs are emptied of air, and the patient must pause for 
a deep breath before he can proceed with his sentence. 
At the same time the face becomes flushed, the flow of 
saliva is increased, and the mental torture of the patient 
tends to prolong rather than cut short the attack. 

DraGnosis.—The diagnosis is usually easy. In addi- 
tion to the clinical features given above, the duration of 
the malady should be carefully ascertained. 

Stuttering almost invariably dates from childhood. 
Attention should be paid to the physical signs of organic 
brain disease. 

The speech-defect which occurs in paretic dementia 

“may simulate stuttering quite closely. There is here 
faulty enunciation of the separate consonant and vowel 
sounds, with marked tremor of the tongue and facial 
muscles. But there is not much disturbance of respira- 
tion ; the tremor of the tongue and lips occurs when the 
patient is not speaking ; above all, thereare elision of syl- 
lables, and other evidences of partial aphasia. The his- 
tory shows a recent development of the trouble. 

On the other hand, stutterers with congenital mental 
defect and unequal pupils have been mistaken for paret- 
ics. Absence of other. symptoms, stationary nature of 
the disease, and attention to the differences given above 
will then decide. 

In clergymen and other public speakers there some- 
times occurs a difficulty in speaking, which may be mis- 
taken for stuttering. It is one of the occupation neu- 
roses, of which the type is writers’ cramp, and is due to 
exhaustion of the co-ordinating mechanism of respira- 
tion. Respiration, as pointed out above, is ordinarily 
reflex, but becomes voluntary when used for speech. 
Some speakers entirely empty their lungs before taking 
breath ; the action of the reflex mechanism is then kept 
too long in abeyance. When this is habitual, the cen- 
tres become exhausted and fail to respond to the reflex 
stimulus.. The trouble usually begins in the glottis, 
which fails to open on inspiration ; a crowing sound is 

- produced when the speaker takes breath; the diaphragm 
and intercostals act weakly and irregularly, and the lungs 
cannot be promptly filled for the next sentence. This 
may happen only toward the end of the discourse, when 


the speaker is tired, but may become so marked that any 
attempt to speak causes great distress, and rest is then an 
imperative necessity. This affection differs from stutter. 
ing by occurring comparatively late in life, not involving 
the muscles of articulation, being rather of a paralytic 
than of a spastic nature. It ordinarily yields to rest and 
respiratory gymnastics. 

Another rare affection, aphthongia, is probably allied 
to the preceding. Here the spasm occurs in the muscles 
supplied by the hypo-glossal nerve, and is brought on by 
any attempt to speak, so that articulation is rendered im- 
possible. In the few cases recorded the disease has been 
caused by emotion or fright. During the attack the jaws 
and tongue are fixed; the sterno-thyroid, sterno-hyoid, 
and thyro-hyoid muscles may be in a state of clonic spasm, 
which begins and ceases with the attempt to speak. The 
prognosis seems to be good. Too little is known of the 
disease to speak of its probable relation to stuttering. It 
may be distinguished by the character and history of the 
attacks. 

The speech-defects in multiple sclerosis, bulbar paraly- 
sis, etc., have been noticed in a previous article. (See 
Stammering. ) 

Proenosis.—There is no doubt that sufferers from this 
affection may be aided by treatment, especially if the lat- 
ter is vigorous and instituted early. The prognosis is 
better in non-hereditary cases, and in patients of strong 
will-power. Almost all writers on the subject have a fa- 
vorite method of treatment, especially those who are con- 
nected with an institute for voice-training, and claim a 
large percentage of cures. Investigation shows that in 
most cases relapse takes place, after an even brilliant re- 
sult. This should not discourage patients from effort, 
but it is necessary to bear in mind that only constant and 
long-continued exertion will overcome a vicious tendency 
fixed by habit. The difficulty tends to decrease with 
time, and many stutterers are able to master it at forty 
or fifty years of age. They are apt to ascribe this to 
some particular form of treatment, which they then ar- 
dently recommend. 

TREATMENT.—Too much stress cannot be laid on be- 
ginning treatment early. The child should be kept, as 
much as possible, from association with stutterers. It 
should be remembered that he is sensitive as well to sym- 
pathy as to blame for his malady, and as little notice 
should be taken of it as possible, except in connection 
with stated lessons. He should be taught, when he has 
an attack, to stop speaking at once until- he has mas- 
tered it. 

Breathing exercises are very important. They may be 
given, following Guillaume, by causing the patient to 
take a long breath, hold it for a moment, and then let it 
out slowly, with occasional stops, but without sound. 
He should especially be made to take a deep breath at 
frequent intervals, and never speak with nearly empty 
lunes. 

After breathing exercises have been continued for 
some time, the patient may proceed to the vowel sounds, 
first the most open one, d, then @, d, é, é, 6, 6, and so on ; 
then the aspirates, hd, hd, etc.; next the easier consonants 
in combination, ld, 1d, lé, 16, la, md, ma, etc. Sentences 
may then be used in which the difficult sounds do not oc- 
cur. Lastly, the explosives, dd, dd, bd, ba, etc., may be 
tried. With all of these the patient should be taught to 
lay the stress on the vowel sounds, so as to avoid the 
slight over-action with the consonants, which is usually 
the beginning of the spasm. One must be sure that the 
pupil has mastered each of the above classes before he is 
permitted to go on to the next. 

We have a mass of evidence from stutterers, in the 
profession and out of it, testifying to the efficacy of rhyth- 
mical movements accompanying speech. They serve a 
twofold purpose—they divert the patient’s attention, and 
give his sentences something of a sing-song character. 
They are aids, but are in no sense curative. The thumb 
and finger may be opened and closed, or any other move- 
ment made which: is convenient to the patient. Some- 
what the same effect is produced by elevating the tip of 
the tongue, as recommended by Mrs. Leigh, but it will 


671 


Stuttering. 
Suet. 


be better, in most cases, to draw the patient’s attention 
to a more distant part of his body. 

Therapeutic measures are of little value. Stimulants 
should be used moderately, if at all. Scrofulous and 
anzemic tendencies should be corrected, and the patients 
should be kept in good general health by exercise, cold 
sponging, and like measures. 

The question is often asked, whether it is possible for 
an adult to master his defect without assistance from a 
teacher. That is entirely an individual matter. Some 
men have perseverance enough to educate themselves in 
this as in other respects. Proper teaching, however, 
saves much time and disappointment. 

The following works may be consulted for further de- 
tails :, 

Guillaume: Dictionnaire encyclopédique des Sciences médicales, art. 

Bégaiement. 

Kussmaul: Stérungen der Sprache. 
Lehwess: Radicale Heilung des Stotterns. 
Merkel: Physiologie der menschlichen Sprache. 
Potter: Speech and its Defects, 
Henry S. Upson. 


1 Gowers: Diagnosis of Diseases of the Brain. 
2 Compare Buzzard : Lecture on ‘Transfer caused by Encircling Blisters. 


STYPTICS are medicines used locally to arrest heemor- 
rhage. They have the property of forming, with the al- 
bumen of the escaping blood, a solid, more or less adhe- 
sive mass, or coagulum, which mechanically closes the 
bleeding vessels. Of the numerous substances which 
coagulate albumen only the following are commonly em- 
ployed: Tannin, alum, chloride of iron, subsulphate of 
iron, iodine, and nitrate of silver. 

Their utility is very conspicuous in hemorrhages from 
small blood-vessels, especially capillaries; but when a 
rapid flow of blood takes place from large arteries, they 
are quite powerless and should not be employed, unless 
other efficient heemostatics cannot be applied. 

Acipum TaNnicuM.—The coagulum which tannin 
forms with albumen adheres quite firmly, and usually 
quickly occludes small vessels. It is generally held that 
tannin also contracts the vessels ; but in a series of very 
careful experiments it was found by Rosenstirn that even 
very concentrated solutions markedly dilate arteries, 
veins, and capillaries. 

Tannin used'as a styptic does not produce any notable 
irritation of the tissues, and causes neither pain nor sub- 
sequent inflammation. It is, therefore, preferable to 
other more irritating substances. It is most effective 
‘when applied in the form of fine powder immediately 
to the bleeding surface, all coagula having previously 
been removed by means of cold water. 

It is often successful, even when it cannot be brought 
in contact, in large quantities, with the bleeding surface. 
Thus epistaxis commonly ceases after it has been snuffed 
up the nostrils. Concentrated solutions also sometimes 
arrest epistaxis. 

To arrest bleeding after tooth extraction, finely pow- 
dered tannin should be freely applied to the bleeding 
surface by means of a piece of soft, moist sponge, or a 
pledget of cotton. Then a thick narrow compress should 
be applied over the sponge or cotton, and the jaws firmly 
closed by means of a roller passed around the head. 

Tannin is used in metrorrhagia when the blood 
issues from small vessels of the cervix uteri. Several 
drachms are usually applied by means of a mass of cot- 
ton previously soaked in water and squeezed nearly dry, 
or by a soft, moist sponge. Sometimes suppositories of 
tannin, made with a small quantity of glycerine, or with 
oil of theobroma, are introduced into the cervix. Bec- 
querel used suppositories consisting of tannin, four parts; 
tragacanth, one part; and bread crumb, a sufficient quan- 
tity. He applied them through a speculum, and kept 


them in place, until dissolved, by a mass of cotton satu- 


rated with a concentrated solution of tannin. 

Tannin has also been employed in gastric, intestinal, 
and pulmonary hemorrhage. Its utility in gastric hem- 
orrhage is very doubtful, as it probably cannot come 
into close contact with the bleeding surface. It should 
be tried only in cases in which the blood issues from 


672 


| 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


small vessels, and administered in the form of powder 
or concentrated solution.- In intestinal hemorrhage, es- 
pecially when the bleeding surface is in the lower part 
of the small intestine, as in typhoid fever, it is useless. 
If given, the pilular form of administration should be 
preferred. In hemoptysis inhalations of atomized solu- 
tions of tannin, containing from one to ten per cent., are 
said to have been successful, especially in cases in 
which the bleeding was moderate but recurred fre- 
quently. ; 

ALUMEN.—Alum may be employed in hemorrhage 
from small vessels of any accessible part. 

In epistaxis powdered alum, either pure or mixed with 
an equal quantity of gum arabic, may be blown into the 
nose by means of an insufflator or a paper funnel, or a 
saturated solution may be thrown into the nostrils. In 
obstinate bleeding from leech-bites a dossil of cotton wool 
may be impregnated with a saturated hot solution of 
alum and pressed upon the bleeding point. The same 
procedure may be adopted in severe hemorrhage after 
tooth extraction, or alum in powder may be applied by 
means of soft, moist sponge, or a pledget of cotton wool, 
which should be firmly fixed upon the bleeding surface. 

Alum is frequently used in hemorrhage from the cer- 
vix uteri. Several ounces of a saturated solution may be 
injected into the vagina, the patient being in such a posi- 
tion as to keep the solution in contact with the cervix. 
Pledgets of cotton wool, soaked in a saturated solution 
of alum, may be applied to the bleeding surface. 

In hemoptysis solutions of alum, containing from one 
to five per cent., are employed in the form of spray. The 
inhalations are held to be most useful when the heemor- 
rhage is moderate, but recurs frequently at short in- 
tervals. 

Liquor FERRI CHLoRipiI.—The solution of chloride 
of iron is the most powerful styptic. It coagulates not 
only the blood which has escaped from vessels, but also 
that within the vessels with which it comes in contact. 
Even diluted with two or three parts of water, it con- 
denses the tissues, contracts the blood-vessels, especially 
arterioles and venules, and produces more or less irrita- 
tion, often followed by inflammation. 

Its action on the albumen of the blood .is not instan- 
taneous, from twenty to forty seconds elapsing before a 
firm coagulum results. If present in considerable excess, 
it gradually dissolves the coagulum. 

Solution of chloride of iron is applicable in cases of 
hemorrhage in which less irritating styptics, such as tan- 
nin and alum, are inefficient, and it may be employed in 
all accessible hemorrhages from small vessels. In recent 
wounds, when other hemostatics have failed to arrest 
the bleeding, the solution, undiluted or diluted with two 
or three parts of water, is frequently used. Before its 
application the bleeding surface should be thoroughly 
cleansed from blood and coagula, so that the styptic may 
come into immediate contact with the open vessels. A 
clean sponge, previously steeped in ice-water and squeezed 
out, should then be firmly pressed upon the bleeding sur- 
face, until a mass of cotton saturated with the iron solu- 
tion, and well pressed between the fingers to remove the 
excess of the chloride, is ready for application. The cot- 
ton should be applied instantly after the removal of the 
sponge. Then another mass of cotton wool, moist but 
not wet with the iron, should be applied over the first 
and gently pressed upon it. If the bleeding ceases, dry 
cotton may be placed over the moist masses, and firmly 
fixed to the part by appropriate dressings. If, however, 
the flow of blood should still continue, the compresses 
should be removed and others applied in. the same man- 
ner. It is important that the cotton compresses be only 
moist, not dripping wet, with the solution of chloride of 
iron, as an excess of the latter exerts a solvent action on 
the coagulum. Asarule, the compresses should not be 
removed before the third day. Then cold water should 
be gently injected into the masses of cotton, so that no 
force may be required for their removal. 

In hemorrhages from cavities, such as the nose, va- 
gina, uterus, and rectum, the solution of chloride of iron, 
diluted with three or four parts of water, is usually ef:- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


fectual. Such a solution was used by Barnes and others 
to arrest post-partum hemorrhage, being slowly and 
carefully injected into the cavity of the uterus. Breisky 
and some other German writers maintain that a very di- 
lute solution, containing only sufficient chloride of iron 
to impart to the water a deep wine-yellow color, is 
equally effectual. In uterine hemorrhage occurring at 
a late period after labor, a mixture of equal parts of 
water and solution of chloride of iron is sometimes ap- 
plied to the cavity of the uterus by means of a pencil or 
a sponge. 

A weak solution of chloride of iron has been given 
internally to arrest gastric and intestinal hemorrhage. 
Some good may possibly follow in gastric hemorrhage, 
if the bleeding occurs slowly from small vessels; but in 
intestinal hemorrhage no reliance should be placed on 
styptics. 

Good observers affirm that they have found inhalations 
of the spray of dilute solutions of chloride of iron, con- 
taining from one to five per cent., very efficient in severe 
hemoptysis, after subcutaneous injections of ergotin had 
failed. 

Liquor FERRI SUBSULPHATIS.—This solution, com- 
monly called Monsel’s solution, is supposed to coagulate 
blood as speedily and firmly as the chloride of iron, and 
to be less irritating to the tissues. Whether it contracts 
blood-vessels has not been determined experimentally, 
but it probably is less active in this respect than the 
chloride. . 

In hemorrhages from accessible parts it may be ap- 
plied undiluted, or diluted with two or three parts of wa- 
ter, in the same manner as the solution of the chloride. 
It is generally preferred to the latter in bleeding from 
cavities, such as the nose, mouth, throat, and rectum. 

Cotton steeped in solution of subsulphate of iron and 
then dried, is known as hemostaticcotton. It is applied 
to bleeding surfaces, previously well cleansed, in a thick 
layer, and firmly supported by a compress and roller. 

Dry subsulphate of iron, obtained by evaporating the 
solution, made into suppositories with cacao butter, is 
frequently employed to arrest hemorrhage from the rec- 
tum and the cervix uteri. 

IoprnE.—In the form of tincture, iodine is used asa 
Styptic in some kinds of uterine hemorrhage. Some au- 
thors state that the best results may be obtained from a 
stronger solution, known as Churchill’s tincture, consist- 
ing of seventy-five grains of iodine, ninety grains of io- 
dide of potassium, and one ounce of alcohol. This prep- 
aration has been highly recommended for the arrest of 
metrorrhagia due to uterine fibroids and cancer of the 
cervix. It may be injected into the uterine cavity if ne- 
cessary, after previous dilatation of the cervix, by means 
ofa hard rubber syringe, the nozzle being pushed as far as 
to the neighborhood of the fundus. The injection should 
be made very slowly, and a mass of cotton should be 
placed at the os uteri to prevent the iodine, as it escapes 
from the cervix, from passing over the vaginal wall. The 
quantity which should be injected varies, but should 
never exceed one drachm. Sometimes the tincture is ap- 
plied to the uterine cavity by means of a pledget of cot- 
ton wrapped around an applicator. Much weaker solu- 
tions of iodine have been successfully employed for the 
arrest of metrorrhagia. 

ARGENTI NiTras.—Nitrate of silver coagulates albu- 
men and strongly contracts blood-vessels. It is never 
used in ordinary hemorrhages, but is very convenient 
- for the arrest of obstinate bleeding from leech-bites, a 
pointed stick being gently pressed upon the bleeding 
point. Samuel Nickles. 


SUDAMEN. An inflammatory affection of the skin, 
involving the closure of the sweat-ducts, with the for- 
mation of numbers of discrete, minute, clear vesicles, 
from the size of a pin-point to that of a pin-head, rising 
directly from the skin, with little or no congestive areola. 
The vesicles usually contain a clear acid fluid which is 
not sticky, and dries up without leaving any crust. The 
eruption usually occurs in the course of fevers or other 
severe general diseases. It was formerly supposed to be 


Vou. VI.—48 


Stuttering. 
Suet. 


a substantive disease, and under the terms swette miliaire, 
suette de Picardie, etc., was even described as epidemic. 
By many physicians the affection is supposed to be a 
form of that previously described in this work under 
the name of Miliaria. The distinction usually made is 
that, while in miliaria there is always a congestive base, 
in sudamen the vesicle rises from the unchanged surface 
of the skin. To this it may be added that miliaria is al- 
most always connected with excessive sweating, in per- 
sons otherwise healthy, while sudamen is a concomitant 
of febrile or other exhausting disease. The treatment is 
the same as that of miliaria. Arthur Van Harlingen. 


SUET (Sevwm, U.S. Ph.; Seowm Preparatum, Br. Ph.; 
Sebum Ovile, Ph. G.; Suif de Mouton, Codex Med.; Mut- 
ton Suet, Mutton Tallow. The Codex also recognizes 
the similar product of the Ox, Suzf de Baeuf, Suif de 
Veau, as well as the marrow, Moelle de Beuf). The part 
of the animal taken for this preparation is the same that 
yields the hardest and best lard, or beef tallow, namely, 
the thick mass of fat lying along the loins and surround- 
ing the kidneys. The whole tissue is suet, the fat melted 
out and purified is tallow. 

The preparation is exceedingly.simple, although not 
always well done. It consists in first cleaning the suet 
from connective tissue, vessels, blood, etc., then cutting 
it in small pieces and washing in cold water, or allowing 
it to soak for a few hours in water; then it is boiled with 
a little water until the tissue is broken up, strained, and 
poured away to cool; the last portion of water is then 
removed by prolonged, moderate heat, which should not 
be allowed to rise above the boiling point of water. In 
the laboratory the steam kettles offer the most perfect 
means of ‘‘ trying out” lard and tallow. 

Mutton suet has no medicinal properties not common 
also to the other animal fats, excepting greater hardness, 
a higher melting point, and perhaps superior keeping 
qualities to most of them. It consists of the usual gly- 
cerine fats, stearin, palmitin, olein, etc., with the former 
in excess, and the latter at a minimum. The pharma- 
copeeial description is as follows: ‘‘A white, smooth, 
solid fat, nearly inodorous, gradually becoming rancid on 
exposure to air, having a bland taste, and a neutral reac- 
tion. Soluble in 44 parts of boiling alcohol, in about 60 
parts of ether, and slowly soluble in 2 parts of benzin. 
From its solution in the latter, kept in a stoppered flask, 
it slowly separates in a crystalline form on standing. It 
melts between 45° and 50° C, (118° and 122° F.), and con- 
geals between 87° and 40° C. (98° and 104° F.).” Suet 
forms about one-fourth of Mercurial Ointment and one- 
half of Tar Ointment. It is also an extensively used do- 
mestic cerate. 

ALLIED SuBsTANCES.—Numerous fats of domestic and 
wild animals are in common household estimation for one 
purpose or another, with very little real difference from 
each other except inodor and hardness. Goose, chicken, 
and skunk oils are extensively used in country families 
allover New England. Something more distinctive, and 
having peculiar claims to attention, are the preparations 
of grease obtained from the wool of sheep, and called by 
the commercial names of ‘‘ Lanolin ” and ‘‘ Agnine, etc.” 
The former of these was introduced as a patented article 
by Liebreich some five years ago. His process for pre- 
paring it is said to be as follows: ‘‘ He takes the suds 
from the washings of wool in the mill, submits it to the 


‘action of a centrifugal machine which separates the 


soapy, oily suds from the dirt associated therewith, de- 
composes the suds by an acid, whereby the acid and the 
saponifying alkali unite, and the saponified wool-fat is 
separated, combined with about one hundred per cent. 
of water; this is thoroughly washed with cold water, 
then heated so as to separate the water and wool-fat, and 
again combined with a definite proportion of water, and 
lanolin is the result.” Or the wool itself may be treated 
with alkaline water and the suds produced proceeded 
with as above; or the fat finally may be dissolved out 
with petroleum, benzin and obtained by evaporation, and 
mixed with a suitable proportion of water (Therapeutic 
Gazette). 


673 


Suet. 
Suicide. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Lanolin is a soft, solid, adhesive, ointment-like, fatty 
substance, of a light yellow color, a woolly odor, and 
slight oily taste ; rubbed upon the skin it at first greases 
it, but soon it disappears by absorption, leaving the skin 
soft, smooth, and nearly clean ; it mixes with its weight 
of water smoothly. It should be neutral in reaction, 
free from glycerine and ammonia, and should never be- 
come rancid. It contains a large amount of cholesterin. 
It is not in the least irritating. The miscibility with 
water, and ready absorption by the skin, make this sub- 
stance of especial value in making a class of ointments 
which of late had fallen considerably, and deservedly, into 
disuse from their unreliability, viz., those containing 
active medicines used with the hope of their absorption ; 
mixed with lanolin these substances are unquestionably 
absorbed, and iodide of potassium, mercury, aconite, 
atropine, morphine may be given in this way through 
the skin; asa simple protective also it equals the other 
fats. It is so sticky that, for convenience in using, it is 
better mixed with a third or half of some other fat (lard 
or tallow). 

Agnine is the name given to another preparation from 
the same source, apparently unmixed with water ; it is 
harder, darker, and less agreeable in color and odor than 
lanolin, to whose uses it is said to be adapted. 

W. P. Bolles. 


SUGAR (Saccharum, U. 8. Ph.; Saccharum Purifica- 
tum, Br. Ph.; Sucre de Canne, Codex Med.); Cane Sugar, 
Saccharose, Sucrose, etc., Ci2eHe2On. 

Common sugar is one of a group of soluble, sweet- 
tasting compounds formed by plants in the process of 
assimilation, or provided in their seeds, fruits, or other 
organs in storage for later consumption. This particular 
variety, although pretty widely diffused among plants, 
is in practice obtained from five or six only, where it is 
very abundant. . These are : 

Saccharum offictnarum Linn.; Order, Graminee, the 
Sugar Cane, a large East Indian grass, whose solid stems 
are laden with it, furnishes most of the sugar of the 
world. 

Beta vulgaris Linn.; Order, Chenopodiaceae, the Sugar 
Beet, aSouth European plant, long cultivated for fodder, 
but utilized for sugar during the present ceftury. It 
supplies half the sugar of the continent of Europe. 

Acer saccharinum, Order, Sapindacee, the Sugar of 
Red Maple, yields the Maple Sugar of America. 

Saguerus Rumphit Roxb. (8. saccharifer Bl.); Order, 
Palme and other Palms, supplies sugar, drink, and 
liquor in India. 

Sorghum saccharatum Pers., another grass, is cultivated 
for sugar in China, and very slightly in the United States. 

Sugar has been known from a very remote period in 
India, where the cane has been used as food from pre- 
historic times. It found its way into Europe about the 
beginning of the Christian era, probably as a natural exu- 
dation, like manna, from the wounded canes. Its prepa- 
ration by extracting and boiling the juice, and its partial 
refinement, are developments of the first third of this era. 
At first sugar in Europe was expensive, a rarity, and 
only used as a medicine or luxury ; its general use as a 
food here dates back only two or three hundred years. 
Even the last half century has witnessed an enormous 
extension of it. 

PREPARATION.—The canes are cut when well grown, 


stripped of leaves, and crushed between strong iron cylin- - 


ders which press out their sweet juice. This is imme- 
diately neutralized with a little milk of lime, to prevent 
decomposition of the sugar and souring, as wellas to pre- 
cipitate some of its impurities. It is then heated, the 
albuminous ‘‘ scum” removed, and the clear juice boiled 
down until it will crystallize upon cooling, when crude 
sugar and its mother liquor (molasses) are the results. 
To this outline many details must be added to give an 
idea of modern sugar-making. The mill has been de- 
veloped to give equable pressure whatever the thickness of 
the feed, and series of vacuum pans have, in most places, 
superseded the old open boilers ; while some processes of 
purification or filtration have been put in use during the 


674 


boiling at the mills. The raw or brown sugar produced 
in this way is then usually exported to northern coun- 
tries—Europe and America—for refinement. This con- 
sists, with many variations and details, in redissolving the 
sugar, straining it, and precipitating impurities again, 
perhaps with lime; by boiling with blood-albumen and 
by filtration through long columns of animal charcoal ; 
the clarified syrup is then condensed in vacuum boilers 
until it will crystallize on cooling ; the sugar so formed is 
drained in moulds, or dried in centrifugal machines, and 
finally sold in loaves, lumps, fine crystals (granulated), 
or powder. The drainings from the sugar in this last 
crystallization, constitute the Sugar-house Syrups of the 
market. 

The process of extracting sugar from the Beet consists 
in cleaning, grinding, and pressing the roots to obtain 
the juice, or, to get a cleaner product, in slicing them 
and subjecting them to a sort of repercolation process ; 
this liquid is then heated with lime and injected with 
carbonic acid, which precipitate albuminoid and other 
impurities, and finally the lime itself is freed from its 
combination with the sugar. The clarified juice is then 
further filtered through animal charcoal, and finally 
evaporated as above. 

From the Maple the sap is collected in the early spring 
by tapping the trees and attaching suitable receptacles ; 
the sap is then simply boiled down in iron pots until it 
will become solid upon cooling, and is then run into pans. 

There are several grades of imperfectly purified sugar 
sold for family use, as brown-, yellow-, coffee-sugar, etc., 
but none of them is suitable for medicinal or pharma- 
ceutical uses ; neither is the maple sugar. 

Sugar scarcely needs a description. That of the 
market is practically pure—a little earthy residue, oc- 
casionally a little coloring matter, and perhaps a trace 
cf one of its derivative sugars may be found, but often 
nothing; the most tempting adulteration is glucose, 
but this in crystallized or granulated sugars is rare. 
The Pharmacopeia gives the following tests of its 
purity: ‘‘ Neither an aqueous nor an alcoholic solu- 
tion of sugar, kept in large, well-closed, and completely 
filled bottles, should deposit a sediment on prolonged 
standing (abs. of insoluble salts, foreign matters, ultra- 
marine, Prussian blue, etc.). Ifa portion of about one 
gram of sugar be dissolved in ten cubic centimetres 
of boiling water, then mixed with four or five drops of 
test solution of nitrate of silver,* and about two cubic 
centimetres of water of ammonia, and quickly heated un- 
til the liquid begins to boil, not more than a slight colora- 
tion, but no black precipitate, should appear in the liquid 
after standing at rest for five minutes (abs. of grape sugar 
and of more than a slight amount of invert sugar).” Su- 
gar is soluble in half its weight of cold, in one-fifth of its 
weight of boiling, water, in one hundred and seventy-five 
parts of alcohol; not soluble in ether. It deviates polar- 
ized light to the right. It forms compounds with both 
alkalies and acids. It keeps perfectly in the air, and 
pretty well in concentrated solutions (syrups). In dilute 
solutions it is readily decomposed by several fungi, the 
commonest of which is the yeast plant, Saccharomyces 
Cerevisie, under whose influence alcohol and carbonic 
acid are produced. Acetic, lactic, and butyric acids are 
also formed from it by their specific ferments. By heat, 
diluted acids, and in other ways, cane sugar is separated 
into dextrose (grape sugar) and levulosan, or uncrystal- 
lizable sugar. Caramel is an empyreumatic product made 
by heating sugar until it becomes brown. It is used in 
coloring foods and liquors. 

ACTION AND Use.—Sugar is at present a very important 
food, whose consumption is constantly increasing as its 
cost is becoming less, and is also a valuable preservative of 
other foods, as fruit; but it has no medicinal importance 
whatever, excepting the negative one of increasing acidity 
of the stomach in certain dyspeptic conditions, and of in- 
creasing the glycosuria and discomfort of diabetics. In 
pharmacy it has several applications, first as a preserver 
of some unstable chemicals, as iodide, suboxide, etc., of 


* Five per cent. solution in water. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


iron, and of fruit juices ; secondly, as an agreeable vehicle, 
as in the syrups and troches; and, thirdly, as a pill cov- 
ering. 

PREPARATIONS.—Syrup, or simple syrup, as it was for- 
merly called (Syrupus, U.S. Ph.), is a solution contain- 
ing sixty-five per cent. of sugar in distilled water. The 
medicinal syrups are made either from this as a basis, or 
directly from sugar, or frequently from both. One of 
them, Syrup of Lime (Syrupus Calcis, U. S. Ph.), is a 
five per cent. solution of lime in combination with some 
of the sugar, which in this syrup is only thirty per cent. 
of the whole. All the Troches (7vochiscz), contain sugar 
as their principal basis, excepting the Troches of Cubeb, 
which contain but a trifling amount. Both the officinal 
confections are made with it. Besides these classes of 
preparations, it is present as a flavor in many others, as 
Elixir of Orange, Sweet Tincture of Rhubarb, etc. 

ALLIED SuBSTANCES.—If the derivatives of sugar and 
its natural varieties were to be included here, the list 
would be very long. The cane itself, when immature, 
contains a good deal of uncrystallizable sugar ; molasses 
consists mostly of it, which is not exactly like the typical 
sugar. It is also easily decomposed, as seen above, into 
two sugars, neither of which is exactly like itself. Many 
fruits are sweet by reason of their glucose or grape sugar, 
others because of the presence of an uncrystallizable com- 
pound generally called fructose. Some of the glucosides 
in their decomposition yield sugars of peculiar properties. 
The sugar developed in malt is different from that of the 
cane, and called maltose. The following have some com- 
mercial importance and relation to cane sugar: Lactose, 
see Milk, Sugar of ; Glucose (starch sugar, etc.), an arti- 
ficial sugar prepared on a very large scale, and used in 
the arts and especially in cheap confectionery ; it occurs 
as a syrup, commercially called ‘‘ glucose,” and as a yel- 
lowish-white crystalline cake or powder, ‘‘ Starch Sugar.” 
It is very much less sweet than sugar, and has, besides, a 
mawkish taste Manna, Liquorice, Honey, and Glyce- 
rine resemble sugar in taste and in some of their applica- 
tions. 

Saccharin.—This interesting substance was first pro- 
duced from toluene, a coal-tar compound, in 1879, by Dr. 
C. Fohlberg, of New York. Its chemical name is given 
- as anhydro-ortho-sulphamin-benzoic acid. It is a white, 
crystalline powder, soluble in something more than two 
hundred parts of cold water, more freely in hot water, 
and abundantly in alcohol and ether. It has no chemi- 
cal relation to the sugars whatever, and was named sac- 
charin, a word already applied to one of the sugars, solely 
on account of its intensely sweet taste, which is said to 
be two hundred and eighty times that of sugar ; one part in 
seventy thousand of water is distinctly tasted. Saccharin 
appears to be a stable compound of no action whatever 
upon the body, five grams a day producing no symptoms, 
the use of which by diabetics and dyspeptics may 
satisfy that craving for sweet which makes their diet so 
unsatisfactory ; half a grain is enough to sweeten a cup 
of coffee, half a dozen grains for a whole day’s food. It 
is eliminated by the urine unchanged. 

W. P. Bolles. 


SUICIDE. The term suicide, to express the act of 
self-destruction, was probably first employed by Desfon- 
taines in the last century. It is derived from the Latin 
words sud (self), and cedere (to kill). Synonyms: Fr., 
Suicide ; Ger., Selbstmord ; It., Suicidio ; Legal, Helo de 
se. Other rarely employed terms are: Gr., avroxeipia ; 
and Lat., Propriicidium. 

Suicide is a voluntary human act of self-destruction, 
which, when undertaken with ‘‘ malice aforethought,” is 
a crime under the law ; and only under these circum- 
stances should it be called self-murder, and be punish- 
able. 

It is claimed by some writers that the act is always 
due to some disorder of the mind at the moment of its 
accomplishment. 

History.—From the earliest times of which we have 
record the custom of self-destruction has existed to a 
greater or less degree, and it would appear that the peo- 


Suet. 
. Suicide. 


ples of antiquity were so taught by their religion that 
they could look upon the act as logical, and perform it 
with stoicism. 

The religion of Brahma justifies suicide, and looks 
upon it, under certain conditions, as an honorable and 
praiseworthy act, which is often solemnized in a public 
manner. Fanatics in India, who believe in the transmi- 
gration of souls, seek an improvement in their condition 
and a freedom from present ills by courting death. The 
Brahmins have in a great measure given up their terrible 
custom of prostrating themselves before the car of their 
gigantic idol Juggernaut, to be crushed to death. Still 
they occasionally do it, and the women throw themselves 
upon the funeral pyres of their husbands. 

Although held in honor among the people of the Ori- 
ent, it was always rare in Persia, and is an exceptional 
occurrence among the Turks. The teachings of the Ko- 
ran are opposed toit. Mahomet forbade it, and incul- 
cated a spirit of patience in adversity. Here, too, the 
belief in fatalism probably. exercised a marked influence, 
and the people were not given to philosophic thought, as 
were those of Greece, where many great men have sought 
death at their own hands. 

When circumstances warranted the act, it was consid- 
ered, in ancient Greece, a virtue for men to destroy 
themselves, thus escaping human ills, and, as they sup- 
posed, ameliorating their condition. 

According to Legoyt,! Strabo relates as an historical 
fact that the inhabitants of the Isle of Ceos, in the Gre- 
cian Archipelago, poisoned themselves after reaching the 
age of sixty, so that the younger could have greater 
abundance ; and Montaigne says that the senate of Mar- 
seilles, which then belonged to Greece, placed poison at 
the disposition of those who wished to commit suicide, 
when their motives were approved of. 

The Hebrews, it would appear, scarcely knew suicide, 
and few cases are recorded. The Bible gives accounts 
of the self-destruction of Samson, Eleazar, Saul, Judas, 
and others. 

The Celts were taught the immortality of the soul and 
their divine origin, still, suicide for the old and infirm 
was encouraged. 

At Rome we find many noted suicides recorded, includ- 
ing that of Junius Brutus, and under the reign of Tiberius 
they appear to have increased in frequency. From the 
fifth to the twelfth centuries suicide almost wholly dis- 
appeared, but in the next century revolutionary ideas 
prevailed, and the previous influence of the Christian re- 
ligion was so far lost that all classes of society suffered 
from a revival of suicide. Jews now resorted to it freely 
as a means of escape from hardships, and to avoid dis- 
loyalty to their faith. 

A decided increase is noted from the beginning of the 
sixteenth century, due to a disregard for religion and a 
revival of customs of antiquity. 

In China and Japan men of honor have long resorted 
to self-inflicted death. 

In Africa it was not rare for individuals and whole 
bodies of men to commit suicide, and Carthaginian gen- 
erals often destroyed themselves after defeat. 

The increase of suicide in civilized countries during 
the present century is shown by carefully gathered sta- 
tistics, and conceded by most writers. 

SratTistics of suicide began to be systematically col- 
lected and studied only in the present century, official 
statistics being published in several European countries 
during the first twenty years of the century. 

The statistics here made use of are, for the most part, 
drawn from the excellent work of Morselli.? 

In 1840, Farr, the director of English statistics, calcu- 
lated that the average annual number of suicides in 
England and Wales was 62.8 per million inhabitants, 
I have calculated from Morselli’s table, covering the 
years from 1830 to 1876, and made up from the work 
of various observers, and find the proportion to be 66.6 
per million. 

The number of suicides is probably much greater than 
is indicated by official reports, and this may vary in ditf- 
ferent countries. 


675 


Suicide, 
Suicide. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


ce 


The following table shows the proportion of deaths by 
suicide in various countries in 1882: 


Per 
1,000,000 


3 Estimated Deaths by 

Countries. population. suicide. inhabi- 

tants. 
PAUISELIR ee. siete Rtas amines sap ca 22,316,567 8,530 158 
IDES 5 septa Sana obehs Sear 1,596,206 283 ily 
AVODIS Pimento cite cee cet cele steste's 5,389, 732 %24 134 
Beloit ae se wceo st ceatrechie tec 5,655,197 595 105 
MONMATK elec ia se cee ees 2,008, 100 513 255 
PUTER CE ye eee or tere © n'e sine ie sista cies 37,769, 000 9,218 191 
FLCALY Ihre’ cietetetawicssjniole sis. ofeskis 8 aie 28,596,512 1,889 49 
POT UI SSI Aer ciatote cel cine cw pp wld ese a14 27,796,189 5,312 191 
SEXO CNR GSS boon ie ere sien 8S 8,040,000 1,128 371 
Sige leas 4 ae ARORA SD ee 4,579,115 482 105 
England and Wales .......... 26,418,861 1,965 74: 
MEeLALU eee ches Pia titeisa 5,097,853 105 21 
3,785,400 167 44 


The German and Scandinavian races furnish the largest 


numbers. Only a few States in this country furnish ac- 
curate information, and there are no statistics for the 
whole of the United States. 

The following table shows the number of deaths by sui- 
cide in Massachusetts, Rhode Island, and Connecticut in 
the years named. 


MASSACHUSETTS, RHODE ISLAND. CONNECTICUT. 
YEARS. | | Zia 
| Per 1.000,000| Per 1,000,000 Per 1,000,000 
Total. inhabitants. Total. inhabitants. Total. inhabitants. 
ahs (iis: 91 62 Q7 124 
AST ale 122 82 19 84 
TOT? peel 6 %6 | 18 its 
USier wa eek 74 Hts) 33 
16407 fo ko ug! | 18 G2 
ada eas ih cl Maty 96 26 101 ea LA an 
ASTGree e119. 72 18 69 49 838 
ABT Goss. + 08 98 22 83 52 84 
ASSIS ee yieo 76 21 %8 55 83 
LSTOS Gn 94 13 48 58 95 
1880.....( 133 U5 10 36 48 vue 
pt cren Wee s liew llr) 88 23 82 69 109 
1882....| 162 88 el 109 65 101 
1883....} 167 89 20 eat rs es ware 
1884....| 184 96 85 


The population is here calculated from the average an- 
nual increase since 1880. 

In an editorial, which appeared in the Medical Record 
of August 14, 1880, it is stated that 60,000 persons kill 
themselves annually in Europe, and assuming that the 
same ratio exists here, nearly 10,000 suicides would occur 
in America. 

Dr. John Lee,’ of Philadelphia, has found that during 
the period from December 31, 1871, to January 1, 1881, 
there were fifty-three suicides in each thousand coroner’s 
inquests held in the city of Philadelphia. Out of the 636 
cases recorded, 444 were married persons, 24 were minors, 
and the greatest number occurred between the ages of 
thirty-five and fifty. 

In statistical tables prepared by Dr. John T. Nagle,‘ of 
New York, covering a period of eleven years, ending 
December 31, 1880, it is shown that 1,193 males and 328 
females committed suicide. Between the ages of ten and 
fifteen there were 15; between thirty-five and forty the 
greatest number was found, viz., 212; and between 
eighty-five and ninety there was only 1; 430 were single, 
759 were married, and 137 were widowed. The means 
employed by the greatest number was poisoning, which 
gave 503. Those dying from firearm wounds numbered 
397 ; 239 died by hanging ; 175 by cut and stab wounds; 
101 by drowning; and 82 by leaps from heights. Of 
German birth there were 627; of Irish, 213 ; of English, 
82; and 868 were native born, the remainder being dis- 
tributed among natives of twenty-two different countries. 

One table shows that the suicides for the year 1880 were : 


New York City......... 152, an average of 12.59 per 100,000 inhabitants, 
Philadelphia \i.....+.. 68 us 33 SO YE 66 “ 
Richmond weeeew Nees 1 = tame 4 “6 “ 

JS WABUITIOTON antec bie cers 18 ae * 410.13 5 b“ iT 
San Francisco .......... 88 me “ 87.65 &6 “ & 
BOSbOI sec siete were sole es 40 ue * 41,03 “ ‘“ 


676 


The same year we find in 


Berlin .............+-.508, an average of 27.44 per 100,000 inhabitants, 
Vieni hk me cmetre tees cmen ae 930) be « 3167 “ “ ce 
TsONC OM ee < nye latelae sete se 3852 BY “- O84 « “ “ 
IV Ar a cespoedoes atadds 84 sy aro. ‘f “ 


In the reports of the New York Board of Health for 
1886, I find that 223 deaths from suicide are recorded ; 
58 native born, and 165 of foreign birth, 98 of whom were 
Germans. Firearms were used 62 times; the rope, 37; 
cutting instruments, 29; drowning caused 16 deaths ; 
Paris green, 11; ‘‘ Rough on Rats,” 8; and leaps from 
heights, 15, As regards sex, 172 were males and 51 fe- 
males. The period between thirty and thirty-five years 
of age gave the greatest number (381 cases). 

During the year ending September 30, 1887, I find 225 
suicidal deaths ; 175 males and 50 females, The whole 
number, and the proportion of the sexes, conforming 
closely to the statistics for 1886. Paris green was em- 
ployed in 11 cases, arsenic in 8, and rat poison (‘‘ Rough 
on Rats”’) in 12. 

According to the London Lancet, the number of sui- 
cides in France during 1876 was 5,617. Of these 4,485 
were men. 

Morselli believes in a law of continual increase, and 
shows by a table that the increase per cent., from 1827 to 
1852, was from 100 to 2388. 

It is shown by one of his tables that Saxony, which 
furnishes the largest number of suicides, has suffered an 
increase from 158 per million inhabitants in 1836-40, to 
391 per million in 1877. 

Another table prepared from the statistics of Italy, 
from 1864 to 1877, shows an increase from 29.2 to 40.6 
per million. 

From these and other data, the following law is formu- 
lated : 

“‘In the aggregate of the civilized states of Europe 
and America, the frequency of suicide shows a growing 
and uniform increase, so that generally, voluntary death 
since the beginning of the century has increased, and 
goes on increasing more rapidly than the geometrical 
augmentation of the population and of the general mor- 
tality.” 

Th ite combined central and southwestern states and 
provinces belonging to Prussia the proportion of 150 
suicides in the million is given. Morselli says: 

‘““The synthetic and most certain law which springs 
out of these facts, is that in the centre of Europe, from 
the northeast of France to the eastern borders of Ger- 
many, a swecidigenous area exists, where suicide reaches 
the maximum of its intensity, and around which it takes 
a decreasing ratio to the limits of the northern and south- 
ern states.” ® 

NaturE.—The question of the nature of the act of 
self-destruction is a difficult, and a delicate one withal, to 
decide, but its great importance calls for much careful 
attention. Morselli says suicide is a social fact, and its 
nature ‘‘may now be reckoned among the most certain 
and valuable discoveries of experimental psychology ;” 
and further on, characterizes it as ‘‘an effect of the 
struggling for existence and of human selection, which 
works according to the laws of evolution among civil- 
ized people.” But the question arises, is a given suicide, 
at the moment the act is committed, in the full and free 
possession of his faculties, and should he be held respon- 
sible for his movements ? If the act be always due toa 
morbid condition of mind (as claimed by Dr. Liebman, 
in a paper read before the Medical and Chirurgical Fac- 
ulty of Maryland, April, 1881), it should not be punishable 
as acrime ; nor would, in this event, the punishment carry 
with it the intended restraining influence upon other 
would-be suicides. The mind which could conceive and 
plan so foul a deed would not, in all likelihood, be influ- 
enced by the thought of legal punishment in case of an 
unsuccessful attempt. 

Insanity is probably present in the vast majority of sui- 
cidal attempts, and the number of those who act calmly 
and in the possession of their faculties must be much 
smaller than is generally supposed. Many obscure cases 
are difficult to explain on any other theory, There is a 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


want of motive. The surroundings and station in life of 
the suicide are the best, and so far as can be learned, the 
social, financial, domestic, and other relations are only 
such as would be conducive to life and happiness. Such 
cases are more common in so-called epidemics of suicide. 
If the attempt has not resulted in death, evidences of in- 
sanity often soon appear, and make it clear that mental 
irresponsibility existed at the time. 

In other cases insanity may have been previously 
known or suspected from conditions present, either im- 
mediately preceding the act or at some more remote pe- 


riod, and still no decided symptoms may have shown | 


themselves until after an attempt at suicide. 
An hereditary mental defect may have been known to 


exist, the person regarded as eccentric, and the attempt. 


not unlooked for. 

Organic disease, excesses, vencry, onanism, etc., may 
have been the cause of a mental aberration whose first 
outward sign has been the suicidal attempt. 

Hammond says :° ‘‘ Closely allied to emotional homi- 
cidal impulse is that form of mental derangement which 
consists in an emotional impulse to the perpetration of sut- 
cide. The conditions may coexist. In some cases the 
contemplation of the act is attended with feelings of 
pleasure. He is neither governed by delusions nor by 
logical reasons. He is actuated by a passion which it is 
pleasant for him to gratify. When the impulse has 
passed, he looks back upon it with horror, and shudder- 
ing at the escape he has made, perhaps seeks medical ad- 
vices” 

' Automatic suicide, or suicide by impulse, is closely al- 
lied to that of the insane, and like it, occurs without 
apparent cause. The sight of a weapon, the finding of 
one’s self upon a height or by the river’s side, or favorably 
situated for the accomplishment of the act, being suffi- 
cient for the attempt. In non-success the circumstances 
of. the act are more or less confused in the suicide’s mind, 
and the only safety for those thus impelled is to hasten 
from the scene. Some persons appearing to be conscious 
of this outward influence, avoid suggestive situations, and 
feeling themselves powerless to resist, ask that precau- 
tions be taken to prevent the act. 

Suicide by suggestion is well illustrated in a personal 
experience of Sir Charles Bell, when surgeon of the Mid- 
dlesex Hospital, which is related by Wynter.’ 

While being shaved, he told his barber of an operation 
he had just performed on a man who had made an un- 


successful attempt to cut his throat, and explained the’ 


anatomical reasons for the failure. The barber, excusing 
himself, went into an adjoining room, and was found a 
few moments later with his throat cut in the proper ana- 
tomical situation to assure success. ‘ 

Epidemic suicide, due to a neuropathic state of the sys- 
tem of those living under the same influences, is well 
known to neurologists, and many instances have been 
observed. An epidemic among the women of Miletus 
is recorded, at a time when the men were away at war, 
which reached great proportions and was checked by a 
decree, that the naked bodies of those who killed them- 
selves should be exposed in public with a rope about the 
neck. In Mexico and Peru the inhabitants killed them- 
selves in great numbers, it is said, after the invasion by 
Spain. Mansfeld had an epidemic in 1697, according to 
Sydenham. There was one at Versailles in 1793, and one 
occurred at Rouen in 1806, and at Stuttgart in 1811. 

Some years ago five inmates of the Hotel des Invalides, 
in Paris, hanged themselves upon the same crossbar 
within a fortnight. 

Double and multiple suicides are occasionally recorded. 
The former usually consisting in the simultaneous death 
of man and wife, or two lovers or friends; the latter in 
the concordance of suicide of bodies of men, such as is 
said to have occurred in China among the philosophers 
of the Confucius School, when deprived of their books 
by the order of the emperor Chi-Koang-Ti. 

Feigned Suicide.—Although the term is not a strictly 
proper one, it applies to those cases occasionally met 
with in which, to excite sympathy, secure desired ends, 
afflict friends, or for some other reason, a person makes 


Suicide, 
Suicide, 


it appear that he has made an attempt upon his own 
life. 
Child suicide requires special notice, as it is not un- 


common to find quite young children, even as young as 


' five years, taking their lives for trifling cause, following 


impulse and sentiment without having the restraining 
influence of mature judgment, and the power of com- 
parison and thought for anything beyond the present. 

By nature children are sensitive to slights and in- 
justice, easily depressed, fretful under restraint, and at 
times revengeful. They have vivid imaginations, are 
quick to imitate, but are defective in the power to reflect 
and form just conclusions. The sense of responsibility 
is wanting, so that no sooner is the act conceived than it 
is put into execution. 

The belief of Durand-Fardel,® that the act of self-de- 
struction is usually accomplished with much self-posses- 
sion, and after reflexion, cannot apply to suicides in 
childhood (see, also, under Age). 

Suicide following homicide is not very uncommon, but 
the subject is almost always melancholic. Esquirol tells 
of a Belgian woman who threw her four children into a 
well and jumped in after them. Both sexes include 
their children in the death they give themselves, but 
women would appear more inclined to this than men. 
In rare cases both parents conspire to kill their children 
and then themselves; such a case is related by Esquirol, 
and one has recently occurred in Paris. 

CAUSES OF SuIcIDE.—In former times, and indeed at 
the present day in some countries, as we have seen, whole 
masses of people, as well as individuals, under the influ- 
ence of their religious or philosophic beliefs, and follow- 
ing the customs of their forefathers for generations, have 
in great numbers become the subjects of self-destruction. 
No such custom is to be found to-day in any civilized 
country, but efforts to do away with it in India have 
failed, and we must put down fanaticism as one cause of 
many self-inflicted deaths. No encouragement is given 
to the act in enlightened lands, but, on the contrary, all 
laws, both human and divine, are strict in its forbiddence. 
Still, suicides have been shown by careful students of the 
subject to be on the increase, and we naturally inquire 
what are the causes which contribute to this state of af- 
fairs, and why do men take their own lives at all. 

The causes are twofold: A subjective condition may 
exist which predisposes the individual to the act, or his 
environment may be such as to produce an objective 
state favorable to suicide. The pathological or other 
subjective condition may coexist with the surroundings 
which furnish the determining cause, or the one or the 
other may be wanting. 

Predisposing causes to suicide are quite numerous, but 
heredity is one of the most important. The transmission 
of a suicidal tendency is an established fact of which 
many instances are known to alienists, and which forms 
a familiar phase of the practice of the family physician. 

This transmitted tendency may lie dormant, or make 
its presence suspected by the development of mental dis- 
ease ; or the suicide may have been looked upon for 
years as one about whom there was ‘‘ something strange,” 
without any actual disease or decided symptoms of nerve 
or mental trouble being apparent. 

The offspring of a suicidal parent appears to inherit a 
system favorable to the development of nervous affec- 
tions leading to self-destruction, and a decided tendency 
appears to exist to commit the act at about the same age 
at which the parent died, and to use the same means ; 
showing that the hereditary disposition is attended with 
a certain uniformity of action. 

Education would appear to predispose to suicide, for it 
has been conclusively shown that more attempts occur 
in centres of civilization, among the best educated classes, 
and in cities where, through the press, pulpit, and stage, 
as well as through educational institutions proper, the 
masses of the people are better informed than those in 
the country, and, as a rule, have more active minds ; but 
in whom the conditions of life are more apt to favora 
spirit of discontent. Among savages suicide is compara- 
tively rare. 


677 


Suicide. 
Suicide. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Occupation appears to have a predisposing influence. 
Thus the trades in which the greatest number of suicides 
occur are shown to be those of tailors, seamstresses, laun- 
dresses, jewelers, carpenters, cooks, etc. The hardships 
of life attending many of these occupations may account 
for the number of deaths. 

Wine merchants and inn-keepers make large contribu- 
tions to the number of suicides, because their occupation 
tends to induce excess in the use of alcohol. 

The liberal professions furnish about one-fifth of the 
total number of suicides ; physicians, chemists, and drug- 
gists give a high percentage, and their occupations may 
be said to predispose to it by bringing them into such 
constant and intimate relations with poisons. 

The stringency of military discipline in Germany, 
France, and Austria has been advanced as a reason for 
the high death-rate from suicide in these countries. 

Morselli finds the greatest number of suicides among 
(1) literary and scientific men, or brain-workers generally, 
professors, teachers, etc.; (2) the military ; (8) workers 
in the trades. 

According to Legoyt (1856-1860), the middle classes and 
outcasts furnish the greatest number in France, and the 
same is found by Block to hold true (p. 251). 

The condition of life has its influence as well, and those 
living solitary lives, as widowers, bachelors, divorced 
women, etc., are more prone to the act. 

Climate and temperature in many instances undoubt- 
edly contribute their share, but the attempts to regard 
them as the main cause of a high percentage of suicides 
in some countries have not been eminently successful. 
Thus the cold, rain, and fog of England have, by various 
writers, been regarded as conducive to self-destruction. 
Thus Montesquieu said, ‘‘ England is the classic land of 
suicide ;” but in Wynter we read (‘‘ The Borderland of In- 
sanity,” 1875) ‘‘ Paris is the headquarters of self-destruc- 
tion.” 

Putting aside the compliments that may be passed be- 
tween these two countries, we must remember that the 
Esquimaux and Falkland Islanders, whose climate is in- 
comparably more severe than either, do not kill them- 
selves. 

The influence of climate is, on the whole, not marked, 
but excessive heat has been known to drive men to frenzy 
and self-destruction. Long since it was pointed out that 
the hot and dry wind of the African sirocco caused de- 
lirium, madness, and many suicides. 

Seasons.—In most countries the maximum of suicides 
is reached in May and June, when nature would seem to 
be most conducive to life. In Saxony and Bavaria, how- 
ever, July is the favorite month. 

Authorities agree that insanity increases in the sum- 
mer time, and this may explain, as Wagner thought, the 
greater number of suicides. 

Sex.—In a general way, the average of female suicides 
for the United States is given as from fifteen to thirty per 
cent. of the whole number. Liebman says three men kill 
themselves to every woman. 

The proportion is given for Germany as under, and for 
England as over, twenty per cent. As accounting for 
this excess of male suicides it has been advanced that 
women have less energy, less resolution, are more gov- 
erned by religious teachings, etc. 

Age.—Considerable regularity is shown, in each coun- 
try, in the number of suicides from year to year. From 
Ogle’s table, as well as from those of Morselli, it is seen 
that, from the tenth year on, the number of cases rises 
steadily to between the ages of fifty-five and sixty-five 
years ; remains almost stationary to about seventy-five, 
and then decreases rapidly. It is rare before fifteen, but 
Seb s the very young, it is common to all periods of 
life. 

The period from the twentieth to the fiftieth year has 
the most instances, for it is then that men pass through 
the most serious portion of their lives. It is then they 
are engaged in the battle for existence, require more com- 
forts of life, and have most care and responsibility. 

According to Ogle, one out of every 119 men who 
reach the age of twenty, ultimately dies by his own hand, 


678 


and one out of every 312 women who have reached the 
age of fifteen. 

Attempts upon their own lives have been made by ~ 
children at as early an age as five years. Durand-Fardel 
found one under five, and two between eight and nine. 
Out of 25,760 suicides in France occurring from 1835 to 
1844, he found 192 to be in persons under the age of six- 
teen. 

According to the census of 1880, Hammond ® says there 
were in the United States, during the preceding ten years, 
2 suicides in children between five and ten years of age, 
12 between ten and fifteen, and 66 between fifteen and 
twenty. He says that Collineau!® relates the case of a 
boy ten years of age, who, ‘‘to make his parents angry,” 
hanged himself on being sent back to school. 

Winslow"! reports several cases at an early age, and 
quotes Casper to the effect that in Berlin, from 1812 to 
1821, 31 children, twelve years of age and under, com- 
mitted suicide for trifling cause. Many cases at this 
early age appear to be similar to the emotional suscepti- 
bility of adult life. 

Suicide is an act which springs froma brain constantly 
influenced by conditions present within the body, as well 
as by those of the external world, many of which we 
have considered as predisposing causes. We will now 
turn our attention to some of the internal and 

DETERMINING CaAvsEs.—Insanity with suicidal ten- 
dency is quite acommon form of mental disease. I shall 
not enter upon a consideration of the various forms of 
insanity in which this tendency is present. We may 
find it as a monomania, or associated with a homicidal 
mania. 

It is often by suicide that the melancholic rids himself 
of his imaginary woes, and the maniac escapes from the 
imaginary foes with which his hallucinations surround 
him. 

There are those who claim that the act of suicide is of 
itself an evidence of insanity. In the maniac there is no 
planning, and no precautions are taken ; violence is cha- 
racteristic of the act, and it is as a rule accomplished 
quickly. Should it fail, there is a knowledge and recol- 
lection of the details. Death may accidentally result 
from the attempts of the maniac to escape from halluci- 
nations, or in his efforts to free himself from restraint. 
This should not, properly speaking, be termed suicide, 
for although it is self-destruction, there is no intention or 
motive, and the term, as commonly used, implies a pur- 


‘pose. 


In some insane persons there is an ever-present hallu- 
cination attended with a morbid sadness, and the act of 
suicide is deliberately planned and, with much precaution 
and calmness, carried into execution; or, if not at once 
successful, it will be persisted in until it is. 

There isa form of anxious melancholy in which, with- 
out any cause either real or imagined, there is, as it 
were, an instinctive but violent desire to die; so strong, 
indeed, is it, that no will-power seems capable of over- 
coming it. The previous anxiety is lost when all prepa- 
rations are made and the desired end appears near, and 
this sudden change to cheerfulness may give friends and 
attendants the cue to watch for the attempt. 

As arule, determined and deliberate attempts at sui- 
cide, with details carefully planned, indicate an unsound 
mind. When the attempt has failed to cause death, it is 
often found that insanity soon appears. In other cases 
the attempt itself relieves the condition which caused it, 
and death is no longer desired. 

The flow of blood from a razor wound, Hammond 
says, may relieve the cerebral congestion present. In 
the same way, a plunge into the cold water may result in 
bringing the would-be suicide to a realizing sense of his 
desire for life rather than for death. 

Others, to assure success, may tie their own hands and 
feet together before making the plunge, and may even 
attach weights to themselves, as in the recent case of a 
young actor who, before plunging into the Charles River, 
in Boston, put on a heavy coat of mail; and of a man 
who jumped from a Brooklyn ferryboat with lead-pipe 
wound round and round the body. The possible occur- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


rence of such cases must be remembered in medico-legal 
and coroner’s investigations, and not be mistaken for 
cases of murder. Financial ruin, famine, and pestilence 
following in the train of wars, etc., have often resulted 
in great numbers of suicides, the nervous system being 
over-excited. 

Disease, as an inciting cause of the suicidal act, is not 
uncommon. The body, worn out with suffering, at last 
affects the mind, or the patient, believing his disease in- 
curable, prefers to make an end of all his woes, and ‘“‘ fly 
to others which we know not of.” 

Statistics for Italy and France show that those affected 
with pellagra furnish a large percentage of suicides. 
Other diseases in which suicide appears to be common 
are those of the digestive organs, liver, etc., cancer, uri- 
nary diseases, phthisis, loss of sight, and chronic’ affec- 
tions generally ; after castration it appears also to be fre- 
quent. Suicides through physical suffering attain their 
maximum in the educated and cultivated classes. 

Financial troubles cause the highest percentage among 
the working-classes, though self-destruction is often seen 
after reverses of fortune, losses in gambling, and finan- 
cial embarrassment in the wealthy. 

Alcohol is a potent cause of self-inflicted death ; drunk- 
enness, poverty, and laziness going hand in hand. 

Passions.—Love, betrayed or disappointed, and jeal- 
ousy are found to be a fruitful cause of suicide among 
students, soldiers, schoolmistresses, and servants. Explo- 
sions of.rage and anger are apt to gradually increase and 
overcome the will-power to resist, until trivial circum- 
stances will occasion violent outbursts, and may lead to 
violent acts against one’s self. Hate, pride, shame, and 
revenge may all lead to suicide. 

Other determining causes often found are domestic 
troubles, remorse, dishonor (as in women pregnant out 
of marriage), poverty, misfortune, grief, pain, and disap- 
pointment. 

Occasionally regret is experienced before the act has 
been fully accomplished. 

Metuop.—The method of securing death, and the 
place or scene of its execution, are influenced by the sur- 
roundings of the individual and the natural facilities af- 
forded ; but the supposition advanced by Esquirol, that 
the occupation governed the choice of instrument, is not 
always borne out by statistics. Still it is found that the 
choice of the soldier falls, as it in theory naturally would, 
upon firearms. Butchers, barbers, and shoemakers re- 
sort mostly to the knife. The favorite method varies in 
-different countries, and although in a given locality or 
city the prevailing custom may change from time to 
time, there is a pretty constant preference for one fixed 
form from year to year. De Guerry’ was the first to 
show a regularity in the method employed. 

The rope appears to be the most common choice, 
second comes the water, firearms third, cutting instru- 
ments fourth, then follow jumping from a_height, 
taking of poisons, inhalation of deadly fumes, etc. 

There are two factors which, as a rule, influence the 
choice of the means, viz., certainty and quickness of ac- 
tion. Women are not so apt as men to make choice of a 
painless method. 

There is also a difference in the means employed by 
women from those resorted to by men. 

In Italy, for example, the men shoot themselves, and 
women resort to the water when weary of life; while in 
Prussia over half the suicides die by hanging, and women 
surpass the men in their tendency to kill themselves by 
the knife. 

Poison, as a choice, appears to be increasing in favor 
in this country, and to be on the decline in France ; in 
fact, the favor it receives among Anglo-Saxon suicides 
is shown to reach 40.8 per cent., including this country. 
Out of 148 cases of suicide occurring in New York in the 
year 1876, poison was used in 31.7 per cent. ; firearms in 
33.1; hanging gave 13.5 ; cutting wounds, 10.8 ; drown- 
ing, 6.8; falls from height, 3.4, and other means 0.7. 
Thus showing that poison and firearms were the choice, 
each in about one-third of the cases. This predilection 
on the part of the English and Irish for poisons is further 


Suicide. 
Suicide. 


shown by the following table, taken from Morselli, and 
giving the suicides among foreigners in New York for 
the year 1876. 


Per 100, English. | French. | Germans. Irish, 
Poisoning Thicet Sec eiee eke 46.1 25.0 28.9 52.4 
A3 FS aT eg) 012d ids Bi eh Curae ire Pats 12.5 17.4 4.8 
Asphyxia and drowning... ee cer 5.7 9.6 
Gunshot wounds.......... 15.4 50.0 35.0 4.8 
Cutting and stabbing ..... 80.8 Boke Y 2 9.5 
Falls from height ......... tft 1215 5.8 18.9 

eb OLS tee crelsc cee 100.0 100.0 100.0 


Of the 39 cases of suicide which I have found reported 
in the daily newspapers of this city during the past fifty 
days, the greatest number (12) was by shooting, and the 
next highest (7) by taking poison. The poison chosen is 
usually the one easily obtained and of known efficacy. 

In England the order of choice is prussic acid, cyanide 
of potassium, laudanum, oxalic acid, arsenic, strychnine, 
vermin killer, oil of bitter almonds. 

In New York a vermin poison known as Rough on 
Rats, and supposed to contain arsenic, has been so much 
employed of late that the authorities have been asked to 
place restrictions upon its sale. 

Drowning as a means decreases as the north is ap- 
proached ; the colder the water, the less its attractions. 

Devergie found that in Paris, from 1827 to 1886, drown- 
ing, together with asphyxia by charcoal fumes, held 
the second place, but in 1851 Trébuchet placed asphyxia 
at the head of the list. This latter mode of death has 
spread rapidly over Europe and increased in fashion in 
Paris. ‘The reasons for this are that it affords the most 
painless and agreeable form of death, and, strange as it 
may appear, man’s vanity extends beyond the gates of 
death, and the suicide desires the body to present a good 
appearance after the breath has left it, and knows that 
there is usually no disfigurement from charcoal fumes. 

Only the other day, the papers contained an account of 
a ‘‘wholesale charcoaling,” in which a father, mother, 
and two children sought death in this way, preferring 
this mode of death to starvation. When heredity is a 
factor in the case, the method of exit from the world is 
apt to be the same as that employed by the ancestor. 

Winslow says that one manner of death having been 
conceived, the man bent on suicide will wait a long time 
until he can carry out his particular plans. We, how- 
ever, often see a man who has failed in one way take the 
first opportunity to secure death in another. Maniacs 
are most apt to throw themselves from a height, and it is 
often difficult to say whether one who has fallen from a 
window did so in simply making an attempt to escape 
imaginary enemies, mistaking the window for a door, or 
possibly walked out without any knowledge of the act, 
or was conscious of the attempt. Some inflict wounds 
upon themselves, or severely injure the head by pound- 
ing it against the wall, impelled by their pains to seek 
this means of gaining relief. Melancholics often hear a 
voice urging them to take their lives, and this ‘‘ voice” at 
times suggests the means. 

Piace.—Much ceremony attends the act in some indi- 
viduals, and publicity is sought. This is often done 
when revenge is intended. Usually, however, suicides 
occur in privacy, and it is not uncommon for a man to 
retire to a concealed and unfrequented spot to carry out 
his object. 

Particular places may become, as it were, fashionable 
for a time, in the suicidal world. Thus, one year, in 
Paris, the Arc de Triomphe, another Notre Dame steeple, 
and another one of the bridges, will be the favorite leap. 
The Milan Cathedral, St. Peter’s at Rome, and the Cam- 
panile at Florence, have all in turn had their epidemics, 
so to speak. 

Esquirol!* relates a very remarkable method which 
was employed in a case reported by Dr. Ruggieri,’ an 
Italian, which shows what an amount of self-inflicted tor- 
ture will be endured. A shoemaker in Naples, who had 
the year before castrated himself and thrown the geni- 


679 


Suicide. 
Sulphides. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


tals from the window, after making a good recovery, con- 
ceived the idea that God had commanded him to suffer 
on the cross. He passed two years in perfecting his 
plans, which were so well carried out that one morning 
he was found with hands and feet securely nailed to a 
cross, with a stab wound in the left side, hanging out of 
his bedroom window. He had constructed the cross and 
attached it by ropes in such a way that after crucifying 
himself he could, by motions of the body, cause it to slip 
from the window. When rescued he was delirious, and 
though recovering from his wounds, he exhausted him- 
self by fasting and died. 

A novel method has just been introduced in this coun- 
try by an anarchist, of exploding a dynamite cartridge in 
the mouth, bearing out Esquirol’s claim, that the instru- 
ment chosen was apt to be the one which the suicide used 
professionally. 

Time.—The time of day most favorable to acts of self- 
destruction appears to be between the hours of six and 
twelve in the morning. This preference for the early 
part of the day extends to the other divisions of time, for 
it has been found that more suicides occur in the fore- 
part of the week and the first half of the month than in 
the latter parts. 

SymprToms.—It is questionable whether we can say that 
there are any actual symptoms by which an act of sui- 
cide can be predicted. In insanity, and especially in me- 
lancholia, an attempt must always be watched for. 

In some cases.a man, who has been previously healthy, 
will complain of pain in the epigastrium, of heaviness in 
the head, will become quiet, listless, lose all ambition, re- 
fuse to work or attend to his usual vocations ; the habits 
are changed, and intoxication may be indulgedin. There 
may be scarcely any other symptoms until he tries to cut 
the thread of life. Weariness of life is often complained 
of, but Esquirol says he has never seen any attempt be- 
cause of this tedium vite alone. 

Some individuals predict that they will some day kill 
themselves and eventually do, but as a rule the one who 
threatens the act rarely commits it. 

In some cases it may be discovered that preparations 
are being made for death, associated with a sadness of 
expression and an uneasiness of action. In melancholia 
the opposite condition may prevail just before the at- 
tempt, when all the plans are laid. The skin of suicides 
has been said to assume a yellow tinge and the features 
to become shrivelled, giving a changed appearance at the 
same time that a change is noticed in the actions. 

Anesthesia isa marked symptom at the actual moment 
of the attempt in many cases, and itis said that after 
the skin is cut the pain in cutting the throat is not 
at all severe. This accounts for the little complaint or 
appearance of pain in cases which, it would appear, must 
have been attended with torture. 

DIAGNOsIs is important in a medico-legal sense, as we 
have seen that few signs or symptoms of value precede 
the act. A knowledge of previous attempts will aid us, 
and at times a hint may be given by some word of the 
individual, or by an ante-mortem letter. 

If the attempt has failed the fact may be acknowledged ; 
if death has resulted writings are to be looked for. The 
body is to be examined for lesions, especially in the 
vital regions. The direction of bullet and penetrating 
stab wounds is to be carefully noted, and the existence 
or absence of powder marks upon the skin, and wadding, 
pieces of clothing, etc., within the wound. If death has 
resulted from a sharp weapon, signs of violence must be 
looked for upon the body and in its surroundings. The 
employment of a razor, although favoring a theory of 
suicide, is not to be regarded as conclusive, because in this 
country it is quite a favorite weapon with the negro race. 
If the razor can be shown to belong to the individual, the 
suicide theory is strengthened. 

If poison has been taken, a bottle or paper which has 
contained it may be discovered near the scene. Though 
most men found hanging are suicides, the possibilities of 
lynching and of hanging a dead body to hide a crime must 
be remembered. In bodies found in the water, great 
care must be exercised.in giving true significance to 


680 


wounds, and determining whether they were inflicted 
before death. The fact that the limbs are tied has not 
great weight, for the suicide might have thought thus 
to assure success, and even have attached weights to the 
body. 

Pathological lesions found on autopsy shed but little 
light on the subject of suicide. 

PROPHYLAXIS.—Cannot something be done, we instinc- 
tively ask, to prevent so great a number of human beings 
from committing so heinous an act? Something at least 
to prevent the ever-constant increase ? The solution of 
the problem must lie largely in the better care of the in- 
sane, and earlier and more scientific treatment of mental 
diseases; Hospitals properly equipped for the treatment, 
supervision, and restraint of the mentally weak and in- 
firm, and the disappearance of the popular prejudice 
against insane asylums, will do much to decrease the 
number of suicides in this large class. 

Legislation.—In epidemic suicide and in alarming in- 
crease of the act, it has been found necessary to enforce 
stringent laws against the bodies, property, and families 
of the suicide at various periods of the world’s history, 
and at times with some apparent success. 

Laws were established in regard to suicide at a very 
early day. Zeno’s motto, which was such a favorite 
phrase of the Stoics, ‘‘ Mori licet cui vivere non placet,’’ 
was found not to have an application to the individual 
whose act caused injury to others and loss to the state. 
It was opposed to the teaching of the Bible, which says 
‘*Thou shalt not kill.” 

Esquirol thinks some threatening law against the indi- 
vidual should be enforced with reference to the social 
usages of the people of each particular country. He 
says comminatory laws have caused suicide to cease in 
Egypt and Miletus. ' 

Legislation, though not powerful to accomplish much, 
should nevertheless exist. It will undoubtedly deter a 
few, and this alone will prove its usefulness. 

The attempt at suicide is punishable in New York 
State by five years imprisonment, according to existing 
laws recently enacted. 

The confiscation of property and denial of the right of 
burial, formerly practised in France, have, of late years, 
been stricken from the Code. 

Formerly, in England, the body of a suicide was treated 
with ignominy, buried in the highway, and transfixed bya 
stake. When this law was abolished, the body could 
still only be buried at night and without religious rites. 
The Canons of the Roman Catholic Church still forbid 
the burial of a suicide in consecrated ground. 

The laws of antiquity, severe as they were upon the 
family, name, and possessions of the individual, had but 
slight effect in repressing suicide, as they naturally would 
have in the insane, who contribute most. largely. In 
some countries the bodies of all suicides are given for 
dissection. 

The public press has it in its power to favor an in- 
crease in suicide by publishing, with minute details, de- 
scriptions of all suicides, thus exciting depraved tastes, 
pampering to the vicious, and putting ideas regarding 
the act into the minds of nervously weak and predisposed 
persons. Fortunately, this tendency is much less marked 
than at a former period, but the danger should be con- 
stantly pointed out and guarded against when suicides 
become at all frequent in a community. 

Silence is the antidote for this form of nervous, imita- 
tive suicide, as Moreau has aptly and truly said. 

TREATMENT.— When a tendency to self-destruction has 
been discovered, moral treatment may be of much bene- 
fit. Kindness, cheerful attention, and society, and the 
assurance of aid and support may brighten hope. Argu- 
ment and sympathy have never done good. When an 
individual threatens to kill himself, the best treatment 
is probably to tell him to go ahead and do it. This usu- 
ally results in a cessation of the threats. 

Those mentally afflicted should be placed in institu- 
tions, and it has been recommended that all having sui- 
cidal tendency be placed together, at least at night, and 
this plan is carried out in many of our institutions. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Suicide. 
Sulphides, 


Tonics and sedatives are usually called for, and remedies 
suited to the physical derangement, whatever that may 
be. 


BIBLIOGRAPHY. 


Block: Vom Selbstmord. Aurich, 1792. 

Bonomi: Del Suicidio in Italia. Milan, 1878. 

Brierre de Boismont: Du Suicide et de la Folie Suicide. Paris, 1856. 

Brigham: Statistics of Suicide in the United States, American Journal 
of Insanity, 1844-45. 

Buonaféde: Histoire du Suicide, 1761. 

Casper: Beitrag zu Med. Berlin, 1825. 

Des Etangs: Du Suicide Politique en France. 

Douay: Le Suicide. Paris, 1870. 

Dumas: Traité du Suicide. Amsterdam, 1773. 

Engel: Zeitschrift des Preuss, Statistischen Bureaus, 1871. 

Engel: Der Philosoph. fur die Welt. Leipsic, 1787. 

Encyclopzedia Britannica, Art, Suicide. 

Esquirol: Maladies Mentales. Paris, 1838. 

Essays on Suicide, etc. London, 1785. 

Gruner: De Suicidio. Jena, 1792. 

Hammond: Treatise on Insanity. New York, 1883. 

Kayser ; Official Statistics of Suicide in Norway. Christiania, 1852, 

Legoyt: Le Suicide Ancien et Moderne. Paris, 1881. 

Less; Vom Selbstmorde. Goettingen, 1767. 

Lisle: Du Suicide. Paris, 1856. 

Mesnier : Du Suicide dans l’Armée, 1881. 

Millar: Journal of the Statistical Society, London, June, 1874. 

Montesquieu: Paris, 1721 

Moreau: Nouveau Dictionnaire, Art. Suicide. 

Morel: Traité de Médecine Mentale, Paris, 1870. 

Morselli: Il Suicidio. Milan, 1879. Translated, New York, 1882. 

Ossiander: Ueber den Selbstmord. Hanover, 1813, 

Petit: Recherches statistiques. Thése. Paris, 1850. 

Preeterius: Der verdammliche Selbst- und Eigenmord. Dantzig, 1693. 

Radcliffe: English Suicide. London, 1862, 

Sailler: Von Selbstmord. Munich, 1783. 

St. Marc de Girardin: Du Suicide et de Ja Haine de la Vie. 

Wagner: Gesetzmassigkeit. Hamburg, 1864. 

Winslow: The Anatomy of Suicide. London, 1840. 


Charles W. Allen. 
1 Le Suicide Ancien et Moderne, Paris, 1881. 
2 Tl Suicidio, Milan, 1879. Translation. London, 1851; New York, 
882. 


Translation. Paris, 1843. 


Paris, 1860. 


Paris, 1843, 


3 Paper on Suicide, read before the American Medical Association, 1882. 

4 Suicides in New York City. Reprint from vol. vii., Public Health 
Papers of the American Public Health Association, 

5 For other statistics see Confronti Internationali (1865-1883), Rome, 
1884, published by the Italian Genera] Statistical Depaftment. 

6 Treatise on Insanity. New York, 1883. 

7 The Borderland of Insanity. 1875. 

8 Etude sur le Suicide chez les Enfants, Annales Médico-physiologiques, 
January, 1855. 

® Treatise on Insanity. New York, 1883. 

10 Du Suicide chez les Enfants. Jour, de Méd. mentale, 1868. 

11 The Anatomy of Suicide. London, 1840. 

12 Statist. Morale Comparée de la France et de l’Angleterre. Paris, 
1864. 
13 Maladies Mentales. Paris, 1838. 
14 Medical Library, September, 1811, 


_ SULPHIDES. Sulphides of four metallic bases occur 

among medicines, namely, sulphides of mercury, anti- 
mony, potassium, and calcium. Of these, the sulphides 
of mercury and antimony are medicinally not specifically 
peculiar, and will be found discussed under the titles of 
the several metals. Thesulphides of the other two bases 
exhibit marked properties, evidently due to the: sulphur 
of their composition, and form thus a distinct group of 
medicines. The common characteristics are the posses- 
sion of, physically, an alkaline reaction, a disagreeable 
smell, and an alkaline and offensive sulphuretted taste ; 
physiologically, quite intense, irritant properties, and a 
special obnoxiousness to animal and vegetable skin. para- 
sites ; and, therapeutically, a local healing influence over 
many skin diseases in their chronic stage, and, given in- 
ternally, an uncertain tendency to abate chronic glandu- 
lar, or cutaneous, or arthritic disease, and to control or 
repress suppuration. In full dose too long continued, 
the compounds tend to impair general nutrition, leading 
to emaciation and muscular weakness. Following are 
in detail the pharmaceutical preparations containing the 
sulphides in question, with their special properties and 
uses : 

PotassaA SULPHURATA : Sulphurated Potassa.—This is 
an officinal preparation of the United States Pharmaco- 
peia, made by heating in a covered crucible to melting a 
mixture of dried potassic carbonate and sublimed sulphur. 
The product solidifies upon cooling, and is then broken 
into pieces and put up in well-stopped bottles of hard 
glass. Products obtained by the foregoing general pro- 
cess are commonly called, generically, hepar sulphuris 


Translation. Phila., 1845. 


(liver of sulphur), the name being expressive of the color. 
Such products are composite bodies, but the composition 
varies according to the degree of heat to which the mixt- 
ure of potassic carbonate and sulphur has been subjected 
in the preparation. By the comparatively low heat di- 
rected in the United States pharmacopeial process, the 
product is probably a mixture of potassic hyposulphite 
and trisulphide (K,8.0, + 2K.S3). Atahigher heat, such 
as is used in the British pharmacopeceial process, the hy po- 
sulphite first formed splits into potassic sulphate and pen- 
tasulphide. Sulphurated potassa appears in ‘‘ irregular 
pieces of a liver-brown color when freshly prepared, turn- 


ing gradually to greenish-yellow or brownish-yellow, hav- 


ing a faint, disagreeable odor, a bitter, alkaline, repulsive 
taste, and an alkaline reaction. Soluble in about two 
parts of water at 15° C. (59° F.), with the exception of a 
small residue ; partly soluble in alcohol, the latter leay- 
ing undissolved the accompanying impurities. The aque- 
ous solution has an orange-yellow color, and exhales the 
odor of hydrosulphuric acid. The latter is abundantly 
evolved on the addition’ of hydrochloric acid, while, at 
the same time, sulphur is deposited’ (U. S. Ph.). The 
product should contain at least fifty-six per cent. of the 
potassic sulphide. It is decomposed by mineral acids, 
and by most solutions of metallic salts, 

Sulphurated potassa possesses the general properties 
detailed above ; it is violently irritant, even to corrosive- 
ness, and overdosage may easily kill by excessive gastro- 
intestinal irritation. The medicine is used, locally, to kill 
parasites, and to favor the healing of skin disease or the 
abatement of rheumatic or gouty troubles, and, inter- 
nally, to assist in the two latter-named operations. The 
parasiticide action is utilized mainly for the destruc- 
tion of the itch-insect, for which purpose this compound 
is exceedingly efficacious. The preparation is applied 
locally, in the form of ointment, lotion, or general bath. 
For an ointment of proper average strength, sulphurated 
potassa may be mixed with lard in the proportion of six 
per cent. of the former ; for a lotion, an aqueous solution 
ranging from three to six per cent. in strength may be 
used ; and, for a bath, about 125.00 Gm. (four ounces) 
may be dissolved in about 120 litres of water (about 
thirty gallons). Concentrated applications should never 
be made, because of the sharp irritation which would 
thereby certainly be set up. Baths containing sulphu- 
rated potassa (commonly spoken of as sulphur-baths), be- 
sides their foregoing use, are sometimes employed in the 
treatment of chronic lead-poisoning, because of the find- 
ing that patients suffering from lead-contamination show 
upon their skins, after immersion in a sulphur-bath, a 
dark discoloration, as from the forming there of lead sul- 
phide. The inference is that the sulphur in some mys- 
terious way coaxes the Jead out of the system through 
the skin-emunctories, in order to satisfy its chemical 
longing for a union with the metal. Sulphur-baths are 
administered warm or hot, and of a duration from half 
an hour to two or three hours. They are apt, particu- 
larly when protracted, to produce a good deal of irrita- 
tion of the skin, even to the development of a papular or 
vesicular eruption. These baths should be prepared in 
wooden tubs. For internal giving, the dose of sulphu- 
rated potassa ranges from 0.12 to 0.40 Gm. (two to six 
grains), several times a day, given in pill, or in some 
aromatized syrup. 

CaLx SULPHURATA : Sulphurated Lime.—The prepara- 
tion thus named in the United States Pharmacopeceia is 
what is commonly, but incorrectly, called sulphide of cal- 
cium. It is a mixture in varying proportions of calcic 
sulphide and calcic sulphate, but should contain at least 
thirty-six per cent. of absolute calcic sulphide—the salt 
which gives the substance its medicinal activity. Sul- 
phurated lime is made, by the process directed in the 
United States Pharmacopeia, by heating to a low red 
heat in a closed crucible a mixture of lime (‘‘ quick- 
lime”) and sulphur. The product, after cooling, is pul- 
verized, and at once put up in small glass-stoppered 
phials. It appears as ‘‘a grayish-white or yellowish- 
white powder, gradually altered by exposure to air, ex- 
haling a faint odor of hydrosulphuric acid, having an 


681 


Sulphides. 
Sulphur. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


offensive, alkaline taste, and an alkaline reaction. Very 
slightly soluble in water, and insoluble in alcohol” (U. 
Sah 

ated] lime, like sulphurated potassa, has the 
general properties of the alkaline sulphides, as already 
detailed. It is powerfully irritant, even medicinal doses 
being apt to upset the stomach. And it is a disagreeable 
medicine for internal taking, also, because of its giving 
rise to eructations of sulphuretted gases. The prepara- 
tion has been used, locally, principally as a depilatory, 
the powder being applied directly to the hairy area, and 
after fifteen minutes the part gone over with a wet 
sponge. Medicine and hairs then come away together. 
Internally, sulphurated lime has rather recently acquired 
a reputation as tending to control suppurations, the dis- 
charge lessening in quantity, and their unhealthy pus 
acquiring a healthier character under the influence of the 
medicine. Given between times in recurring suppura- 
tions, as in recurring crops of boils, it is also held to 
abate the frequency and severity of the attacks. The 
dose of sulphurated lime ranges from 0.008 to 0.006 Gm. 
(one-twentieth to one-tenth of a grain), several times a 
day, or even hourly, given most conveniently in tritura- 
tion with sugar of milk. Hdward Curtis. 


SULPHITES AND ‘‘HYPOSULPHITES” (Thiosul- 
phates). I, GENERAL MEDICINAL PROPERTIES OF SUL- 
PHITES AND ‘‘ HYPOSULPHITES.”—A number of sulphites 
and ‘‘ hyposulphites” being used in medicine because of 
a virtue which they are considered to derive, in common, 
from their acid radicles, such salts form a distinct group 
of medicines, which it is convenient to discuss under a 
single heading. The class-characteristics are as follows: 
The salts are soluble in water, have a combined saline 
and sulphurous flavor, and are, in physiological opera- 
tion, locally bland and constitutionally innocuous. From 
a medicinal point of view, their most important reaction 
is that in the presence of stronger acids they are decom- 
posed, with the evolution of sulphurous acid. Given 
medicinally, they are thought to undergo this change in 
the stomach through the agency of the free acid of the 
gastric juice. The decomposition is said to be slower 
with ‘‘hyposulphites” than with sulphites. As a sec- 
ondary result of the chemical change, sulphates are 
formed, such being the combination in which the base 
reappears in the urine when a sulphite or ‘‘ hyposul- 
phite” is swallowed in ordinary dosage. Medicinally, 
these salts are employed with the single view of obtain- 
ing by their means the germicide and antiseptic action of 
sulphurous acid. But in this connection it must be care- 
fully borne in mind that sulphites and ‘‘ hyposulphites,”’ 
while maintaining their chemical composition as such, 
have been experimentally proved to be practically de- 
void of either germicide or antiseptic power.! They 
can, therefore, even theoretically, be of avail in this line 
only under circumstances determining their decomposi- 
tion and the evolution thereby of sulphurous acid. Such 
reaction may take place in the stomach, but is seemingly 
impossible in the blood, and with the inference naturally 
following from these premises clinical experience is in 
accord. For these salts have been vaunted in the treat- 
ment of pyrosis and sarcine, and their employment has 
proved fairly efficacious; but they have been even more 
strenuously advocated for the treatment of constitutional 
diseases assumed to be caused by infection of living or- 
ganisms (Nolli), and have, in the hands of the majority 
of the profession at least, signally failed. The salts 
have also been used, with variously reported success, as 
lotions for the cure of parasitic skin disease, or for the 
abatement of the pain of chilblains, sprains, etc.—appli- 
cations in which it is certainly doubtful if they exert any 
specific influence. 

II. THE MEDICINALLY USED SULPHITES AND ‘‘ Hy- 
POSULPHITES.”—The salts of this category are the nor- 
mal sulphite of potasstwm, the normal and acid sulphite, 
respectively, of sodiwm, the sulphite of magnesium, and 
the normal thiosulphate of sodvwm (commonly called hy- 
posulphite). 

Normal Potassic Sulphite, K2503.2H20.—The salt is 


682 


officinal in the United States Pharmacopoeia under the 
title Potassti Sulphis, Sulphite of Potassium. It occurs 
as ‘‘ white, opaque, obliquely rhombic, octahedral crys- 
tals, or a crystalline powder, somewhat deliquescent, 
odorless, having a bitter, saline, and sulphurous taste, 
and a neutral or feebly alkaline reaction. Soluble in 
four parts of water at 15° C. (59° F.), and in five parts of 
boiling water ; only sparingly soluble in alcohol. When 
gently heated, the salt loses its water of crystallization 
(18.5 per cent.) ; at a red heat it is decomposed and leaves 
a residue of an alkaline reaction” (U. 8S. Ph.). The salt 
should be kept in well-stopped bottles. 

Potassic sulphite may be used locally in twelve per 
cent. aqueous solution, or given internally in doses rang- 
ing from 1.00 to 4.00 Gm. (fifteen to sixty grains), three 
or four times a day. 

Normal Sodie Sulphite, Na,.SO;.7H.O.—The salt is 
officinal in the United States Pharmacopeeia as Sodii Sul- 
phis, Sulphite of Sodium. It occurs in ‘‘ colorless, trans- 
parent, monoclinic prisms, efflorescent in dry air, odor- 
less, having a cooling, saline, and sulphurous taste, and 
a neutral or feebly alkaline reaction. Soluble in four 
parts of water at 15° C. (59° F.), and in 0.9 part of boil- 
ing water; only sparingly soluble in alcohol. When 
gently heated, the salt melts, then loses its water (fifty 
per cent.), and at a red heat it is decomposed and leaves 
a residue having an alkaline reaction. A fragment of 
the salt imparts to a non-luminous flame an intense yel- 
low color, not appearing more than transiently red when 
observed through a blue glass” (U.S. Ph.). The salt 
should be kept in well-stopped bottles, in a cool place. 

Sodic sulphite may be used in same manner and dose 
as the potassic salt. 

Acid Sodic Sulphite, NaHSO;.—The salt is officinal in 
the United States Pharmacopceia as Sodii Bisulphis, Bi- 
sulphite of Sodium. It occurs in ‘‘ opaque, prismatic 
crystals, or a crystalline or granular powder, slowly oxi- 
dized, and losing sulphurous acid on exposure to air, 
having a faint, sulphurous odor, a disagreeable, sulphur- 
ous taste, and an acid reaction. Soluble in four parts of 
water, and in seventy-two parts of alcohol at 15° C. (59° 
F.); in two parts of boiling water, and in forty-nine 
parts of boiling alcohol. When strongly heated, the salt 
decrepitates, and is converted into sulphur and sulphate 
of sodium. A small fragment of the salt imparts to a 
non-luminous flame an intense yellow color, not appear- 
ing more than transiently red when observed through a 
blue glass” (U. S. Ph.). This salt must be kept in well- 
stopped bottles. 

This sulphite is less stable than the normal sodic salt, 
and more disagreeable to taste. In other respects it is 
similar. 

Magnesic Sulphite, MgSO;.6H.O0.—The salt is officinal 
in the United States Pharmacopeia as Magnesti Sulphis, 
Sulphite of Magnesium. It occurs as a ‘‘ white, crystal- 
line powder, gradually becoming oxidized on exposure to 
air, odorless, having a slightly bitter, somewhat sulphur- 
ous taste, and a neutral or slightly alkaline reaction. 
Soluble in twenty parts of water at 15° C. (59° F.), and 
in nineteen parts of boiling water ; insoluble in alcohol. 
When heated to 200° C. (892° F.), the salt loses its water 
of crystallization (50.9 per cent.), and is converted into 
magnesia and anhydrous sulphate of magnesium” (U. 8. 
Ph.). The salt should be kept in well-stopped bottles. 

Magnesic sulphite is the least unpleasant of the sul- 
phites to taste. Uses and dose as with the potassic salt. 

Normal Sodic Thiosulphate (‘‘ Hyposulphite ”), NaS. 
O;.5H20.—The salt is officinal in the United States Phar- 
macopeeia under its former chemical title of Sodiz Hypo- 
sulphis, Hyposulphite of Sodium. The present confusion 
in the use of the term hyposulphite arises from the fact 
that before the discovery by Schiitzenberger of what is 
now, and properly, called hyposulphurous acid—namely, 
the bodyH.SO.—the name in question was applied to 
thiosulphuric acid (H28.203). Hence it comes about that 
though a true sodic hyposulphite is known, the salt that 
passes current by that name is not a hyposulphite, but a 
thiosulphate. The old title, however, is so firmly fixed 
by long and popular usage that it has been retained by 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, 


the United States Pharmacopeeia, and is the title by 
which the salt is universally knownas a medicine. Sodic 
‘‘hypo-sulphite” occurs as “‘ large, colorless, transparent, 
monoclinic prisms or plates, efflorescent in dry air, odor- 
less, having a cooling, somewhat bitter and sulphurous 
taste, and a neutral or faintly alkaline reaction. Soluble 
in 1.5 part of water at 15° C. (59° F.), and in 0.5 part of 
boiling water, in the latter case with partial decomposi- 
tion ; insoluble in alcohol. When rapidly heated to about 
50° C. (122° F.), the salt melts ; when slowly heated until 
it is effloresced, and afterward to 100° C, (212° F.), it loses 
all its water (86.3 per cent.), and at a low red heat it is 
decomposed. <A fragment of the salt imparts to a non- 
luminous flame an intense yellow color, not appearing 
more than transiently red when observed through a blue 
glass” (U.S. Ph.), The salt must be kept in well-stopped 
bottles. 

Sodic ‘‘hyposulphite” is more stable than the sul- 
phites, undergoing decomposition by acids less easily. 
In properties, uses, and modes of administration it re- 
sembles potassic sulphite. The internal dose is generally 
from 1.00 to 1.30 Gm. (fifteen to twenty grains), 

Edward Curtis. 


1 Sternberg: American Journal of the Medical Sciences, April, 1883, 
p. 821, 


SULPHOCARBOLATES: Phenolsulphonates. Carbolic 
acid (phenol), added to strong sulphuric acid, dissolves 
with the formation of the acid body, CsH,(OH). SOsH, 
termed phenolsulphonic acid by the chemist, but com- 
monly known as sulphocarbolic acid. Sulphocarbolic acid 
unites with bases to the formation of salts, and in these 
salts it was hoped there might be found substances which 
would retain the therapeutic powers of carbolic acid 
while free from the poisonous properties of that body. 
So far as observation has gone, however, this hope does 


not seem to have been realized. A single salt of sulpho-' 


carbolic acid is officinal in the United States Pharmaco- 
peeia, as follows: 

Sopu SULPHOCARBOLAS, Sulphocarbolate of Sodium, 
NaC,.H;S0O,.2H.0, U. 8S. Ph.—This salt is described as 
‘colorless, transparent, rhombic prisms, permanent in 
the air, odorless or nearly so, having a cooling, saline, 
_ somewhat bitter taste, and a neutral reaction. Soluble 
in 5 parts of water, and in 182 parts of alcohol at 15° C. 
(59° F.) ; in 0.7 part of boiling water, and in 10 parts of 
boiling alcohol. When heated, the salt loses its water 
and becomes a white powder” (U.S. Ph.). This is a 
bland salt, producing but little constitutional disturbance 
in ordinary medicinal doses beyond some lightness of the 
head. It has been prescribed in doses ranging from 0.65 
to 2.00 Gm. (from ten to thirty grains) for the purpose of 
constitutional antisepsis in so-called zymotic diseases, 
but without striking results. Hdward Curtis, 


SULPHO-SALINE SPRINGS. Location and Post Office, 
Cincinnati, Hamilton County, O. 
ANALYSIS (E. 8. Wayne).—One pint contains : 


Grains. 
Carbonateoiimagnesiaves.ccce. foe ck oe ces oka laid 1.141 
Carbonate ob limon aia me. beztk Sache keie ees 2.417 
Olilorisde: Os MOLASSI UIs an Se dose hota ae oc een 0.493 
Obloride! Gr BOUIN san, 0) ee oe see lcci narne boltueinc cee 66.846 
@bhloridgiciimagnesiumns. cos pater l ace cen: 2.157 
Obloride of Callan see cates eee eee eee oe ee eeieda 2.773 
Chioriderotelithinmiasg: 1. shee ae eat aah 0.029 
Sulpiare OL Potassa err. ees aciciescieatee oe heloe antes 0.287 
Sualphaterohlimernersns. seen eee eek ee kee 3.650 
hosphate:o sodar ease ste ee eee eee nae ee 0.167 
Fodiae OL MASHESINM Ua. ers eta aan. Pelee a 0.037 
Bromide Of MAPNesUll Lele eee eee ras 0.049 
Oxide orivonl!. 67 sad se teas fees Ao ee eee 0.053 
Silica eee TEee Ee eee ee eins ee 0.098 
BELG URL Je 0 Sra vo overs athaave eheta cove tuaee,.b10: stecred Mei araIne th arene 80.197 
Gas. Cub. in. 
Carboniviacid 2b eecctt cra vor ee Pane oe ane te ee 1.57 
MuUlpMiretted NY ArOven. Seas. sce neat erence cee 0.91 


THERAPEUTIC PROPERTIES.—This well is a strong 
sulpho-saline one, and has a local reputation as a cathartic 
and alterative. As warm baths, the water is very useful 
in chronic skin diseases, and rheumatism. 


Sulphides. 
Sulphur, 


This water flows from an artesian well (2,408 feet deep) 
bored for the purpose of supplying a brewery. Being 
unfit, on account of its mineral properties, for that pur- 
pose, it has been utilized as a mineral spring, and a large 
bath-house has been erected, furnished with every con- 
venience. ‘The water has a temperature of 62° F, and is 
abundant, Git Bik, 


SULPHUR. Sulphur is used in medicine in the con- 
dition of fine powder, three styles of which are ofticinal 
in the U. 8. Pharmacopeeia, as follows : 

SULPHUR SUBLIMATUM, Sublimed Sulphur.—This prep- 
aration, commonly calied flowers of sulphur, is crude sul- 
phur purified by distillation in an apparatus so arranged 
that the vaporized sulphur shall condense in the form of 
a powder upon the walls of the receiving chamber. Sub- 
limed sulphur is a ‘‘ fine, citron-yellow powder, of a 
slight, characteristic odor, and generally of a faintly acid 
taste, and an acid reaction. It is insoluble in water or 
alcohol. When ignited, it burns with a blue flame, form- 
ing sulphurous acid gas, and leaving no residue, or only 
a trace” (U.S. Ph.). Sublimed sulphur always contains 
a little sulphuric acid, whereby it is unfitted for internal 
medicinal use. 

Sulphur Lotum, Washed Sulphur.—This preparation 
is simply sublimed sulphur freed from contaminating 
sulphuric acid. The sulphur is digested for three days 
with diluted water of ammonia, by which process the 
sulphuric acid is fixed as ammonic sulphate, and the 
mass is then thoroughly washed with water upon a mus- 
lin strainer. The ammonic sulphate is thus washed 
away, and the purified sulphur is finally dried at a gentle 
heat, and passed through a No. 30 sieve. Washed sul- 
phur is ‘‘a fine, citron-yellow powder, odorless and 
almost tasteless, insoluble in water or alcohol, but com- 
pletely soluble in a boiling solution of soda, or in disul- 
phide of carbon. When heated to 115° C. (239° F.), washed 
sulphur melts, and at a higher temperature it is volatil- 
ized, without leaving more than a trace of residue. 
Water agitated with it should not redden blue litmus 
paper (abs. of free acid.)” (U. 8. Ph.). When derived 
from a sulphur originally obtained from metallic sul- 
phides, washed sulphur may contain the very dangerously 
contaminating substance, arsenic, in the form of the tri- 
oxide or trisulphide of that element. Proof of absence 
of arsenic is afforded by digesting a sample of washed 
sulphur with two parts of ammonia, filtering, and find- 
ing the filtrate unaffected by super-saturation with hy- 
drochloric acid, and not precipitated by passing through 
it a stream of hydrogen sulphide. 

SuLPHUR PREcrIPITATUM, Precipitated Sulphur.—This 
preparation, formerly known as milk of sulphur, is an 
exceedingly fine powder of sulphur, gotten by precipi- 
tating with diluted hydrochloric acid a solution of sul- 
phur salts of calcium, obtained by mixing sublimed sul- 
phur and slaked lime with water. The sulphur, after 
precipitation, is collected upon a strainer, thoroughly 
washed with water, and dried at a gentle heat. Precipi- 
tated sulphur is ‘‘a very fine, yellowish-white, amor- 
phous powder, odorless and almost tasteless, insoluble in 
water or in alcohol, but completely soluble in a boiling 
solution of soda or in disulphide of carbon. By heat it 
is completely volatilized” (U.S. Ph.). Precipitated sul- 
phur should stand the same tests for absence of free acid 
and of contaminating arsenic as washed sulphur (see 
above). This variety of sulphur-powder differs from the 
foregoing in being lighter in color, and of finer particles. 
From the latter fact it derives the advantages of greater 
smoothness and readiness of mixing with fluids; but, to 
offset, it has the disadvantage of tending to develop an 
acid upon keeping. Ma? 

Sulphur, as the pharmacopeeial descriptions say, is in- 
soluble in water, and practically so in alcohol, but dis- 
solves in varying proportions in solutions of the alkalies 
and in oils, fixed and volatile. Because of its insolubil- 
ity in aqueous fluids, sulphur is practically devoid of 
physiological activity while under its own form, but, 
when rubbed in ointment upon the skin, or when taken 
internally, a feebly irritant action appears, presumably 


683 


Sulphur. 
Sulphurie Acid. 


due to a sulphide formed in small quantity by the chem- 
icals present in the secretions of the part. What little 
of an internally taken dose of sulphur is absorbed is also 
probably in the condition of a sulphide, and the constitu- 
tional effects that follow are a feeble reflex of those of 
the alkaline sulphides (see Sulphides), In single, consid- 
erable dose the local irritation displayed by sulphur de- 
termines increased intestinal activity, showing itself by 
relaxation of the bowels, but this with but little increase 
of secretion. The stools are therefore generally com- 
posed of solid or semi-solid fecal matter, and the op- 
eration of the medicine is mild and slow, the call to stool 
rarely occurring until from six to eight hours after the 
taking of the sulphur. If habitually used as a laxative, 
sulphur may induce a low catarrh of the alimentary tract. 
A disagreeable feature of its internal taking for any pur- 
pose is the tendency to the generation of flatus, offensive 
from the presence of sulphuretted gases. 

The therapeutic applications of sulphur are as follows : 
By some it is given internally as a means of getting the 
constitutional effects of the sulphides in constitutional 
diseases, but by the majority of practitioners the internal 
use is in laxative dose only, for a laxative effect. Such 
dose is from 4.00 to 12.00 Gm. (one to three drachms), 
the washed or precipitated preparations being selected, 
and the powder mixed with molasses or diffused in milk 
for the taking. Externally, ointments containing sul- 
phur are a good deal used as mildly irritant applications 
in skin diseases generally, and, specifically, as efficient 
parasiticidal dressings in itch. The pharmaceutical 
preparations of the United States Pharmacopeeia are ‘as 
follows : 

Unguentum Sulphuris, Sulphur Ointment.—This prep- 
aration is compounded of thirty parts of sublimed sul- 
phur and seventy of benzoinated lard, thoroughly incor- 
porated. It may be applied without dilution, and is a 
very commonly used ointment for the treatment of the 
itch. It has a disagreeable sulphuretted smell, which 
may be to a certain degree masked by the addition of a 
little of some odoriferous volatile oil. 

Unguentum Sulphuris Alkalinum, Alkaline Sulphur 
Ointment.—Washed sulphur and half the quantity of 
potassic carbonate are rubbed together with a little water, 
and the whole then thoroughly mixed with benzoinated 
lard. The finished ointment contains twenty per cent. of 
sulphur. In this preparation the alkali of the potassic 
compound probably determines a more rapid solution of 
the sulphur, so that the ointment is more prompt and 
thorough in action than the simple one just described, 
but it is for that reason more likely to provoke untoward 
irritation. Edward Curtis. 


SULPHUR DIOXIDE (formula SO,). This compound, 
commonly miscalled sulphurous acid gas, is the product 
of the combustion of sulphur in air. It is a colorless gas, 
of a well-known characteristic ‘‘ sulphurous” odor, and 
is both offensive to the nostrils and intensely irritant to 
the larynx. Even the fumes of a single burning sulphur 
match-head easily excite coughing, and air highly charged 
with the gas is fatal to life. Sulphur dioxide dissolves 
freely in water—in one-fiftieth of its volume at ordinary 
temperatures—forming in the process of solution an acid 
een sulphurous acid proper (H2SO:-) (see Sulphurous 

cid). 

The medicinally valuable property of sulphur dioxide 
is its peculiar noxiousness to the vitality of disease-germs 
—a germicidal potency in which this compound, among 
gases, is rivalled only by chlorine and the vapors, respec- 
tively, of bromine and of iodine. And considering the 
cheapness and ease with which, by the simple combustion 
of sulphur, sulphur dioxide can be obtained, the gas leads 
the list of practically available and really efficient aérial 
disinfectants. Yet in its application the inherent uncer- 
tainties in the general method of aérial disinfection must 
never be forgotten. Could we be certain that every dis- 
ease-germ present in a chamber would be fully exposed 
to the action of the disinfectant gas, then we might rely 
with corresponding fulness upon the disinfection thus at- 
tained ; but when we bethink us how easily these germs, 


684 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


microscopic in size, may be safely fortified against as- 
saults of a gas by lodgement in cracks and crannies of 
furniture and fabrics, then we cannot but realize the 
important truth, that even the most thorough so-called 
disinfection by this, the most potent of the practically 
available aérial disinfectants, is at best but an unreliable 
procedure. In this connection the strong and offensive 
smell of sulphur dioxide is a distinct advantage, since, 
after fumigation by the gas, a chamber and all articies 
therein must be thoroughly aired, and thus additionally 
disinfected, before the human nose will permit of their 
resumed use. 

For the determination of the exact germicidal power 
of sulphur dioxide, very careful experiments were made 
by Sternberg,’ by submitting vaccine virus, moistened 
with glycerin on the one hand, and dried upon ivory- 
points upon the other, to the action, in a closed chamber, 
of air charged with varying percentages of sulphur diox- 
ide, the exposure ranging from six totwelve hours. After 
exposure the virus, or the charged ivory-points, were 
used for vaccination side by side with some of the same 
sample of virus which had not been exposed to the germi- 
cide. The general results were that, in the case of moist 
lymph, destruction of infective power followed a twelve- 
hour exposure to air charged with a proportion of sul- 
phur dioxide such as would be produced by burning 
three-quarters of a grain of sulphur for each cubic foot 
of air; and, in the case of the dried virus, similar results 
followed with an impregnation equivalent to the com- 
bustion, per cubic foot of air, of three grains of sulphur. 
These results accord with common experience, and teach 
that at least a one per cent. impregnation of air with sul- 
phur dioxide will ordinarily be required to sterilize float- 
ing germs. 

For the practical application of sulphur dioxide as an 
aérial disinfectant, the gas is most easily and cheaply 
obtained by burning sulphur, and in calculating the 
quantity of sulphur required it is obviously wisest to err 
very far on the safe side. A good rule is therefore to 
allow from two to three pounds for each one thousand 
cubic feet of chamber to be disinfected. The strength 
of fumes thus generated being vastly in excess of what 
is respirable, the procedure is only possible in vacated 
rooms. In a chamber to be operated upon, therefore, 
all living creatures must be removed, and every pos- 
sible outlet for the gas, such as door-ways, windows, 
and chimneys, must be closed, and even cracks and key- 
holes should be stopped with cotton or pasted over with 
paper. Then all articles needing disinfection must be 
thoroughly exposed on all sides to free access of the 
gas—bureau-drawers being opened, carpets, curtains, and 
blankets hung over lines across the room, and mattresses 
ripped open and the hair loosely strewn on the floor. 
The proper quantity of sulphur, in the form of sublimed 
sulphur, is then best mixed with one-fortieth of its weight 
of powdered charcoal, to secure readier combustion, and 
put into an iron pot, or upon a metal plate resting upon 
the legs of a half-open pair of tongs set across a wash-tub 
half full of water. By these precautions all danger of acci- 
dental setting of the floor on fire is avoided. A single 
door being left unsealed, the operator fires the sulphur 
by a live coal or a teaspoonful of flaming alcohol, and 
immediately retires, closing and sealing the door behind 
him. The sulphur is left to burn itself out, and next 
day the chamber is cautiously entered, the windows 
thrown open, and all articles thoroughly aired. It is 
possible also to generate sulphur dioxide by burning car- 
bon disulphide in a specially constructed lamp, but from 
the great inflammability of that compound the procedure 
is not altogether safe, and presents no advantages over 
the simple method by the combustion of sulphur. 

Edward Curtis. 


1 American Journal of the Medical Sciences, April, 1883. 


SULPHUR IODIDE. Under the title Sulphuris Iodi- 
dum, Iodide of Sulphur, the United States Pharmacopeceia 
recognizes a preparation made by fusing by heat a mixt- 
ure of one part of washed sulphur and four parts of iodine. 
The fused mass, after cooling, is broken into pieces and 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Sulphur. 
Sulphuric Acid. 


kept in glass-stoppered bottles. The article is described 
as ‘‘a grayish-black solid, generally in pieces, having a 
radiated, crystalline appearance, the characteristic odor 
of iodine, a somewhat acrid taste, and a faintly acid re- 
action. It is insoluble in water, but very soluble in di- 
sulphide of carbon; also soluble in. about sixty parts of 
glycerin. Alcohol and ether dissolve out all the iodine, 
leaving the sulphur. When exposed to the air it gradu- 
ally loses iodine. On being heated, it sublimes, the first 
part of the sublimate consisting of iodine, and the subse- 
quent portion containing both iodine and sulphur. On 
continued heating it is volatilized, without leaving more 
than a trace of residue. If 100 parts of Iodide of Sulphur 
be thoroughly boiled with water, all the iodine will es- 
cape, and about 20 parts of sulphur will remain” (U. S. 
Ph.). 

This substance is differently regarded by chemists, 
some considering it a definite compound, corresponding 
to the formula I,S2, and others thinking it more proba- 
bly a mere physical mixture. If a true chemical com- 
pound, it is one of exceptional instability, as the forego- 
ing narration of its properties makes evident. To the 
therapeutist it presents itself practically as a joint repre- 
sentative of free sulphur and free iodine. It has oc- 
casionally been given internally for the purposes for 
which iodine is so administered, but the commoner em- 
ployment is external as a gently irritant, iodized applica- 
tion in various skin diseases. It is best applied in the 
form of ointment made with lard, containing the sulphur 
iodide in the proportion of about eight per cent. 

Hdward Curtis. 


SULPHURIC ACID: Oil of Vitriol, H.SO,. This 
well-known acid is officinal in the United States Pharma- 
copeia under the title Actdum Sulphuricum, Sulphuric 
Acid, and is defined to be ‘‘ a liquid, composed of not less 
than ninety-six per cent. of absolute sulphuric acid, and 
not more than four per cent. of water’ (U.S. Ph.). Sul- 
phuric acid is a heavy liquid of an oily appearance, color- 
less when newly made, but apt to acquire a smoky hue 
upon keeping. The specific gravity varies in different 
samples, but a gravity of 1.840 is recognized as standard 
by the U.S. Pharmacopeia. The acid has an intense 
_ affinity for water. Mixed with that fluid, it unites there- 
with with the evolution of considerable heat and with a 
contraction of volume, forming a clear solution. By 
reason of the same affinity, many organic bodies are de- 
composed upon treatment with sulphuric acid, the acid 
abstracting from their molecule the elements of water. 
Thus, by dehydration, oxalic acid is chemically broken 
up, alcohol is converted into ethylene gas (C2H,), wood 
and sugar are blackened, and textile fabrics and animal 
tissues are destroyed. Sulphuric acid, if diluted, also 
attacks most of the common metals, the prominent ex- 
ceptions being gold, platinum, and iridium. Certain of 
the metals, such as copper, mercury, antimony, bismuth, 
tin, lead, and silver are also acted upon by the concen- 
trated acid, if the same be heated. 

Upon the living animal system strong sulphuric acid 
acts purely as a powerful caustic. Its action is a spread- 
ing one, and the sloughs have a dusky or blackish hue, 
quite different in color from the yellow sloughs produced 
by nitric or hydrochloric acids. Swallowed in any quan- 
tity, the strong acid is an intense corrosive poison. Burn- 
ing pain in the mouth, throat, and stomach is experi- 
enced in the very act of swallowing, speedily followed 
by violent vomiting, the ejecta being intensely acid and 
containing blood. The voice is apt to become changed 
and whispering, and the shock from the corrosion is usu- 
ally very severe, the sufferer very likely dying in col- 
lapse in from eighteen to twenty-four hours after taking 
the poison ; or, in exceptional cases, even much earlier— 
in a few instances so early as two or three hours. If the 
poison be not speedily fatal, parotitis with salivation and 
nephritis are not uncommon sequel. The severity of 
the poisoning is largely influenced by the fact of pres- 
ence or absence of food in the stomach, the former con- 
dition saving from direct contact of the concentrated 
acid upon the gastric walls. One drachm is about the 


least quantity reported to have produced death, and on 
the other hand, so large quantities as from two to three 
ounces have been swallowed and the patient has recov- 
ered. The lesions in sulphuric acid-poisoning are patches 
of corrosion where the acid has struck. Mouth, throat, 
and cesophagus may show whitish, or ashen, or brownish 
areas of corrosion, and in the stomach patches of brown 
or black may alternate with lines of red, where the mu- 
cous membrane, protected by foldings from concentrated 
action of the acid, has escaped corrosion, but has taken 
on inflammation. Perforation of the stomach is com- 
mon, The gastric contents are generally discolored a 
dark brown and are of viscid consistence, and may show 
no traces of the acid, especially if death have been post- 
poned several days and the patient have been under 
treatment. In such cases all the acid will have been 
discharged in the early vomiting. The treatment of sul- 
phuric acid poisoning is to neutralize the acid, and then 
treat the lesions on general medical principles. For neu- 
tralization, magnesia and chalk are commonly chosen ; 
but, as Taylor points out, a soluble alkali like the sodic 
carbonates, given in solution, will obviously act more 
certainly and speedily. Whatever alkali be selected, it 
should be given freely, but, at best, neutralization ac- 
complishes little, since the damage is done at the moment 
of swallowing the acid. Demulcents, such as milk, 
gruel, white of egg, and oil should, next, be freely ad- 
ministered. The stomach-pump should be avoided, lest 
the nozzle perforate the corroded gastric walls; and the 
spontaneous vomiting is so free that there is no indica- 
tion for the giving of emetics. 

The most important points of medical jurisprudence 
connected with the subject of sulphuric acid-poisoning 
are these: First, that fatal poisoning by this agent al- 
most certainly means either suicide or accident. For the 
acid is so intensely sour that it is hardly conceivable that 
a fatal dose, criminally offered, would be unsuspectingly 
quaffed by the intended victim, even though attempted 
to be disguised in some article of food or drink. Forci- 
ble administration to children, or drunken or sleeping 
persons, is, however, possible, and a few cases of homi- 
cide of children by this method have been reported. 
Next, the jurist must remember that the acid may kill 
without actual swallowing, death ensuing by asphyxia 
from swelling of the larynx, corroded by the poison ; 
and, next, that in any case the mouth and lips may show 
no marks of the acid if the draught have been taken 
from a spoon. Inrare cases even throat and esophagus 
have shown no signs of corrosion. Again, although the 
symptoms almost invariably begin immediately upon 
swallowing, even if the potion have been one of diluted 
acid, and the pain is intensest agony, yet the sufferer 
may at first be able to walk and even disguise his suffer- 
ings from the notice of casual observers. As regards 
period of death, the acid has killed in so short a time as 
one hour, and at all intermediate periods thereafter up 
to the lapse of two years. Rapid deaths are generally by 
suffocation, from occlusion of the larynx, and long de- 
layed ones from stricture of the cesophagus. 

Therapeutically, strong sulphuric acid is occasionally 
used as a caustic, but the very intensity of its action is 
in its disfavor, so that nitric acid is generally preferred. 
The acid must be kept in glass-stoppered bottles. 

Diluted, so as not to be corrosive, sulphuric acid, like 
all sour acids, tends to check acid, and to increase alka- 
line secretions, to inhibit fermentations, and, of course, 
to neutralize alkalinity. Dilute preparations of sulphuric 
acid are, therefore, available to repress morbid sweat- 
ings, both applied locally as lotions, and given inter- 
nally to allay thirst and quicken appetite; to prevent 
fermentation of food in the prime vie, and so to cure 
diarrheeas due to the irritation of the products of such 
fermentations, and to neutralize the alkali of alkaline 
pyrosis. For these various purposes the following offi- 
cinal preparations of the United States Pharmacopceia 
are available : 

Acipum Suntpuuricum Dinurum, Diluted Sulphuric 
Acid.—This preparation is a simple aqueous dilution of 
sulphuric acid, of ten per cent. strength. It is a colorless 


685 


Sulphuric Acid. 
Superfoetation. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


fluid, intensely sour of taste, and of about the specific 
gravity 1.067. It should be kept in glass-stoppered bot- 
tles. This grade of acid, although not corrosive, is quite 
irritant, and, for medical use, requires considerable fur- 
ther dilution. The dose is from ten to thirty drops, di- 
luted thirty- or forty-fold, and to be taken through a 
tube, with the mouth well rinsed after the swallowing. 

ActpuM SULPHURICUM AROMATIOUM, Avomatic Sul- 
phuric Acid, Elixir of Vitriol.—This preparation consists 
of alcohol charged with sulphuric acid and tincture of 
ginger, and flavored, in addition, with a trace of oil of 
cinnamon. In 1,000 parts of product are represented 
200 parts of sulphuric acid, 45 of tincture of ginger, and 
1 of oil of cinnamon. The preparation is a limpid, yel- 
low fluid of an aromatic, ethereal, and strongly sour 
taste, and of the specific gravity 0.955. As its odor sug- 
gests, it probably contains some ethereal product of a 
reaction between the acid and alcohol of its composition. 
The United States Pharmacopeia considers, thus, that 
there is a certain amount of ethyl-sulphuric acid present. 
Aromatic sulphuric acid should be kept in glass-stop- 
pered bottles, 

This preparation is the favorite one for the internal 
administration of sulphuric acid. It is to be given in the 
same manner as the dilute acid (see above), and in the 
same or somewhat lesser doses. 

Hdward Curtis. 


SULPHUROUS ACID, H.SO;. Sulphur dioxide gas 
(SO.) is readily absorbed by water, and in so dissolving 
is to be regarded as uniting with water, molecule for 
molecule, with the formation of the acid body, H:SOs. 
The United States Pharmacopeia recognizes under the 
officinal title Actdum Sulphurosum, Sulphurous Acid, an 
acid representing 3.5 per cent. of sulphur dioxide and 
96.5 per cent. of water, and of the specific gravity 1.022 
to 1.028. Sulphurous acid is a colorless fluid, smelling 
pungently of sulphur dioxide, and tasting both sulphur- 
ous and sour. It has a strong acid reaction, and first 
reddens and then bleaches litmus paper. It is wholly 
volatilized by heat, and tends constantly to undergo con- 
version into sulphuric acid by the absorption of oxygen. 
This change is hastened by the action of light, hence the 
Pharmacopeeia directs that sulphurous acid be put up in 
glass-stoppered, dark amber-colored bottles, and be kept 
in a cool and dark place. The pharmacopeeial process 
for making the acid is to generate sulphur dioxide by 
heating a mixture of sulphuric acid and charcoal, and to 
conduct the mixed sulphur and carbon dioxides into dis- 
tilled water. The sulphur dioxide dissolves in the water 
with the formation of sulphurous acid, and the carbon 
dioxide mostly escapes. 

In its medicinal properties sulphurous acid resembles 
sulphur dioxide (see Sulphur Dioxide), and may be prac- 
tically regarded, indeed, as a simple aqueous solution of 
that compound, It is a pretty potent germicide, and 
upon tender surfaces of the animal body is decidedly 
irritant. It bleaches vegetable colors. The acid is used, 
externally, as a wash in parasitic skin diseases, generally 
diluted two- or three-fold, and, internally, is occasionally 
prescribed in cases of pyrosis and sarcine. It is, how- 
ever, an exceedingly disagreeable medicine to take. The 
dose is 4.00 Gm. (about one fluidrachm) of the officinal 
acid, taken in a wineglassful of water. 

Edward Curtis. 


SULPHUR SPRINGS (TEXAS). Location and Post- 
office, Sulphur Springs, Hopkins County, Tex. 

AcceEss.—By the Jefferson Branch of the Missouri Pa- 
cific Railway. 

ANALysis.—Dr. J. M. Hooper, of Sulphur Springs, 
Hopkins County, Tex., sends us the following analyses 
of the water of two wells in that town. There is one 
well, he remarks, that has not yet been examined, which 
is thought, however, to be superior to these. He adds 
that he will be happy to answer any questions about the 
waters of the various wells in the town. 

The water of the Weaver Well is acid in reaction, with 


686 


a specific gravity of 1.008, and each gallon contains the 
following solid constituents : 


Grains 
Sulphate of:ferri¢ oxidevr. ns. cede ct aiee Pheer Oa: 
Sulphate of aluminiumeen anaes hee esc ca ons 23.235 
Sulphate of marnesiim soe. sets oe ees ss <cies creer 24.345 
Sulphate of meray fh resee eee wherein acne soe ties 45.678 
Sulphate ofisodimmeyeniye re cieieste sr biel a ais one oases 1.342 
Sulphate of potassium seme cotineks sce neve ohare 0.849 
Ohloride‘of Sodium yeni eee ace cee eee coe one 1.560 
Oarbonate: of lime (5. aot eewrsciediecicateees ss ot sents 4.286 
Phosphate: of lime oes iieise seminars och eeese koe 0.633 
Silicic acid 7°. h s.cee.t Noe k ee lee on cebe cb raeiee se eae 1.425 
Free sulphuric acidig.eaanecse esiisenernr R iereyeie ats, SRE 1.211 
Nitrous acid} 202202. tee ee eee ete ee ode Cee trace 
Organic mattera. ic Goes seats sites hide steios a atc 2.473 


The Pate Sour Well, also of acid reaction, has a specific 
gravity of 1.0096, and in each gallon the following solid 
constituents have been found : 


Grains. 
Calcieisuiphatecs: ts ccusss ene se fete cmeciaeae seers 84,713 
Merric sulphaber ie ikess tee aise ae te sete eee rote 63,194 
IMASTIESICISUID MALO S. em <matciec telse eins Seiten Jets eee OOl 
Sodicsch lorie.) 2.5 svete Sree aed clerics sree: vine ice eine 5.017 
Silex sere e aan tee ictelet ac erts sisters esata © ie ateereats 1.944 
Organic and volatile matter’): 0. \....20-..-5 -s)4- 3.797 
Mree sul pauriG acid ered fs tad > clotstssn boo ee cise tees ee eaters 1.321 
TOGIMOics erace choco s eiieinays cles cateansl os icks het t weticteLslerepiia ote trace 

GiB alt. 


SUMACH (Rhus Glabra, U. 8. Ph.). ‘The fruit of 
Rhus glabra Linn. ; Order, Anacardiacee” (Terebintha- 
cee). The smooth sumach is a very common, and, when 
in full fruit, a very striking, American shrub. It has, 
like all its genus, large pinnate leaves and small, poly- 
gamous, greenish, regular, pentamerous flowers in pani- 
cles ; ovary single, one-ovuled ; styles or stigmas three. 
This species has smooth, somewhat glaucous leaves, 
white beneath, of from eleven to thirty-one leaflets, and 
close, upright, terminal, conical panicles of flowers and 
fruit. Berries, when ripe, of a most brilliant crimson 
color; they are ‘‘sub-globular, about one-eighth of an 
inch (3 millimetres) in diameter, drupaceous, crimson, 
densely hairy, containing a roundish-oblong, smooth 
putamen. It is inodorous, and its taste acidulous.” The 
pleasant acid taste of sumach berries is all in the crim- 
son pubescence with which they are covered, and is due 
to malic acid and acid malate of lime; the internal parts 
of the seed contain, like the rest of the plant, tannic acid. 
A fluid extract (Hzatractum Rhois Glabre Fluidum, U. 8. 
Ph., strength 7;) is officinal. Hither this diluted, or a 
decoction, may be used as a pleasantly sour, astringent 
gargle. 

ALLIED PLANTS.—See Ivy, Poison. 

ALLIED Drues.—Tamarinds, Barberries, Rose Hips, 
etc. W. P. Bolles. 


SUMBUL, U.S. Ph. (Sumbul Radix, Br. Ph., Musk- 
root). The root of Herula Sumbul Hook, f.; Order, Um- 
bellifere. This large perennial herb, belonging to the 
asafcetida-, galbanum-, and ammoniacum-yielding group 
of the family, has a large, rather short, cylindrical root, 
attaining a diameter of four or five inches, and a length 
of say a foot, when it divides into several stout branches, 
and a tall, erect, rather simple stem, six or eight feet in 
height. The leaves are large, tripinnate, with broad, 
sheathing petioles. Flowers small, greenish, polygam- 
ous, in compound naked umbels. All parts of the plant, 
but especially the root, exude a resinous, fragrant, milky 
juice (Bently and Trimen, 131). The sumbul plant is a 
recent addition to medical botany, having been discoy- 
ered by Fedschenko in Central Asia, in 1869. The root 
itself as a perfume, and afterward as a medicine, ap- 
peared in Europe about 1840. 

Sumbul root comes in transverse slices, one or two or 
more inches in diameter, and from one-half to an inch 
in thickness; the surface of these dried disks is a dirty 
brown, or gray marbled with dirty white ; the edges have 
a dark, loose, papery bark. Resin drops can be seen 
on it by aid of alens. The tissue is hard, but spongy ; 
odor decidedly like that of musk, but weaker. 

ComposiTion.—The most important constituent is the 
resin, of which there is nine per cent. (Flickiger) ; it has 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


a musky smell, more developed in contact with water, 
and a bitter, aromatic taste. The root contains also a 
small quantity of dull-bluish colored oil. 

Action AND UsE.—Sumbul has not any important 
medicinal value; like asafcetida, and its namesake, 
musk, it is gently stimulant and slightly anti-spasmodic, 
and may be given for the same nervous conditions as 
they ; but its principal employment is in the preparation 
of some perfumes, where it takes the place of musk. A 
tincture (Tinctura Sumbul, strength +!5) is officinal. 

ALLIED PLANTs.—See ANISE. 

ALLIED DruGs.—AsAFa@TIpA, Musk, VALERIAN. 

W. P. Bolles. 


SUMMIT MINERAL SPRING. Location and Post- 
office, Harrison, Cumberland County, Me. 

Access.—By the Grand Trunk Railway to Norway 
Station ; thence by conveyance nine miles to the spring. 

ANALYsIs (46° F., F. L. Bartlett).—One pint contains : 


Grains. 

Carbonate of soda and potassa...................... 0.175 
Carbonatelof magnesia) Sir). o2 H0..cckin anak cee eee 0.031 
Carbonate otslime preety en ee). eee ore 0.123 
Ohiloride ob sodium. srs wo renee chvacin hetiansteee oo cis 0.021 
Oxdeotiron:and alumina. 2... een eae cee. traces 
RSLLI CAI rae Sra ga cletae Settee lhe Sen sma aen, cote nas ate 0.122 
Organiciand volatile: matters ..j.e0 a-ei ene eee 0.029 

TOCA Ran crete wep sae ee crretccemes cs So So oa 0.501 


THERAPEUTIC PROPERTIES.—This is almost an abso- 
lutely pure water, and on that account alone it should 
be valuable as a solvent and general tonic. The State of 
Maine abounds in these pure springs, some of which 
have established reputations as therapeutic agents—for 
example, the Poland and the Underwood Spring. 

Gb ar. 


SUMMIT SODA SPRINGS, Location, Alpine County, 
Cal. 

Accrss.—By Central Pacific Railroad to Soda Springs 
Station ; thence by stage twelve miles to the springs. 

ANALYSIS.—One gallon contains : 


Grains 

ibicarpanate: Of limen stuns per eniae site tala ciel « se ioe te 43,20 
Carbonate of marnesiay clo. sseiecs cs ste scares ke cece 4,20 
Carponave: orsodares ween wares ae weeks nice Ac. cealecs 9.50 
GQioridetol sodium psa ceo tke oak scree atatd anes 26.22 
Oxiictotelronsryrs see sae oie ie 3 oie aoe tbiefs.s 625 eteas 1.75 
SHEE: Gudlniaey ab PAS Se OIC aan Be a See On cre F 2.06 
JRAUC NGOS UTTER, meen BASS OEE 24 eR ce A Baer as, rey a a aie Me TEN 
[POGAR RA Rees hee ae on he ow aotatele's Wao ails cia trace 
a MOTE ate GS ROR Oe einec, ha Heiner S Pa cmusee 88.68 
Cub, in 

Oarbonieiacideae maine rts: cece cock hues nice oe eee 186.35 


THERAPEUTIC PROPERTIES.—The presence of so large 
‘a proportion of carbonic-acid gas in this water, together 


with the oxide of iron, furnishes the latter in a very de- . 


‘sirable form—that of the carbonate. There is no doubt 


but that this water will eventually prove very popular as. 


a tonic and alterative agent. 

These springs are situated in the Sierra Nevada Moun- 
tains of Eastern California, at an altitude of about seven 
thousand feet. Game abounds in the surrounding coun- 
try. From the latest accounts no hotel had yet been 
erected at the springs. Ger Bas 


SUNDEW (Drosera, Codex Med.), Drosera rotundifolia 
Linn.; Order Droseracee. 

This little plant, and others of its genus, have been 
used now and then for generations in medicine, generally 
for phthisis, and as often have fallen into neglect. They 
“appear to contain, besides ordinary vegetable products, 
a peculiar acid, irritating to the skin. In common with 
other insectivorous plants, the glandular hairs of the 
leaves secrete a substance capable of dissolving albumin- 
ous substances. They have probably no medicinal value, 

ALLIED PLANTs.—The most interesting plant in the 
order is the famous Venus Fly Trap, Dionea Muscipula, 
of North Carolina, whose leaves close like the jaws of a 
steel trap upon unfortunate insects alighting on them. 

W. P. Bolles. 


Sulphuric Acid. 
Superfoetation. 


SUPERFCTATION. By this term we mean the im- 
pregnation of a female already pregnant. Superfcetation 
proper must be clearly distinguished from superimpreg- 
nation (superfecundation). Most writers admit the pos- 
sibility of the latter: 7.e., that two ova belonging to the 
same period of ovulation can be fecundated during sex- 
ual intercourse practised by the same or different persons 
near the same period of time. This seems to be proved 
by that class of cases in which the same woman has 
given birth to twins bearing evident traces of being the 
offspring of fathers of different races. 

Dr. Mosely tells of a negress who brought forth two 
children, one a negro and the other a mulatto. She said 
that a white man on the estate had had intercourse with 
her directly after her black husband had quitted her. Rev. 
Dr. Walsh narrates the case of a creole woman who had 
three children at a birth, of three different colors—white, 
brown, and black—with all the features of the respective 
classes. Fodéré, on the authority of Buffon, records the 
case of a woman who gave birth to twins, one being 
white and the other black. She confessed that immedi- 
ately after her husband had left her she was forcibly 
raped by a negro. Dr. Nowlin reports the case of a 
negress who gave birth to twins, one a pure African, with 
all the typical features of that race, and the other a very 
bright mulatto, exhibiting evident characteristics of the 
Caucasian race. The mother was a pure black, with all 
the typical features of the African, as was also her hus- 
band. Upon inquiry, he ascertained from the mother 
that she had permitted intercourse with a white man the 
day succeeding the same act with her husband. Such 
cases seem to have been very common in slave-holding 
countries, and Beck gives nearly half a page to such 
references. 

Scanzoni, who rejects even the idea of superfecunda- 
tion, explains such cases on the ground that children 
sometimes resemble the father and sometimes the mother, 
both in features and complexion. In twin pregnancies 
one child may resemble the father and the other the 
mother ; and it seems quite possible that all that is nec- 
essary for the production of a black child and a white 


one is cohabitation between a black man and a white - 


woman, or, what is vastly more common, a white man 
and a black woman—one child resembling the father and 
the other the mother. Few, however, agree with Scan- 
zoni in this view, and the possibility of superfecundation 
is pretty generally admitted, being based chiefly on what 
we know from comparative physiology. 

On the other hand, the possibility of superfcetation has 
been vigorously opposed by many writers, and the evi- 
dence in its favor leaves much room for doubt. The 
idea implied is, that a woman who is already pregnant 
may, at a stage of pregnancy more or less advanced, 
again conceive, and carry at the same time the fruit of 
two conceptions between which there must be a consider- 
able interval. 

It is admitted by all that superfcetation may take place 
in extra-uterine pregnancy, and in cases of double uterus 
or bilocular uterus. An example of this is reported by 
Montgomery, in which, while the product of an extra- 
uterine pregnancy remained encysted within the abdo- 
men, the woman bore three children. Dr. Steigervahl 
records a similar case, and Dr. Cliét, of Lyons, reports 
a very interesting one in which a woman died suddenly, 
and at the post-mortem examination there was found an 
extra-uterine foetus of five months in the abdomen and 
a foetus of three months in the uterus. 

A careful analysis of the so-called cases of superfceta- 
tion shows conclusively that the phenomena in most of 
them can be explained by twin pregnancies. But, onthe 
other hand, there are numerous examples advanced in 
support of this idea which cannot be explained by this 
hypothesis. 

One of the arguments is based on the cases in which 
two living children have been born at different and 
widely separated periods. The following are the inter- 
vals in some of these cases: Four and a half months, 
Marianne Bigaud; five and a half months, Benoite 
Franquet ; five months, a woman of Arles ; seventeen 


687 


Superfcetation. 
Suspension Splint, 


weeks, a case of Dimerbroeck ; six weeks, a case of 


Lebas; four weeks, a case of Dr. Moebus; fifty-two | 


days, a case of Thielmann; forty-two days, cited by 
Fordyce Barker; one month, Giuseppe Generali (vide 
Ganahl, ‘‘ Superfcetation,” Paris, 1867). Supposing that 
two children be born at an interval of four months, and 
both be capable of being reared, we must acknowledge 
that superfcetation is probable, or admit that a five- 
months’ child is capable of being reared, which is in the 
highest degree improbable. 

Another argument is advanced by Dr. Bonnar, who 
gives a number of cases in which children born in wed- 
lock succeeded each other with very unusual rapidity. 
The question of superfcetation is here looked upon from 
a different point, in reference-more particularly to the 
period after parturition at which the female procreative 
organs are again capable of exercising their functions. 
He gives three cases in which there intervened between 
the two deliveries 182, 174, and 127 days respectively ; 
and all the children were sufficiently developed to be 
reared and, without exception, to reach maturity. In the 
latter case, subtracting from the interval (127 days) which 
occurred between the two deliveries 14 days, which Dr. 
Bonnar assumes to be the earliest possible period at which 
a fresh impregnation can occur after delivery, we reduce 
the gestation to 113 days—that is, to less than four months. 
As both these children survived, the second child could 
not possibly have been the result of a fresh impregnation 
after the birth of the first; nor could the first child have 
been a twin prematurely delivered, for, if so, it must 
have reached only a little more than the fifth month, at 
which time its survival would have been impossible. 

In regard to the objections based on the supposition that 
the decidua so completely fills up the uterine cavity that 
the passage of the spermatozoa is impossible, we may say 
that the decidua reflexa does not come into apposition 
with the decidua vera until about the eighth week of 
pregnancy, and, therefore, until that time there is a fre 
space between the two membranes. 

Lastly, respecting the cessation of ovulation during 
pregnancy, this no doubt is the rule, but there are, how- 
ever, a sufficient number of well-authenticated cases of 
menstruation during pregnancy to prove that ovulation 
is not always absolutely in abeyance. 

Therefore, the most reasonable conclusion seems to be 
that, although the vast majority of cases of so-called su- 
perfcetation can be explained by twin pregnancies, there 
is a small number of cases which cannot be explained 
upon this hypothesis, and this makes the existence of su- 
perfcetation seem probable. Dilion Brown. 


SUSPENSION SPLINT, HODGEN’S. The value of 
extension in the treatment of fractures of the femur is 
universally conceded. The effort to obtain continuous 
extension with immobility has resulted in a multiplicity 
of methods of treatment, some of which are compli- 
cated and troublesome, others cruel and inefficient. The 
most simple and effective continuous extension is found, 
I think, in oblique suspension, as first advocated by Na- 
than R. Smith, when he introduced his anterior splint. 
Suspension, with the amount of traction determined by 
the obliquity of the suspending cord, is more easily ap- 
plied and efficiently maintained in that modification of 
Smith’s anterior splint devised and so successfully used 
by the late Dr. John T. Hodgen, of St. Louis, than by 
any other method. This splint, in the hands of an ex- 
pert, secures nearly perfect immobilization, and extension 
so equable and effective as to give practically perfect re- 
sults. The freedom of motion allowed to the patient does 
not interfere with immobilization of the fractured bone. 

The illustration shows the splint in use, with leg sus- 
pended, as for the treatment of fractures of the thigh. 
The simplicity of the structure of the splint is evident, 
and the manner of the suspension of the leg is made 
plain. The leg is resting on muslin strips which pass 
under it. These are secured by pins at each end, after 
overlapping the arms D E and D’ E’ of the splint. Each 
strip supports its proportion of the weight of the leg. 
These strips extend from the heel to the gluteal fold. 


688 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


The adhesive strip H, softened by warmth or by turpen- 
tine, is applied to the leg, and secured in position by a 
roller which extends as high as the knee. This strip 
secures the leg in the splint, since it is fastened by the 
cord and block N to the foot of the splint at F. 

The splint itself is composed of a single piece of No. 2 
wire, bent as shown in Fig. 3746. The sliding hooks 
D, D' and E, E’ are used for attaching the suspending 
cords to the splint. The use of the arch O is to maintain 
the proper width of the splint at its upper end, viz., 20 
or 25 ctm. (eight or ten inches), This arch is loose, and 
is easily slipped over the ends of the wire which forms the 
splint before the latter is applied to the leg. The width 
of the splint at the foot is about 10 ctm. (four inches), 
and is determined by the bend in the wire which forms 
the body of the splint. The wire hooks E, E’ and D, D’ 
present at one end a free loop for the attachment of the 
supporting cord, while the other end is coiled somewhat 
snugly about the lateral bars of the splint (at D and E). 
The lateral bars, to which the muslin strips are attached, 
extend upward on each side of the leg, so that the two 
ends of the wire reach, the one to a point above the 
pubes, and the other, on the outside, nearly to the crest 
of the ilium. The bend in the splint at the knee permits 
slight flexion of the leg. 

The distance from the foot of the splint to the bend of 
the knee is 56 ctm. (twenty-two inches), and from the 
angle to the upper free ends 50 ctm. (twenty inches). The 
suspending apparatus is composed of, first, the pulley A, 
which is fixed in a framework over the bed, or, prefer- 
ably, in the ceiling; secondly, the sliding block B, and 
the cord B, A, C; thirdly, of the two cords D, C, E and 
D’, C, E’, of equal length, and with a loop at each end 
for attachment to the wire hooks at D, D’ and E, EH’. 
These cords are passed through a loop in the cord at its 
end C. The suspension of the leg and splint is readily 
accomplished by sliding downward the block B on the 
cord B, A, C. 

The splint, as stated above, is a modification of Nathan 
R. Smith’s anterior splint, the lateral arms being sub- 
stituted for the anterior wires, to which the leg in his 
splint was secured by a roller bandage. Here the leg is 
sustained by the muslin strips, any one of which can be 
readily and quickly changed so as to give increased or 
diminished support to any part of the leg, thus maintain- 
ing the proper outline of the bone during the rapid 
atrophy of the soft parts which ensues upon theen forced 
rest of the limb. 

The extension is maintained through the adhesive strip 
H, which, extending from one tuberosity of the tibia to 
the other, across the board N at the sole of the foot, 
is fastened by a cord to the cross-bar at F, and thus 
securely holds the leg in the splint. Through this me- 
dium the extending force is transferred from the splint 
to the leg. The board at the sole of the foot should be 
as wide as the adhesive strip, and about 7 or 8 ctm. 
(three and one-half inches) long. It then protects the 
malleoli from the lateral pressure of the adhesive strips 
through which the extending force is applied. 

The splint as shown in Fig. 3745 is cheap, and readily 
made by any blacksmith. The splint as represented in 
Fig. 3746 is more expensive, but can be adjusted to a 
leg of any size. 

The lateral bars B and C are hollow square tubes, 
furnished with thumb-screws at their extremities, B, C. 
These tubes are of sufficient size to admit the terminal 
ends of the lateral bars, and by pushing in or pulling 
out the extremities of the lateral arms the length of the 
splint may be varied. Its width can also be changed by 
sliding the lateral arms into the hollow tube A, A, which 
is furnished with thumb-screws at A, A. The splint is 
fitted by sliding B, A and C, B to the proper point, and 
securing them by setting the thumb-screws at B and C. 
The hooks D, E, for suspending the splint, slide on the 
lateral bars B, C. The splint is used in the same man- 
ner as the one before described. The foot-piece P is to 
prevent passive extension of the foot. Its use is optional 
with the surgeon. Its chief utility is found in cases of 
compound fracture of the leg. The foot-piece here 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


shown is a thin board fastened to the heavy cross-wire, 
which is curved so that one end fits around the lateral 
arm of the splint, and the other is so bent as to maintain 
the foot-piece at its proper angle. Dr. J. Freund, of 
Champion, Mich., has devised a foot-piece which answers 
a good purpose. It is held in position by two transverse 
slips of wood fastened by thumb-screws, and _ has the in- 
clination of the foot-piece maintained by 
a third thumb-screw which is fixed in 

A one of the transverse slips. 
The application of the Hodgen sus- 
pension splint is simple and, in 
skilful hands, painless. Suppose 
the leg, with its fractured fe- 
mur, is resting upon the bed. 
A roller bandage is applied to 
the foot and ankle, to pre- 
vent swelling, excoriation, 
or. tenderness, from the 
pressure of the bandage 
or of the adhesive strips 
on the malleoli. Then 


| 


rosy _! de 
SSS EEUZ”™ iis ae 


= 


(WGCH, 0.0... eA 


SS 
Fra. 8745. 


the adhesive strip H, with its foot-piece and cord, is 
placed in position, an assistant grasps the foot with one 
hand, and, with the other hand under the knee, lifts the 
leg from the bed, while at the same time he makes steady 
extension of the femur. The surgeon then continues the 
application of the roller as high as the knee-joint, and 
thus secures more perfect adherence of the plaster to the 
leg. The leg is again allowed to rest upon the bed, but 
the assistant maintains moderate traction on the foot, so 
as not to relax extension of 

the fractured bone while an 

the splint is put in posi- 
tion. <A late- 
ral arm of the 
splint is placed 
upon either 
side of the leg, 
and the cross- 
bar is brought close to the sole of 
the foot. The cord and block N, 
with the adhesive strip, is now fas- 
tened to the foot of the splint. 
Strips of muslin are passed under 
the leg, one at the ankle, one at the 
knee, and perhaps two at the thigh. These are secured by 
pins to the lateral arms of the splint, while it is held with 
its upper end so that the inner arm is above the pubes, 
and its lower end is on a level with the malleoli. The 
leg can now be suspended by attaching the cords D E 
and D' KE’, and adjusting the slide B so as to lift the 
splint and leg from the bed. The cradle of cloth strips 
upon which the leg is to rest, is now made complete by 
adding strips of muslin, and adjusting them to the out- 
line of the leg as indicated in the cut. The upper end 
of the §vire which is to be above the pubes, may be bent 
upward to permit greater freedom in the movements of 


Vou. VI.—44 


a 
pea a 


Superfeetation. 
Suspension Splint. 


the body. No special or violent attempt at adjustment 
is made, nor is it necessary, except where there is marked 
lateral displacement, as in some transverse fractures. 
The free swinging of the leg, and the efficiency of the ex- 
tending force, secure a perfect adjustment in a few 
hours. The fracture sets itself. The degree of exten- 
sion is regulated by the obliquity of the cord and the 
weight of the leg, 

If the pulley through which the cord passes is fixed in 
a ceiling which is 8 or 4 metres (9 to 12 feet) high, a per- 
pendicular line dropped from the pulley should fall from 
20 to 380 ctm. (7 to 10 inches) beyond the foot of the 
adult patient. In the case of a child, where the weight 
of the leg is less, the obliquity of the cord should be 
greater. Or, to express it more accurately, the obliquity 
of the cord should be sufficient to make an angle of 
from 15 to 25 degrees with the perpendicular. If there 
is any tendency for the patient to slide toward the foot 
of the bed, it may be obviated by raising the foot of 
the bed by means of blocks. In the case of a child it 
may be well, in addition, to pass a cord loosely about 
the body under the arms, and fasten it to the head of the 
bed, to serve as a check to any great change in the posi- 
tion of the patient. 

The degree of extension necessary to accomplish the 
result desired, may be determined in part by the sensa- 
tions of the patient. The position of comfort is the one 
of safety, as extension is required only to overcome the 
contraction of the muscles. The counter-extending 
force is the weight of the body. 
Much less extension is required 
in such splints as suspend the 
leg and remove the resistance 
of friction of the leg on the bed, 
than is required when the leg 
rests upon the bed, and weight 
and friction are first to be over- 
come. It is never necessary, 
when using the splint, to apply, 
in the case of an adult (as rec- 
ommended by Hamilton when 
speaking of other methods of 
making extension), twenty pounds as an extending weight; 
or, as he states it in his work on ‘‘ Fractures and Disloca- 
tions,” published in 1880, ‘‘ one pound for a child one year 
of age, two pounds fora child two years of age, and so on, 
adding one pound for each year up to the twentieth.” An 
extension of twenty pounds, applied through an adhesive 
strip to the leg, and pulling upon the knee-joint and femur, 
is a serious trial to the patient’s endurance, and it taxes 
the surgeon’s ingenuity to maintain steadily such a force. 


Fia. 3746. 


The amount of extension required in this suspension 
splint is much less, being from three to ten pounds. 
This is all sufficient, for there is no friction to overcome, 
and so long as the patient maintains a position in bed 
approximating the ohe he occupied when the splint was 
adjusted, there is no variation in the extending force. It 
is quiet, persistent, non-irritating, and effective. There 
is no perineal band to fret and worry the patient. The 
extending force is determined by two factors, and these 
are entirely within control of the surgeon, viz., the ob- 
liquity of the extending cord, and the weight suspended. 
The first can be varied by the relative position of the 
bed and the suspending pulley, and the latter can be 
increased if desired by placing sand bags across the lat- 
eral bars of the splint. The weight of the leg distributes 
some of. the extending force to each of the muslin strips 


689 


Suspension Splint. 
Sycosis,. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


upon which it rests, and thus diminishes somewhat the 
traction upon the adhesive strip. 

It seems difficult for some persons to understand how 
extension can be applied to a fractured thigh by direct 
traction upon the leg, without counter-extension through 
a perineal band. They fail to recognize the efficiency of 
the weight of the leg and the stability of the body, asa 
counter-extending force. The amount of the extending 
force that is transmitted through the adhesive strip in 
the suspension splint, may be measured by substituting a 
spring balance for the cord, which in the cut connects 
the block N with the foot,of the splint. A small portion 
of the extending force is, however, transmitted through 
the strips which support the limb in its cradle, and those 
who wish can, by mathematical formule, compute the ex- 
tending force. 

Professor Francis E. Nipher, of the Washington Uni- 
versity, and Dr. A. K. Worthington, used the 
following formule for determining the extending 
force (the line D in the diagram (Fig. 3747), rep- 
resents, approximately, the line of the splint and 
of the femur) : 

The pull on the short cords, C E, 
and C EH’, and also that on C D, and 
C D’ (see Fig. 3745), can be accurately 
measured. ‘The angles a and 6 (Fig. 
38747) can also be measured. The trac- 
tion force along C 
EK, and C E’, is rep- 
resented by A, and 
A. that along C D, and 
CD’, by B. 


Sanwe neces seme ewe aE 


‘] 
4 
a 
8 


ieee 


Fia. 3747. 


The forces A and PB being known, as also the angles a 
and b, we can readily calculate the horizontal compo- 
nents, F and F’. The resultant of F and F’ will represent 
the direct traction force exerted along the line D; or the 
amount of efficient extension applied in the line of the 
femur. 

In a particular case, where the patient weighed 150 
pounds, and the suspending cord, C (or in Fig. 3747, A, 
B, C) formed an angle of 15° with the perpendicular : 


It was found that the pull........... 


A = 11.5 pounds, 
BUC ENG PULL ee aha tice as ieee eens 0.5 hd 


Berk 


Ln e an ols saeae eeecn oer care oveeteicle cies ree rey “APOE 
PURE ANP ICR west. ee dees aes whines Deeb 
Hence, by trigonometry............. F = A os. a, 


Ce hae wince RSet eae oie wren einige ss F’ = B cos. b. 

F = 11.5x cos, 40 = 8.8 pounds. 
BY A(: kx COR. 1b = 210 ee 
F and F’ = 6.1 pounds. 


ey 


F and FE” act in different, opposing directions, hence 
their resultant is the difference between them, or 6.1 
pounds, which represents the amount of the extending 
force applied to the femur in this case. If the angle C 
was increased to 36°, it was found: 


Tnatithe angle® sae cese one aien csi icsee secs as cles 
sé as 


eC 


and the force or pull on 
the angele och ee soe ee RRs Paty ce old wo ¥ al cls:'s Sos 
é 


Here the forces F and F”’ are exerted in the same di- 
rection, since the angle is greater than a right angle, 
and their resultant is the sum of the forces which (by 
the same formule as before) is found to be 14.7 pounds. 
The weight of the leg was estimated at 21 pounds. 

The loop OC, in the cord B, A, C (Fig. 3745), is loose 
and can be slipped along the cords D, C, E, and D’, C 


690 


KE’, so that the angle made by these cords with the splint 
can be changed with the obliquity of the suspending 
cord, B, A, C. : 

The leg is open for inspection, and the supporting 
strips can be readjusted as the parts atrophy. The slight 
natural anterior curve of the femur can be maintained. 
The circulation is undisturbed, the nutrition is not inter- 
fered with by the pressure of the retentive apparatus, 
and is as perfect as it can be during the enforced quiet. 
The leg can be kept cool or warm, as desired. The pa- 
tient may sit up or lie down, as comfort suggests. The 
bed-pan can be used without disturbing the fracture, and 
the best possible result can be obtained, viz., no shorten- 
ing and early union, without bed-sores or any of the con- 
stitutional complications which are liable to follow con- 
finement in a fixed position. 

The flexion of the knee is sufficient only to put the leg 
in a comfortable position, relaxing slightly the tension of 
the hamstring muscles and the gastrocnemius. The 
slight flexion of the thigh on the pelvis puts at rest the 
psoas and iliacus, and the rectus extensor of the thigh. 
The muscles are placed in a state of equilibrium. 

The splint is well adapted to the treatment of all frac- 
tures of the femur, whether they are intra- or extra- 
capsular, through the trochanters, the shaft, or the con- 
dyles. Nor does the age of the patient interfere with its 
use, though a fixed dressing may be more convenient for 
children under six months or a year of age. 

After a long and successful experience with the splint 
in private practice and hospital work, and after having 
observed its employment by the late Dr. John T. Hodgen 
during the last fifteen years of his life, 1 know of but 
one practical difficulty which arises in its universal and 
immediate use in all fractures of the femur. This objec- 
tion pertains only occasionally to the fractures of the 
middle third of the bone in children. These exceptions 
are rare, extremely so, and if a perfect adjustment of the 
extending force to the necessity of the individual case 
could be obtained at once, they would be reduced to a 
minimum, The objection is found in the spasmodic 
contraction of the muscles, which at times is so frequent 
and violent, immediately after injury, that some lateral 
pressure is necessary to the comfort of the patient. This 
spasm may in part be controlled by lateral supports to 
the thigh, or by permitting the leg to rest upon the bed 
with extension applied after Buck’s method. No form 
of dressing will uniformly control it. After this irrita- 
bility subsides, the leg is more comfortably and more ef- 
ficiently treated in the suspension splint. This clonic 
contraction of the muscles is more likely to be present if 
the extending force is in excess of the necessities of the 
case. The excessive tension acts as an irritant to the 
muscles. ; ' 

Fortunately these cases are rare. Clonic contractions 
will, in isolated cases, occur in any splint and under any 
plan of treatment, for no lateral support or compression 
can prevent the contraction which accompanies a muscu- 
lar spasm. 

Opiates are sometimes useful, in the case of nervous 
children, for a few days after such an injury is received. 
The splint, and the manner of applying extension, af- 
ford the most perfect means of neutralizing the tonic 
contractility of the muscles, which so often determines 
shortening. The oblique suspension gives continuous 
and equable extension of an amount sufficient to accom- 
plish a perfect result, without waste of any force, and it 
insures to the patient the most perfect liberty attainable 
by any known means compatible with comfort and safety. 

H, H. Mudd, 


SWEET CHALYBEATE SPRINGS. Location and 
rede bogs Sweet Chalybeate Springs, Alleghany Coun- 
ty, Vie. 

Accrss.—By the Chesapeake & Ohio Railway to Al- 
leghany Station; thence by stage about ten miles to the 
springs. 

THERAPEUTIC PROPERTIES.—This is a famed afd val- 
uable calcic-chalybeate water, used either as a beverage 
or for bathing. ‘There are four springs, differing little in 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Suspension Splint. 


Sycosis. 
composition. The water is sparkling, and has a sweet ANALYSIS. —One pint contains ; 
and ferruginous taste. It is indicated in all conditions : Grains 
accompanied by anemia, ehlorosis, etc. eh Fata: ee ey biel g Vojatitnasiinas oallatee anand ce pe 
These springs are located in the western part of Vir- Ohloride.oteodiam 0.7, el ids Nov akccaese sss. <0,087 
ginia, in a valley of the Alleghany Mountains, amid the Chloride of magnesium .... 0.0.00. ...e cede eceesnue ee 0.039 
beautiful scenery of that section. There are good hotel paacuncbovsiee Pphang Osh) Tek Aaa ee tn iat REE eae 
accommodations and bathing conveniences of all kinds. Sulpball oc Riaeaen MN ne he eye 1 tee 
The flow is eight hundred gallons per minute. Sulphate of lime............ AREA Cel SP Aas aie 1.646 
ALYSIS.— Peroxiderok ironic, Vata nin waiieee fie ee aks te reise 0.018 
AN 5 enine SODIN Geir cols Gee ae oat ET ORs ie as ee een « trace 
CiArOmAte OS NING ood odaqs - Uns cide tile save Sas cites 0.887 ae PR GR DMN re ate or pees De ian met gosiece! pinot: 
BUNOF Ne Gedo tehtte Wa sae en oy die «bea 0.011 Srp irhe amar gains NN EO oe Pa a es 
Chloride of magnesium ... 0.196 
Ghivtide of Galsium). (abu 0.003 SOCAL hehe laid sie cle aie Ra ua eee eile Peeters era ci 7.586 
Sulphate of soda.......... 0.404 Cub. in 
Sulphate of magnesia ..... 0.897 Carbonic-acid) Gass .cwe sticks sais seeder elec oe ante ce te 11 
Sulphate of lime.......... 4.110 
Sesquioxide of iron .......... Sb. Eat ORE OPA eae 0.092 THERAPEUTIC PROPERTIES. —These are well-known 
ee ie and valuable calcic waters. Their natural temperature 


Carbonic-acid gas, 13 cu. in. Temperature, 75° F, 


Average temperature at hotel : 


6 A.M. 12 Mm. 6 P.M. 
July 2 to September 5, 1870... . 703¢° 841g° ick 
July 24 to August 19, 1871...... 65° 80° 78° 


George B. Fowler. 
SWEET SPRINGS (MO.). 


Mo. 
Post-office, Brownsville, Saline County, Mo. 
Accress.—By the Lexington Branch of the Missouri 
Pacific Railroad to Brownsville ; thence by stage one 
mile to the springs. 
Awnatysis (C. P. Williams).—One gallon (231 cu. in.) 
contains: ~ 


Location, Saline County, 


Sweet Springs. Akesion Spring. 


Grains. Grains. 
Chloride of sodium ............. 86.91773 %56.11398 
Chloride of potassium........... 3.39796 28.56395 
Chloride of lithium ............. 0.04756 0.29886 
Chloride of magnesium ......... 22.29123 87.31837 
Chloride of calcium...........-- 14.72127 %4.79091 

G@arbonutaor lime merc. cc.. ees O:5651 27s ey Werte: 
@arbonaterot iron. <2 o.ce eens 0.56656 0.26683 
Carbonate of manganese ........ 0.00190 0.19911 

Sulphate of lime......... ...... 940913 airs ee cre ki es 
Bromide of magnesium ......... 0.11802 0.13108 
IMapneslumi nitnater is Josh oseces  s-esee 0.17805 
AINIMONIMIM NIETALG Hon. selec cles.< se eGlela's 1.17193 
SOCIUIM EU PHIGE ese Sale ere Semis te! ves s ee : 2.60873 
Galciini sulphitens oes. cece. eosje | veMe alee 57.93380 

BATU SU IDHAGG eo uroee sass ceneiee ne asleiers 8.15046 °, 

Calcitm phosphaterc...s..ccseen oc pe kten 0.24267 
Oalcium, cCarbonate...’......... ... Dearne 40.25091 
= PALUIRIEN A Hert omclere cole sie cles 0.08921 0.16679 
SUlicae ee Ne siete cha eieeta thy; 1.08471 0.51319 
Organic, mation es 2s. 5 wos cc. 4.01300 8.04696 
Toba de tet easats salaic 152.27140 1,052.94695 


THERAPEUTIC PROPERTIES.—The Sweet Spring is a 
mild and agreeable saline water, of efficacy in digestive 
and urinary disorders. The Akesion is a very strong 
saline, impregnated with sulphur, and is much employed 
as an active cathartic. 

The extensive and commodious baths add greatly to 
the comfort and remedial value of this resort. 

These springs are located in Western Missouri, on the 
bank of the Blackwater River. The hotel, a large build- 
ing with modern appliances for convenience and com- 
fort, stands in a well-shaded lawn of thirty acres, and, 
with the numerous cottages, affords the best of accom- 
modations. The arrangements are most complete for all 
descriptions of baths, including two plunges, each thirty- 
four feet in diameter. The baths are supplied from the 
salt-sulphur springs, five miles distant, the water being 
pumped at the rate of two hundred thousand gallons per 
day. In addition to the above two springs there are 
two others, the White and the Black Sulphur, the waters 
of which are supplied when desired. 

Grabs i. 


SWEET SPRINGS (W. VA.). Location and Post-office, 
Sweet Springs, Monroe County, W. Va. 

Accrss.—By the Chesapeake & Ohio Railroad to Alle- 
ghany Station ; thence by stage ten miles to the springs. 


is about 75° F., which renders them very popular as 
baths. The contained carbonic-acid gas and the slightly 
sweetish taste (common to calcic waters) induce one to 
drink of the waters freely, and thus diuresis and mild 
catharsis is promoted. We are of the belief that their 
value in gravel, dyspepsia, and sterility is due chiefly to 
the quantity which one is able to take, thereby establish- 
ing a physiological condition of the secretive organs, 
rather than to any contained ingredients. 

These springs are located in a beautiful valley, be- 
tween the Alleghany and Sweet Springs Mountains, at 
an elevation of two thousand feet above the sea. The 
surrounding country is charming, and affords numerous 
delightful drives and walks to many points of interest. 
The hotel and cottages, built of brick, afford first-class 
accommodations for eight hundred guests, 

The bath-house is arranged to supply hot and cold 
baths, of either mineral or pure water, and contains two 
large plunges, about sixty by thirty feet. The flow of 
the springs is eight hundred gallons per minute. 

Gobet: 


SYCOSIS, sometimes called sycosis non-parasitica, to 
distinguish it from tinea sycosis, is a chronic inflamma- 
tory, non-contagious disease of the skin, involving the 
hair-follicles, characterized by the formation of pustules, 
papules, and tubercles, which are perforated by hairs. 
The subjective sensations are burning and itching. The 
disease is confined to the beard and hairy parts of the 
face. Papules and then pustules form, each one having 
a hair as its centre, and showing little inclination to rupt- 
ure. The pustules are generally discrete, but are some- 
times so numerous as to be crowded together. They are 
accompanied by marked redness of the surrounding skin, 
sometimes by swelling, burning, and pain. Unless the 
suppuration is profuse, the hairs cannot be extracted 
without giving much pain. “The cause of the disease is 
not known. It sometimes, however, occurs on the upper 
lip, following nasal catarrh. It occurs equally in those 
who shave and in those who do not. The disease is es- 
sentially an inflammation of the hair-follicles. In the 
early stages the hairs are firm in their follicles, but when 
there has been a good deal of suppuration they become 
loose and may be pulled out. A cicatrix, with baldness, 
is then apt to result. 

Sycosis is apt to be mistaken for eczema of the beard, 
and more especially for tinea sycosis, or true barber’s itch. 
From the latter it is, however, distinguished by several 
marked characteristics. In both affections the hair-folli- 
cles are attacked ; but in the parasitic disease the lesions 
are simply large, rounded red lumps, or nodules of vari- 
ous sizes, with few or no pustules. ‘The hairs, however, 
in spite of the fact that there is no suppuration about their 
roots, come away easily, and sometimes drop out spon- 
taneously. The discovery of the spores of the vegetable 
parasite in the roots of the diseased hairs, when looked 
for under the microscope, will greatly aid in the diagno- 
sis. (See under Tinea.) From eczema of the beard, sy- 
cosis is distinguished by the absence of oozing or itching, 
and also by the fact that eczema rarely attacks the beard 
without showing itself elsewhere. It spreads about in 
crusts and pustules in the neighborhood, while sycosis is 


691 


Sycosis. [mitis. 
Sympath. Ophthal- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


strictly marked by discrete pustules, each with its hair 
running through the centre. 

External treatment is that most generally useful in sy- 
cosis. Exposure to irritating influences is to be avoided. 
The hair should be kept clipped close or shaved. ‘The 
latter is to be preferred. Although painful at first, it is 
in some cases absolutely necessary, if a favorable result is 
to be reached, that shaving should be practised every 
second or third day, according to the rapidity with which 
the beard grows. When shaving is to be performed for 
the first time, the hairs should be clipped close, and then 
a poultice should be applied to soften thecrusts, After 
such careful preparation, the use of the razor is much 
less painful than it would otherwise have been. Shav- 
ing having been established as a habit, the local medical 
treatment may be begun. When the disease is acute, and 
there is a good deal of pain and swelling, black wash 
may be thoroughly applied every two or three hours, fol- 
lowed each time, so soon as the skin is dry, by oxide of 
zinc ointment, gently applied by means of the finger, or 
spread upon soft linen and bound upon the parts, 

The following wash, not to be followed by ointment, 
is likewise of service in acute sycosis: BR. Pulv. zinci 
carb, precip., pulv. zinc. ox., 444 Gm. (3j.); glycerine, 
8 Gm. (3 ij.); liq. plumbi subacetat. dil., 8 Gm. (3 ij.) ; 
aquée rose, 240 Gm. ( % vijss.). 

In subacute cases the following wash is very good: RB. 
Sulphur. precipitat., 8 Gm. (3ij.); pulv. camphore, 
0.65 Gm. (gr. x.); pulv. tragacanth, 1.8 Gm. (9j.); 
aque calcis, 128 Gm. (Ziv.). M. Shake well, and apply 
from two to four timesaday. If ointments are to be 
employed, the following will be found soothing in the 
acute stage: R. Pulv. zinc. carb. precip., pulv. zinci ox., 
aa 4 Gm. (3j.); ung. aq. rose, 82 Gm. (%j.). M. To 
be applied immediately after shaving. Another conve- 
nient ointment, slightly more stimulating, is composed 
of 1 part of calomel to 82 parts of oxide of zinc oint- 
ment. 

When the affection is of long standing, and when there 
is much infiltration, sapo viridis should be well rubbed in 
with a flannel rag and a little water, then washed off, and 
finally diachylon ointment should be applied. Depilation 
is to be used only when the roots of the hairs are loos- 
ened by suppuration. 

The prognosis in sycosis should be guarded, for while 
some cases yield readily to treatment, others, particularly 
when the disease involves a considerable area of the face, 
last for months and even years. In spite of the most as- 
siduous attention, relapses are not uncommon. 

Arthur Van Harlingen, 


SYMPATHETIC NERVOUS SYSTEM, DISORDERS 
OF THE. Under this heading it is mainly intended to 
discuss the grounds for and against the commonly ac- 
cepted opinions as to the origin of certain troubles being 
due to disorders (functional or organic) of the sympa- 
thetic system of nerves. 

Although the physiology of the sympathetic has been 
advanced considerably within recent years, there has not 
been a commensurate advance in our knowledge of its 
diseases. 

In fact, with the exception of a few important symp- 
toms which we know to have a direct causal connection 
with alterations in the sympathetic, our knowledge of 
its diseases is very superficial and in many cases purely 
problematical. 

Of the many diseases that are attributed to changes or 
alterations in the:sympathetic, the following are the 
chief: Hemicrania, exophthalmic goitre, angina pectoris, 
Addison’s disease, diabetes mellitus, unilateral hyperidro- 
sis, glaucoma, neuro-retinitis, ophthalmia neuro-paraly- 
tica, etc. 

HEMICRANIA OR MiGRaAIneE.—In 1860 Du _ Bois-Rey- 
mond noticed, while suffering from an attack of migraine, 
that the temporal artery on the affected side was hard 
and cord-like to the touch, that the face on the same side 
was pale, and the eye retracted and injected. 

During the decline of the attack the ear on the affected 
side became warm and red. He concluded that the 


692 


cause of the attack was a tetanic contraction of the coats 
of the vessels on the affected side of the head. 

It is impossible to account for this spastic contraction 
on any other grounds than that there is an affection of 
the sympathetic or of its medullary centre. Du Bois- 
Reymond looked upon this spastic contraction as the fun- 
damental cause of the terrible pain present in these cases. 
He compares the pain to that of uterine pain in labor, 
and considers that it is due to pressure on the nerves 
of sensation in the muscular tissue. 

The above views so ably put forward by their distin- 
guished originator are, however, entirely inadequate to a 
proper explanation of the origin and course of a true 
migrainous attack. 

I think it must be admitted that true migraine is an 
essential neurosis—that it is, in fact, due to a discharge 
from the sensory area of the brain, ‘‘or in that part of 
the sensory area which is the anatomical correlative of 
the sensation of pain in the head.”! | 

The discharge is seldom, however, entirely limited to 
the sensory area of the brain, but is found to extend to 
other parts. Frequently it extends to the medulla, espe- 
cially to the vaso-motor centre. It is in this way that 
the vaso-motor phenomena are more truly explained. 
The discharge may involve the cilio-spinal region and in 
this way cause the oculo-pupillary phenomena occasionally 
seen during an attack. 

It will be seen, therefore, that the phenomena of sym- 
pathetic disorder present in migraine are only a result, 
and that only occasionally, of deeper-seated change. It 
is, therefore, according to this view, incorrect to speak 
of migraine being a disorder of the sympathetic system. 
Further, it is only on this view that a satisfactory expla- 
nation can be given of migraine. 

EXoPHTHALMIC GOITRE.—In spite of the able and per- 
sistent attempts made to explain the phenomena of exoph- 
thalmic goitre by attributing them to changes in the sym- 
pathetic, we are at the present time further away than 
ever from accepting such an explanation. At first sight 
it appears to be comparatively easy to explain wholly and 
completely the remarkable triad of symptoms by refer- 
ring them to lesions of the sympathetic system, but, on 
deeper examination of many reported cases, it will be at 
once apparent that this cannot be the true explanation of 
this affection. 

Very numerous opinions have been advanced at differ- 
ent. times as to the nature of this disease, at first attrib- 
uted to deficiency of the cellular elements of the blood, 
and afterward to organic lesions of the heart. 

Laycock was the first to include the disease among the 
pure neuroses. ‘Trousseau was the first to maintain its 
sympathetic origin. 

To discuss this subject fully, it will be necessary to 
deal with the symptoms individually. 

We will first treat of the cardiac palpitation, which is 
an essential symptom. It is always present. The other 
symptoms may be each and ali absent, and still we may 
have to do with exophthalmic goitre. They may all be 
present, but unless there is a greatly increased cardiac 
action accompanying them, then we have not to do with 
exophthalmic goitre. To account for this increased car- 
diac action, irritation of the accelerator fibres running 
in the sympathetic has been assumed, and to explain the 
dilated condition of the thyroid vessels, a paresis of the 
vaso-motor fibres running in the sympathetic had to be 
supposed. We are asked to believe that one and the same 
change brings about two distinctly opposite effects; viz., 
paralysis of one set of fibres (vaso-motor) and irritation 
of another set (accelerator). -This is certainly highly im- 
probable, but what is contrary to all sound physiological 
principles is, that any one set of fibres can remain in a 
constant state of irritation for many months or even for 
many years. 

Friedreich interprets the palpitation as being due to a 
paralysis of those vaso-motor fibres which supply the 
coronary arteries, and in this way leading to more blood 
being sent to the muscular tissue, and consequently to in- 
creased vigor of its ganglia. The unstable heart of the 
exophthalmic patients points to poverty of blood-supply 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


rather than to an excess. We therefore see, no matter 
on what grounds the sympathetic origin of the circula- 
tory derangements present in this disease is attempted to 
be explained, that they are entirely inadequate. 

If, then, the essential symptom of the disease be unex- 
plainable by supposing a sympathetic lesion, it is unlike- 
ly, indeed, that the disease can be brought about by such 
a lesion. 

The exophthalmos is no doubt due to various causes, 
increased fat in the cellular tissue of the orbit being one 
of these. This has been proved in a number of instances 
at the post-mortem examination. 

Those who contend for the purely sympathetic origin 
of this disease consider that the exophthalmos is prin- 
cipally caused by contraction of the muscles of Mueller, 
induced by irritation of the cervical sympathetic. 

As a proof of the very unsettled state of our knowledge 
of the nature of this affection, it is enough to say that 
other writers have attributed the loss of consentaneous 
movement between the globe of the eye and its lid to 
paresis of Mueller’s fibres. 

If exophthalmic goitre were really an affection of the 
sympathetic, we would expect to find changes in this 
nerve in fatal cases. Although, in afew of the recorded 
cases, changes have been found, post mortem, in the cer- 
vical sympathetic and its ganglia, there has been no con- 
stant relation between the severity of the symptoms 
present during life and the extent of the changes after 
death. Even coarse lesions of this nerve and its ganglia 
have been found in cases where, during life, there has 
been no suspicion of any exophthalmic goitre. Again, in 
well-marked cases of the disease, no changes have been 
found by such competent observers as Recklinghausen, 
Wilks, Paul, Ranvier, and Ross. 

One strong reason for thinking that the essential cause 
of the affection is elsewhere than in the sympathetic is 
the absence of any pupillary changes. It is hardly possi- 
ble to conceive of great changes in the trunk of the sym- 
pathetic without changes in the size of the pupil. 

There are facts of a positive character which point 
strongly to the central nervous system as being the seat, 
at least, of the principal and initial changes. 

Filehne has produced protrusion of the eyeballs, en- 
largement of the thyroid gland, and increased action of 
the heart in rabbits by wounding the restiform bodies. 

The rather frequent occurrence of glycosuria, and 
even diabetes, points also in the direction of the central 
origin of the trouble. So also do tremor and the extreme 
restlessness and sleeplessness which are frequent symp- 
toms. Insanity in various degrees is also corroborative 
of this view, and, lastly, may be mentioned cases of this 
disease complicated by ophthalmoplegia externa. There 
is, for instance, the well-known case of Warner and Bris- 
towe, where, in addition to ophthalmoplegia externa, there 
was bilateral paresis of the seventh and fifth nerves, and 
tremor of the legs. Another strong clinical argument for 
the central origin of this disease is that, at times, it has 
been seen complicating progressive muscular atrophy— 
accompanying this disease as does bulbar paralysis. 

The evidence adduced is, I believe, sufficient to prove 
that the cause of exophthalmic goitre is due to certain 
changes in the medulla. These changes principally af- 
fect the vaso-motor centre. What their precise nature 
may be is unknown. 

Jendrassik” maintains that they are of an inflamma- 
tory nature. He considers that exophthalmic goitre is 
due to a polio-myelencephalitis. 

UNILATERAL PROGRESSIVE ATROPHY OF THE FAcrE.— 
There are several cases on record where undoubtedly 
this disease was directly due to some injury of the sym- 
pathetic in the neck. The vaso-motor and trophic fibres 
of the face run in the sympathetic before passing to the 
trigeminus. In addition to the face-atrophy in the cases 
above referred to, there were present symptoms indicat- 
ing injury of the oculo-pupillary branches of the sympa- 
thetic also. The majority of these cases are, however, 
due to disease of the nucleus of the fifth, orto direct in- 
jury of the nerve itself after it has received the vaso- 
motor and trophic fibres for the face. 


Sycosis. [mitis, 
Sympath. Ophthal- 


ANGINA PEcToRIS.—In the present state of our knowl- 
edge of the nature of angina pectoris it is impossible to 
say to what extent the sympathetic is involved. There 
are, no doubt, many instances of this disease where the 
symptoms present are, at any rate partly, due to disturb- 
ances of the sympathetic, but whether this disturbance 
is primary or secondary we are unable to say. It is com- 
mon to describe an ‘‘ angina pectoris vaso-motoria;” that 
is, an angina due to irritation of the vaso-motor nerves. 
This irritation leads to contraction of the arterioles, and 
consequently greatly increases the work of the ventricles. 
The resistance to the passage of blood may be so great as 
to bring about acute cardiac starvation, and consequently 
lead to an attack of true angina. 

Probably, however, the strongest evidence that we have 
of the reality of a true vaso-motor angina is the result 
obtained by the action of drugs. It is an every-day ob- 
servation that the nitrites, which quickly dilate the arte- 
rioles, rapidly relieve an attack, or prevent it from coming 
on. 

We, however, are entirely ignorant of the way in which 
this special vaso-motor irritation is brought about. 

Appison’s DisEASE.—In a number of cases of Addi- 
son’s disease there have been found extensive pathological 
changes in the abdominal plexuses of the sympathetic as 
well as in the suprarenal capsules. On the other hand, 
we have quite a number of post-mortem records of this 
disease where the sympathetic was perfectly normal. 
This represents our present knowledge of this subject ; 
and it is too scanty to lead to any definite conclusion. 
Even if we had positive information as to the primary 
origin of the changes in the sympathetic, we would be 
unable to explain the connection between them and the 
symptoms of the disease. 

UNILATERAL HyPERIDROSIS.—This may occur alone 
or as one of a group of symptoms. As the latter it is 
occasionally seen in exophthalmic goitre, diabetes melli- 
tus, tabes dorsalis, and in general paralysis of the insane. 
It may be limited to the neck and face, or it may involve 
the whole of one side of the body. Itis highly probable 
that this symptom is owing to a lesion of the sympathetic 
itself or of its medullary or spinal centres. 

DIABETES MELLITUS.—Notwithstanding the length of 
time that the clinical features of this disease have been 
known, we have as yet no adequate explanation of its 
true nature. Many and varied have been the offered ex- 
planations. An explanation which at times has received 
much support is the one attributing the fundamental 
cause to changes in the sympathetic. It is well known 
that we can induce diabetes experimentally by irritating 
what is called the ‘‘ diabetic area” in the floor of the 
fourth ventricle. This area corresponds with the chief 
vaso-motor centre. Sugar may also be made to appear 
in the urine by irritating the sympathetic in the neck, or 
in any part of its course above the tenth rib. In these 
situations the sympathetic contains the vaso-motor fibres 
for the vessels of the liver. 

Such experimentally induced glycosuria gradually dis- 
appears entirely, even when the cause that induced it is 
still in operation. That occasionally a temporary glyco- 
suria may be induced in man by irritation of the sympa- 
thetic, where it contains the vaso-motor fibres of the liver, 
is highly probable. It is, however, as highly improbable 
that a true (essential) diabetes can be due to any such 
changes. James Stewart. 


1 Hughlings Jackson: The Lancet, 1875, vol, ii., p. 244. ; 
2 Archiy fur Psychiatrie und Nervenkrankheiten, Band xvii., Heft ii. 


SYMPATHETIC OPHTHALMITIS is an intlammation 
of one eye caused by a pre-existing inflammation in the 
other. It is therefore a secondary process in a previously 
healthy organ, induced wholly by a diseased condition in 
the corresponding but distant organ. 

In the vast majority of cases the primary cause is a trau- 
matism inflicted upon the first eye, which is followed by 
an inflammation usually somewhat prolonged. After a 
period varying from a few days to years, this is followed 
by an inflammation in the other eye, and it is to this that 
the designation sympathetic is given. 


693 


Sympathetic 
Ophthalmitis. 


The first definite or accurate description of the disease 
was given in 1844,* by Dr. Wm. Mackenzie, the Glasgow 
ophthalmologist, who, adopting the pathological views 
reigning at that time, called it reflex or sympathetic oph- 
thalmia, thus distinctly claiming for it a nervous char- 
acter. This view has been almost universally held until 
within a couple of years past, when the bacteriological 
investigators have invaded this, as they have gradually 
almost every other, field in pathology, and there are now 
quite pronounced differences of opinion concerning the 
nature of the affection. 

Whatever views may finally be accepted as to the 
pathogenesis of the disease, the clinical picture, as origin- 
ally drawn, must be regarded as a remarkable instance 
of the result of keen observation and accurate deduction 
on the part of the great Scotch surgeon; and although 
since his time, as a result of the study of additional cases, 
our knowledge has increased, and we now know more of 
the complications which may arise and of the individual 
differences which may present themselves, still the im- 
portant fact remains established, that a pronounced and 
usually fatal inflammation may arise in one eye as the 
direct consequence of an inflammation of its fellow. 

The recent report of a collective investigation com- 
mittee, appointed by the Ophthalmological Society of 
the United Kingdom, has added much to our practical 
knowledge of the subject ; 211 cases (of which 131 were 
until then unpublished) were reported upon with various 
degrees of fulness, and I shall refer to that report with 
great freedom as the principal source of information in 
the compilation of this article; and the statistics there 
presented may be taken as representing about the pro- 
portions usually met with. 

As has been stated, a direct traumatism -is in the vast 
majority of cases the cause of the primary inflammation, 
and in 179 of the above cases this was distinctly the case. 
It was early noticed by Mackenzie that penetrating 
wounds in the ciliary region, involving in the cicatrix 
the iris, ciliary processes, or ciliary muscle, were especi- 
ally liable to excite sympathetic ophthalmitis, and this 
report shows that in 100 cases it was distinctly mentioned, 
and in a certain proportion of 74 others this must have 
been the case, though for want of definite statements the 
exact number cannot be determined. In 21 others, an 
old perforating ulcer (presumably non-traumatic in ori- 
gin) with phthisis bulbi was ascribed as the cause; in one 
a foreign body lodged for a long time undiscovered in the 
orbit ; and in one there was irritation from an artificial 
eye occurring fifteen years after the enucleation of the 
globe. Several cases are reported in which the sympa- 
thetic ophthalmitis did not appear until after the enuclea- 
tion of the eye first injured, and the question is thus 
presented whether it may not have been caused by the 
operation of enucleation, undertaken really as a therapeu- 
tic measure. In but seven cases was a spontaneous non- 
perforating iniammatory process stated directly to be the 
cause of the sympathetic disease, and these were all diag- 
nosticated as spontaneous chronic irido-choroiditis. I 
have included among the traumatic cases six cases of 
glaucoma with iridectomy, in five of which the lesion in 
the fellow-eye presented the character of sympathetic 
ophthalmitis, not glaucoma—which, however, it has been 
asserted may by itself be truly sympathetic. 

This report does not give a separate table of cases hav- 
ing foreign bodies remaining in the eye as a cause of the 
sympathetic disease, nor do the histories allow me to make 
one; it is to be inferred, however, in a large number ; 
and the experience of ophthalmologists has always been 
that this is an especially dangerous condition, and more 
dangerous as the foreign body lies upon or approaches 
the ciliary region. This is par excellence the dangerous 
locality. 


* Hirshberg has called attention to the fact that v. Ammon in 1835, in 
an essay on iritis, calls direct attention to a sympathetic iritis following a 
traumatic iritis of the other eye, and reports two cases, closing as follows: 
“The intimate sympathy of both eyes when disease is thus fully proved, 
making jt the duty of the oculist, in cases of traumatic iritis of one eye, 
to pay the closest attention to the iris of the other, in order to detect at 
the outset sympathetic inflammation, by which the eye is liable to be 
lost.” V. Ammon’s essay is in Latin, I follow Hirshberg’s translation. 


694 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, 


Penetrating wounds in which the iris becomes included 
in the cicatrix, even when made intentionally by the sur- 
geon, asin the operation for iridodesis, have so frequently 
had this unfortunate result, that the operation has, ina 
great measure, been abandoned as unjustifiable. Other 
operations in which a hernia of the iris is accidentally 
formed, as cataract extractions and even lacerations of 
false pupillary membranes following cataract extractions, 
by dragging upon the ciliary muscle and processes, have 
set up sympathetic trouble. 

The form in which the sympathetic affection first 
shows itself is nearly always an inflammation of the 
uveal tract ; it may be a simple plastic or a serous iritis, 
an irido-cyclitis, an irido-keratitis, or an irido-choroiditis. 
Exceptionally cases are reported in which the first dis- 
tinct lesion is a neuritis, a neuro-retinitis, or a simple re- 
tinitis. Mackenzie, writing in pre-ophthalmoscopic times, 
and judging from the symptoms alone, believed the sym- 
pathetic lesion to bea retinitis, followed rapidly or ac- 
companied by an iritis; but we now know that this is the 
exception, that the retina is not the part first affected, 
and that also, in a certain limited number of instances in 
which the disease runs a mild course, it escapes alto- 
gether. In later days it has been asserted that a true 
sympathetic glaucoma may exist. 

The course of the inflammation in the injured eye (the 
excitor) presents no characteristic features different from 
those which we might expect to follow the injury, to in- 
dicate that it is to be followed by sympathetic ophthal- 
mitis. It would. be but a repetition of descriptions al- 
ready given in the article on injuries of the eye, to describe 
the various courses of the inflammation which may fol- 
low the injury in the first eye; we have here to do only 
with the course of the sympathetic ophthalmitis. This 
much, however, may be said, that a violent suppurative 
inflammation (a panophthalmitis) is not so likely to cause 
sympathetic ophthalmitis as one of a milder and more 
chronic type. Indeed, von Graefe at one time advised ex- 
citing this form of inflammation, rather than allowing it 
to take the more chronic course with its attendant dan- 
gers. A more extended experience has since shown, 
however, that this advice is injudicious. In the present 
state of our knowledge we can simply say, that a sym- 
pathetic ophthalmitis is liable to follow an inflammation in 
the other eye presenting certain features. For example, 
the injured eye is the seat of frequently recurring attacks 
of an inflammation of a rather mild type, excited by no 
seemingly sufficient extrinsic cause. There is an area, 
often so small that it can be detected only by the touch 
of a blunt probe, which is the seat of very pronounced 
tenderness, and this area usually widens out with each 
recurring exacerbation of the inflammation. After this 
condition has existed for a variable period, usually of 
from a month to a year, the fellow-eye is liable to show 
symptoms that are now recognized as indicating that a 
morbid process has begun in it. 

The time at which the symptoms may first show them- 
selves in the second eye is, however, liable to greater va- 
riations than those reported in reply to the questions of 
the committee above referred to; the shortest and long- © 
est intervals were asked for, and, excluding ‘‘anomalous” 
or doubtful cases, they report eighteen in which the in- 
terval was.less than four weeks, therefore to be regarded 
as short, and in four it was less than two weeks, 

The longest period is more difficult of determination, 
as new injuries or inflammations, independent of the orig- 
inal injury, so frequently complicate the course of the 
disease that an exact statement is often impossible; ex- 
cluding, however, doubtful or anomalous cases, in ten 
at least one year had elapsed between the injury and the 
first symptoms in the fellow-eye; but the literature is 
full of cases in which the period of immunity extended 


-from ten to twenty years, and still longer periods. In 


many cases the injured eye was wholly lost and there 
had been no evidence of inflammation for a long time, 
and the symptoms in the fellow-eye started up without 
any recognized cause. In cases in which the fellow-eye 
is attacked while the injured eye is still in a condition of 
inflammation, it occasionally happens that the patient 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


and surgeon assert that they are able to refer the cause 
of the sympathetic attack to early use of the eyes, to ex- 
posure to bright light, etc. Mackenzie charges the dis- 
ease directly to too early or excessive use of the injured 
eye. This, however, cannot hold good for those cases 
in which the fellow-eye is not affected until several years 
have elapsed after the injury, a period of perfect quies- 
cence having passed over in the interim ; it is quite prob- 
able that the use of the eye has little to do with the 
sympathetic disease. The periods of quiescence in the 
remaining traumatic cases in the above report, varied be- 
tween one and a half and twenty years, and this agrees 
with the experience of ophthalmologists in general, and 
means that no limit can positively be set to the period dur- 
ing which these sympathetic symptoms may not arise. 
In some cases mentioned in the report and elsewhere, 
secondary degenerative changes, especially calcification 
or ossification of the choroid, are given as the exciting 
cause of the sympathetic disease.. 

There are at present two prevailing opinions concern- 
ing the pathology of the affection. One is a develop- 
ment of Mackenzie’s opinion of the nervous character, 
but instead of asserting that it is propagated through the 
optic nerve, this theory regards the ciliary nerves as the 
medium of transference. The other view is that the in- 
flammation in the second eye is due to the presence of 
bacteria, which have penetrated it through the peri-vas- 
cular lymphatic system of the optic nerve. The former 
was the view almost universally held fifteen or twenty 
years ago, when the school of von Graefe was at its most 
brilliant epoch ; the latter is now advocated by his favor- 
ite pupil and successor, Schweigger, by Deutschman, Alt, 
Leber, Mooren, and many others. 

As already stated, the sympathetic manifestation may 
occur under different forms, and in just so far does the 
symptomatology differ, so that a detailed description of 
all the clinical features must be but a description of these 
different, but at the same time allied, diseases; to avoid 
unnecessary repetition, therefore, reference is made to dis- 
eases of the iris, and uveal tract, and to diseases of the 
optic nerve and retina. It is necessary, however, to ap- 
preciate clinically two general classes, or stages, that of 
irritation, and that of actual inflammation. In its light- 
est form the sympathetic manifestation may be simply an 
irritation or an irritability on use,—a certain intolerance 
of light, a slight pain or weariness after reading, etc., a 
difficulty in fixing the eyes intently on a small object— 
in other words a weakness of the accommodation ; in ad- 
dition there is a trifling and transitory redness of the cir- 
cumcorneal conjunctiva. In ‘other cases the intolerance 
of light may have amounted to entire disuse of the eyes 
(Donders) for many years, and yet no structural changes 
may have taken place, as shown by complete recovery of 
vision on the adoption of the proper treatment. These 
cases, however, of long-continued sympathetic irritation 
are of the rarest occurrence, and it is perhaps incorrect 
to include them in an article on sympathetic ophthalmi- 
tis, which of course means an inflammation with organic 
changes. Some writers have taken that position, but it 
is of the utmost clinical importance to understand that 
there is an initiative or premonitory stage (in these cases 
unduly prolonged) of a most obstinate disease, which, if 
recognized early, may perhaps be successfully treated ; 
while if this initial stage be allowed to pass on to the de- 
velopment of actual lesions, the result, in a very large 
proportion of cases, is a permanent and great impairment 
of vision, often total blindness. This initiative stage 
usually, lasts but a short time, a few days or perhaps 
weeks, and it is quite possible that it is not thought of by” 
the patients until impairment of vision or other decided 
evidences of inflammation, such as pain and redness, dis- 
turb them. An examination at this time will usually 
show unmistakable evidences of an iritis, the discolora- 
tion and contracted pupil being associated early with 
posterior synechia and blocking up of the’ posterior 
chamber. If these evidences of more advanced disease 
be not present, palpation, either through the closed lids 
with the finger, or more directly with a probe or other 
blunt instrument over the ciliary region, will usually 


Sympathetic 
Ophthalmitis. 


show that there is a point of extreme tenderness from 
which the pain radiates to the rest of the globe. The 
statement has been made (Bowman) that this point cor- 
responds exactly with the focus of most intense inflam- 
mation in the other eye, 7.é., the incision in a penetrating 
wound, or the entanglement of the iris and ciliary body 
after an operation, or the seat of the lodgement of the for- 
eign body in the ciliary region. 

The progress of the sympathetic inflammation is usu- 
ally rapid and intractable to the action of remedies ; the 
iris fails to respond to the action of any mydriatic, the 
pupil becomes occluded, the posterior chamber becomes 
filled with plastic. lymph, and the iris bulges forward at 
the periphery, while the pupillary edge remains adherent 
to the lens. The contraction of the plastic lymph effused 
behind the iris, over the ciliary body, and behind the lens, 
drags upon and separates the retina from its attachment 
to the choroid, lymph is effused behind it also, and it 
finally presents nothing but a funnel-shaped cord, extend- 
ing from the optic nerve to the posterior surface of the 
lens. At first the globe is harder, but later, on the ap- 
proach of the fatal changes, the tension diminishes, and 
the atrophic condition of all the interior structures is 
shown in the collapse, with depressions at the insertions 
of the recti muscles, which afterward takes place. 

Sometimes the inflammation extends from theiris to the 
lining membrane of the posterior surface of the cornea 
(Descemetitis), even involving the corneal tissue’ proper. 
Lymph is deposited in more or less distinctly isolated 
spots (keratitis punctata), giving a mottled or dotted ap- 
pearance as seen by oblique illumination. Some authors 
(Reindorf) describe a form of obstinate ulcerative kera- 
titis, the ulcers which are scattered through the cornea 
first healing and then breaking out again, leading finally 
to perforations, and the eye is lost by the formation of a 
staphyloma of the cornea, or an irido-choroiditis with con- 
secutive glaucoma. 

Another form has been described by Warlomont and 
Testlin, under the title of serous iritis, coming on later 
than the plastic form and of slower course. ‘‘It does 
not affect the uveal track until after it has attacked the 
deeper parts. The symptoms are a contraction of the 
visual field, a medium dilatation and sluggishness of the 
pupil, and a progressive diminution of the acuity of 
vision. The globe becomes hard, the iris is discolored, 
the optic nerve excavated, and opacities form in the vit- 
reous body. The posterior surface of the iris becomes 
covered with an exudation (of lymph), and filiform pos- 
terior synechise are produced,” ‘This is, however, a very 
clear picture of a glaucomatous process. 

For some time after the invention of the ophthalmo- 
scope and the consequent accessibility of the retina and 
optic nerve to direct observation, the opinion became 
quite general that Mackenzie’s view of the neuro-retinal 
beginning in the fellow-eye was erroneous, but that the 
first sympathetic lesion was always in some part’of the 
uveal track, as above mentioned. The methodical use 
of the ophthalmoscope in later years, however, has shown 
the occurrence of an initial neuro-retinitis in a much 
larger proportion of cases than was formerly supposed. 
Excluding all cases in which the retinitis could be re- 
garded as secondary to an inflammation of any part of 
the uveal track (of the second eye), the statistics of the 
committee above referred to give about four per cent. of 
cases of initial neuro-retinitis in the sympathetic disease. 
These are all cases in which the vision was decidedly 
affected, and for the relief of which the patient applied 
to the surgeon. The percentage would be considerably 
increased if all cases were examined with the ophthal- 
moscope, irrespective of symptoms. Cases are reported 
in which a papillitis appears without failure of vision or 
other subjective symptoms, and after remaining a short 
period disappears again, leaving no traces. The course 
of the disease is sometimes an extension to the choroid 
and iris, with the same marked tendency to contraction 
in the effused lymph that is so noticeable when the pro- 
cess begins in the iris, etc., and in the worst cases with 
similar results. Judging, however, from the somewhat 
limited number of cases reported, it would appear that 


695 


Sympathetic 
Ophthalmitis. 


this form of inflammation is by no means so severe as 
when the anterior segment of the globe is first affected ; 
for, of the seven cases reported by the above-mentioned 
committee, two recovered with perfect vision, one with 
vision ‘‘ not perfect,” two with V = 3%, one with V =+,, 
and in but one was vision totally lost—certainly better 
results than we expect to obtain in the usual form of the 
disease ; and reports from other sources give similar re- 
sults. Gepner, of Warsaw, reports an unusual case of 
intermittent sympathetic retinitis, coming on some three 
months after the injury, in which a distinct but transitory 
oedema of the retina was seen by the ophthalmoscope, ac- 
companied by an amblyopia of #75 (0.1), but all of which 
entirely disappeared in the course of a few hours, with a 
return of V=1. The condition was observed by the 
surgeon twice—but it had existed for about two weeks 
before coming under observation. After the enucleation 
of the wounded eye the sympathetic trouble ceased en- 
tirely, and the vision remained perfect for several years, 
as long as the patient was under observation. 

Ever since von Graefe, in 1857, described a ‘‘sympa- 
thetic amaurosis with excavation of the optic nerve ” (fol- 
lowing a spontaneous irido-choroiditis), cases have from 
time to time been described as ‘‘ sympathetic glaucoma.” 
Subjected to a critical analysis, however, most of them 
turn out to be consecutive glaucoma, the attack (of glau- 
coma) in the second eye following usually with a very short 
interval the operation of iridectomy made for a glaucoma 
of the primarily affected eye. This is not what should 
be understood by sympathetic disease, as has been well 
shown by Mauthner, Schweigger, Maats, and others. 
Neither are we justified in calling the condition a sym- 
pathetic’ glaucoma, when an eye, which has been for a 
considerable length of time affected with a recognized 
form of sympathetic trouble, such as serous iritis or iri- 
do-choroiditis, becomes glaucomatous, with plus tension 
and other evidences of increased inflammatory action. 
If the glaucoma were truly sympathetic, it should oc- 
cur at the usual time after an injury to the other eye 
in which traumatic inflammation had been excited, and 
should be true glaucoma, and not merely a glaucomatous 
degeneration engrafted upon a preceding sympathetic in- 
flammation. Furthermore, it should respond to the or- 
dinary treatment of sympathetic trouble, viz., enucleation 
of the other eye, and not to that for ordinary glaucoma, 
namely, iridectomy on the eye affected. Unfortunately 
for the determination of this question, the surgeon, feel- 
ing the importance of leaving nothing untried for the relief 
of so imminent a danger to his patient’s vision, carries out 
the enucleation of the excitor and the iridectomy on the 
sympathizer at one sitting, so that it is impossible to say 
to which the good result, if it occur, be due. Neverthe- 
less, the facts observed in certain cases of Webster and 
Agnew, and of Dobrowolsky, lend considerable weight to 
the glaucomatous interpretation. These and other cases, 
such as those of Camuset and Krachner, of sympathetic 
cataract, and of Barbier, Krause,and von Graefe, of choro- 
iditis disseminata, in which the history points apparent- 
ly very positively to the sympathetic origin, must be 
classed among the very exceptional cases to which the 
explanation usually given of the pathology does not ap- 
ply, and which seems to show that we have not yet de- 
monstrated all the channels for the transmission of sym- 
pathetic disease. . 

Mackenzie’s interpretation of the symptomatology was 
that it was a ‘‘ reflex” inflammation, carried from the in- 
jured to the sound eye directly along the optic nerve; 
therefore that it was primarily a neuro-retinitis in the fel- 
low-eye. This remained the general opinion until the 
discovery of the ophthalmoscope, bringing the fundus of 
the eye directly under observation, showed that the pos- 
terior segment of the globe was quite free from disease, 
at least so long as the media remained clear enough to al- 
low it to be seen, and that the initial evidences of disease 
were confined to the anterior segment. Confirmatory of 
this ocular demonstration as to the non-participation of 
the optic nerve, an accurate study of the clinical pheno- 
mena soon showed that instead of this being the nerve 
along which the disease travelled, the ciliary nerves 


696 


REFERENCE HANDBOOK OF:THE MEDICAL SCIENCES. 


throughout were the medium of conduction of the sym- 
pathetic trouble. The organs or tissues to which the cor- 
responding nerves are distributed are the seats of the 
initial lesions in the fellow-eye ; the nerves are presum- 
ably the means of communication to it. The clinical 
evidence already recited seems to be quite complete ; the 
view has received the almost universal acceptance of the 
profession, and the results of therapeutical procedures 
based upon this view confirm it. 

The interpretation of clinical phenomena is, of course, 
a speculation based upon evidence which must in legal 
phraseology be designated as circumstantial, and must 
always be open to the admission of new facts, as new 
cases or new methods of investigation are brought to bear 
upon it. As previously stated, investigations in bacteri- 
ology have made this, the isolated example of an asserted 
‘“sympathetic” inflammation, the object of considerable 
study, with the result of establishing a possibility amount- 
ing, they claim, to proof, that there is an infectious ele- 
ment (micro-organism) concerned in the propagation of 
the disease. To exactly what extent the bacteria are re- 
lated to the disease, whether they are essential to the 
production of the various phenomena observed, or wheth- 
er their presence be simply accidental and of no im- 
portance, are, however, points which are still to be re- 
garded as sub judice. 

Deutschmann, in a series of experiments extending 
over several years, has studied the effects upon the fellow- 
eye of the introduction of micro-organisms and of irritat- 
ing substances into the vitreous body and into the optic 
nerve-sheath. His experiments were all made upon rab- 
bits, and he gives the following as the results of his in- 
vestigations: 1. The injection of aspergillus, of croton- 
oil, or of staphylococcus aureus and albus, was uniformnlye 
followed by papillitis, neuro-retinitis, and choroiditis of © 
the fellow-eye ; 2, the process can be traced by post-mor- 
tem examination along the sheath of the nerve, starting 
from the seat of the injury ; 3, in the case of the bacteria, 
similar organisms to those injected, and those only, are 
found in the secondary lesions. The progress of trans- 
mission from one eye to the other is a matter of several 
weeks, though the amount and the strength of the injec- 
tion (depending upon the dilution of the injected fluid 
with a saline solution) influence greatly the rapidity of 
the transmission. 

Besides the experimentally excited sympathetic dis- 
ease, Deutschman also reports the results of examina- 
tions of eyes which had caused sympathetic inflamma- 
tion in their fellows, and which had been enucleated as 
a therapeutic measure. In all he found micro-organisms 
and the extension of inflammation along the nerve and 
sheath as far as the specimen allowed examination. He 
thinks it probable that there are various micro-organisms 
capable of producing sympathetic ophthalmitis ; in other 
words, that it is not a specific inflammation. In answer 
to the objection that purulent micro-organisms usually 
excite an acute (virulent) process, he denies that this is 
constantly the case, and cites an instance of experimen- 
tal disease in a rabbit inoculated with a culture fluid of 
staphylococcus albus, obtained from the anterior cham- 
ber of a patient suffering from sympathetic ophthalmitis. 
At the end of five weeks the rabbit’s eye showed begin- 
ning atrophy of the optic nerve, an opaque white disk, 
strikingly narrowed vessels, atrophic nerve-fibres, and 
all the evidences of an essentially chronic non-suppura- 
tive inflammation. 

For these reasons, and from a consideration of the re- 
sults of other experiments and clinical observations, the 
bacterial nature of sympathetic ophthalmitis has been ac- 
cepted by many ophthalmologists of authority. Schweig- 
ger, Leber, Snellen, Mooren, Alt, Mules, and others have 
put themselves unreservedly on record as believing this - 


_to be the best explanation of the intricate subject of sym- 


pathetic ophthalmitis. 

To the writer, however, the view has not. presented it- 
self so convincingly ; the progress of bacterial infection 
elsewhere:in the human subject is so much more rapid 
than in sympathetic ophthalmitis, and the course here is 
so different from that of other well-authenticated septic 


= REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, 


— 


(bacterial) infections of the eye, as in metastatic choroid- 
itis and retinitis, that it seems to be going too far, for 
the sake of a theory, to regard the processes as essen- 
tially the same. The advocates of this view apparently 
ignore also some very important clinical facts that 
should be regarded as characteristic of the disease. In 
order to establish their theory, they insist upon an essen- 
tial difference between sympathetic irritation and sym- 
pathetic inflammation, asserting that the former never 
passes into the latter, and that if it remains in the irrita- 
tive stage there is no propriety in calling it sympathetic 
inflammation. As has already been stated, among the 
clinical facts which first direct the attention of the pa- 
tient to his eye, and for which he first consults the sur- 
geon, is a certain, perhaps trifling, photophobia, lachry- 
mation, and pain on use; as the patient usually expresses 
it, his eye gets tired easily, and if the disease be unre- 
lieved after a variable time, and perhaps after repeated at- 
tacks alternating with apparent recoveries, a pronounced 
inflammation sets in. These facts are undisputed, and 
the claim that the irritation is but a premonitory stage 
to the inflammation is certainly not a forced one. 

The uncertainty of the time of the appearance of 
the inflammation in both the injured and the sympathiz- 
ing eyes, varying, as it may, from a few weeks to even 
forty years after the receipt of the injury, argues against 
the microbial theory. And the fact that in one set of 
cases there may be repeated attacks of irritation, while 
in another set the original wound may heal, and the eye 
may remain in a quiescent condition for years, the in- 
flammation starting up then, with no new wound (or it 
may even be that the injured eye takes on no fresh ac- 
tion, but the fellow-eye becomes inflamed and goes 
through the stages of iritis, irido-cyclitis, or neuro-reti- 
nitis, to the loss of a greater or less degree of sight), is in- 
explicable by any theory of constant bacterial infection, 
but is quite reconcilable to the nervous view. If the 
bacteria were introduced at the time of the injury, what 
has prevented their development during the years of qui- 
escence of the eye? If present at all, they were always 
in the same culture medium, and wherefore then this 
long delay, and what is the cause of their sudden activ- 
ity ? There can be no change in the culture medium 
but that which has already taken place many times be- 
fore during the long period of inactivity. 

These well-established clinical facts do not harmonize 
with the bacteriological theory, while there is nothing to 
disprove the opinion, gradually developed through years 

_of observation of the clinical phenomena, that the sym- 
pathetic inflammation is brought about by a neuritis of 
the ciliary nerves of both eyes, caused in the first eye by 
the entanglement of the terminal fibres in the cicatrix of 
the wound, propagated thence to the fellow-eye. This 
propagation may be by way of the ciliary nerves, and 
through the medium of the ophthalmic ganglia of the 

‘sympathetic nervous system and the vaso-motor nerves, 
to the ciliary nerves of the fellow-eye, there exciting tro- 
phic disturbance in the tissues to which the nerves are 
distributed, and giving rise to the various inflammations 
of the anterior segment of the globe above described ; or 
the irritation may be transmitted more directly by the 
optic nerves to the posterior segment, giving rise to the 
neuro-retinitis described. The former is the common 
mode, the latter the exceptional. 

The writer is aware of the indefiniteness in the descrip- 
tion of the extension of the inflammation through the 
medium of the sympathetic system ; so also is our knowl- 
edge of the physiology of this system indefinite, but it is 
doing no violence to our knowledge of the action of this 
complex system to assume this much. 

There is also a certain analogy (not identity) between 
‘this sympathetic process and those trophic changes ob- 
served in distant parts following severe injuries to the 
main nerve-trunk. The observations of Mitchell, More- 
house, and Keen have shown that there. may be very gen- 
eral changes of the tissues to which the nerve is distrib- 
uted, evident especially in the skin and its adnexa, and 
the joints, although the muscular, osseous, and cellular 
tissues may all occasionally show grave changes. In the 


Sympathetic 
Ophthalmitis. 


joints (arthropathies) the evidence of an inflammatory pro- 
cess is shown in a painful swelling, a slight redness about 
the articulation, extreme sensibility, and finally, persist- 
ent rigidity and a semi-anchylosis which resists all treat- 
ment. When the acute stage has disappeared the tissues 
around the articulation are indurated, and there results a 
partial anchylosis. In theskin there isa peculiar, glossy 
redness or erythema, there may be eruptions of different 
kinds, the glands disappear, etc. Mitchell has shown 
that these trophic disturbances follow incomplete sec- 
tions, contusions, punctures of a nerve—in other words, 
causes which determine an irritation of a nerve rather 
than its complete local destruction. It seems to me that 
we are justified in believing that the conditions which 
pertain in sympathetic ophthalmitis bear a sufficiently 
strong resemblance to those of nerve-irritation, and conse- 
quent trophic changes, to justify us in accepting this in 
preference to the bacteriological theory. 

The intractable nature of this disease, and its obstinacy 

in resisting treatment have already more than once been 
referred to. Mackenzie was led to seek for a reason for 
the fact that a certain number of cases of ophthalmitis, 
beginning apparently in a mild way, were so excessively 
obstinate in their resistance to modes of treatment which 
were fairly successful in other cases, He noticed that 
they were all associated with an injury to the other eye, 
and he then grouped them into the class we are consider- 
ing. The futility of all the ordinary methods of treat- 
ment for sympathetic iritis and its complications, as well 
as for neuro-retinitis of sympathetic origin, was early 
recognized. Although the observation of a greater num- 
ber of cases has shown that adi do not run an absolutely 
unfavorable course, still instances of this kind are excep- 
tional, and we should regard every case that presents it- 
self as threatening total blindness of that eye, even though 
a considerable degree of vision may remain in the injured 
eye. 
In 1857 Dr. August Pritchard, of Bristol, England, 
recognized the importance of relieving the sympathizing 
eye of the source of the irritation by removing the in- 
jured eye entirely, when vision in it was totally lost. 
This operation (enucleation, Arlt), was followed by a re- 
lief of the inflammation in the fellow-eye, and has ever 
since been acknowledged to be the most promising means 
of combating this so fatal disease. Although a wider ex- 
perience has shown ‘its limitations, it or its modifications 
may still be regarded somewhat as a specific for this 
unique form of inflammatory action. 

The uncontrollable tendency in the plastic material 
thrown out in the inflammation of the uveal tract, to con- 
tract after the active stage has passed, the contraction be- 
ing as certain as that following deep burns of the skin, 
shows the importance of getting early control of the dis- 
ease before the plastic lymph has been effused. And 
the results of the operation show that, to be of much 
benefit, the enucleation must be performed either as a 
prophylactic measure, before any evidences of irritation 
or inflammation have shown themselves, or during the 
irritative stage, before organic changes have taken place. 
If performed after inflammation has fairly begun, while 
it may possibly mitigate the severity of the process, it 
seldom saves good vision; the secondary (cicatricial) con- 
traction usually produces such a fusion of iris, lens, cap- 
sule, and ciliary body that no subsequent operative 
interference is of avail. It is still doubtful, if the enu- 
cleation be delayed, whether it mitigates the ophthal- 
mitis at all; occasionally it seems but to add to the sever- 
ity of the symptoms, the subsequent course being even 
more rapid than before. 

The importance of an early operation, if it is to be 
done at all, is, therefore, very great, and the question of 
probability of sympathetic ophthalmitis occurring at all 
is of the utmost importance; for while there can be no 
doubt as to the advice to offer when the question is dis- 
tinctly between total blindness and mutilation, when it is 
simply between mutilation and a more or less remote 
chance of blindness patients will always hesitate and often 
decline the operation. Statistics are wanting as to the 
exact proportions between all injuries and sympathetic 


697 


Sympathetic 
Ophthalmitis, 


ophthalmitis ; but, as has been stated, injuries of the cili- 
ary region, causing the entanglement of the iris, ciliary 
muscle and processes, and choroid, ‘‘ especially if there 
be loss of vitreous” (Mackenzie), and foreign bodies re- 
maining In the globe, whether the penetration be through 
the ciliary region or not, are all such constant sources of 
danger that if the vision be destroyed the surgeon should 
take the responsibility of advising the removal of the eye. 
The sooner this is done in such cases the better, usually, 
though in childhood the enucleation is liable to check the 
normal development of the orbital cavity and produce a 
greater deformity than if it be practised after the bones 
of the face have attained nearly their full development. 

Whether the globe should or should not be removed 
during active suppuration has been discussed in the ar- 
ticle Panophthalmitis, but the necessity is not so great 
on account of the sympathetic dangers as of relieving 
present suffering. Leaving for a moment the question 
of the effect of this operation on the preservation of vi- 
sion in the fellow-eye, it must be remembered that there 
is still a positive, though fortunately but very slight, 
danger to life in the operation for removal, even without 
a panophthalmitis ; deaths have followed from menin- 
gitis or from shock in several reported instances, and in 
how many unreported cases no one knows. 

If there still be vision, or a remote prospect of saving 
some, the wound being in a dangerous situation, the 
problem becomes more difficult of solution, for, if the 
patient wait for symptoms in the fellow-eye, he may de- 
lay too long, or the irritative stage may be so rapidly 
followed by the inflammatory process that the operation 
is useless ; and yet neither surgeon nor patient wishes to 
sacrifice an eye there is a prospect of seeing with. Fur- 
thermore, there have been unfortunate cases in which 
the enucleation itself has seemed to precipitate, if not 
cause, the outbreak of the sympathetic disease. 

Recognizing, as we must, the double path of the disease 
from one eye to the other, it is evident that if the disease 
be of the neuro-retinal form, and have advanced along the 
optic nerve to a distance beyond the point of division, 
‘the operation is likely to be an additional irritation to the 
already inflamed tissue, and may readily be sufficient to 
cause the loss of the fellow-eye; and if there be a bacte- 
rial influence at work there will be a better chance for 
the introduction of the germs. 

Undoubtedly many eyes with some useful vision in 
them have been sacrificed to the fear that the fellow-eye 
may become affected; but the converse is also true, and 
many more eyes have been lost and total blindness has 
resulted by reason of the repugnance to submit to enu- 
cleation. The surgeon is at fault in the former case, the 
patient usually in the latter. 

If the patient can be depended upon, as most persons 
of intelligence may, the operation may be postponed, 
with the express understanding, however, that he will 
report immediately upon the appearance of the first 
symptom of irritation, such as lachrymation or other dif- 
ficulty in the use of eyes for near work, photophobia, or 
phosphenes (photopsia), when the surgeon must deter- 
mine whether there is any danger of an increase of the 
process, or may detect by the ophthalmoscope the pres- 
ence of optic neuritis (papillitis) or choroidal trouble. 
In the presence of any positive evidences of disease, 
however slight, the operation must be advised. If the 
injured eye is the seat of chronic inflammation, with pe- 
riods of eXacerbation, it should be removed; or, if the pa- 
tient first presents himself with the history of repeated 
slight attacks of irritation in the fellow-eye, the removal 
of the injured eye should be advised. 

The history of the enucleation in those infrequent 
cases of serous iritis or of glaucomatous processes, does 
not warrant so favorable an opinion of its utility. Why 
this should be the case it is difficult to say, but the obser- 
vations seem to be fairly uniform and may be regarded 
as an argument against the existence of a sympathetic 
glaucoma. Mauthner has formulated his opinions on 
the advisability of enucleation as follows: It may be per- 
formed as a prophylactic measure ; it must be done in the 
irritative stage ; it must not be performed in active iritis, 


698 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


serous or plastic; it can be done in irido-cyclitis (the 
sympathizing eye being quite blind and not in a condi- 
tion of active irritation).* While rules thus positively 
stated are legitimate subjects of criticism, they may be re- 
garded as representing in the main the general views of 
ophthalmologists of the day. 

In view of the natural repugnance of the patient’ to be- 
ing subjected to so severe a mutilation, and of the sur- 
geon to being compelled to inflict it, ophthalmologists 
have sought to devise some means to accomplish the sep- 
aration of the injured eye from its fellow, in which this 
objection would not apply. Regarding the nerves, optic 
and ciliary, as being the media of transmission of the 


.morbid influence, von Graefe advised and practised the 


division of these nerves behind the injured eye, and for 
several years afterward the bibliography of ophthalmol- 
ogy was plentifully strewn with reports of optico-ciliary 
neurotomy and its effects, and although the authors con- 
tinued to report successful cases, that is to say, cases in 
which disease did not develop in the fellow-eye (prophy- 
laxis), or in which the eye was benefited, the practical 
demonstration of the benefit of the operation, its general 
adoption by the profession, is yet wanting. The uncer- 
tainty of being able to make successfully the division of 
the ciliary nerves has always stood in the way of the sur- 
geon’s ability to guarantee to the patient a relief from 
the threatening blindness with as much confidence as he 
could were enucleation to be performed. The operation 
has never received an equal degree of sanction by the 
profession as has enucleation, and has gradually fallen 
into comparative disuse. It is, however, to be proposed 
as a tentative procedure in cases where the repugnance 
to removal of the globe cannot be overcome, but\if the 


symptoms return or persist, the enucleation must be per- 


formed later. \ 
The neurotomy may be performed with or without di- 


vision of the rectus muscle; there is not much choice, 


between the external and internal. If performed without 
division of the muscle, a longitudinal incision, parallel to 
and just above the upper border of the external rectus 
muscle, is to be made through the conjunctiva, a pair of 
long-bladed scissors, curved on the flat, are introduced, 
and then all the short ciliary nerves external to the optic 
nerve are freely divided. A strabismus hook is next in- 
troduced, and the optic nerve is seized and drawn as far 
out of the wound as possible, thus rotating the globe on 
its vertical axis and turning the cornea inward. This al- 
lows the nerve to be cut off far back in the orbit, when 
the portion attached to the globe may be seized with the 
forceps, the globe reversed further yet, and the piece of 
the nerve still attached removed close to its entrance in 
the globe. The ciliary nerves internal to the optic nerve 
are now accessible and must be entirely removed. 

The division of the muscle allows freer access to the 
posterior part of the globe and secures a much more cer- 
tain division and resection of the nerves, both optic and 
ciliary, and the operation is thus more readily carried 
out, but a considerable strabismus is apt to remain. To 
avoid this it is well before dividing the muscle to pass a 
thread through it and after the neurotomy has been 
performed to stitch it again to its place. 

Either of these operations, and especially the latter, 
has the very serious objection of being liable to be fol- 
lowed by considerable heemorrhage, which, by filling the 
orbit, pushes the eyeball forward (exophthalmos) and is 
sometimes followed by such severe and uncontrollable 
pain as to require the enucleation after all,—a condition . 
of things which can but tend to aggravate the disease 
sought to be relieved. 

Is there any other treatment than getting rid of the 
source of the irritation which is of avail? Can anything 
be done to check the progress of the disease in the sym- 
pathizing eye itself? But little; though no surgeon 
could feel himself justified in making no attempt to save 


an eye thus affected, however hopeless he may think it. » 


* The exact meaning of the last sentence, ‘‘ it can,” etc., is not alto- 
gether clear unless it be that the injured eye is to be removed to relieve 
intolerable pain, even if the sympathizing eye be blind; otherwise the 
word sympathizing is a misprint for injured. 


X 


\ 


\ 


a 


. 


four hours the fundus was no longer to be seen. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, 


‘ 


In iritis and irido-cyclitis the instillation of atropine 
must be persistently carried out. By its paralyzing 
action on the iris and ciliary muscle, it keeps them at rest, 
thus alleviating pain and tending to reduce inflammatory 
action, and it may happen that the iritis will subside 
while the pupil is dilated and before it becomes blocked 
up with lymph. lLeeches may be applied to the temple, 
or if these be unobtainable Heurteloup’s or some other 
form of artificial leech, with cupping, may be substituted. 
With the idea that mercury checks adhesive inflamma- 
tion some form of this drug may be administered to the 
production of gentle salivation. These are the routine 
remedies in general use, and their good effects are not to 
be ignored or underestimated, but neither is the surgeon 
justified in building much hope upon them in either his 
own or his patient’s mind. I have seen an iris which 
was fully dilated with atropine in the early stages of 
sympathetic ophthalmitis, the patient being kept on the 
verge of poisoning with it, gradually contract day by day ; 
lymph continue to be poured into the pupil, the latter 
become hopelessly blocked up, the iris bulge forward, 
and total blindness ensue, in spite of the atropine, mer- 
cury, and leeches. In.other cases, milder usually from 
the start, this treatment occasionally seems to be followed 
by such amelioration of the symptoms that the surgeon 
cannot but hope that the next case will prove equally re- 
sponsive to his treatment. These are, however, the ex- 
ceptions. 

The results of operative interference in the acute 
stage are usually disastrous. An iridectomy is almost 
surely followed by an increase of the iritis. It is not 
until the eye has been entirely free from inflammation 
for several months, and when there is also good reason to 
believe that there is no detachment of the retina or other 
lesion of the fundus—that is, that the acute inflammation 
was confined to the iris and the changes which followed 
were merely incident to this,—that, in cataract with closed 
pupil and a blocking up of the posterior chamber, a 
broad iridectomy, with simultaneous or successive extrac- 
tion of the cataract, may be made. In all probability 
successive lacerations and removals of false pupillary 
membranes and membranous deposits behind the iris, 
with repeated iridectomies, will be required. If it be 
necessary to repeat any operative procedure, or if succes- 
sive operations be required, time must be given between 
them to let all inflammation subside. These operations 
are described in other parts of this work under the proper 
heads of Cataract and Iridectomy, so that it is’ unneces- 


‘sary to repeat their description here. 


ADDENDUM.—Through the very great courtesy of Pro- 
fessor William H. Welch, of Johns Hopkins University, 
and Dr. R. L. Randolph, of Baltimore, Md., Iam enabled 
to give here, in advance of publication elsewhere, the re- 
sults of a series of attempts to verify Deutschmann’s ex- 
periments on the production of sympathetic ophthalmitis 


in the lower animals. 


‘ The experiments were performed upon dogs. Four or 
five drops of a solution of staphylococcus pyogenes 
aureus were injected into the corpus vitreum, using for 
this purpose a hypodermic syringe which had been pre- 
viously thoroughly sterilized, taking especial care that 
none of the solution came in contact with the edges of 
the puncture, thus avoiding, as far as possible, the inocula- 
tion of the surrounding tissues, and .setting up a general 
inflammation. Clouding of the vitreous was observed in 
every instance an hour after the operation. In twenty- 
In 
every case but three, panophthalmitis ensued, followed 
by rupture of the eyeball and disorganization of its 
contents. In the three cases mentioned the eye recovered 
after a severe kerato-iritis, which left the cornea clouded 
and deposits upon the anterior capsule (of the lens). 
The pupils, however, responded to light, showing that 
the optic nerve-fibres possessed functional activity. It 
was impossible to see whether the fundus had participated 
in the inflammation. Examination of the uninjured eye 


- with the ophthalmoscope revealed in every instance a 


perfectly normal fundus ; not even did the blood-vessels 
of the retina show anything that would suggest that they 


Sympathetic 
Ophthalmitis, 


sympathized with the condition existing in the inoculated 
eye. 

‘The dogs were all killed at periods varing from twenty 
days to three months. On examining sections of the in- 
oculated eyes, dense, round-celled infiltration was seen 
throughout the coats, in which the papilla participated. 
In several the inflammation extended to within half an 
inch of the chiasm. In only one case did the neuritis 
reach the chiasm, and then it was confined and stopped on 
that side of the chiasm adjacent to, and continuous with, 
the optic nerve of the inoculated eye. The presence of 
organisms in the tissues of the eye, or optic nerve, of the side 
not inoculated was never detected. 

‘‘ This is the first time that dogs have been used for ex- 
periments of this nature. It is possible that they possess 
an immunity from sympathetic ophthalmia, or that we 
are not apt to have the disease when the eyeball ruptures, 
though the case in which the inflammation was seen in 
the chiasm happened in a dog whose eye had ruptured 
forty-eight hours after inoculation. In this case, how- 
ever, the inflammation must have spread from continuity 
and exhausted itself by the time it reached the chiasm. 
Certainly if the cocci had been the cause morbi, there is 
no reason to think that they would have lost vitality after 
reaching the chiasm. ‘The same reasoning would apply 
to the other cases where the inflammation had travelled 
some distance up the optic nerve.” 

Comment on these experiments is superfluous on my 
part. Iallow myself, however, to say this much: I was 
entirely unaware that they were in progress until after 
the above article was finished, and I then learned of 
them through my friend Dr. Theobald. I am, of course, 
pleased to be able to confirm the views I have expressed, 
which were derived from a study of the clinical phenom- 
ena, by the negative results of experiments carried on by 
such competent authorities. 


BIBLIOGRAPHY. 


The following works have been consulted in the preparation of this 
article: 

Mackenzie, Wm.: Traité pratique des Maladies de ’Giil. Traduit et 
augmenté par Warlomont et Testlin, 1857, Tom. ii.; et 1865, T. iii., 
Supplement. 

A Practical Treatise on the Diseases of the Eye. From the fourth Lon- 
don edition, with Notes and Additions by A. Hewson. Philadelphia, 
1855. 

Archiv fir Ophthalmologie, 1855-56, Bd. ii., Abth. 2. <A. v. Graefe: 
Ueber die Coremorphosis gegen chronische Iritis und Irido-choroiditis. 

Ibid., 1857, Bd. iii., Abth. 2. A. v. Graefe: Ueber sympathische Amau- 
rose eines Auges bei Irido-choroiditis des anderen und ber dessen 
Heilung. 

Ibid., 1858, Bd. iv., Abth. 1. Heinrich Muller: Beschreibung einiger 
von Prof. v. Graefe exstirpirter Augipfel. 

Tbid., 1860, Bd. vi,, Abth. 1. A. v. Graefe: Vorwort zur Beitrige, etc. 

Ibid., 1860, Bd. vi., Abth. 2. A. v. Graefe: Ueber ein neues Operations- 
verfahren in verzweifelten Fallen chronisher Iritis und Irido-cho- 
roiditis. 

Tbid., 1860, Bd. vi., Abth. 2. A. v. Graefe und Schweigger: Hitrige Iri- 
do-cyclitis mit sympath, Iritis des anderen Auges. 

Ibid., 1866, Bd. xii., Abth. 2. A. v. Graefe: Zur Lehre der sympath- 
ischen Ophthalmie, 

Ibid., 1868, Bd. xiv., Abth.1. Schiess-Gemuseus: Glioma Retine, begin- 
nende simpathischen Erkrankung des Zweiten Auges. 

Ibid., 1874, Bd. xx., Abth. 1. Brecht: Ueber concentrische Hinengung 
des Gesichtsfeldes sympathishes entstanden. 

Ibid., 1876, Bd. xxii., Abth. 4. Hirschberg: Zur sympathischen Reizung 
und Entzindung. - 

Ibid., 1881, Bd. xxvii., Abth. 1. Leber und Deutschmann: Zur Neuro- 
tomie optico-ciliaris ; Leber; Bemerkungen iiber die Enstehung der 

. sympathischen Augenentzundung. 

Klinische Monatsblitter fur Augenheilkunde, Verhandlungen der Oph- 
thalmologen-Versammlung, 1863. 

Crichett :. Ueber sympath. Ophthalm.; discussion von A, v. Graefe, Don- 
ders, Soiberg Wells, Pagenstecher, Warlomont, Horner, Liebrich. 

Royal London Ophthalmic Hospital Reports, 1866 to 1887. Articles by 
George Lawson, Argyll Robertson, Henry Power, J. C. Renton, George 
Critchett, Anderson Critchett, AV. J. Milles, R. Marcus Gunn, 

Mooren: Ueber sympathische Gesichtsstérungen, 1869. 

Transactions of American Ophthalmological Society, 1874. H. Derby: 
Sympathetic Ophthalmia persisting after Enucleation, Recovery after 
Removal of Extremity of Optic Nerve and surrounding Tissues; B, 
Joy Jeffries: A Foreign Body in the Globe, only producing Sympa- 
thetic Trouble after Thirteen Years, 

Ibid., 1880. Webster: Sympathetic Inflammation following Operations 
for Cataract; discussion by Matthewson, H. Derby, E. Williams, 
Knapp, Pomeroy, Noyes, Harlan, Thomson, Agnew. : 

Ibid., 1882. Spaulding: A Case of Sympathetic Neuro-retinitis ; discus- 
sion by Webster, Prout, Mittendorf, Schell, Theobald, H. Williams, 
Green, Knapp, R. Derby. Seeley, Buller, Noyes, 

Ibid., 1884, Fox: Clinical History of a Case of Sympathetic Ophthal- 


mia, 
Ibid., 1885. Webster: A Case in which Enucleation of an Eye for Glau- 


699 


Sym. Ophthalmitis. 
Symphysiotomy. 


coma Absolutum was followed in Thirty six Hours by an Attack of 
Glaucoma in the Fellow-eye. 

Report of the Fifth International Ophthalmological Congress, New York, 
1876. Alt: Sympathetic Neuro-retinitis ; discussion by EH. Williams, 
Noyes, R. Derby. Knapp, Risley, Harlan. ; 

Transactions of the Medical Society of the State of New York, 1879. 
Webster: Is Glaucoma ever of Sympathetic Origin ? 

Archives of Ophthalmology and Otology, vol. v., 1876. J. Samelsohn: 
A Contribution to the Nosology and Treatment of Sympathetic Oph- 
thalmia; Hirschberg: Historical Notice on Sympathetic Ophthalmia ; 
Alt: On the Anatomical Causes and the Nature of Sympathetic Oph- 
thalmia. 

Ibid., 1879, vol. viii. Mules: A Rare Form of Intra-ocular Growth, prob- 
ably Sympathetic. ; 

Ibid., 1880, vol. ix. Knies: Contribution to the Knowledge of Diseases 
of the Uveal Tract; Knapp: Further Observations on Optico-ciliary 
Neurotomy and Neurectomy. 

Tbid., 1881, vol. x. Chisholm: Two Cases of Sympathetic Ophthalmia ; 
Ayres: Contributions to the Study of Sympathetic Ophthalmia. 

Tbid., 1884, vol. xiii,, No.1. Theobald: Some Recent Theories regard- 
ing the Pathogeny of Sympathetic Ophthalmia, viewed from a Macro- 
scopic Standpoint, 


Pagenstecher und Genth: Atlas der pathologischen Anatomie des Aug- 


apfels. Wiesbaden, 1875. 

Zehender : Handbuch der Augenheilkunde. Stuttgart, 1876, 

Graefe und Simisch Handbuch der Augenheilkunde, 1876, Bd. iv., Cap. 
v. Wecker: Die Erkrankungen des Uveal tractus und des Glaskorpers. 

Ibid., 1877, Bd. v., Cap. vi. Schmidt: Glaucom. ; und Cap. viii., Leber: 
Krankheiten der Netzhaut und des Sehnerven. 

Schweigger: Handbook of Ophthalmology, 1878. Translated by Farley. 

Wecker: Ocular Therapeutics. Translated by Forbes. London, 1879. 

Solberg-Wells: Treatise on Diseases of the Hye. Edited by C. 8. Bull. 
Philadelphia, 1880. 

Noyes: A Treatise on the Diseases of the Eye. New York, 1881. 

Mauthner: Vortrige aus dem gesammtgebiete der Augenheilkunde. 
Wiesbaden, 1881. Bd. i.; Die sympathischen Augenleiden. 

Berlin : Ueber den Zusammenhang zwischen orbital und intracraniellen 
Entziindungen. Volkmann’s klinische Sammlungen, No. 186, 1880. 

Dobrowlsky : Glaucoma sympathicum. Klinische Monatsblatter fur Au- 
genheilkunde, 1881, p. 123. 

Mitchell, Morehouse, and Keen: Gunshot Injuries of the Nerves. Review 
of, in Am. Jour. of the Med. Sci., January, 1865. 

The International Encyclopedia of Surgery, New York, vol. iii., 1888. 
M. Nicaise: Injuries and Diseases of Nerves. 

Ibid., 1884, vol. v. E. Williams: Injuries and Diseases of the Eye. 

Transactions of the International Medical Congress in London, 1881. 
Papers on Sympathetic Ophthalmia by Snellen, Brailey, Poncet; dis- 
cussion by Mooren, Grunhagen, Pfluger, Samelsohn, Leber, Boucheron, 
Panas. 

Transactions of the Ophthalmological Society of the United Kingdom, 
vol. vi., 1886. Report of the Committee on Sympathetic Ophthalnitis, 
E. Nettleship, Secretary. 

Andrew: Case of Syinpathetic Ophthalmia from Glaucoma. Ophthal- 
mological Section of British Medical Association, 1880. Referred to in 
the Supplement Heft of the Centralblatt fir Augenheilkunde, 

Centralblatt far Augenheilkunde, February, 1886. Mules: Evisceration 
of the Eye, and its Relations to the Bacterial Theory of the Origin of 
Sympathetic Disease. Extract from British Medical Journal. 

Ibid., April. Hoffmann: Hin Fall von geheilter sympathischer Enzun- 
dung ohne vorausgegangene Enucleation. 3 

Ibid., May. Gepner (Warsaw): Hine seltene Art von Sympathisher Au- 
genaffection. 

Gifford: In Archives of Ophthalmology, 1886, vol. xv,, pt. 8. Reported 
by Dr. C. 8S. Bull in New York Medical Journal. 

Jahresbericht der Ophthalmologie, 1870 to 1885. It is impossible to enu- 
merate all the references treating of sympathetic ophthalmitis in this 
excellent though tardy publication. 

Mooren: 5 Lustren Ophthalmo. Wirksamkeit. Wiesbaden, 1882. Ueber 
die Verbreitung der Sympathischer Storungen. 

Ayres: Archives of Ophthalmology, vol. xi., p. 330. 

Deutschmann: Ein Experimenteller Beitrige zur Pathogenese der Sympa- 
thischen Augenentzundung. V. Graefe’s Archiv fiir Ophthalmologie, 
Bd. xxviii., Abth. 2, S. 291. 

VY. Rothmund: Casuistischer Beitrag zur Lehre von der sogennanten 
Sympathischen Augenentzundung. Festschrift der Munchner medi- 
zin. Facultiéit zum Jubilaum der Universitat Wurzburg. 

Deutschmann: Ueber experimentelle Erzeugung sympathischen ophthal- 
ne on Graefe’s Archiv fiir Ophthalmologie, 1883, Bd. xxix., Abth. 

» 8. 261. 

Deutschmann: Zur Pathogenese der sympathischen Ophthalmologie, V. 
Graefe’s Archiv, fiir Ophthalmologie, 1884, Bd. xxx., Abth. 3, S. 77; 
nebst Nachtrag, S. 331, und Abth, 4, S. 845. 

Michel: Lehrbuch der Augenheilkunde, Wiesbaden, S. 444. 

Deutschmann: Zur Pathogenese der sympathischen Ophthalmie, ‘* Oph- 
thalmia Migratoria.” V. Graefe’s Arch. fur Ophthalmologie, 1885, Bd. 
ex Abthy2: S272 

Schweigger: Ueber Resection der Sehnerven. 
ogy, vol. xv., p. 50. Py 

Caudron: Emploi des Applications chaudes prolongées dans le Traitement 
a i sympathétique. Revue Générale d’Ophthalmologie, p. 

bibs White Cooper: On Wounds and Injuries of the Eye. London, 


Archives of Ophthalmol- 


George Lawson : Injuries of the Hye, Orbit, and Eyelids. 


Philadelphia, 
1869. 


William H. Carmalt. 
SYMPHYSIOTOMY. Delivery of the foetus by pubic 
section, in cases of pelvic deformity, was devised in 1768, 


by Jean René Sigault, a French medical student, who 
sent the proposition to the Academy of Surgery of Paris, 


700 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


by the members of which it was regarded as the wild 
scheme of an ignorant youth. Not regarding this stamp 
of disapproval, he made it the subject of his thesis at 
Angers, in 1773. In so far as his method was designed 
to apply to the living woman in parturition, it was orig- 
inal with Sigault, but it had twice been tried upon the 
dead woman. The first operation upon a woman who 
had died in labor was performed at Warsaw, in 1655, by 
Dr. Jean V. C. Delacourvée, of France, then in practice 
there, the subject, aged forty-eight, having been in labor 
four days ; and the second was in 1766, under Professor 
Jos. Jacques Plenck, of Bude, Hungary, for the libera- 
tion of a locked head in a post-mortem Ceesarean section. 
It does not appear that it ever entered into the thoughts 
of either of these obstetricians that such an operation 
might be of value in the cases of living women. 

After his graduation Dr. Sigault embraced an early 
opportunity of carrying his scheme into effect, and on - 
October 1, 1777, performed the initial operation, upon 
Madame Souchot, a dwarf of three feet eight inches in 
height, and delivered her of a living child, having a bi- 
parietal diameter of three inches ‘and one line. The pel- 
vis measured in its true conjugate, two inches and three- 
quarters (Eng.), and the child presenting by the feet was 
readily extracted. This was the fifth pregnancy of the 
mother, and her first child delivered alive. A permanent 
disability resulted from the use of the knife, in the form 
of an incontinence of urine. 

The result of this case, although in a measure imper- 
fect, and not a fair test of the value of the operation, be- 
cause of the working space, three inches, in the superior 
strait, gave great credit to the operator, much to the an- 
noyance of the Academy of Surgery, by which it had 
been condemned nine years before. Not content with a 
moderate degree of praise upon the test of one operation, 
Dr. Sigault was lauded as a public benefactor; a medal 
was presented to him by the Faculty of Medicine, and 
the government granted to the operator and the pane 
—the latter the wife of a soldier—each a pension. This 
excess of adulation created a feeling for and against the 
operation, in which the Academy of Surgery took an ac- 
tive part; and as it was claimed that the pubic section 
was to take the place of the Cesarean operation, the med- 
ical profession became divided into Symphysiotomists and 
Cesareanisis, each advocating the one plan of delivery to 
the disparaging of the other. The basis of the scheme of 
Sigault was the claim that relaxation of the pelvic syn- 
chondroses took place during the latter months of preg- 
nancy, and it was only requisite to open the pubic sym- 
physis by the knife, after which the sacro-iliac junctions 
might be made to move like a hinge, and admit of a wide 
separation at the point of section, without strain or in- 
jury of the posterior synchondroses. This measure of 
relaxation was denied by many, upon the results obtained 
by experiments anything but crucial, made upon dead 
bodies, under which the ligaments tore. Years later, 
when the excitement was over, and the operation rarely 
performed, experiments properly conducted, and without 
prejudice, under Dr. Girard, of Paris, in 1800, and Dr. 


Ainsiaux, of Liége, in 1811, elicited very different results. 


The bodies of women who died in labor were used as sub- 
jects of the test, and it was found that when operated 
upon soon after death the mobility of the pelvic bones 
upon each other was quite marked, and would admit of 
a wide separation at the pubes without laceration. Dr. 
Ainsiaux obtained, under these circumstances, as much as 
three inches ; but found that when a woman had been 
dead thirty-six, thirty-eight, forty-eight, or fifty-four 
hours, he could only separate the bones one and one-half 
to one and one-fourth inch without laceration. 

The original Sigaultian operation was very simple in 
its method of execution, but was liable to accidents, from 
the knife incising too deeply behind the symphysis, or 
through the pubic arch, or not taking the central line of 
junction between the pubic bones, but cutting a piece 
from one of them, leading to a delayed union, with per- 
haps escape of a fragment of bone. 

In the year 1778 the operation was fairly inaugurated, 
as it was performed eleven times, under eight operators, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


in Germany, France, Belgium, and Bavaria, four of the 
sections having been the work of Sigault himself, who 
ended his experience, after having had five cases, with 
‘four women and one child saved. Under the whole 
eleven operations of the year, six women were saved, 
and ten children were lost. This was certainly not very 
encouraging for an operation designed to save two lives 
and to supersede the Cesarean section, if not entirely, 
at least in large measure. Too much was expected of 
the operation, and attempts were made in cases where 
the pelvic contraction was entirely too great for success. 
Sigault failed, on this account, with his fifth and last 
operation, which was upon a dwarf of thirty inches high, 
pregnant with a foetus twenty inches long, and having a 
conjugate herself, computed at twenty-two or twenty- 
three lines. She died of pelvic injuries in five days. 
This failure appears to have put a check upon his am- 
bition, and he subsequently declined to test his method 
upon a woman having a two and one-half inch conju- 
gate. Pelvic injuries and feetal death appear to us now 
to have largely resulted from the method of delivery 
usually adopted—the child being turned and its head 
drawn through the superior strait, thus forcing open 
the sacro-iliac symphyses, and destroying the fcetus at 
the same time. 

In the second year of the operation (1779) there was a 
falling off in numbers to four, saving all of the women 
and two children, the cases being all in France, and two 
of them under the care of Dr. Alphonse Leroy, who be- 
came an early advocate of the operation, and performed 
it during a period of twenty-six years, his last delivery 
under it being in 1804. Leroy operated in this period 
only five times, but is twice recorded as having assisted 
others. Four of his own patients recovered, and three 
children were saved ; two others were delivered in a mori- 
bund state, both by the feet. 

In 1780 there were but two operations as far as re- 
corded, and the same in 1781; after which they varied 
in numbers from one to four each year until 1840, be- 
tween which and 1858 (when they ceased, with two fatal 
exceptions in Bologna, in 1863 and 1865, until the re- 
vival of the method in a much less fatal form in Naples, 
in the year 1866) there were but six cases. 

From 1777 to 1866, the year of the revival referred to, 
there were 86 operations, of which the results have been 
recorded ; a few others have been mentioned, but no par- 
ticulars given. Of the 86 women, 57 recovered, and 29 
died ; 45 of their children were delivered dead ; 6 in a 
dying condition ; the fate of 6 is not mentioned, and 29 
were saved. It is evident that the operation gradually 
fell into disuse, largely on account of its failure to save 
the lives of the children. 

The subcutaneous method of incision was introduced 
at Utrera, Andalusia, Spain, on August 9, 1780, by Pro- 
fessor Francisco Canivel, of the University of Cadiz, 
who directed an operation performed by a licentiate, 
Amonio Delando. The case was that of a primipara, 
aged forty-two, in labor three days, and was the eigh- 
teenth operation in chronological order. As is done in 
Naples with so much success at the present day, the in- 
cision was made from below upward, and from within 
outward. The woman recovered in thirty-eight days, 
and the child was saved. Cazeau, very erroneously, 
credits the initiation of this method to Dr. Imbert, of 
Lyons, who recommended it in 1838, fifty-three years 
after its first successful performance. 

Symphysiotomy was first performed in Italy by Dr. 

_ Antonio Lavaguigno, of Genoa, on December 24, 1781, 

upon a subject having a conjugate of 65 mm. or 2;°s 
inches. The foetus presented by the head, and being 
thought dead, was extracted with a crotchet, and lived 
several hours. The woman died in seventeen days, her 
external and internal parts being gangrenous. This de- 
structive condition of the soft parts appears to have been 
a not unusual sequel of the operation of Sigault in its 
early days, particularly in cases of extreme pelvic de- 
formity, where tractile force, rather than nature’s pro- 
cess of extrusion, was relied upon for the delivery of the 
_ foetus. Symphysiotomy was first performed in Naples, 


Sym. Ophthalmitis. 
Symphysiotomy. 


in 1787, by Professor Domenico Ferrara, upon Vittoria 
di Montesarchio, who recovered, but in whom the sym- 
physes failed to unite. She was living and able to walk 
twenty years later, being employed as a messenger ; her 
child was lost. 

Between the operation of Ferrara and that of Jacolucci, 
on July 25, 1858, when the old period may be said to 
have closed upon symphysiotomy in the city of Naples, 
there were performed in that city, including the two 
named cases, twenty-seven operations, of which sixteen 
were under Professor Genaro Galbiati, who was the in- 
ventor of the strong curved button-ended bistoury (fal- 
cetta) in use at the present day in making the subpubic 
section. Galbiati’s operations were largely upon pelves 
having a 2° inch conjugate, and hence a very severe 
test of the method. Hight were of this measure; two 
were of 24 inches; three were of 22; three were mala- 
costeon deformity ; and in one, the conjugate was re- 
duced to 51 mm., or only 2 inches ; this last died unde- 
livered. Eight of the women were saved, and but four 
of the children. The whole twenty-seven Neapolitan 
operations saved sixteen women and ten children. 

Failing to obtain from the operation of Sigault the ad- 
vantages of the Cesarean section in cases of extreme pel- 
vic stenosis, Professor Galbiati devised and executed, in 
1832, the murderous operation known as bipubiotomy. 
Having a pregnant dwarf under his care, 34 feet high, 
with a conjugate of only an inch, he conceived the plan 
of opening her pelvis like a bellows, by disconnecting its 
anterior from its posterior portion, by a subcutaneous 
section made with a chain-saw through the horizontal 
and descending rami of the ossa pubes on either side. 
This scheme he put into execution on March 30th of that 
year, and delivered the woman of a dead fetus, but such 
was the injury inflicted on the mother that she died in 
agony four days later, her vulva, vagina, and surround- 
ing tissues being all gangrenous. Not contented with 
this test, Dr. Nanziante Ippolito repeated the experiment 
in the Ospedale det Incurabilt, ten years later, with a simi- 
lar fatality ; and recently we have noticed a proposal in 
Europe, by some one who must be ignorant of what has 
been already done, to make trial of this murderous and 
unscientific measure. 

Since the year 1818 symphysiotomy has had its home 
exclusively in Italy, and but very few operations have 
taken place outside of the city of Naples, in whose Hos- 
pital for Incurables the work has been chiefly done. In 
1858 it entirely died out even there, and for a period of 
eight years there was not an operation. Rachitic defor- 
mity being quite prevalent, and there having been lost 
over ninety-two per cent. of all of their Cesarean cases 
in seventy-five years, although all of the children were 
delivered alive, the medical staff of the hospital felt 
called upon to do something to lessen this fearful mortal- 
ity, and, strange as it may appear, her obstetricians chose 
to revive the much-abused and destructive operation, es- 
pecially to children, of Jean René Sigault ; and the work 
recommenced on January 5, 1866. By the use of the sub- 
cutaneous method of incision, and the avoidance of ver- 
sion, or any unnecessary tractile force, it was soon found 
that the foetal head would slowly expand the superior 
strait, become moulded to its form under the contrac- 
tions of the uterus, aided by the expulsive efforts of the 
mother, and finally extruded without material injury to 
the sacro-iliac synchondroses, or causing the death of the 
foetus, except in small proportion. Since the above-named 
date the operation has been performed in Naples 76 times, 
with a saving of 57 women, or seventy-five per cent., and 
58 children, or 7634; per cent. In these are included two 
operations where labor was induced in the seventh and 
eighth months respectively, saving both women and one 
child ; and one in which the foetus being dead, and the 
conjugate under two inches, the superior strait was en- 
larged by separating the symphysis, and the foetus was 
then delivered under craniotomy. The woman recovered 
in forty-two days. Professor Novi, who performed this 
operation, on September 8, 1872, doubted the propriety of 
risking the Cesarean section for the removal of a dead 
foetus, which being of full size could only be removed 


701 


Symphysiotomy. 
Synovitis. 


by craniotomy alone, at great risk, through so narrow a 
pelvis. He has had three craniotomy cases since. 

The association of symphysiotomy with the induction 
of premature labor, in the cases of rachitic dwarfs having 
very small pelves, is well illustrated in the following rec- 
ord, and by photographs sent to me from Naples. Prob- 
ably the operator at the present day would weigh the 
question of performing the Sanger operation at term. 
Lucia Esposito, a rachitic dwarf, aged twenty, and 3 
feet 72 inches high, having a true conjugate of 2,4; inches, 
entered the obstetric clinic of Naples on May 15, 1880, in 
the seventh month of her pregnancy. When the extent 
of her deformity was ascertained it was determined by 
Professor Ottavio Morisani to bring on her labor in the 
first week of the eighth month, and this was accordingly 
done on June 9th. On June 11th, labor being sufficiently 
advanced, the symphysis was opened, and the foetal head, 
which presented by the vertex, began to descend, passed 
into the pelvic cavity, met with some delay at the peri- 
neum, and was finally extruded. The foetus began soon to 
breathe regularly ; it weighed 44 pounds; measured 152 
inches in length ; occipito-mental diameter, 4% inches ; 
biparietal, 8 inches; occipito-frontal, 34 inches; and bi- 
temporal, 22 inches. The child, when three days old, 
was sent to a foundling hospital. Being in summer, 
the wound was treated by irrigation, and at the end of a 
week by an immovable apparatus for fixing the pelvis, 
an opening being left over the wound. Union was com- 
plete in thirty-four days, and the patient left her bed in 
forty, being soon able to walk without pain or inconven- 
ience. 

In the early days of Sigault’s operation the main con- 
tention was upon the measure that might be gained in 
the sacro-pubic diameter by each inch of separation of 
the ossa pubis, and the amount of injury to the sacro-iliac 
synchondroses that must be inflicted by the forcible sep- 
aration of the innominata. Since the revival of the op- 
eration the value of slow separation and head-moulding 
have been considered, and the gain in the transverse and 
oblique diameters found of great importance to the pas- 
sage of the head. Careful and accurate pelvic measure- 
ments must be made, ‘and the operation should not be 
undertaken where the conjugata vera is less than 67 
mm., or 28 inches. The operation is best adapted to 
the symmetrical rachitic pelvis. If there is any asym- 
metry, extra care must be taken in finding the anatomi- 
cal centre of the symphysis, so as to avoid slicing off the 
end of one os pubis, as has several times happened, in 
which event the exsected piece will become carious and 
a fistula will remain until it is discharged or removed. 
The operation is not admissible where disease has af- 
fected one or both of the sacro-iliac symphyses, as in the 
oblique pelvis of Naegelé, or the still narrower and an- 
chylosed one of Robert. In the flat-sided pelvis produced 
by coxal&ic anchylosis of one hip-joint, where one ilium 
is undeveloped, there is apt to be a bony union between 
the sacrum and ilium, making pubic section unavailable. 

The amount of separation usually obtained in the op- 
erations at Naples, 50 mm. (2 inches) it is claimed, may 
be secured without risk of injury to the sacro-iliac sym- 
physes. Version should not be resorted to when the head 
can be made to engage. The forceps have been applied 
in about one case out of four. Under the first fifty opera- 
tions in the Ospedale det Incurabili of Naples (1866-1880) 
vesico-vaginal fistula was produced in but one case, 
which was easily cured by an operation. Firm union of 
the symphysis pubis was secured in the cases of the 40 


women who were saved out of the first 50 operated on, » 


and Professor Morisani has assured me that these women 
had good health after the operation. Of the 50 foetuses 
delivered, 46 presented by the vertex, and 42 of these 
were alive on removal. 

Causgs OF Deatu.—In 19 Neapolitan subjects the 
causes of death are thus recorded: Metro-peritonitis, 3; 
septic metro-peritonitis, 1 (endemic in hospital); iliac 
phlegmon and metro-peritonitis, 1; peritonitis, 2; endo- 
carditis, twenty-four days after operation, 1; endocarditis 
and diphtheritic vaginitis, 1; puerperal infection, para- 
metritis, pelvic abscess, and tetanus, 1 ; gangrenous endo- 


702 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


metritis, 1; long labor and repeated application of for- 
ceps prior to section, 1; long labor and pelvic tumor, 1; 
labor three days, foetus dead, operation unjustifiable, 1; 
operation unjustifiable, foetus dead, c. v. 354; inches, 1; 
the same, labor induced, foetus dead, c. v. 74 mm. (nearly 
3 inches), 1; not stated, 2. ; 

The history of symphysiotomy not only embraces two 
entirely distinct periods, but its prognosis is signally 
changed as regards the mother, and much more decidedly 
so in reference to the foetus in utero; in fact, an entire 
revolution has been produced in the second period, as 
compared with the first. This is shown not only in the 
diminution of the death-rate, but in the causes which 
lead to death. I have given those since 1866, and will 
now mention some taken from the records of the eigh- 
teenth century, viz., external and internal gangrene, pel- 
vic injuries, gangrene of the genitalia, intrapelvic parts 
found gangrenous, etc.» Foetal death has largely dimin-. 
ished since version and traction by the feet have become 
the exceptions in practice. Now the foetal mortality is 
twenty-four per cent., and was but 18 out of the first 50, 
commencing in 1866. In the old period about five fe- 
tuses out of eight were either dead or moribund when ex- 
tracted. 

DISTRIBUTION OF CASES.—Symphysiotomy has never 
been performed in the United States, and only once in 
Great Britain. In Italy there have been 115 operations ; 
in France, 32; Holland, 6; Belgium, 4; Germany, 38; 
Spain, 1; England, 1; total, 162; it is said also to have 
been performed in Constantinople—no results have as 
yet been found reported. | 

Symphysiotomy can never take the place of gastro- 
hysterotomy in cases of extreme pelvic stenosis, as by 
general consent among operators the minimum available 
conjugate has been fixed at 67 mm., or 28 inches., Of 68 
cases reported by Professor Ottavio Morisani, Director 
of the Obstetric Clinic of Naples, only 2 were under this 
measure ; 18 gave the 67 mm., and the balance ranged 
from 68 to 81 mm., there being 20 at the last computa- 
tion (3,3; inches). There were five deaths at each meas- 
urement, 7.¢., 67 and 81, and eight at the intermediate 
points. 

Thus it will be seen that the operation of Sigault ha 
a conjugate range of a fraction over half an inch, and 
covers the ground within which craniotomy can be most 
safely performed. Executed with the care and skill of 
a Morisani, the operation he has revived in preference to 
it (7.é., craniotomy), has no greater fatality, and possesses 
the material advantage of saving the foetus. In these 
days, when the opposition to craniotomy increases as the 
risks of the Cesarean section diminish, there is a grow- 
ing inclination on the part of gynecologists to adopt the 
use of the knife, in some one of the several forms in 
which it may be employed, for the saving of mother and 
child. The Sanger operation is now the most highly 
extolled for its moderate death-rate, and fcetal-saving 
under it is almost universal. But there is an objection 
of long standing against the Cesarean section, where 
the sacro-pubic diameter measures from two and three- 
fourths to three and one-fourth inches. A well developed 
foetus will become head-locked in a three-inch pelvis, and 
will die if not liberated ; craniotomy may accomplish this, 
with very little risk to the woman, but the child will be 
lost. Foetus after foetus has been thus disposed of, for one 
and the same woman, until a numerous progeny has been 
destroyed that she might escape death. Should there not 
be an end to infantile destruction in such cases, and does 
not symphysiotomy afford a means whereby the fetus 
may be saved, without very great danger to the mother ? 

The induction of premature labor, as in the hands of 
the late Dr. Cesare Belleozzi, of Bologna, who operated 
more than one hundred and twelve times, may accom- 
plish this end ; but what is to be done where the patient 
is not examined until near her maturity of gestation, or in 
actual labor? There is this to be claimed in favor of 
symphysiotomy, or the Sanger Cesarean operation at full 
term, that a very small proportion of infants delivered 
prematurely, live through the first year, because of their 
immaturity of development. Robert P. Harris. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


SYNCOPE, or fainting, is a condition of sudden un- 
consciousness of short duration, ending with complete re- 
covery. It can be produced by unpleasant mental im- 
pressions, such as fear, dread, and shocking news, or the 
sight of suffering of others. Some persons faint from the 
sight of blood or the expectation of any trivial operation. 
Acute personal suffering may also lead to syncope, per- 
haps more through mental influences than by direct re- 
flex action. Operations on the ear and the male genital 
organs are especially apt to cause fainting. Oppressive 
heat may also induce fainting. While syncope may oc- 
cur in perfect health, though rarely, it is much more 
likely to take place in conditions of enfeebled health. 
Nervousness, in the sense of imperfect control of the in- 
hibitory nervous system, anzemia, convalescence from de- 
bilitating diseases, and almost all forms of heart disease, 
render the individual prone to fainting on slight provo- 
cations. 

Prior to the loss of consciousness the subject feels weak 

and faint, sometimes dizzy, becomes pale in the face, 
which is usually covered with cold sweat; the sight 
fails, everything becomes dark, there is often a roaring 
noise in the ears, until at last the control over the mus- 
cles is lost and the subject falls down unconscious and 
limp. . 
The unconsciousness lasts rarely longer than a few 
minutes. On recovery a feeling of faintness may persist 
for a short time. Inenfeebled health several fainting fits 
may follow in succession. On the other hand, the ten- 
dency to syncope may be checked before unconscious- 
ness occurs by removing the cause—for instance, avoiding 
the sight of some awe-inspiring scene. 

On account of the rapid and perfect recovery, a faint- 
ing fit could hardly be mistaken for an apoplectic seiz- 
ure. From major epilepsy it differs by the want of 
spasms. But from an attack of minor epilepsy (petit 
mal) fainting cannot be distinguished, except by taking 
into account the preceding causes, if any, and the his- 
tory. 

in the light of modern physiological knowledge the 
essential condition of syncope must be regarded as ane- 
mia of the brain, presumably the cerebral cortex—the 
seat of consciousness. For unconsciousness can be ex- 
perimentally produced in animals by inducing cerebral 
anemia, aS by hemorrhage or ligature of the carotid 
and vertebral arteries, and it occurs also in man under 
similar conditions. The pallor of the face during faint- 
ing renders it likely that the blood-vessels inside of the 
_ cranium are also constricted. Moreover, any measures 
which increase the blood-supply to the brain, like the re- 
cumbent position or the inhalation of nitrite of amyl, 
may check the fainting tendency before consciousness is 
lost. The cerebral anemia produced in animals by hem- 
orrhage or ligature of the arteries of the head leads to 
convulsions, while in ordinary fainting no muscular 
spasms occur. Whether the anszemia during syncope is 
not as intense as during the experimental state, or whether 
the constriction of the blood-vessels does not involve the 
region of the basal ganglia in syncope, is not settled. 
The pulse is usually slow during fainting, and sometimes 
long pauses exist between separate pulsations—evidently 
action of the vagus. This inhibition of the heart through 
vagus action occurs similarly in experimental cerebral 
anzemia from excitation of the vagus centre. Whether 
a primary excitation of the vagus can lead to fainting is 
not known. In most instances fainting must be regard- 
ed as an influence of emotions upon the centres of the 
vaso-constrictor nerves of the cerebral hemispheres. 

In order to prevent the loss of consciousness from a 
threatening attack of fainting the cause should be avoided 
as far as possible. It is well to loosen any tight apparel, 
especially the corsets of women, since constriction of the 
waist increases the liability to syncope. ‘The cerebral 
anemia should be counteracted by placing the patient on 
his back, with the head low. Unnecessary meddling is 
not called for. Amyl nitrite may be of service if on 
hand. These measures may also shorten the period of 
unconsciousness. For this purpose any mode of stimu- 
lation of the skin, like a fresh draught or sprinkling with 


Symphysiotomy. 
Synovitis. 


cold water, may also be employed. The liability to faint- 
ing can be combated only by those means which restore 
a more or less perfect health according to the general 
condition of the patient. 

H. Gradle. 


SYNOVITIS, ACUTE. Synonyms: Hydrops articu- 
lorum acutus, acute serous synovitis, arthro-meningitis, 
sero-synovitis ; French, Synovite aigué; German, Die 
Synovitis. 

Synovial membranes approach so closely to the serous 
membranes that they are often classified with them. 
But, although structurally much the same, 
they differ from the serous membranes in se- 
creting a peculiar fluid, synovia, and they are not, like 
the peritoneum, etc., closed sacs. In all joints where mo- 
tion takes place (diarthrodia) a lubricating fluid is neces- 
sary, and this fluid is furnished by the so-called synovial 
membrane, the structure and pathology of which we 
come now to consider. Every diarthrodial joint is lined 
with a layer of synovial membrane, except in the places 
where the articular cartilages are in contact. Here there 
is no membrane,! except at the edge of the cartilages, 
which the synovial membrane may overlap for two or 
three millimetres,’ before merging into the cartilaginous 
structure. Fasciculi, and folds of the capsule, the in- 
ternal ligaments, and fatty internal protrusions are all 
covered by the membrane. In the foetus an endothelial 
layer is found over the cartilages, which wears off when 
the joints begin to be used. The limits of the synovial 
membrane are most easily made out in inflammation, 
when a red collarette is seen surrounding the white car- 
tilages. Faraboeuf? compares this to the chemosis in 
acute conjunctivitis. 

Synovial membrane is thin and elastic. Externally it 
merges into the tissue of the joint-capsule, while its 
inner surface is smooth and moist. Histologically the 
structure is a basement tissue of elastic and connective- 
tissue fibres, upon the inner surface of which lies a single 
layer of endothelial cells (His). Hueter* has, however, 
asserted that there is no such pavement layer, but only 
clumps of cells here and there; but his methods of ex- 
amination seem to have been at fault.° In gross the 
inner surface of a joint presents a smooth and shining 
surface, interrupted, especially where the membrane folds 
to pass from one surface to another, by the synovial 


Anatomy. 


. fringes (plice synoviales)—villous structures of varying 


size and length, somewhat resembling intestinal villi, the 
largest being perhaps one centimetre long. These fringes 
were thought by Havers,* who described them, to be 
true glands, and he called them mucilaginous glands. 


Subsequent anatomists disputed this, but Rainey’ found 


them in structure to be secreting organs. They are richly 
supplied with blood-vessels, for each villus contains the 
convoluted twig of an artery. Some of the fringes, how- 
ever, are merely hernia-like protrusions into the joint of 
small masses of fat* covered by membrane; these fill up 
unoccupied spaces. The nerves are derived from the 
same nerve-trunks that supply the muscles of the limb. 
The nerve-filaments terminate in small plexuses, un- 
equally distributed, under the synovial membrane. The 
lymphatic network is not easily demonstrated, but that 
it exists is evident from the fact that coloring matter in- 
jected into the joint disappears very quickly, to reappear 
in the lymphatic channels of the limb, 

Synovia is a clear, alkaline fluid, much like the white 
of egg in general appearance; when rubbed between 
the fingers it imparts an oily sensation. It is largely se- 
creted by the cells which cover the synovial fringes. In 
structure it contains albumen, mucin, some fat, leuco- 
cytes, and epithelial cells. A fluid identical in compo- 
sition with synovia can be produced by rubbing up a 
portion of the epidermis in a weak alkaline solution. 
This fact suggests® that most of the mucin is derived 
from the endothelial cells soaking in the weak alkaline 
fluid secreted by the fringes, and this view is strength- 
ened by the fact, discovered by Frerichs,* that, when 
joints are quiet, the synovia in them contains only half 
as much mucin as when they are in motion. 


703 


Synovitis. 
Synovitis. 


The classification of acute inflammations of the sy- 
Dathelogy novial membranes is best made, on a simple 

’ pathological basis, according to the following 
scheme : 

(1) Synovitis with effusion—serous, purulent. pf 

(2) Synovitis without effusion, dry or plastic synovitis. 

Acute serous synovitis is the most common ofall. The 
pathological process is simple and typical; for some 
known or unknown cause, a joint, most frequently the 
knee, becomes the seat of an inflammation which is 
manifested in the usual way. There are hyperemia of 
the vessels of the membrane, an increased rapidity of the 
blood-current, and then dilatation of the capillaries, with 
stasis. Migration of the white corpuscles from the ves- 
sels follows, and a profuse serous secretion is poured out 
from the dilated vessels into the perisynovial tissues and 
into the joint. The endothelial cells are very rapidly 
produced, and are cast off, half formed, into the joint. 
This process, carried far enough, constitutes ‘‘ catarrhal 
synovitis,” a purulent form. ‘To the naked eye the sur- 
face of the membrane is seen to be bright red, from the 
dilatation of the surface capillaries; it is not so shiny as 
usual, and has ordinarily a boggy, softened, oedematous 
appearance, from infiltration, which is most noticeable 
in the synovial fringes. Here and there, especially in the 
more acute cases, may be seen a patch of extravasation, 
where a distended blood-vessel has burst. The fluid in 
the joint is often colored more or less red by these ex- 
travasations. The cartilages in an inflammation of this 
grade are not affected, but are seen to be of a clear blu- 
ish-white color, and surrounded by the sharply marked 
line of inflamed synovial membrane. 

The joint at this stage is more or less distended with 
an abnormally large amount of synovial fluid, at first 
thinner than usual, on account of the copious effusion of 
serum into the joint, then becoming more or less opales- 
cent as the endothelial cells are cast off into it and be- 
come macerated, and as the leucocytes increase in num- 
ber. The amount of fibrin in the fluid varies greatly ; in 
severe acute attacks the amount is generally so large that 
the fluid is glairy and sticky, and, on standing, distinct 
flocculi separate out and float around. When there is so 
much fibrin in the joint-fluid that it consolidates on the 
synovial surfaces, the case belongs rather to the class of 
dry synovitis. At this stage, unless it become chronic, 
the inflammation subsides, or goes on to the formation of 
a purulent exudation. If it subsides, the blood-supply 
diminishes, the newly formed capillaries are obliterated, 
and the distended ones resume their normal calibre, the 
cell-proliferation ceases, the cells already thrown off fur- 
nish mucin to the synovia, the excess of fluid is absorbed, 
and everything returns to a normal condition. The syno- 
vitis is cured. 

If, however, instead of undergoing resolution, the 
joint-inflammation takes on a more active, perhaps a 
more destructive, character, we have soon to deal with a 
purulent effusion. Cell-proliferation and the migration 
of leucocytes become so prominent a part of the process, 
that where there was formerly serum there is now a sero- 
purulent or purulent fluid. From being simply red and 
glazed the synovial surface becomes velvety in appear- 
ance, and the cartilages become yellowish-white and their 
surface is indistinct and covered with lymph and flocculi 
of pus. In some cases the destructive process seems lo- 
calized, and ulcerations of synovial tissue, and even of 
cartilage, take place, while the surrounding parts show 
only a moderate grade of inflammation. From this it is 
easy to see how any amount of mischief may result. The 
whole synovial membrane may become granulating tis- 
sue, the cartilage is perhaps eroded also, the bone is bare, 
and the periarticular tissues become the seat of abscesses 
as soon as the capsule breaks, perhaps before. .It is hard 
to set a limit to so destructive a process as this. Two 
grades of this purulent effusion are properly recognized : 
One, called purulent synovitis, where the pus is secreted 
by the surface layers of the membrane and no deep-seated 
lesion results; this is the ‘‘catarrhal inflammation” of 
Volkmann,'® and often appears to lack any serous stage.. 
It is said to be rather ‘‘ the perversion of an excessive se- 


704 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, 


cretion than an inflammatory tissue-degeneration.” The 
second grade is called suppurative synovitis, and it signi- 
fies that the deeper layers of the membrane are involved. 

Recovery from purulent synovitis may be complete, 
and no trace of the mischief may be left behind. Recov- 
ery from suppurative synovitis generally, although not 
necessarily, means a joint impaired by adhesions. On 
the other hand, as we have seen, there is no limit to the 
destructive possibilities of suppurative synovitis ; com- 
plete. disorganization of the joint, dislocation of the 
bones, and, worst of all, systemic infection are only too 
apt to follow. 

Dry synovitis, arthro-meningitis crouposa, is a very ob- 
scure affection pathologically. There is an absence of 
much fluid, as the name implies, and the synovial mem- 
brane is covered with a dry, leathery coating, which ap- 
pears to be the deposition from a slight exudation, very 
rich in fibrin, into the joint. Anchylosis of the joint 
may follow with surprising rapidity. This form of sy- 
novitis is much more common in the sheaths of tendons 
than in the joints. Hueter!! believes that suppurative 
synovitis often results from this, and he prefers to call it 
synovitis sero-fibrinosa. 

In few pathological conditions are the four classical 
symptoms of inflammation more marked than in acute 
synovitis. Pain, heat, redness, and swelling 
comprise a large part of all that can be said of 
it. First, in simple acute synovitis: A) few hours after 
the receipt of a wound or blow, some wrench, some ex- 
posure, or over-exertion of a joint, commonly the knee, 
an uneasy, hot feeling is noticed, and before long it be- 
comes a positive pain. This is associated with a tense, 
burning feeling and a sense of helplessness in the affected 
limb. Any motion adds to the discomfort, and manipu- 
lation of the joint, if carried to extreme flexion or ex- 
tension, Causes pain ; sometimes any motion at 
all is painful. The feeling of distention that 
accompanies the height of the effusion may be distress- 
ing, but from the sixth, seventh, or eighth day, when this 
height is reached, the pain rapidly funds pain 

yi 


Symptoms. 


Pain. 


is ordinarily felt in the joint that is inflamed, but it may 
be ‘‘ reflected” to some other joint supplied by the same 
nerve-trunks, This curious phenomenon is most fre- 
quently noticed in hip-joint. inflammation, where the 
pain may be referred to the knee of the affected side. 
The intimate relations and anastomoses of the sciatic, 
obturator, and anterior crural nerves seem to furnish the 
best explanation of this, although Bonnet thought it due 
to the position of the patient, lying in bed with the leg 
rolled over on its outer side, a consequent strain being 
put upon the external lateral ligaments. Wright says 
that there are three factors in this knee-pain: (1) The 
nerve-relations mentioned above ; (2) sympathy between 
the ends of the bones; (8) muscular spasm. When the 
synovitis becomes purulent, or is so from the first, pain 
is a more prominent symptom and much more severe 
than it isin simple synovitis. If it goes on to destruc- 
tion of the joint-structures and to osteitis, the pain be- 
comes extreme, and the patient is waked from sleep at 
night by the muscular jerks (starting-pains), which press 
the inflamed and ulcerated joint-surfaces together. Even 
in simple synovitis the pain is worse at night. 

Along with the pain goes tenderness in most cases, as 
one would expect from the inflamed condition of the 
synovial sac and the irritable state of the ar-— 
ticular nerves. Hypereesthesia of the skin is 
especially present in pyemic synovitis, but the 
ordinary tenderness is the pain felt on deep pressure and 
manipulation of the inflamed joint. There is a spot in 
each joint where tenderness is apt to be especially 
marked : In the knee it is over the inner condyle, about 
a finger’s breadth inside of the inner border of the pa- 
tella ; in the ankle-joint, in front of the outer malleolus ; 
in the hip, behind the great trochanter. The pain mean- 
time is by no means localized, but there is a bruised, 
helpless feeling extending to the whole joint. Certain 
cases, however, are characterized by severe local pain 
and tenderness in some one spot, and these cases are con- 
sidered by Volkmann” to be due to the deposit of a 


T ender- 
ness. 


Synovitis. 
Synovitis. 


fibrinous clot on the synovial membrane at that spot; the 
theory, however, lacks anatomical proof. 

In simple serous synovitis intra-articular swelling be- 
gins on the first, second, third, or fourth day. It is of 
two kinds—effusion into the joint and effusion 
around the joint. In simple synovitis the in- 
filtration into the periarticular tissues is slight, but if 
pus appears the skin becomes red and boggy, and it is 
seen that serum has infiltrated into the tissues around 
the joint. The same is true of the synovitis associated 
with acute rheumatism, where the periarticular infiltra- 
tion makes a shapeless and puffy joint; whereas intra- 
articular distention betrays itself by a characteristic shape 
in each superficial joint, dependent upon the elasticity of 
each synovial sac. This intra-articular distention varies 
from a small effusion up to a condition in which the skin 
is shiny, tense, and pale, and the venous return from the 
lower segment of the limb may be so much impeded that 
the superficial veins stand out as if ready to burst ; or an 
exudation may take place from the obstructed and over- 
filled vessels and produce a most marked cedema of the 
foot and ankle. The capacity of the sac of the knee- 
joint, when extremely distended, is some six or seven 
ounces; in average cases of simple synovitis it holds 
about four ounces. The average capacity of the shoul- 
der-joint sac is three ounces.’ But in the deeper joints 
swelling may not be discoverable; in the hip, for in- 
stance, there may be no such signs of articular distention 
to be found, or the soft parts in front of the joint may be 
full and prominent, and sometimes fluctuation may be 
felt through the joint.'4 The common state of affairs in 
both hip- and shoulder-joints acutely inflamed is a gen- 
eral enlargement of the joint, without the clearly articu- 
lar shape to be seen in the knee and elbow, for instance. 

Redness and heat are less constant and less important 
symptoms than pain and swelling. Redness is not often 
present in simple synovitis, especially when 
there is much effusion ; in such case the skin 
is apt to be paler than normal, from the press- 
ure upon the skin and superficial blood-vessels by the 
distended capsule. Pysemic, gouty, or rheumatic syno- 
vitis is apt to be attended by a blush, which is generally 
quite marked in the two latter affections. In the case of 
the deeper joints redness as well as heat is ordinarily ab- 
sent. More or less local heat about the inflamed joint is 
present. In an acute serous synovitis the rise of local 
temperature is, according to Barwell, from 1.5° to 2.4° 
F. above the normal. If the synovitis is purulent or 
suppurative, the local rise of heat is as great as in any 
acute purulent inflammation. 

When in a state of acute inflammation a fairly con- 
stant abnormal position. is assumed by each joint; the 


Swelling. 


Redness 
and heat, 


es AD, wat 
osttion. —_ will serve well enough asatype. The hip is 


flexed and adducted or abducted, the ankle is slightly 
extended, the arm is carried at the side, the elbow is 
flexed at a right angle, and the wrist drops slightly and 
is somewhat flexed. Fixation of the muscles holding the 
joint is present at the same time, and the abnormal posi- 
tion is firmly maintained by them when manipulation of 
the joint is attempted. At first this muscular guard 
seems to be purely voluntary, and is only excited by the 
pain which movement causes, but in time it becomes in- 
voluntary, until in chronic joint disease it may be pres- 
ent in cases where movement causes no pain at all. 
Bonnet, of Lyons,!” investigated this question of malpo- 
sition in inflammation, making some experiments which 
have become classical, and until lately his theory met 
with universal acceptance. Joints in the cadaver were 
injected with fluid by means of an ordinary hand syr- 
inge, and Bonnet found that the limbs assumed the 
same positions as when inflamed during life. Solidify- 
ing injections showed also that the joint-capsule pos- 
sessed the greatest capacity in these positions. So here 
was afforded an easy solution of the whole problem—the 
limb simply assumed the position in which the joint 
would hold the most fluid. But certain objections were 
urged against this theory. Bonnet’s injections had been 
made with so much pressure that the condition of affairs 


Vou. VI.—45 


semiflexion of the knee in knee-joint synovitis | 


in the joint was not to be compared with that in acute 
synovitis. And there are two very forcible clinical ob- 
jections—certain cases of knee-joint disease, for example, 
with an extreme amount of effusion, present little or no 
flexion, and in the whole class of chronic tuberculous 
joint diseases, where the malpositions are most marked 
and most constant, effusion is oftenest absent or very 
slight in amount.!® All this, of course, points to some 
second factor in originating and maintaining these posi- 
tions. The explanation of Hilton '*® represents the other 
point of view; he says ‘‘that the irritated or inflamed 
condition of the interior of the joint (say the knee-joint), 
involving the whole of the articular nerves, excites a cor- 
responding condition of irritation in the same trunks 
which supply both sets of muscles, extensors, and flex- 
ors; but that the flexors, by virtue of their superior 
strength, compel the limb to obey them, and so force the 
joint into its flexed condition.” This phase of the ques- 
tion is elaborated a little more fully by Liicke,!7 who 
says that the extensors are lighter in color, and are not 
so well supplied with blood,!® and that impairment of 
motor functions, after fatigue from electrical stimula- 
tion, is more marked in the extensors than in the flex- 
ors.!8 In summing up, Liicke offers practically the same 
explanation that Hilton does, saying that the patient 
finds it most comfortable to hold the limb in this posi- 
tion, all the muscles being tense and set. It is easy to 
see that the whole question of the position of -inflamed 
joints is far from settled. 

Atrophy of the muscles controlling an inflamed joint 
begins early and may be very marked, even in a simple 
acute synovitis. In five cases, seen by Valtat ?° 
from the eighth to the eleventh day of the sy- 
novitis, muscular atrophy was present in all to the extent 
of at least two or three centimetres. The character of 
the joint disease seems to matter but little in the produc- 
tion of this phenomenon. Traumatic or simple, acute or 
chronic, serous or purulent synovitis, all show muscular 
atrophy, and the more acute the disease, the faster the 
wasting goes on. That this is something more than the 
mere atrophy of disuse is shown by the fact that it be- 
gins so sharply and so early, that it is greater in the dis- 
eased limb than in the well one, even when the patient 
has been in bed from the first, and that the muscles, al- 
though atrophied, are not soft and flabby, but tense. Sir 
James Paget says: ‘‘I wish I could explain it better than 
by calling it reflex atrophy,” and Brown-Séquard’s cx- 
periments lead him to think that the trouble is an irrita- 
tion of the nerves, and independent of the trophic cen- 
tres. Valtat injected the joints of guinea-pigs and dogs 
with irritant solutions, mustard-oil and ammonia, and 
found that muscular atrophy came on quickly. In one 
case, in eight days there had been a loss of thirty-two 
per cent. by weight in the anterior thigh-muscles, and 
twenty-four per cent. in the anterior calf-muscles ; in an- 
other case it reached forty-four per cent., and in all cases 
the extensors wasted more rapidly than the flexors. He 
attributes.much influence in the matter to the amount of 
pain present, a point already clinically noted by Paget. 
Valtat also calls attention, in this connection, to 
the paralysis of the muscles of the affected limb 
often accompanying acute joint disease, the loss of power 
already mentioned, and also a diminution of faradic ex- 
citability after severe muscular wasting. In a case of 
knee-joint synovitis, which he mentions, there was com- 
plete paralysis of the flexors of the leg at the end of 
twenty-four hours. Such a paralysis, to a greater or less 
degree, seems to precede the wasting of the muscles. 

The general condition of a patient with simple acute 
synovitis suffers but little. The rise of temperature, if 
any, is slight, unless a rheumatic condition ex- 
ists, and only with the advent of pus does the 
temperature rise to any extent. A sudden chill, 
an increase of pain, a tendency to fever, all make one 
suspect the formation of pus, and when that has ‘once 
come the general condition may become ever so bad. 
Gonorrheal, rheumatic, and pyzemic synovitis are ac- 
companied by fever and the other symptoms of the affec- 
tions which they represent. 


Atrophy. 


Paralysis. 


General 
condition. 


705 


Synovitis. 
Synovitis. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


It is hardly worth while to go deeply into the symp- 
tomatology of dry synovitis. It is rare, and its clinical 
as well as its pathological characteristics are but ill de- 
fined. Bonnet describes it as being characterized by 
much fever and periarticular swelling, severe pain, with 
a tendency to bad positions, and rapid obliteration of the 
joint by anchylosis. Barwell says that the pain of syno- 
vitis with effusion is not worthy of comparison as to 
severity with the pain of dry synovitis, and that there is 
always pyrexia and a doughy look to the skin, and he, 
too, speaks of the tendency to anchylosis. Volkmann 
thinks that Bonnet confused this affection with ulcera- 
tion of the cartilages. However, the fact remains that 
there are cases of joint disease in which pain, and not 
swelling, is the prominent symptom, where no pus can be 
found, and where anchylosis is most rapid and unex- 
pected. 

Considered in relation to cause, acute synovitis falls 
into two classes, traumatic and non-traumatic, 
as shown in the following schema: 


( Traumatic, 


Varieties. 


From exposure, 
f sims From over-exertion. 
Not to be accounted for. 
Rheumatic, 
Gonorrheal, 
Pyzemic, 
Non-traumatic. 4 Puerperal, 
Exanthematous, 
Gouty, 
Syphilitic, 
Secondary to neighboring disease, 
| Catamenial and metric. 


' Synovitis acute. 4 


Traumatic synovitis is, of course, the more common, 
since sprains, blows, and wounds of all sorts are likely 
to contribute more cases than all the rest put together 
(see Joints, Injuries to). The non-traumatic forms of 
synovitis chiefly claim our consideration here. Laying 
aside, then, traumatism, the most frequent causes of sim- 
ple serous synovitis are exposure to cold or wet and over- 
use of the limb affected, and consequent direct mechan- 
ical irritation of the joint. This is often enough called 
rheumatic, even when it lacks the constitutional symp- 
toms of acute rheumatism, and occurs in persons by no 
means predisposed to rheumatic attacks, Such cases may 
be rheumatic, yet they lack evidence of being so, and the 
term had much better be reserved for the form of syno- 
vitis, generally polyarticular, which accompanies the at- 
tacks of more or less generalized rheumatism. 

Simple synovitis sometimes arises when it is impossible 
to assign any cause for it, and pursues its regular course ; 
this form, too, is called rheumatic, on evidence which may 
be very good or very insufficient. Acute simple syno- 
vitis occurs mostly in young adults, and is more frequent 
in men than in women. 

What should really be called rheumatic synovitis is 
only too familiar in acute articular rheumatism. It is 
serous in character, and the extra-articular swelling is 
apt to predominate and mask the distention of the syno- 
vial sac. It.may involve one or, more commonly, sev- 
eral joints, and is, of course, associated with tke constitu- 
tional symptoms of rheumatism ; ordinarily it is a simple 
serous synovitis, lasting from three days to several weeks; 
it rarely goes on to suppuration, and it shows a strong 
tendency to become subacute or chronic. 

Gonorrheal or urethral synovitis stands half-way be- 
tween the rheumatic and pyzmic varieties, and possesses 
some features of each. It occurs oftenest in the second 
week of an acute urethritis, and ordinarily attacks the 
knee, but no joint is exempt. It generally attacks one 
joint at a time, but it may be polyarticular. It may 
come on acutely, with fever and much pain, or it may 
begin insidiously and pursue a more chronic course. It 
is occasionally found in women, but is very much more 
rare in them than in men.** The manner of its relation 
to gonorrhceea is not known; the doctrine that it was a 
metastasis is no longer held, nor does the suggestion that 
it is due toa mild purulent infection meet with much 
acceptance. It may even follow the passage of a sound, 
or some urethral irritation where no gonorrhea exists ; 4 


706 


ordinarily it is serous, and is stubborn and painful ; some- 
times, though rarely, it becomes suppurative, and simu- 
lates pyzemic synovitis very closely. 

Pyemic synovitis is characterized by the rapid forma- 
tion of pus in a joint, ordinarily the knee, ankle, or 
shoulder ; and the inflammation of this joint is apt to be 
followed by that of several others, involved in rapid suc- . 
cession. The serous stage is generally unnoted, although 
it is probably present. Associated as this affection is 
with general pyemia, there is little to be expected that is 
favorable. The destruction is generally rapid and exten- 
sive, and the pus which is evacuated may be thin and 
foul, or thick and flaky. Formerly a separate class was 
made of puerperal synovitis ; but since the nature of pu. 
erperal fever has been recognized, this form naturally 
falls under the class pyeemic, where its symptoms entitle 
it toa place. It is apt to be milder, however, than ordi- 
nary pyemic synovitis. A class of pyzemic joint-affec- 
tions in new-born children, resulting from infection from 
a suppurating cord, has been described by Mildner.* 

Cases of synovitis sometimes follow the exanthemata 
and typhoid fever. Of the exanthems, not even varicella 
is always exempt, but scarlatina and measles are most 
likely to leave joint-complications. The synovitis ordi- 
narily comes on during convalescence, and the frequency 
with which chronic tubercular osteitis is found after the 
exanthemata °° suggests the possibility of the transition 
of the acute synovitis into this affection ; ordinarily it is 
a serous synovitis, almost always polyarticular, and _al- 
though it usually simulates rheumatic synovitis and is 
mild, it may become suppurative and follow more closely 
the course of the pyzmic affection. \Fortunately, inflam- 
mations of this class are rather rare an idea of its fre- 
quency in typhoid fever may be obtained from the sta- 
tistics of Giterbock,?’ derived from 3,130 cases treated 
at the Vienna Hospital from 1868-71, Where only 2 cases 
of joint-complication were noted. And Barwell could 
find no joint-complications on record in the London Fe- 
ver Hospital. ® 

Gouty synovitis is the local manifestationof the gen- 
eral disease. It is a serous synovitis, ordinarily of the 
great-toe joint, with considerable periarticular infiltration 
and redness of the skin. It tends to involve other joints 
in succession, and there is at the same time going on a 
slow change in the joint—alteration of the cartilages, and 
a deposit of urate of soda in them—and finally erosion of 
the cartilages down to the bone, with obliteration of the 
joint. In short, there is a chronic structural change in 
the joint, which is merely interrupted by these attacks 
of acute synovitis. 

The occasional occurrence of clearly marked acute 
synovitis, either monarticular in the knee, or polyarticu- 
lar, is noted in the febrile stage of syphilis.”® 

There is a class of cases of acute purulent synovitis 
which can be best designated as synovitis from direct in- 
fection. Such cases occur in acute periosteitis, acute osteo- 
myelitis, chronic osteitis, and periarticular abscess, in all 
of which the disease is apt to be located near the ends of 
the bones. In periosteitis the pus collecting under the 
periosteum may break through and escape externally, or 
burrow along to the joint and enter it. In the latter 
case, of course, an acute purulent inflammation of the 
joint immediately starts up. Osteo-myelitis, in its de- 
structive course, is likely enough to reach a joint and the 
pus to enter it, when the same purulent infection will 
occur. In chronic osteitis of even slight extent a tuber- 
cular nodule may have formed in the epiphysis near the 
joint-surface ; it softens and breaks down, and, instead of 
passing into the outside tissues, the pus follows the line 
of least resistance and reaches the joint by perforation of 
the cartilage. The chronic symptoms light up with a 
fresh accession and an acute synovitis is clearly present. 
There seems, also, reason to believe that an acute syno- 
vitis may be secondary to a chronic abscess, probably 
tubercular in character, which in its course reaches and 
enters the joint-capsule. These last four classes of cases 
are, of course, merely secondary and incidental to a 
chronic and much more important disease, but they de- 
serve mention, : 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Under miscellaneous cases should be mentioned what 
Barwell calls catamenial and metric synovitis, a multiple 
synovitis which he considers analogous to the urethral 
synovitis of men. It occurs (1) in pregnant women ; (2) a 
month to six weeks after labor in women who have not 
_ had puerperal fever ; (3) in non-pregnant women in con- 
nection with menstrual irregularity or suppression. Mr. 
Thomas Smith calls attention to a peculiarly destructive 
form of synovitis in infants, which he calls ‘‘ acute sup- 
purative arthritis.” It ordinarily begins from the sy- 
novial cavity, but not always, and its origin is neither 
traumatic nor syphilitic. 

First, as to the diagnosis of synovitis with effusion : 
The swelling produced by the distended capsule is the 
most characteristic sign ; it is irregular in out- 
line, bulging, and fluctuating, where the joint 
is superficial. In the ankle-joint the swelling is not very 
clearly marked, but it ordinarily is chiefly anterior and the 
capsule bulges out in front of the malleoli. In the knee 
the patella is lifted by the effusion, and floats. In exami- 
nation for this the fingers of both hands should encircle 
the limb firmly in front, above and below the patella, 
thus confining the effusion to the space directly under 
the patella and over the intercondyloid depression on the 
femur. The forefinger of one hand then lightly but 
sharply presses on the patella, which can be felt to de- 
scend and hit the femur. This matter of fully extend- 
ing the leg and grasping it is of much importance, as 
otherwise a small effusion may escape detection. Acute 
synovitis of the hip is a rather obscure affection, and in 
children the diagnosis is not generally possible. In cases 
with much effusion in adults, however, swelling may: be 
found in the groin above Poupart’s ligament and behind 
the great trochanter. In the case of the shoulder the 
whole joint is larger than usual, without any definite out- 
line ; and if the distention is great, the axilla may be more 
shallow than normally, and the depression beneath the 
acromion behind is lost. In the elbow there is bulging 
of the sac behind on each side of the triceps tendon. 
The wrist, when inflamed, shows an encircling swelling. 
The positions assumed by the various joints, when in- 
flamed, have been given above, but simple position is of 
little service in differentiating synovitis from other joint- 
and bone-affections, and the same is true of muscular 
atrophy. Synovitis is to be distinguished from osteitis, 
bursitis, articular neuralgia, and hysterical joint disease. 
A diagnosis of acute synovitis in children should be 
made with very great care, for they are not prone to 
have acute synovitis, and are. very prone to have chronic 
osteitis. The diagnosis, for example, between acute sy- 
novitis of the hip and morbus coxarius can ordinarily be 
made in the case of adults, but in children the diagnosis 
of an acute synovial inflammation of the hip should be 
made only after permanent recovery has followed, in a 
few weeks, upon the symptoms caused by an injury, not 
. at the time of the acute symptoms. Let anyone read the 
symptoms of acute hip synovitis, as Gibney,”® ¢.g., gives 
them, and see which of them, except speedy recovery, is 
not compatible with hip disease. Suppose that a tuber- 
cular focus has been formed in the epiphysis of the femur 
near the joint, when the pus reaches the joint, just as 
likely as not after some fall, of course an acute synovitis 
is set up, aS we have seen. ‘That may be the first symp- 
tom in the case,*® and if a diagnosis of primary acute 
synovitis is made, as the symptoms would seem to war- 
rant, itis a serious blunder. The same is true of all the 
joints, when children are to be considered. There are 
cases of primary acute synovitis in children; they are 
not common, to be sure, but no attempt is made to deny 
their existence ; simply the practical diagnosis cannot 
ordinarily be made. ‘Typical bone disease begins with 
stiffness of the joint, pain—especially at night, interrupt- 
ing sleep—wasting of the muscles of the limb, and absence 
of effusion. With regard to the chief diagnostic mark 
of typical synovitis I quote from Mr. Bryant: ‘‘ Any in- 
flammation of the synovial membrane, of whatever kind, 
always shows itself within a few days or hours of its 
origin, by effusion and consequent distention of the artic- 
ulation,” 


Diagnosis. 


Synovitis, 
Synovitis, 


From bursitis, synovitis is distinguished by the differ- 
ent location of the swelling, the less degree of joint-stiff- 
ness and pain, except when manipulation bears directly 
on the inflamed bursa, and the absence of muscular atro- 
phy. In the case of deep burs the differential diagno- 
sis may not be easy at first. Bursitis, however, rarely 
begins without cause; it is associated oftenest with me- 
chanical irritation, as the names ‘‘housemaid’s knee,” 
‘‘miner’s elbow,” etc., show. It should be remembered, 
however, that burse often communicate with joints, and 
that synovitis and bursitis may exist together during an 
acute synovial inflammation. The bursee, when inflamed, 
form in their way as characteristic a swelling in each 
joint as the joint-capsule itself, when distended by intra- 
articular effusion. The two are easily distinguished. 
Articular neuralgia is said to exist apart from joint dis- 
ease.*? The pain is out of proportion to the local symp- 
toms, heat and swelling are not present, cutaneous hy- 
peresthesia generally is, and so, possibly, is muscular 
fixation. : 

Hysteria simulates chronic oftener than acute joint 
disease, yet sometimes, following a fall or an over-exer- 
tion, sensations closely simulating the symptoms of an 
acute synovitis may be complained of. Ordinarily the 
diagnosis is easily enough made by the absence of heat, 
swelling, and localized tenderness, and by the general 
make-up of the patient, but some cases offer much diffi- 
culty, as muscular wasting and rigidity may be present 
to a marked degree.*? Pyzmic, gouty, and rheumatic 
synovitis are easily to be distinguished from each other 
by the presence of the constitutional affections of which 
they are merely the symptoms, while urethral synovitis of- 
ten offers some little trouble from the fact that the patient 
is anxious to conceal his urethral discharge. Rheumatoid 


‘arthritis belongs rather to the class of chronic joint dis- 


eases, and would hardly be confounded with acute syno- 
Vitis. 

Finally, as to the diagnosis of dry synovitis: Its acute- 
ness, severe pain, and the absence of swelling are its lead- 
ing characteristics. To diagnosticate it from osteitis would 
be sometimes impossible, but ordinarily its more acute 
course will establish its identity. From the other affec- 
tions it can be more easily distinguished by the methods 
mentioned in the section on the diagnosis of synovitis 
with effusion. 

The prognosis in simple serous synovitis of traumatic 
or non-traumatic origin in adults is good, if the general 
condition of the individual affected be even 
fair. Suppuration is not common, except from 
wounds; and when it occurs, there is generally some evi- 
dent cause for it, such as infection by tapping, a broken- 
down constitution, etc. Under effective treatment a com- 
plete restoration of the joint is the rule. From the sixth 
to the eighth day the effusion will ordinarily begin to sub- 
side, and its absorption is much aided by pressure and 
rest. The third possibility in a simple synovitis is that 
it may become chronic. In some cases the swelling does 
not subside much, but the pain goes away, and, although 
the joint remains swollen, the patient may go to business 
and use the leg fairly, but he has dropsy of the joint, 
chronic serous synovitis, or an irritability may remain 
after the absorption of the fluid, and succeeding light 
attacks may follow one another, each leaving the joint 


Prognosis. 


worse than it was before; these cases are apt to eventuate 


in chronic joint disease. Neither of these latter classes is 
very common in healthy adults, and the prognosis is, as 
we have seen, favorable, especially when, after the ap- 
pearance of the effusion, the pain and fever quickly sub- 
side. Rheumatic synovitis, on the other hand, has a ten- 
dency to become subacute or chronic, and to leave stiff 
joints. The occurrence of suppuration in either rheumat- 
ic or simple synovitis is a serious matter, and, although 
prompt treatment will in most cases be efficient, the prog- 
nosis will be much more doubtful, especially if the sup- 
puration should have come on without apparent cause. 
The occurrence of a joint-affection in pyemia does not 
make very much difference in the outlook, for the prog- 
nosis depends wholly upon the general character of the 
disease, whether mild or malignant. If mild, in from 


707 


Synovitis. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Syphilis. 


five to ten days the joint-symptoms improve, and a com- 
plete restoration of the joint is not impossible.** On the 
other hand, the destruction may go on to any extent, pre- 
ceding a fatal termination. In general, however, it is not 
common to find complete restoration of joint-function 
after either purulent or suppurative synovitis, although 
it may take place. The synovitis occurring after the ex- 
anthemata is said to tend toward recovery after a few 
days. At the same time, bearing in mind how often 
chronic joint disease follows these exanthemata,® it is 
best not to give an unreservedly favorable prognosis. 
The form occurring in typhoid fever is generally puru- 
lent and more grave. Gouty synovitis, when left alone, 
lasts from a week ta ten days; efficient treatment will 
generally shorten its course to three or four days. Gon- 
orrheal synovitis is at best a slow affair; it is character- 
ized by a slow course, with a tendency to relapse and be- 
come chronic. Recovery is not common in a less time 
than a month or six weeks. 

The occurrence of synovitis as a complication in chronic 
osteitis is merely an incident in the course of a long dis- 
ease. 

The important points in the treatment of acute syno- 
vitis are to put the joint at rest and to keep it so, and, 
secondly, to put it at rest in good position, so 
that if anchylosis should take place, as useful a 
limb as possible would be obtained ; that is, the knee 
should be put up very slightly flexed, the elbow at a right 
angle, with the thumb upward, the hip very slightly 
flexed on the trunk and neither adducted nor abducted, 
the ankle at a right angle, the wrist in the line of the arm, 
and the shoulder with the arm at the side. The splint 
that offers the most definite and absolute support to the 
two limb-segments is to be chosen. Ordinary wood and 
tin splints, accurately padded and firmly applied, are gen- 
erally the most serviceable, except in the ankle, where in 
severe cases carved wooden side splints often will not an- 
swer, and wet millboard or plaster of Paris must be ap- 
plied ; and in the hip, where bed-extension and a long 
outside splint, as in fractured thigh, will be most ser- 
viceable. Millboard splints are applied according to the 
directions of Gamgee.*® The joint is wound by rollers 
of sheet-wadding until one or two layers cover it every- 
where, then wet millboard is shaped to the joint and 
bandaged on by linen rollers, applied with firm, even 
compression, which may be considerable if the method is 
properly applied. Plaster of Paris splints are made by 
the application of crinoline-gauze bandages impregnated 
with finely divided plaster. The limb is first wound in 
sheet-wadding, and then the plaster rollers are applied. 
The method does not give in all cases certain, definite 
support. [I quote from Dr. Judson * in regard to it. He 
says: ‘‘It may be an exaggeration, but it conveys the 
idea, to say that a plaster of Paris or silicate splint, ap- 
plied to the leg and thigh, contains a mass of jelly in 
which the femur is but little restrained from motion.” 

The problem of getting a limb into good position for 
the application of a splint is not always aneasy one. The 
knee, for example, is apt to be more flexed than is desir- 
able, especially in a case ‘of some days’ duration ; and if 
easy manipulation fails to bring it into correct position, 
recourse must be had to manipulation under ether, or ex- 
tension by weight and pulley, before a ham-splint can be 
applied. Unless there is some strong reason to the con- 
trary, the latter of the two methods should be chosen, and 
the muscles which maintain the flexion of the joint will 
be found to yield with surprising readiness to continuous 
extension, with even so small a weight as three to five 
pounds, counter-extension being obtained in the usual 
way, by raising the foot of the bed. Once obtained, this 
good position is easily kept. This extension method also 
relieves the pain and discomfort surprisingly in severe 
cases, whereas manipulation under ether is ordinarily so 
painful that opiates are required after it. It is not gen- 
erally practicable to apply extension to the wrist or an- 
kle. The plan of putting up the limb in whatever po- 
sition it happens to be, and waiting for it to straighten 
under rest, is neither safe nor always effectual. With the 
larger joints rest in bed should be enforced. This treat- 


Treatment. 


708 


ment should be the same, whatever the origin or the 
character of the synovitis, with the one exception of that 
following penetrating wounds of the joints. Here clean- 
liness takes precedence of everything. If the opening is 
not already large enough through which to wash out the 
joint, it should be made so, and the whole joint thor- 
oughly irrigated with 1 to 5,000 corrosive sublimate solu- 
tion, or 1 to 80 carbolic acid ; no means should be neg- 
lected to remove all foreign material from the joint, then 
the case should be dressed antiseptically and treated in 
the usual way. 

Having then put the limb into good position, and hav- 
ing fixed it so, less important matters are to be consid- 
ered. A simple synovitis of moderate severity may prac- 
tically be let alone, after applying some compression to 
the distended sac. A flannel bandage, cut bias, to give 
the full elasticity of the cloth, affords light compression ; 
small dried sponges, laid over the joint and held in place 
by stout linen rollers, and then wet, afford either the 
lightest or the most severe compression. The applica- 
tion of a rubber bandage .is one of the most common 
forms of producing compression. It can be loosely ap- 
plied and produce but light pressure, or by stretching it 
only slightly during its application very severe compres- 
sion may be obtained. The objections to it are the mac- 
erating of the skin under it, and the tendency thereby in- 
duced to erythema and eczema, and also the fact that it 
must be very lightly applied, for with much tension the 
discomfort is likely to become unbearable a short time 
after application ; but when properly used it is often of 
the greatest benefit. The method of Gamgee, above al- 
luded to,*® is applicable to almost any joint, and affords 
even, comfortable, and efficient compression. If, how- 
ever, the intra-articular distention is extreme, or if at the 
end of a week it does not begin te diminish, the joint 
should be aspirated and compression at once applied. 
Dr. H. A. Martin said :* ‘‘ [*have never known a case 
where a joint was ‘ aspirated,’ and no such support [as 
the rubber bandage] afterward applied, in which the effu- 
sion did not return, whether the synovitis was the result 
of injury or disease.” If the aspiration is done with 
proper antiseptic precautions it is attended by practically 
no risk; simply a needle of fair size is ‘thrust into the 
most elevated part of the sac and connected with a com- 
mon aspirator-tube. The puncture should be sealed with 
plaster or iodoform collodion. The claims of Dr. Mar- 
tin ** for this method are clearly extravagant. I quote 
directly from his article: ‘‘(1) That in a little over nine 
years I have treated over one hundred and forty cases of 
synovitis of the knee and its sequele by aspiration, with 
a single strapping of the joint and subsequent use of the 
bandage. (8) The patient was in nearly all cases 
permitted to walk about. (4) That in not asingle instance 
had there been a failure of absolute and entire cure. (5) 
That in no instance had this desirable end been postponed 
for more than seventeen weeks,” etc. The experience of 
other surgeons in this treatment does not coincide with 
that of Dr. Martin. 

The application of cold to the joint often gives relief 
to the pain and a sense of comfort. This can be done by 
a poultice of ice and saw-dust, by the ice-bag, or by the 
rubber coil wound around the limb. In other cases warm 
applications are more agreeable and equally useful. Hot- 
water bags can be used, or poultices, or fomentations of 
laudanum and hot water. In any synovitis of a severe 
character in a full-blooded individual the application of 
leeches to the joint is a measure of the greatest value, 
especially if there is much local heat and tenderness, and 
a tendency to suppuration is suspected. Nor should the 
leeches be used sparingly ; from six to twelve should be 
put on all over the joint, and allowed to fill themselves, 
and then the bleeding is either to be encouraged by warm 
applications or checked by cold ones, as seems most ad- 
visable. On the other hand, painting with iodine, blis- 
tering, firing, and the other forms of counter-irritation 
seem a needless and bothersome infliction in simple acute 
synovitis ; if, however, it shows a tendency to become © 
chronic, then the time for counter-irritation has come, 
and blisters encircling the joint, in connection with as- 


. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Synovitis. 
Syphilis. 


piration and subsequent compression, should be made use 
of. When the effusion has subsided and only a moder- 
ate thickening of the tissues is left, the splint should be 
removed and passive motion begun at the earliest pos- 
sible moment, along with massage ; for the tendency 
which inflamed joints have to become anchylosed should 
always be borne in mind. The experiments of Moll * 
did but little to clear up this question of anchylosis ; for 
although from them it was perfectly evident that a sound 
_ joint might be immobilized indefinitely without losing 
any of its mobility, yet when inflammation of the joint 
was present, from a fracture near it; Moll was unable to 
say in what proportion of cases anchylosis occurred, al- 
though the joint was obliterated in several of the animals 
experimented on. As to methods of manipulation and 
massage,*! a skilled masseur is, of course, the best per- 
son to handle the limb, but deep kneading of the muscles 
and gentle flexion and extension of the joint, increasing 
in extent each day, answer every purpose.. The muscu- 
lar atrophy will cause the. limb to be weak; and, if it 
has been severe, although it would probably recover it- 
self, restoration can be hastened by the use of a weak 
continuous current, perhaps of the faradic also.*° It is 
not worth while to attempt to use the limb very much 
until its function is fairly well restored by passive mo- 
tion. _The use of palm-oil, etc., is, of course, much in- 
ferior to massage with the dry hand, but if the pain per- 
sists, on using tbe limb, stimulating liniments and blisters 
are very useful. If anchylosis should have already taken 
place, there are two methods to pursue: (1) To break it 
up at once under ether, a method which will ordinarily 
cause a relapse of the synovitis; or (2) to wait some 
months before attacking it. The latter method will gen- 
erally be advisable. The constitutional treatment of 
acute serous synovitis amounts to nothing more than the 
routine of keeping the bowels open, and administering 
diaphoretics if the temperature is elevated. If, however, 
there is any reason to suspect a rheumatic cause for the 
attack, salicylate of soda should be given in full doses. 

When the formation of pusin a joint is once estab- 
lished, there is ordinarily only one treatment to be con- 
sidered, namely, incision. When the skin over the joint 
becomes red and cedematous, and the pain more severe, and 
when the patient is feverish, a full purge should be given, 
the joint should be kept absolutely quiet, and leeches ap- 
plied in abundance, followed by cold and light compres- 
sion. If, now, the trouble increases and fluctuation is 
apparent, the introduction of an aspirating-needle will 
-show pus in all probability, but aspiration will rarely 
give more than temporary relief. The joint must be 
opened by a free incision, made under every antiseptic 
precaution, thoroughly scrubbed out with corrosive sub- 
limate or carbolic acid solutions, freely drained, and put 
into a desirable and fixed position, covered by a full anti- 
septic dressing. When the wound heals, passive motion 
should be begun at the earliest possible moment, in order 
to save as much of the joint’s motion as possible. The 
constitutional condition of patients with purulent syno- 
vitis is not good, and should be treated by alcohol, qui- 
nine, iron, and forced nourishment. The treatment of 
rheumatic, gouty, and gonorrhe@al synovitis is consid- 
ered in the articles, elsewhere, treating of those affections. 
Joints affected with pyzmic synovitis must be opened, 
but antiseptic precautions are, of course, useless. The 
treatment of exanthematous synovitis should be espe- 
cially watchful, and the patient’s general condition should 
be most carefully looked after. Robert W. Lovett. 

1Cornil and Ranvier: Path. Hist., 227. Philadelphia, 1880, 

2 Cadiat et Robin: Dict. Encyc. des Sc. Med., ix., 8, 249. 

3Farabceuf: Thése d’Agrégation, 38. Paris, 1876. 

4Hueter: Virch. Archiv, Bd. xxxvi., Heft 1. 

5Tillmanns: Arch, f. mik, Anat., Bd. x. 1874. 

6 Clopton Havers. 1691. 

7 Rainey: Proc, Royal Society, May 7, 1846. 

8 Barwell: Diseases of the Joints, p. 22. London, 1881. 

*Frerichs: Wagner. Handworterbuch der Phys., iii., 1, 446. 

10 Volkmann, Pitha, und Billroth: Handbuch der Chir., Bd. ii., 2, 494. 

11 Hueter: Gelenkkrankheiten, p. 63. 1870. 

12 Bonnet: Mal. des Artic., T.i., p. 52. Lyons, 1845. 

13 Wright: Hip Disease in Childhood, p. 39. London, 1887. 

14 Bryant’s Surgery, p. 872. 


15 Tannelongue; Coxotuberculose. Paris, 1886. 


'6 Hiiton : Therapeutic Influence of Rest, p. 156. 

17 Lucke: Deutsch. Z. f. Chir., March 9, 1885. 

18Sonnenburg: Deutsch. Z. fiir Chir., vii., 485, 

19 Fischer: Deutsch. Z. fiir Chir., viii., 1, 37. 

20 Valtat: L’Atrophie musc. dans les Mal. articulaires, p, 54. 
1877. 2! Paget: Clinical Lectures and Essays, p. 209. 

22 Brown-Séquard: Le Progrés Méd., March 7, 1885. 

23 Bumstead and Taylor: Venereal Diseases, 255. 1883. 

24 Fournier: N. Dict. de Méd. et de Chir, pratiques, vol. v., 224. Paris. 

25 Mildner: Prag. Vierteljahrschrift., vii., 100. 1845. 

26 Gibney: Diseases of the Hip. New York. ; 

27 Betz: Jour. f. Kinderkrankheiten. 1851. 

28 Volkmann: Loc. cit., p. 505. 

29 Smith: St. Bartholomew’s Hospital Reports, xv., 1880. 

30 Volkmann: Samml. kl. Vort., series 6, p. 1397. 

31 Bryant : System of Surg., chap. Dis. of Joints, p. 869. 

32 Ranney: Surgical Diagnosis, 8d ed., p. 61. 
cea ae Hysterical Element in Orthopedic Surgery. New York, 

34 Sedillot: De l’Infection purulente, 
Archiv, i,, 329. , : 

35 Gibney: Diseases of the Hip, p. 212. New York, 1884. 

36 Gamgee: The Treatment of Wounds and Fractures. London, 1883. 

37 Judson: N. Y. Med. Journal, i., 624, 1886. 

38 Martin: Trans. Am. Med. Ass.. 1877. 

39 Martin: Trans. Int. Med. Congress, ii., 445, 1881. 

40 Moll: Arch. f, Path. Anat.; cv., 466, 1886. 

41 Witt: Langenbeck’s Archiv, xviii., 275. Mosengeil: Langenbeck’s 
Archiv, xix., 429. 


Paiis, 


Paris, 1849. Roser: Wagner's 


SYPHILIS. The word syphilis was probably first sug- 
gested by Syphilus, the name of one of the characters in 
a pastoral poem composed by Fracastor in 1530. This 
name was unquestionably coined by the poet for his 
fictitious character, by a combination of ois, hog, and 
gidos, fond of—a not uncomplimentary designation for a 
swine-herd. 

Definition.—Syphilis is a specific, infectious, and 
chronic disorder, resulting either from inheritance or from 
immediate or mediate transference of the disease from 
an infected to a sound individual, beginning always, in 
the latter event, after the lapse of a characteristic incuba- 
tive period, by the appearance of an initial lesion, at the 
site of infection, commonly termed a chancre; and fol- 
lowed after an interval of time by symptoms of systemic 
derangement, usually evolved in a determinate order, 
which eventually may affect any organ of the body, one 
attack usually conferring upon the subject of the disease 
immunity against subsequent infection. 

Synonyms.—Many of the names which have been em- 
ployed to designate the disease seem to have originated 
in attempts to shift the reproach of its origin and exist- 
ence from the people of one nation to those of another. 
It has been called morbus gallicus, the French disease, 
lues venerea, mal vénérien, vérole (in France), sifilide (in 
Italy), French pox, chronic pox, ‘‘bad disorder,” ‘‘ bad 
disease,” Lustseuche, Krankheit der Franzésen, radezy ge 
(in Sweden), and other names, It is also said to be iden- 
tical with frambeesia and yaws, but there is some doubt 
as to these points. 

History.—Toward the close of the fifteenth century, 
soon after, in fact, the discovery of a new continent, 
syphilis made its appearance among Europeans and be- 
came the subject of discussion in medical literature. By 
many it was then supposed to have originated in conse- 
quence of the relations newly established between the in- 
habitants of the old and of the new worlds, and it was there- 
fore often termed the ‘‘ American disease.” Later inves- 
tigation, however, makes it appear probable that syphilis 
appeared among the races of men at a more remote period 
of antiquity. Evidence of syphilitic disease of the bones 
has been recognized in the skeletons of prehistoric man. 

In later and historic epochs also,.symptoms scarcely to 
be distinguished in their description from those of syph- 
ilis are described in the ancient literatures of China, 
Mexico, Peru, Arabia, Greece, Rome, and in the sacred 
writings of the Hebrews. It is probable that, at the pe- 
riods which have been assigned for the origin of the dis- 
ease in the fifteenth century, its rapid extension was 
largely due to the awakened activities of mankind in the 
direction of geographical discovery and international 
traffic. It is a well-known fact that epidemics of infec- 
tious diseases are usually most severe in communities 
which have long been virgin of such accidents. 

The literature of syphilis may almost be said to date 
from the period so long assigned as that of its first appear- 


709 


Syphilis. 
Syphilis. 


ance among the races of men. It hassince been adorned 
by the names of such eminent medical authors as Astruc, 
Van Swieten, Boerhaave, Bell, Sydenham, Colles, Hunter, 
Ricord, Gross, and Bumstead. The contributions to the 
subject made by contemporary authors have been as vol- 
uminous as valuable. The evolution and involution of 
the syphilitic process in every organ and tissue of the 
body have been observed and described with as much 
detail and accuracy as have been bestowed upon any of 
the problems ih medicine. a : 
Geographical Distribution.—Syphilis exists to-day in 
almost every country to which commerce has pushed its 
ventures, 
ince may be wellnigh regarded asa measure of the ex- 
tent of the intercourse of the inhabitants of such a coun- 
try with the world at large. It exists in Great Britain, 
Russia, France, Italy, Norway, Sweden, Denmark, 
Prussia, Austria, Portugal, Switzerland, and in every 
other country of Europe. Its victims are usually more 


numerous in the larger centres of population where 


the activities of trade are greatest. England, for ex- 
ample, with her enormous maritime traffic, pays a heavier 
price of this character for her commercial profits than 
France, which is popularly supposed to suffer in larger 
measure. In a few of these countries, Italy, for example, 
where many of the people are densely ignorant, filthy, 
and poor, epidemics of the disease have occurred with 
disastrous results. On the African. coasts, in Egypt, 
Madagascar, and Abyssinia ; in all countries of Asia with 
which Europeans sustain commercial relations ; in Japan, 
where the disease is reported to be both widely prevalent 
and virulent; in the Levant ; in all parts.of Asia Minor, 
and throughout all districts lying upon the shores of the 
Black Sea, syphilis is found, varying both in types of in- 
tensity and in preponderance. The same is true of all 
the countries of North and South America, Oceanica, and 
the Sandwich Islands. In the United States of America, 
syphilis may be recognized in every hospital and in the 
practice of almost every physician of repute. It is fortu- 
nately, however, much more common in the large cities, 
the rural populations escaping to a happy extent. It is 
found here among those who are native to the soil, in- 
cluding the negroes and Indians, as well-as among the 
Chinese and other individuals of foreign birth who have 
immigrated hither. 

It appears, in brief, that the extent and severity of the 
disease are not related to climate, isothermal lines, or de- 
grees of latitude and longitude. They are intimately 
related, rather, to certain social traits in mankind, distin- 
guished in their commercial, military, and religious ex- 
cursions, trading ventures, pilgrimages, wars, fairs (¢.9., 
that of Nijni-Novgorod), and encampments of armies ; 
their hygienic and medicinal methods ; and, more or less 
in consequence of what precedes, to the density of popula- 
tion and the degree of intelligence possessed by infected 
classes as displayed in their management of the malady. 

Nature of the Disease.—Syphilis is a specific infectious 
disease, always occurring in consequence of transmission 
from a diseased to a sound individual, and always trans- 
mitted as such. It does not sustain etiological relations 
with scrofulosis, tuberculosis, leprosy, or any other 
known disorder. It is capable of transmission by inher- 
itance, and also by the medium of fluids furnished by 
the pathological tissues of diseased individuals. These 
fluids when isolated may be said to embody all the power 
and potency of the disease, and hence are described as 
virulent, or containing the virus of syphilis. 

This virus, or contagious element of the secretion, 
which may be removed from one individual and artifi- 
cially introduced into another with the result of thus pro- 
ducing the complete evolution of the symptoms of the 
disease, has been the theme of much discussion. Its very 
existence has been doubted by Bru, Jourdan, and others. 
Chemical analysis has failed to isolate it. Salisbury, 
Lostorfer, and others, have thought they discovered the 
germs of the disease in this secretion, but failed to make 
good their pretensions. Later, Pisarevski, Klebs, Ber- 
mann, Aufrecht, Morison, and Birsch-Hirschfeld, have 
discovered, in fluids of this kind, micrococci, which by 


710 


The degree of its depredations in any prov-. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


them were supposed to be the etiological factors of the 
disease. Finally, on November 12, 1884, Lustgarten an- 
nounced to the Vienna Society of Medicine that he had 
recognized the bacilli of syphilis. They were somewhat 
smaller than those of tuberculosis, from two to seven 
thousandths of a millimetre in length, and about three 
thousandths of a millimetre in width, straight or curved, 
and isolated or grouped, with contents distinguishable in 
the form of from two to four light, ovoid, colorless 
points supposed to be spores. While Doutrelepont, 
Klemperer, and others have verified these observations, 
it is held by Cornil that the microbe, supposed by Lust- 
garten to be the essential element of the syphilitic virus, 
was indistinguishable in more than one-third of all chan- 
cres examined by him and his collaborators ; while Koeb- 
ner asserts that, though these organisms are recognized 
in most of the genital lesions of syphilis, they are not 
found in buccal and other extra-genital lesions of the 
same disease. The claim is also put forward that they 
are more or less identical with the bacilli which can be 
recognized in normal smegma. Lastly, it is admitted 
that the essential conditions requisite to establish the fact 
that any micro-organism is the sole factor in syphilis have 
never been satisfactorily met. | These are: The fairly con- 
stant demonstration of the bacilli in lesions of syphilis, 
whether occurring in one or another region or viscus of 
the body ; next, the reproduction of generations of these 
germs in sterilized culture-fluids ; lastly, the infection of 
sound human beings by the medium of the latter, and 
the production in such infected subjects of a typical 
syphilis, capable of transmission to a sound individual by 
the usual methods. 

In the absence of positive data of this kind, we are not, 
however, left for an explanation of the nature of syphilis 
to such mazes of speculation as were\the only resource 
of the earlier writers on this subject. Though unable to » 
declare to-day that this or that specific germ is the essen- 
tial factor in the disease, the remarkable advance of 
knowledge on the subject of bacterial affections gives us 
a basis sufficient to establish the belief that syphilis be- 
longs to the class of infectious granulomata ; and is the 
result of the introduction of a parasite into the human 
economy. ‘The disease should be classed to-day with tu- 
berculosis and leprosy, whose etiological bases are now 
scarcely questioned ; and, possibly, also with glanders, 
mycosis fungoides, actinomycosis, and other affections 
with respect to whose precise bacterial relations there is 
some doubt. 

Neisser, in fully accepting the consequences that fol- 
low the acceptance of this position, established by anal- 
ogy but unsupported by demonstrable fact, has in this 
light satisfactorily explained many of the phenomena of 
syphilis. The bacteria may be transmitted by intra-uter- 
ine inheritance or extra-uterine infection at a given point 
where multiplication of the germs occurs. Whether in- 
stantaneous general infection follows by the sudden ad- 
mission of these micro-organisms into the circulating 
fluid; or by the slower process of invasion of the lymph- 
channels and extension through the lymph-glands to the 
general economy, it seems clear that the initial sclerosis 
of the disease, a ‘‘ chancre,” becomes a focus of infection 
which only gradually participates in the same process of 
distributing the germs of the disease throughout the gen- 
eral economy. Later, the lodgement of these germs in 
various parts of the body determines the development 
there of the specific products of the disease ; possibly 
also exercises there that specific local modification which 
renders the tissue then capable of reacting in a certain 
characteristic morbid behavior, after the operation of ex: 
ternal irritants (mucous patches in the mouth of the 
smoker, etc.). Neisser believes that the nearer the date 
of infection, the larger the number of bacteria present at 
any one moment in the body ; and, as a corollary from 
the above, the more numerous, symmetrical, and super- 
ficial the lesions. But in later periods, with a smaller 
number of bacteria and a gradual decrease in capacity 
for infection and hereditary transmissibility, there are 
fewer, deeper, more asymmetrically disposed, and more 
malignant manifestations of the disease. 


‘nized chancre. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


EVOLUTION OF THE DISEASE IN PERIODS.—Every case 
of acquired, as distinguished from inherited, syphilis be- 
gins with a chancre. Cases reported to have originated 
in other ways are to be regarded as instances of unrecog- 
In popular phraseology, the period of 
the disease during which are displayed the local phenom- 
ena of the chancre and its characteristic adenopathy of 
contiguous lymphatic glands is termed the period of 
primary syphilis. The period of so-called secondary 
syphilis is that which begins with the earliest symptoms 
of constitutional, as distinguished from purely local dis- 
ease, and whose symptoms are, for the most part, as re- 
gards cutaneous manifestations, both symmetrical and 
superficial. Not only the skin and its appendages (nails, 
hair, etc.), but the eyes, lymphatic glands, and other or- 
gans may be affected in this period of the disease. It 
rarely begins as early as the twenty-fifth day after the 
appearance of the chancre ; and is even more rarely post- 
poned to the sixth month after such appearance. No 
definite term of duration can be assigned to its manifes- 
tations ; hence the limit between so-called secondary and 
tertiary syphilis is of artificial importance and of variable 
date. Secondary manifestations in syphilis usually cease 
to occur after the second year of infection, but may be 
displayed for a year or more afterward. 

So-called tertiary syphilis includes the later lesions of 
the disease, graver in type, deeper, often visceral in situa- 
tion, and possibly single, usually asymmetrical in develop- 
ment. They may be evolved as early as the third or fourth 
month following the primary lesion, and persist or recur 
during a series of subsequent years. In exceptional cases 
there is a reversal of the order of evolution indicated by 
these popular phrases, first employed with precision by 
Ricord, so that so-called secondary syphilitic symptoms 
succeed the so-called tertiary. In tertiary syphilis the 
subcutaneous, osseous, fibrous, nervous, and other tissues 
of the body are affected, together with the viscera. 

For a study of the symptoms displayed in the period 
of primary syphilis, the reader is referred to the admir- 
able and complete article, entitled Chancre, to be found 
in the second volume of this work. In the pages which 
follow, syphilis will be considered from the earliest of its 
constitutional manifestations throughout its career, be- 
ginning, therefore, with the so-called secondary period. 

THE SracGe oF INVASION OF SYSTEMIC SYPHILIS.— 
After the appearance of a chancre, from. forty to fifty 
days usually elapse before the appearance of the first 
syphilitic eruption. This period may be shortened to 
three weeks; and, in exceptional cases, prolonged to sev- 
eral months. There is strong reason to believe that it 
may be prolonged under the influence of mercury. In it 
the chancre commonly progresses from complete evolu- 
tion to involution ; and, when there has been ulceration 
of that lesion, to cicatrization. Usually, also, when ten 
or fifteen days only of this period have elapsed, the ade- 
nopathy connected with the chancre has appeared and 
reached its full development. With the chancre healing 
or cicatrized, and with one or several of the neighboring 
glands, possibly their lymphatics also, in a state of pain- 
less induration, the concluding three-fifths of this period 
is one of apparent inactivity of the disease. It has been 
called for that reason a second incubative period of the 
disease. In the view of the inexperienced, the subject 
of the disease at this time may be possibly regarded as in 
a condition of health. Careful examination, however, 
reveals usually the following significant symptoms : 

(a) The Chancre Features.—If the chancre be examined 
it will be found, if recognized at all near the conclusion 
of the period, either ulcerated, cicatrized, represented by 
asclerosis, or preparing for transformation to a lesion of 
secondary syphilis. Sometimes a deeply ulcerated and 
formidable chancre persists as such till the complete evo- 
lution of secondary syphilis ; oftener, before the date of 
such evolution, a previous ulceration has resulted in a 
tender cicatrix surmounting one of the several grades of 
induration which characterize the primary lesion. In 
yet other cases, without any distinct ulceration, the char- 
acteristic sclerosis of the disease persists (upon the genital 
region, finger, lip, etc.), ranging in bulk from a parch- 


Syphilis. 
_ Syphilis. 


ment-like thickening to a large nut-sized semi-solid mass 
usually freely movable upon the tissues beneath. Care- 
ful search for this sclerosis in every suspected region 
should be made in all first examinations of a patient at 
this period. In yet other cases the chancre is represented 
by an erosive lesion capping any form of sclerosis which, 
participating in the process of systemic evolution of symp- 
toms, soon exhibits an elevated floor which may be coy- 
ered with a whitish pellicle resembling the surface of a 
mucous patch, and be thus in fact changed to a true gran- 
ulating mucous patch, the so-called transformation of 
chancre in situ. In all or any of such events, just prior 
to the evolution of secondary syphilis, there is often a 
marked, pathological activity of some sort in the chancre- 
site, the sclerosis becoming larger, the declining maculo- 
papule more vivid, the ulcer deepening or reopening, or 
the superficial erosion becoming a smooth, granulating 
surface with an opalescent pellicle spreading over its 
area. 

(b) The Lymphatic Glands and Vessels.—With very 
few exceptions one or more, usually several, of the lym- 
phatic ganglia nearest the site of the chancre are found 
enlarged and indurated in this invasion-period. From 
the tenth day after the appearance of the primary lesion 
to the conclusion of the invasion-stage (that is, the date of 
appearance of the first syphiloderm) these symptoms per- 
sist. In general, it may be said that the first half of this 
period is required for complete evolution of the local 
adenopathy which in the latter half may be somewhat 
less conspicuous, but which yet often, at the termination 
of this stage, exhibits the evidence of pathological activ- 
ity described above. In some cases the glands become 
swollen, tumid, and tender at the onset of general symp- 
toms. The induration of the glands may persist after- 
ward for months, the duration of the syphilitic bubo 
depending somewhat upon the treatment pursued. Sup- 
puration of these indurated glands is very rare. The 
lymphatic vessels in anatomical connection with such 
glands may also undergo this specific induration, and be 
represented by dense quill-sized cords, single or multiple, 
reaching from the site of the chancre to the single lym- 
phatic gland or cluster of glands which are superficially 
involved. 

Besides this persistent indurated condition of one or sev- 
eral of the glands near the chancre-site, noticeable in the 
invasion-stage of general syphilis, there is usually appre- 
ciable toward its conclusion a remarkable and often sud- 
denly occurring engorgement of the superficial ganglia. 
This symptom is not of local but of systemic importance. 
It is related less to the chancre than to the general oncom- 
ing syphilis. It is an early and almost constant symptom 
of general infection, often, as just described, particular- 
ly conspicuous prior to the evolution of the first syphilo- 
derm ; at other times, not fully developed till such early 
symptoms have been declared, and in both cases usually 
persisting for some weeks after its appearance. 

Reference is made to a tumid and engorged, very rare- 
ly indurated, often softish condition of the chain of lym- 
phatic glands extending along the posterior border of the 
sterno-cleido-mastoid muscle, or of the post-auricular, 
suboccipital, epitrochlear, or submaxillary glands. These 
glands, usually so small as to be scarcely recognizable by 
the finger passed over the skin, may increase till they are 
of the size of a bean ora small nut, and are even con- 
spicuous to the eye of the observer. The two glands be- 
neath the occiput are often very significantly enlarged in 
this way, irrespective of the occurrence of any lesion 
upon the scalp or vertex. This general engorgement of 
certain special lymphatic ganglia is often symmetrical, 
the glands, for example, behind one ear, or over the mas- 
toid process, corresponding in size and firmness to those 
of the other side of the body. Occasionally this engorge- 
ment of glands in special regions of the body is propor- 
tioned in extent to the syphilodermata developed in con- 
tiguous regions, of the scalp, for example, where the 
suboccipital ganglia are affected. 

(c) State of the Blood.—Syphilis, though often popu- 
larly described as a ‘‘ blood disease,” is actually one in 
which but very few alterations can be demonstrated in 


711 


Syphilis. 
Syphilis. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the blood ; and these but for a relatively brief period of 
its long course. Grassi, Wilbouchewitch, and Mélassez 
have by the process of repeatedly counting the number 
of red blood-corpuscles present in small selected portions 
of a drop of that fluid, determined that these constitu- 
ents of the blood were from one-half to one-seventh fewer 
in number, in certain stages of syphilis, than in the aver- 
age of sound health. With this proportionate decrease 
in the number of the red corpuscles, there is a relative in- 
crease in the number of the white globules. This change 
is characteristic of the early stage of syphilis only. Itis 
often especially noticeable just prior to the evolution of 
the first syphiloderm. If syphilis is ever demonstrated 
to be caused by a specific bacillus, it will be found doubt- 
less that, in the period under discussion, these micro- 
organisms are multiplying, and by the avenue of all 
the vascular channels gaining access to distant parts of 
the body ; even, it may be supposed, to special regions 
where months later a tertiary gummatous product may 
form. 

(d) Chloro-anemia.—The chloro-anemia which is the 
result of systemic intoxication in syphilis occurs from 
time to time in most well-marked cases of the disease. 
It may be an early or late symptom, and in grave and so- 
called galloping cases is throughout a marked feature of 
the malady, In tertiary and ulcerative types of syphilis, 
it may depend more upon the local symptoms than upon 
the general condition, and, in some cases, is without ques- 
tion a resultant of the long-continued inroads of the poi- 
son upon the general health. 

This chloro-anemic, anemic, cachectic, or asthenic 
state is often conspicuous in the invasion-period now 
under consideration, with mild or grave symptoms, par- 
ticularly in persons of a naturally weak constitution, or 
in those prostrated by other previous disorders. Often, 
just before the appearance of the earliest syphiloderm, 
the patient exhibits a pallor of the face, accompanied by 
a discolored, muddy, leaden, or saffron-like tint of the 
skin. With this there may be emaciation, weakness, and 
vague rheumatoid pains in different parts of the body 
(substernal, plantar, temporal, tibial, etc.). There is ano- 
rexia, and the patient will often describe his condition 
as one of ‘‘ biliousness.” In exceptional cases there is 
decided icterus, with yellowish conjunctive and urine of 
high specific gravity and heightened color. With this 
condition may be associated the ganglionic engorgement 
already described; the characteristic induration of the 
glands nearest the chancre ; and the persistence of the in- 
itial sclerosis as a dense ridge, button, plaque, nodule, 
agglutination of tissue (digital chancre), or thin circum- 
scribed sheet (‘‘ parchment” form of induration). 

(e) Syphilitic Fever.—Recurrent, remittent, more or 
less persistent, and even intermittent elevations of tem- 
perature are of frequent occurrence in syphilitic sub- 
jects, more particularly in the early stages of the disease. 
Greater stress is laid upon this by certain English au- 
thors than the subject seems to deserve. 

From one week to a fortnight before the first syphilo- 
derm appears, with and without the icteroid, cachectic, 
or anemic hue of the skin described above, the bodily 
temperature may rise to any point from 101° to 105° F., 
the lower figures representing the average of all cases 
where any such form is recognized by the physician ; 
the higher, cases characterized by a tolerably profuse 
first exanthem of syphilis. Usually this is a’ transitory 
symptom of the disease; but at times it persists for 
weeks. In cases, it is preceded by a sensation of chilli- 
ness or distinct rigors. When remittent, the exacerba- 
tion is usually vespertine. There is commonly coinci- 
dent thirst, malaise, cowrbature, and osteocopic pains 
with headache and backache. In some cases, the febrile 
state is so insignificant as to attract no attention. 

SYPHILODERMATA (syphilides, cutaneous lesions of 
syphilis).—The skin-symptoms of syphilis are numerous, 
widely different in type and career, and of the highest 
importance in the diagnosis of the disease. In any given 
case of syphilis, the greater number of skin-lesions are 
displayed during the first two years after infection, that 
is, during the so-called secondary stage of the disease. 


712 


They, however, occur often in grave forms in the late 
or tertiary period of syphilis. 

General Characteristics of ithe Syphtlodermata.—The 
skin-lesions of syphilis resemble the skin-lesions of al- 
most every non-syphilitic disorder, yet differ from the 
latter in certain special features. The study of these dif- 
ferences is essential to the recognition of the identity of 
the syphilitic exanthem. Their characteristics, general- 
ly considered, may be classed as follows: (1) Absence of 
subjective sensations. For the most part the syphiloder- 
mata are not accompanied by pruritus, or sensations of 
burning, heat, pricking, etc. Notable exceptions to this 
rule may be found, but it is fairly constant of applica- 
tion, and due to the chronicity of the syphilitic exanthe- 
mata, their remarkable tendency to recurrence, and their 
striking amenability to treatment. (2)Career. They are 
rarely pyrexic; their course is essentially chronic ; they 
are exceedingly liable to recur ; and yet, as distinguished 
from the lesions of epithelioma and lepra, they are rela- 
tively rapid in evolution. They are greatly influenced 
by treatment, and are hence rarely seen when unmodi- 
fied ; but it is highly probable that all of them have, with- 
in variable limits, a cyclical career which would be pur- 
sued in most of the cases if no interfering agent modified 
theirevolution. (8) Polymorphism. Multiformity of le- 
sions, that is, the occurrence of multiple lesions of differ- 
ent elementary forms at one time upon the same person, 
is characteristic of several diseases of the skin, including 
syphilis. In the latter, papules, tubercles, pustules, ul- 
cers, and macule may coexist upon the skin of an in- 
fected individual, who thus presents a striking contrast 
with the psoriatic patient, for example—the skin of the . 
latter being possibly extensively covered with exclusively 
squamous lesions. (4) Color. The color of a cutaneous 
exanthem differs not only in different individuals of dif- 
ferent color-type (blonde, brunette, African, etc.), but 
also in the same individual from year to year; e.g., the 
lupous patch of childhood differs from the same occur- 
ring at puberty. This is true of the syphilodermata, 
whose color exhibits the widest range of. differences un- 
der different circumstances. Certain combinations, how- 
ever, of the brown, the purple, and the duller hues of 
other colors are especially striking when seen in syphilo- 
dermata that are typical also in seat and configuration. 
The so-called characteristic color of the syphilodermata 
has been compared with that of raw ham and of coffee, 
shades which, when at all distinct, are highly suggestive. 
After complete involution of many of the syphiloder- 
mata, especially those seated on the lower limbs, the 
deeper pigmentations, suggesting chocolate, coffee, or 
ink in color, are often recognized. Most of these deeper 
tints are gradually and completely removed in the months 
or years that succeed complete involution of the lesion. 
(5) Contour. Many syphilitic lesions of the skin have a 
remarkable tendency to assume, wholly or in part, when 
grouped, a circular outline. This contour is often pre- 
served when there has been both a grouping of element- 
ary lesions and subsequent metamorphosis or degenera- 
tiow of the lesions thus grouped. In this way the figure- ° 
of-eight, the letter S, the dumb-bell, the kidney, and the 
horseshoe may be represented in outline by syphilitic 
papules in groups, ulcers, crusts, and even cicatrices. 
(6) Site. Any part of the skin of the human body may 
become the seat of a syphiloderm ; and, indeed, the entire 
surface may be thus invaded, either by simultaneously 
evolved lesions or by rapid extension from one point. to 
another. Syphilis may, however, affect for long periods 
of time a single region of the skin exclusively. This 
region may thus be preferred as the result of local irri- 
tation ; for example, the palms of the syphilitic hand- 
worker ; the uncleansed anal region of the syphilitic in- 
fant ; and the mouth of the syphilitic tobacco-chewer. 
The so-called ‘‘ corona veneris” is a group of dull-red- 
dish, scaling papules on the forehead, which are peculi- 
arly significant in male patients where the lining -of the 
hat irritates the brow. (7) Amenability to Treatment. 
Mercury more particularly, and to a less extent the salts 
of potash after ingestion, are regarded by many practi- 
tioners as tests of the syphilitic character of any exan- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


a 


Syphilis. 
Syphilis. 


them. There are few eruptions which amend under 
treatment of this character as readily as do the syphilo- 
dermata, but it is an error to conclude that the latter 
only are thus manageable. The almost infinite variabil- 
ity of the skin-picture in syphilis is largely due to its 
modification in this way by an appropriate therapy. (8) 
Characters of individual lesionss The scales of syphilis 
are rarely lustrous or nacreous ; they are commonly small, 
dirty gray, or darker in color, and rarely very abundant. 
Syphilitic papules are small or large, but often remark- 
able for a collarette of dirty, whitish scales surrounding 
their bases. The crusts of syphilis are apt to be dark- 
hued, in shades of deep-yellowish, greenish, chocolate, 
and black, from the tendency of many syphilodermata 
to ulcerate and the production in such ulcers of the pus 
and blood from which these colors are chiefly derived. 
The oyster-shell-like crust of rupia is wellnigh pathog- 
nomonic of syphilis. Syphilitic ulcers are prone to ex- 
hibit the circular outline, or traces of the reniform, figure- 
of-eight, letter S, and other shapes named above. 
cicatrices left by such ulcers have necessarily a similar 
contour. They are, for the most part, smooth, supple, 
soft, and unattached. When recently formed, especially 
on the lower extremities, they are deeply pigmented in 
shades of chocolate and black. All, however, in time 
become white and lustrous, suggesting a thin sheet of 
mica when the centrifugal discoloration, which each 
very slowly undergoes, is complete. 

THE MACULAR SYPHILODERM. (a) The Macular Syph- 
tloderm due to Hyperemia.—This is also termed the ery- 
thematous syphilide, syphilitic roseola, and the exan- 
thematous syphilide. It is usually the earliest of the 
eruptions of secondary syphilis, commonly appearing 
about forty-five days after the appearance of the chancre. 
It is developed in the form of symmetrically arranged, 
roundish, oval-shaped, or irregularly outlined, from the 
size of a split-pea to that of a small coin, non-elevated, 
rosy, reddish-yellow, dusky-red, or salmon-and-red mac- 
ule, disappearing under pressure. Often at the outset it 
most resembles a slight mottling or marbling of the sur- 
face, and at times requires for its recognition careful ob- 
servation on the part of the physician. It is probably 
more often unnoticed by the patient than any other symp- 
tom of syphilis, at times escaping observation entirely. 
It may be generalized, but is usually most conspicuous on 
the belly, loins, chest, and back. In well-marked cases 
the face (brow, temples, chin), back of the neck, and ex- 
tremities, including the palms and soles, are conspic- 
~ uously marked with it. It may be accompanied by the 
syphilitic febrile symptoms already described, substernal 
and other pains, engorgement of the cervical ganglia, mu- 
cous patches of the mouth, and other symptoms peculiar 
to this period. It may persist for a week and fade; or 
recur in fresh maculations. As the eruption survives, it 
is more persistent in color under the pressure of the fin- 
ger. It is decidedly and promptly amenable to mercury. 
It is not. to be confounded with the exanthematous fevers 
(the thermometer readily indicating the difference) ; nor 
with urticaria and the medicamentous rashes, which-are 
more acute in type and accompanied by well-marked sub- 
jective sensations ; nor with the yellowish patches of tinea 
versicolor, where a vegetable parasite is visible under 
the microscope. None of these affections exhibits the 
other signs of syphilis present in the person displaying 
the erythematous syphiloderm. The chief diagnostic 
danger, however, in this connection lies in ignoring, in 
certain cases, the special character of this indolent, 
scarcely appreciable exanthem, which rarely attracts at- 
tention by subjective annoyance, rather than in any dif- 
ficulties in determining, after its discovery, to what spe- 
cial disease it is due. 

(b) The Macular Syphiloderm due to Pigmentation.— 
This is also termed by some authors the pigmentary 
syphilide. It occurs in an irregularly circular, ill-defined 
reticulum, of brownish or chocolate shaded maculations, 
the color of which does not fade under the finger. Often 
there is unusual whiteness about the pigmentations, cen- 
trally or peripherally situated, Dr. Fox, of New York, 
having shown that after the central pigmentation occurs 


The 


there is a centripetal decolorization with deposit of pig- 
ment in excess in the interspaces of the original macule. 
The eruption is common about the neck and shoulders of 
blond women. The author has seen very perfect illus- 
trations of this condition in concentric circles of large 
pin-head-sized macule, alternating with rings of pigment, 
in Chinese subjects of syphilis. These lesions are ob- 
stinate under treatment, and are by many authors not in- 
cluded among the true exanthemata.of the disease. They 
are rather curious pigment-anomalies, occurring in syph- 


‘lis as in other diseases influencing the nervous centres. 


THE PAPULAR SYPHILODERM.—The papule is the type 
of most of the syphilodermata. Many of the others are 
evolved from it; and it is probable that a large propor- 
tion of chancres and most mucous patches, condylomata, 
tubercles, and similar lesions are essentially papules 
which have been moditied by the accidents of site, moist- 
ure, heat, etc. Syphilitic papules are circumscribed ele- 
vations of the surface, ranging in size from a millet-seed 
to a split-pea. They may occur as the earliest cutaneous 
symptom of the disease in its secondary stage, or be de- 
veloped from the erythematous syphiloderm described 
above. They may be small or large, pointed or flat, dis- 
seminated or in groups. 

The Small Acuminate, Papular Syphiloderm (‘‘ syphi- 
litic lichen,” miliary papular syphilide).—This eruption 
appears in the form of pointed, firm, circumscribed pap- 
ules the size of a pin-head or of a millet-seed, often copi- 
ously developed, with or without febrile symptoms, over 
the belly, chest, arms, back, and extremities. In color 
they vary from rosy-reddish to mulberry or purplish 
shades, the hue differing widely in light and dark skins, 
Often the outer layer of the stratum corneum of the epi- 
dermis is slightly separated about the individual papule, 
which is thus surrounded by a faintly defined collar of 
scales. Often, also, when irritated they exhibit a minute 
vesicle, pustule, or scale at the apex. Where numerous, 
they are usually symmetrical and very closely set to- 
gether. Brownish-red blotches are apt to follow their 
involution. The eruption may persist for months, and, 
with or without relapses, may appear in circular or semi- 
circular groups, a ring of minute papules partly or wholly 
surrounding a confluent central patch. 

The Large Acuminate, Papular Syphiloderm.—The small 
lesions described above may be, in special localities, de- 
veloped to lenticular dimensions, retaining the conical 
apex. They may be seen often on the back, shoulders, 
and chest as purplish red rather than bright red in color, 
especially in the coarse skins of male patients. They 
may develop at the apex minute pustules whose involu- 
tion leaves a small crust capping such papular lesions. 
They should not be confounded with iodic acne. 

The Small Flat, Papular Syphiloderm.—This eruption 
is made up of roundish or oval, reddish to deep brownish, 
distinctly circumscribed and softish papules, from the 
size of a large pin-head to that of a split-pea, and having 
a flat surface. They are often seen on the chest, face, 
buttocks, extremities, palms, and soles, and are frequently 
found near the mucous outlets, though decidedly less often 
grouped about the mouth and nose than are other lesions 
to be described later. They may be few, or developed in 
a copious exanthem. They may be covered with a thin 
seborrheic crust, after whose removal is exhibited one of 
the characteristic and almost indescribable color-shades 
peculiar to syphilis, a lucent mixture of red, brown, and 
purple, suggesting the varnished section of a raw ham. 
They may be fringed or capped with scanty, dirty-yel- 
lowish scales. Bumstead and Taylor describe this erup- 
tion as rarely occurring in cachectic subjects with a 
diphtheroid deposit over the papules, covering thus a 
granulating or superficially ulcerated surface. 

Cicatrices seldom follow its involution under mercurial 
treatment. It commonly requires a week or ten days for 
complete development and, though occurring as an early 
syphiloderm, may relapse in any stage of the secondary 
period. Circinate forms of grouping, with an unchanged 
central area of integument, are rather more distinct in re- 
lapsing than in early forms of the exanthem. These are 
readily distinguished from. psoriasis by the absence of 


713 


Syphilis. 
Syphilis. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the abundant nacreous scales of the latter disease, with 
a history of clearing, not of a primarily cleared cen- 
tre. 

The Large, Flat, Papular Syphiloderm.—This eruption 
appears in the form of distinctly circumscribed, vivid or 
purplish-red, flat or slightly globoid papules, disks, ‘‘ but- 
tons,” or nodosities, from the size of a pea to that of a 
small coin, many of which distinctly exhibit the quality 
of color seen in a new copper penny. ‘They may become 
scaly at the surface or the base, or become granular, 
moist, and secreting in these situations. They are insen- 
sitive, and rarely productive of pruritic sensations. It 
may be developed as a first or later general syphilitic ex- 
anthem, or be evolved from the macular lesions of the 
erythematous syphilide, or, very conspicuously and com- 
monly, in the middle of the exanthematous period of 
syphilis, with a primary or relapsing and abundant crop 
of lesions in some special locality—the face (alee of nose, 
forehead, mouth), palms, soles, axilla, buttocks, and ex- 
tremities. Upon the forehead these lesions are apt to 
form the so-called corona veneris, glazed papules of cop- 
pery hue, arranged often in a line above the brows. 
They may develop an elevated rim and sunken centre ; 
may ulcerate, especially in cachectic subjects or in locali- 
ties subject to unusual moisture or irritation, Rarely 
gyrate and serpiginous lines of these papules are to be 
seen in special localities, e.g., about the non-bearded lips 
and chin, or the axilla, where they may form rings.. 
They are to be distinguished from certain isolated psoria- 
tic patches, circinate in outline, (1) by their color, as dis- 
tinguished from the more vivid hue of psoriasis ; (2) by 
their scanty dull-hued scales ; (3) by the history and con- 
comitant symptoms of syphilis. 

Syphilitic papules of all types may undergo any one of 
the following transformations, whose features may often 
be recognized at one and the same time in the course of 
the disease : 

(1) The evolution of papules may, as a result of hyper- 
plasia or vegetation, proceed to the production of the 
larger lesions recognized under various titles—warts, 
papillomata, condylomata, frambeesioid vegetations, etc. 
In this way isolated or confluent, softish, warty growths, 
light or deep reddish in color, freely furnishing a secre- 
tion, often of most nauseous odor, may cover large sur- 
faces of the body or a single region only (scalp, anus, 
genitalia). These may be crusted from desiccation of 
the puriform mucus which smears them; in other cases 
ulceration ensues. | 

(2) The evolution of the papules, as a result of the 
same processes in special situations, results in the produc- 
tion of broad, flat lesions. These are the results merely 
of the vegetative process occurring where mucous or cu- 
taneous surfaces are in such close apposition that eleva- 
tion of the lesion is restricted and lateral expansion only 
is possible. In this way are produced the true condy- 
loma, and the pinkish, whitish, and softish lesions known 
as the mucous patch of the skin, the vegetating mucous 
patch, plaque muqueuse, etc. They are well-defined, 
slightly raised, flattened disks, from the size of a bean to 
that of a large coin, their whitish color largely due to the 
muco-purulent secretion with which they are smeared, and 
which furnishes the characteristic, disgusting odor of these 
lesions. Heat, moisture, friction, perspiration, and neg- 
lect of the bath are the fertile agents in their production 
in the axille, perineum, groins, the inner faces of the 
thighs, about the vulva, and elsewhere. 

(8) Papules may scale at apex or base, and the scal- 
ing become so significant a part of the process that the 
papular character of the lesion is almost disguised. In 
this way is produced the papulo-squamous syphiloderm. 
The scales are commonly scanty, desiccated, dirty gray in 
color, often attached, rarely freely shed from the sur- 
face. Beneath them may be seen elevated papules of the 
so-called copper color, having the smooth, glazed surface 
of such lesions, or dull-red macule. Very rarely, indeed, 
the surface is granulating. 

PALMAR AND PLANTAR SYPHILODERMATA.—Syphilitic 
papules of the palmar and plantar surfaces are peculiar : 
1, Because of the unusual thickness of the epidermis of 


714 


the region affected ; 2, because of the intermittent fric- 
tion, contact, and exposure to which the organs are sub- 
jected. They may be early or late, transitory or pecu- 
liarly obstinate, and recurrent lesions. Careful inspection 
of the palms of the majority of patients exhibiting a co- . 
pious macular exanthem will result in the detection of a 
few pea-sized discolored’ blotches in this region, which 
often cover themselves with a thin, slightly adherent scale. 
In greater approximation to the type of the average cuta- 
neous papule, firm, circumscribed, dull-reddish, and dis- 
tinctly elevated lesions, from the size of a large pin-head 
to that of a pea, are often seen in the same region. A 
variation from this type produces the dirty-whitish, cor- 
neous, epidermal masses embedded in the palms and 
soles like foreign bodies, and almost as readily separable. 
These are arrested forms of complete evolution of the 
syphilitic papule in the palms and soles. When progress- 
ing, unmodified by treatment, they become depressed and 
poorly defined in outline, coalesce so as to form circum- 
scribed patches, from the size of a coin to that of an egg 
or larger, with newly developed outlying lesions. ‘The 
next features are unquestionably impressed upon the 
patch by the traumatisms and stretching of the infiltrated 
skin. Scaling follows, centrally and at the periphery ; 
fissures form in the lines of the furrows; ulcers de- 
velop centrally situated,\ circular, oval, or stellate in out- 
line. <A purplish-floored\ulcer is often seen here, its con- 
tour suggesting the fracture of a pane of glass. Recur- 
rent and abortive attempts \at reproduction of the palmar 
and plantar epithelium result in the formation of strata 
of ragged-edged epidermis, which irregularly fringe the 
deep losses of tissue. The entire palm or sole may be 
involved, and the process gradually sweep up to the wrist — 
or ankle, and over the digits, affecting also the nails. 
The dorsal surfaces are occasionally involved, but always 
by extension from the palms or soles. Psoriasis limited 
to the palms and soles is of exceedingly rare occurrence ; 
the specific lesions of this region are far more common, 
and are often accompanied by other unmistakable signs 
of syphilis with a history of infection. Squamous eczema 
is at times limited to the palms and soles, but, in the vast 
majority of all cases, affects the entire region, including 
the palmar faces of the digits, and is accompanied by itch- 
ing. 

THE PusTULAR SYPHILODERM. —Pustules occur as 
early and late manifestations of syphilis, being, how- 
ever, less frequently observed than the lesions just de- 
scribed. ‘They are of the size of a pin-head to that of a 
bean, transitory or persistent, with mild or grave symp- 
toms, and may originate as macules or papules, be isolated 
or grouped, scanty or abundant, and result in crusting, 
ulceration, and cicatrization. ‘‘ Papulo-pustular,” ‘‘ pus- 
tulo-crustaceous,” and similar terms are employed to in- 
dicate these mixed forms. Authors have also employed 
the phrases, ‘‘acne-form,” ‘‘ variola-form,” ‘‘ impetigo- 
form,” ‘‘ecthyma-form,” etc., to designate the several 
varieties of the pustular syphilodermata. These terms 
are here purposely omitted, for the reason that the sev- 
eral diseases whose names are selected for comparative 
purposes are represented by lesions widely varying in the 
different stages of each disease, and exhibiting different 
features in different individuals. The phrases ‘‘ syphi- 
litic psoriasis,” ‘‘ syphilitic eczema,” etc., are similarly 
discarded, as tending to contribute to the same confusion 
in the mind of the practitioner and student. 

The Small, Acuminate, Pustular Syphiloderm.—These 
are of the size of a pin-head and larger, vivid or dull-red, 
roundish, rapidly or slowly formed, and superficially 
seated, isolated, or well-nigh confluent pustules, which 
may be copiously developed in a general exanthem with 
syphilitic fever, or, more commonly, recognized in clus- 
ters about the regions where the pilo-sebaceous follicles 
are large and abundant. They may begin as macules or 
papules. The apex of each becomes yellowish green as 
the pus forms, which may desiccate into minute crusts or 
may cover underlying ulcers of similar size. They may 
assume at times the circinate outlines. They are often 
seen on the scalp, face, neck, and trunk; rather less fre- 
quently on the extremities. Involution is often followed 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Syphilis, 
Syphilis. 


by rather persistent pigmentations ; more rarely by mi- 
nute atrophic scars. 

The Large, Acuminate, Pustular Syphiloderm.—Y ellow- 
ish-brown, conical pustules, of the size of a pea and larger, 
may develop slowly from the small lesions just described, 
‘or rapidly from maculo-papules. They are usually su- 
perficial in situation, become crusted at the apex, and, 
after the formation of the crust, may be depressed cen- 
trally. Ulcers frequently form as the result of this pro- 
cess, whose healing may leave small cicatrices. They 
form over the scalp, face, neck, shoulders, and extremi- 
ties ; and are usually the expression of either a graver 
form of syphilis or of a syphilis less judiciously managed 
than the lesions previously described. 

The Small, Flat, Pustular Syphiloderm.—This is a rela- 
tively frequent manifestation of syphilis, beginning by 
the development of circumscribed macules or maculo- 
papules, which rapidly form flat, roundish pustules, the 
size of a pin-head and larger, and superficial in situation. 
They are usually grouped, isolated, and at first not con- 
fluent; but their reddish and purplish areole become 
fused, and the whole is soon covered with a flattened, 
dirty-yellowish, and greenish crust, which commonly sur- 
passes the limits of the patch. On the removal of the 
latter, a violaceous surface is seen, granulating, puriform, 
occasionally superficially eroded, possibly ulcerated. 
These lesions are often seen in and about the scalp, and 
about the lips, chin, beard, and trunk. In persons of 
weak constitution, and not properly treated, the face will 
occasionally be found almost completely covered by an 
irregularly crusted mask, formed in the manner described 
above, the pustulo-crustaceous lesions occasionally spread- 
ing in a Serpiginous course, or forming the familiar rings, 
or segments of rings, seen in the grouped syphiloder- 
mata. 

The Large, Flat, Pustular Syphiloderm.—Pustules, the 
size of a bean and larger, deeply seated, or projected from 
_the surface, may represent any of the forms described 
above, proceeding to full evolution, usually in cachectic 
subjects. They represent, also, the later periods of the 
so-called secondary stage of syphilis. Often they have 
dark-red, deep, infiltrated bases with violaceous areole ; 
and the pus finally desiccates into thick, bulky, greenish, 
or blackish crusts, firmly adherent to the edges of a foul- 
based, hemorrhagic, or pus-filled chamber beneath ; or, 
after bursting, they leave open, sharply cut ulcers, with 
blood or pus freely formed from an exposed, eroded, 
sloughing surface. The ulcerative phase, with its crust, 
~ is, indeed, often the conspicuous feature of the process, 
the deep-seated pustular lesion which ushered in the mis- 
chief being thus speedily metamorphosed. These ulcers 
may be few or numerous, superficial or deep ; and may 
be in outline circular, oval, semicircular, dumb-bell- 
shaped, etc. Their cicatrization commonly results in a 
typical syphilitic cicatrix. 

Rupita.—This term was at one time employed as the 
name of a distinct disease. It has long since lost any 
applicability to non-syphilitic disorders. Every rupia 
should to-day. be recognized as syphilitic. Indeed, ac- 
cording to modern usage, the name merely describes cer- 
tain peculiarities in the syphilitic crust. The explana- 
tion of its former temporary and unmerited elevation to 
the dignity of a disease supposed to have a separate en- 
tity, is to be found in the fact that occasionally a patient 
will be extensively covered with rupioid crusts, who ex- 
hibits no other symptom of syphilis. 

The crusts thus named may be few and small, or large 
and generalized. First appear macules, then pustules, 
whose contents desiccate into crusts of greenish, brownish, 
and blackish shades, covering and nicely fitted over un- 
‘derlying ulcers. The ulcer slowly spreads at the periph- 
ery, and its purulent and hemorrhagic secretions add 
by desiccation to the bulk of the crust. The additions 
are made beneath and laterally to the under surface and 
edges of the closely adjusted crust, which hence be- 
comes a conical, stratified shell, usually with a slightly 
concave inferior surface, the whole often compared to an 
oyster-shell. Each succeeding stratum of incrustation, 
from the conical apex of the crust to its base, represents, 


therefore, a somewhat larger ulcer and a somewhat more 
abundant secretion. There may be an outlying viola- 
ceous areola. The indolently spreading ulcers beneath 
correspond in size to the shells which cap them. They 
may be superficial or deep, but usually have a foul, 
purulent, or hemorrhagic floor, and punched-out edges. 
Grave as is the condition of the patient who is exten- 
sively covered with the largest-sized rupioid lesions, the 
best of results may be anticipated under proper hygienic © 
management and energetic treatment. 

THE VESICULAR SYPHILODERM.—Vesicles are rarely 
the results of the syphilitic process in the skin. They 
usually point to an exudation more acute in type than 
that recognized in the indolently traversed cycle of syph- 
ilis. Occasionally miliary papules exhibit a vesicular 
apex containing a droplet of serum. Circinate and other 
groups of vesicles are described by French writers as of 
occurrence in this disease. Two explanations of the so- 
called vesicular lesions are at hand: first, the develop- 
ment of eczema, herpes, etc., in infected persons—phe- 
nomena not rarely observed by an expert; second, the 
occurrence of vesicular lesions provoked by extensively 
applied or internally ingested medicaments employed for 
the relief of the systemic disorder. 

THE BULLOUS SYPHILODERM.— Discrete, roundish bul- 
le, from the size of a pea to that of a small egg, appear 
simultaneously or in crops upon the syphilitic skin, in 
consequence of a more or less circumscribed elevation of 
some portion of the epidermis by accumulation of a clear 
lactescent serum, pus, or blood. The contents usually de- 
siccate into bulky, adhesive, stratified, greenish or dark- 
colored crusts, which may cover granular, eroded, or 
ulcerative surfaces. Often they are surrounded by a vio- 
laceous halo, _ The ulcer, after removal of the crust, may 
spread in depth or area, or cicatrize; this according to 
the vigor of the patient and the treatment pursued. Le- 
sions of this sort are rather more often recognized upon 
the extremities than elsewhere, in consequence of the 
greater distance of the latter from the centres of circula- 
tion. They are more often encountered in late periods 
of secondary or tertiary disease, and in cachectic sub- 
jects. They are for these reasons most often seen in the 
tender skin of the infant who is the victim of hereditary 
syphilis. 

It should never be forgotten, when making a diagnosis 
of the bullous syphiloderm, that the iodide of potassium, 
in exceptional cases, is capable of producing such lesions 
in typical aspect when administered to the syphilitic as 
well as to the non-infected patient. American observers 
chiefly have called attention to this important fact, among 
them Drs. O’Reilly, Graham, Morrow, and the author. 

THE TUBERCULAR SYPHILODERM.—Hyperplastic evo- 
lution of the papule, besides producing the aberrations 
from type already described, may also result in the for- 
mation of definitely circumscribed, deeply seated, single 
or multiple, bright-reddish or livid, solid, cutaneous, or 
more commonly subcutaneous, lesions, from the size of a 
pea to that of a small egg, known as tubercles. ‘These 
are usually late secondary, or early or late tertiary syphi- 
litic symptoms, which, in consequence of difference of in- 
volution, are divided into two classes. 

The resolutive tubercular syphilide is characterized by : 
Slow evolution without marked subjective symptoms, 
disappearance after absorption of the plastic infiltration 
commonly involving the entire thickness of the derma, 
and the production, without previous ulceration, of an 
indelible scar. The lesions begin as superficial, reddish, 
and roundish gummatous nodules, the size of a pin-head, 
which, as they attain the larger dimensions named above, 
become flatter, smoother, more lustrous, and more deeply 
tinted. They are largely facial or cervical in situation, 
but may also spread over the trunk and extremities, 
They are often free from scales, except when seated upon 
the palms or soles, in which situations they may be cov- 
ered with thick corneous plates beyond whose borders can 
be recognized a violaceous halo, These lesions may be 
generally disseminated, or grouped in distinctly circum- 
scribed patches, either circular in outline or exhibiting 
some modification of the latter (e.g., the reniform, horse- 


715 


Syphilis. 
Syphihs. 


shoe-shaped figure, etc.). The former are the earlier, the 
latter the later, of occurrence. 

When facial in situation, the tubercles may spread in 
a fan-shaped area over the forehead, or extend over the 
bridge of the nose to the cheeks, assuming, as Bumstead 
and Taylor have graphically shown, the butterfly shape. 
The thinned, atrophic centre and elevated rim of the 
patch may be then significant. 

An exaggerated grade of confluence and proliferation 
of these tubercles results in the hypertrophic, leontiasic, 
or vegetative syphiloderm. In these instances the nose, 
the chin, the ear, or some other part presents an enormous 
increase in bulk, with definitely distinguished lobules 
separated by furrows, the picture presented strongly re- 
sembling the elephantiasic condition. Again, a volumi- 
nous verrucous growth may spring from some portion of 
the scalp, and even in the end encroach upon a large part 
of that region, the warty mass freely projecting comb- 
like masses from the surface, smeared often with a puri- 
form and offensive secretion (frambeesia syphilitica, pa- 
pilloma syphilitica, etc.). 

The ulcerative tubercular (tuberculo-ulcerative) syphilide 
is a somewhat later manifestation of the disease, or one 
which, developing as it does rarely within a few months 
after the evolution of the chancre, occurs in neglected, 
untreated, cachectic, or so-called ‘‘ galloping,” cases. 
Here also the lesions appear upon the face, trunk, and 
extremities, with the general characteristics already de- 
scribed, but more commonly in definite groups. Instead 
of undergoing, however, the atrophic changes observed 
in the resolutive form, a portion, rarely all, of the tuber- 
cles forming the patch, soften or become covered with a 
greenish or blackish crust from desiccation of the ichor- 
ous or sanguinolent liquid furnished by the breaking 
down of the gumma, beneath which an ulcer forms some- 
what larger in size than the lesions from which it sprang. 
In this way the face may display over the chin, forehead, 
or cheeks, a dense tumefaction composed of a group 
of closely agglomerated, livid papules, ulcers, and crusts, 
the size of a pea, or a distinctly outlined ring of such le- 
sions disintegrating at the periphery and surrounding an 
atrophic, cicatricial, or even ulcerated, central area. 
Gangrene and phagedena very rarely complicate these 
destructive processes. The ulcers which form are of a 
typical syphilitic aspect, with pultaceous floor, steep, 
“clean-cut” edges, ichorous secretion, and serpiginous 
tendencies. 

Mixed forms of commingled resolutive and ulcerative 
tubercles are not of rare occurrence. The following are 
common clinical pictures: A patient, from five to ten 
years after infection, has the forehead, nose, and cheeks 
fully covered with numerous, firm, smooth, shining nod- 
ules, the size of a pea, vivid and dull-red in hue, occupy- 
ing an infiltrated integument of the same general color. 
Some of the tubercles are slightly crust-capped, others 
are irregularly excavated as if wasting at such points. 
Between them are distinctly defined, atrophic, non-pig- 
mented depressions, from the size of a large pin-head to 
that of a pea, resembling youngish scars. These are 
spread with some regularity between young and mature 
tubercles, even at the scalp-border and among the hairs, 
over the tip of the nose, and well over the cheeks. Un- 
even and verrucous patches may indeed occupy distant 
portions of the scalp, where hairs have fallen from an 
atrophic area. Sometimes they undergo colloid degen- 
eration. Attention is particularly directed to this com- 
plexus of nodules, crusts, atrophic disks, minute ulcers, 
and scanty pustules when occurring in this region, as it 
is a feature very rarely seen in any other disease than 
syphilis. 

Still other symptoms are well shown in the accom- 
panying colored plate, which admirably reproduces a 
colored photograph from the collection of Dr. George 
Henry Fox, of New York. Numerous plaques are here 
visible, distributed over the trunk and shoulders, having 
the exceedingly definite and circular outline, atrophic or 
cicatricial centre, proliferating or disintegrating border, 
and characteristic tint of patches of syphilitic tubercles. 
At one or another point may be recognized almost all of 


716 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, 


the several changes described above. The extreme facial 
disfigurement produced in exceptional cases by a recur- 
ring series of these metamorphoses is shown in the ac- 
companying illustration, executed from a photograph of 


Fie. 3748. 


one of the author’s patients, who had been suffering for 
many years from a tubercular syphiloderm of the face. 
In most of these cases, the changes wrought in the 
course of time after the employment of an appropriate 
therapy are marvellous. The violaceous tint disappears ; 
the scars, if any have resulted, are transformed into thin, 
superficial, uncolored, or dead-whitish, inconspicuous 
blemishes ; the natural fat of the panniculus adiposus is 
restored ; and, even in middle life, after the fullest grade 
of evolution described above has been reached in the face 
of a woman, a fair degree of comeliness is restored. 
Lupus vulgaris is distinguished from this condition by 
its onset at an earlier period of life, its far narrower limi- 
tations, its greater asymmetry, its profounder and more 
disfiguring scars, and its much more indolent career. 
The tubercles of lepra producing the characteristic leon- 
tiasic aspect of the face are far more chronic in evolution, 
more deeply pigmented and ‘‘ varnished,” less often ul- 
cerated, crusted, and commingled with scars. The pearly, 
milium-like nodules of epithelioma are quite unlike the 
tinted tubercles of syphilis, are never so numerous, and 
the smooth-glazed, bright-red, and scantily secreting floor 
of the epitheliomatous (rodent) ulcer never suggests the 
foul excavations of syphilis. Psoriasis is always scaly, 
never ulcerative in type, never crusted nor pustular. The 
most difficult cases for differential diagnosis are those of 
hypertrophic acne of the nose, with gaping orifices of 
sebaceous ducts whence comedo-plugs may have been ex- 
pressed, interspersed between dull-reddish acne-papules. 
Here the history of the case, the absence of scalp-lesions, 
the stricter limitation of the patch to the tip and ale of 
the nose, the absence of a distinct ulcer, and the conspic: 


REFERENCE HANDBOOK 


oh | PLATE XXIX. 


MEDIGAL SGIENCES. , 


“LINDNER EDDY & CLAUSS, LITH. N.Y 


TUBERCULAR SYPHILIDE. 


From the Collection of Photographs of Skin Diseases of Dr. George Henry Fox. 


¥ = 
ot 
tere ett ean ektae 
5 ada Y cK 
Pe ele a) PN 


me is 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Syphilis. 
Syphilis, 


uously smaller size of the scar-like depressions, usually 
furnish a clew to the distinction sought to be established. 

THE GUMMATOUS SYPHILODERM.—Single and multi- 
ple, isolated or massed nodules, from the size of a pea to 
that of an egg, or larger, originating simultaneously, but 
commonly invading the skin as they develop, occur in 
late, rarely in early, periods of syphilis, and are termed 
gummata in consequence of the gummy material they 
furnish when disintegrating. They are rarely numerous, 
often not more than from two to six affecting a single 
patient. As an exceptional fact, hundreds may be seen 
covering different regions of the body. They are pecu- 
liar to syphilis ; in other words, they do not pursue, in 


the course of other affections, the same classical cycle of - 


evolution and involution. Yet they are really syphilitic 
tumors, allied, on the one hand, to the hyperplastic pro- 
cess which produces the papule and tubercle; and, on 
the other, to the histological type of tumors in general. 


Pathologists have some ground for believing that the so-. 


called gummous material of this lesion is to be recognized 
in the nodules that glue the iris to the capsule of the lens, 
and even in the neoplasm that constitutes the mass of th 
initial sclerosis. 

After development, gummata may for a long period of 
time be perceptible beneath the skin as smooth, circum- 
scribed, insensitive, firm nodules, undergoing no change. 
Later, they become slightly painful; there is passive hy- 
pereemia of the overlying skin; attachment between the 
skin and the tumor is effected ; then follow, usually, fluc- 
tuation and evacuation (spontaneously or by surgical in- 
terference) of inspissated blood and pus, or of the con- 
tents of a true, circumscribed abscess. The gummatous 
mass constituting the tissue, bathed in pus and blood, is 
slowly or rapidly removed by this process, in the course 
of which is formed the.gummatous ulcer. This has the 
circular outline, precipitous edge, sloughy floor, foul se- 
cretion, livid halo, and phagedenic tendencies already de- 
scribed as characteristic of the syphilitic ulcer in gen- 
eral, with this special added feature, that it is particu- 
larly deep. Its floor rests on subcutaneous tissues. It 
involves fascize, periosteum, muscles, large vessels, bur- 
se, nerves, bones, tendons, and other important tissues. 
Its walls, carefully inspected, often exhibit the sharp and 
- resisting edge of a dense aponeurosis, the glistening white 
border of a tendon, or the firm periosteum sheathing an 
osseous plate. . 

Occasionally gummata are lodged in, rather than be- 
neath, the skin, the firm, movable mass being then read- 
ily defined by palpation. Whether superficial or deep in 
situation, they may undergo complete resolution. When 
disintegrating by ulceration, they may go on to produce 
those extensive and formidable losses of tissue, compli- 
cated with erysipelas, pyzemia, etc., in the subjects of 
cachexia and alcoholism, which make syphilis, in some 
of its manifestations, a veritable scourge. Though occa- 
sionally numerous, not more than from six to eight are 
usually to be recognized in the person of a single patient. 
They are most frequently developed upon the lateral sur- 
faces of the legs, and next, proportionally after these, 
over other parts of the extremities, the face, scrotum, 
buttocks, neck, and the breasts of women. The impor- 
tance of their recognition in the last-named situation, 
when the question of cancerous and other malignant tu- 
mors of this organ is presented for consideration, can 
scarcely be overestimated. The author has seen a gum- 
ma, the size of a turkey’s egg, in the breast undergo com- 
plete involution under specific medication only. 

The elephantiasic aspect of the face and legs of certain 
patients who are afflicted with extensive gummatous tu- 
mors and infiltrations of the cutaneous and subcutaneous 
tissue is a matter of great moment for the diagnostician. 
In almost every community there is some such patient, 
with a striking deformity, the nature of whose malady 
has been altogether unknown for years. In such cases 
there is often an obscure history, which, perhaps, the ex- 
pert alone has been able to correctly interpret. The pa- 
tient has been supposed. to be the victim of ‘‘ elephanti- 
asis.” The nose, lips, cheeks, and chin are possibly 
densely thickened, distorted, empurpled, and irregularly 


ridged and seamed with nodules, scars, and ulcers; or 
the leg is in the pachydermatous condition seen in the 
‘“Madura foot” and other diseases. It is a large, un- 
wieldy organ, ridged, of cartilaginous hardness, fur- 
rowed, and covered with an integument looking like the 
bark of a tree. Careful inspection, however, always re- 
veals in this mass the typical cicatrices of ancient gum- 
matous ulcers, and the traces of new and old nodules 
buried in the hypertrophied and cedematous mass. Here, 
as in so many other of its formidable aspects, syphilis re- 
veals its amenability to proper management. The changes 
that can be wrought by treatment in these apparently 
desperate cases are in the highest degree satisfactory. 

THE SERPIGINOUS SYPHILODERM.—Though not dis- 
tinguished by the name of an elementary lesion whose 
preponderance might justify such a position, this syphi- 
loderm has an individuality requiring its separate consid- 
eration. 

In its superficial forms it is preceded by the appear- 
ance of small, pointed or flat syphilitic pustules, which 
form a circular or partially circular group of lesions in 
disks of the size of an egg and larger. These disks are 
soon covered with a yellowish, greenish, or blackish crust, 
which gradually clears from the centre, leaving there a 
granulating or smooth, reddish or normally tinted, atro- 
phic or only superficially altered integument, surrounded 
by an entire or broken ring of attached crusts, beyond 
which is a livid halo. Underneath this latter is a super- 
ficial, centrifugally spreading ulcer, uniformly annular in 
contour, or here and there broken by bridges and islands 
of unaltered skin. Often this annular ulcer is seen to be 
composed of roundish excavations, the size of a pea and 
larger, arranged circle-wise, with confluent crusts. In 
other cases the crust is scarcely more than a narrow ring, 
no broader than the smallest penknife-blade, which, as it 
spreads centrifugally, leaves cutaneous areas of former 
invasion, the size of the palm and larger, pinkish-red or 
slightly pigmented in color, at times decidedly cicatri- 
form, at other times texturally unaltered. In this way 
an entire buttock or limb, or the face, may be progres- 
sively involved. 

The deep serpiginous syphiloderm always spreads, as 
Bumstead and Taylor have well indicated, from a gum- 
ma or other late lesion of syphilis. A deep ulcer results, 
which attacks the subcutaneous tissues. The centre’ is 
soon represented by a tender or firm scar ; the advancing 
edge by a thick, greenish or blackish, adherent crust, 
covering a deeply cut circular exulceration with punched- 
out walls and foul secretion. The dull, purplish areola 
of all similar lesions is visible at the periphery beyond its 
advancing edge. Its progress over the skin is decidedly 


“more serpiginous than in the direction of the radii of a 


circle. Here and there a kidney-shaped, or horseshoe- 
shaped edge exhibits a deeper excavation, or a more te- 
nacious, bulkier, and darker crust. In yet another part 
of the same disk the ring may be represented ‘by a par- 
tially cicatrized border, or a wide bridge of unaffected 
skin. This is a late, exceedingly obstinate, and intrac- 
table form of syphilis, leaving generally 9 deforming 
scar. It is to be distinguished from lupus (which is 
more often seen on the face) by its definite outline, its 
deep pustular, rather than nodular, elementary lesions, its 
sharply cut ulcerations, but, above all, by its relatively 
rapid progress. 

MALIGNANT SYPHILODERMATA.—Syphilitic cutaneous 
and subcutaneous lesions are at times malignant in type, 
and then commonly precocious in occurrence and acute 
in course. They are described by Bazin and other 
French authors as ‘‘malignant precocious syphilides.” 
The intensity and violence of the symptoms in these 
cases is in general due to the occurrence of the disease 
in cachectic subjects, those who are debilitated by age 
or previous or concurrent diseases, those deprived of 
the essentials of healthy living, viz., wholesome food 
and drink, hygienic environments, freedom from-men- 
tal anxiety, and a proper adjustment of labor to bodily 
vigor. 

In patients of this class the chancre is scarcely cica- 
trized before so-called tertiary lesions appear. They are 


717 


Syphilis. 
Syphilis. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


divided by most authorities into (a) the puro-vesicular 
syphiloderm ; (6) the tuberculo-ulcerative syphiloderm ; 
(c) the gangrenous tuberculo-ulcerative syphiloderm. 
These names are mainly groups of symptom-phrases, the 
lesions themselves exhibiting a wide variation indicated 
by both mild and grave characters. 

The milder forms are really precocious, rupioid lesions 
following isolated or grouped pustules, which are rapidly 
followed by ulcers, thickly covered with laminated crusts. 
In a more accentuated form the malignity of the out- 
break is indicated by the development of lenticular 
tubercles, which hasten to break down into ulcers of 
characteristic syphilitic edge, secretion, floor, base, and 
areola, which attack the face, trunk, hands, or extremi- 
ties. The graver forms are precocious, tubercular, ul- 
cerative, and gangrenous. A group of nodules in or be- 
néath the skin surrounds itself with significant purpuric 
points, supposed to indicate an endarteritis of the periph- 
eral vascular elements. The whole rapidly or slowly 
becomes gangrenous, showing a dry, blackish eschar, 
which spreads at the periphery, and insidiously, as it en- 
croaches upon the sound tissues in the vicinity. Some- 
times a line of demarcation is formed, not between the 
gangrenous mass and the sound skin, but between the 
former and a thickened empurpled zone which surrounds 
it. When the slough is removed, a conical crateriform 
ulcer is exposed, having a fetid secretion, a sloughy floor, 
and markedly everted edges. The destructive process 
may progress till fatal results are produced, the patient 
succumbing to fever or marasmus and adynamia. But 
this is rare. Under the best treatment .repair sets in, 
granulation is followed by cicatrization, and there is 
apparently complete restoration of the general health. 

Cutaneous lesions and symptoms other than the forms de- 
scribed above are neither numerous nor important, but 
have been described by authors. Dr. E. B. Bronson, 
of New York, has described an erythanthema syphilit- 
icum in which vesico-pustular and other lesions were 
grouped upon an erythematous base. Hemorrhagic 
effusions within the skin occur chiefly in patients: who 
are the subjects of hemophilia, and who have also con- 
tracted syphilis; in children afflicted with hereditary 
syphilis; in patients with paraplegia resulting from 
syphilitic involvement of the cord (purpura of the 
lower extremities); and as an accident of a number 
of secondary and tertiary lesions. The author has seen 
two such cases occurring in syphilitic disease of the 
cord. Itshould never be forgotten that the iodide of 
potassium, when administered for the relief of syphilis, 
may produce purpuric spots, especially over the lower 
extremities. 

Lastly, eczema, psoriasis, the animal and vegetable 
parasitic affections of the skin, pruritus, and the various 
dermatides, all the forms of acne due to the ingestion 
of the iodic compounds, and other cutaneous disorders 
affect the syphilitic as well as the non-syphilitic patient. 
Each of them exhibits its special peculiarities, apparently 
not at all or very slightly modified by the syphilitic diath- 
esis, and is recognized. in its identity as distinct from the 
manifestations of syphilis without great difficulty on the 
part of the diagnostician. This recognition is a matter 
often of the highest moment, as the anxiety and dread 
occasioned in many patients by the discovery of these in- 
tercurrent affections (to which the mass of mankind is 
subject) are out of all proportion to the real import of the 
symptoms presented in such cases. 

TREATMENT OF THE SYPHILODERMATA.—The internal 
treatment of the syphilodermata is that of syphilisin gen- 
eral, including the use of mercury, the iodide and other 
salts of potassium, iron, cod-liver oil, and a nutritive reg- 
imen. 

Many of the lesions, however, require local treatment. 
The salves which are most effectively used with this end 
in view contain one of the salts of mercury. Among these 
may be named the ammonio-chloride, in the strength of 
from tive grains to half adrachm to the ounce (0.33-2.0 to 
32.00) ; the red oxide, in the strength of from five to ten 
grains (0.83-0.66) to the same quantity ; the ten or twenty 
per cent. oleate of mercury ; the mild chloride, in the 


718 


strength of from ten to thirty grains (0.66-2.0); mer- 
curial ointment, f!n the strength of from half a drachm to a 
drachm (2.0-4.0) to the ounce; and the ointment of the 
nitrate of mercury in nearly the same strength. The 
bases of these salves may be vaseline, cold cream, lano- 
line (Liebreich’s wool-fat), or simple cerate, a drachm 
(4.0) or more of glycerine being added to the ounce (82.0) 
of each when requisite to produce softness in the mass. 
Vaseline is preferably employed as a basis for salves to 
be applied over the scalp and hairy parts. 

Besides the mercurials the tars are employed with ad- 
vantage, including the oleum cadini and the oleum rusci 
(rectified or crude), in the strength of from half a drachm 
to a drachm to the ounce (2.0-4.0 to 82.0) of basis, adding 
an equal quantity of finely levigated prepared chalk to 
obtund the sharpness of the tar. These are €xcellent ap- 
plications to palmar and plantar syphilodermata, when 
preceded by maceration of the affected surfaces for several 
minutes in water as hot as can be tolerated. Often the 
thick epidermal scales of these regions/are best removed 
at the time of these macerations by th¢ aid of a shampoo 
prepared by adding an ounce of glycerine to two or more 
ounces of the tinctura saponis viridis of the Pharma- 
copeia. After the shampooing with hot water, the 
hands or feet are dried, the salve well rubbed in, and 
gloves are drawn over the hands, of stockings over the 
feet. Other ingredients are often incorporated with such 
salves with excellent effect. Among them may be 
named salicylic acid, ten to twenty grains to the ounce 
(0.66-1.33 to 32.0) ; chrysarobin, pyrogallol, and ichthyol, 
in the same strength ; zinc oxide and the subnitrate of 
bismuth, half a drachm to a drachm to the ounce (2.0-4.0 
to 82.0); and the oleate of lead, in the form best known 
as Hebra’s unguentum diachyli albi. — 

Powders occupy a most important place in the local 
management of the syphilodermata, more particularly 
those that are ulcerative in type. Among them may be 
named iodoform, hydronaphthol (1 part to 50 of fuller’s- 
earth), and iodol, boric and salicylic acids, calomel, 
starch, camphor, and lycopodium. Many of these are 
advantageously employed over such moist lesions as 
condylomata after they have been washed in a lotion of 
chlorinated soda or carbolic acid, so as to be not only 
deprived of their usual disgusting odor but thoroughly 
cleansed. 

Lotions of the kind just .suggested are useful in the 
management of a number of the secreting syphiloder- 
mata. Others are compounded with the corrosive sub- 
limate, one-half to one grain to the ounce (0.33-0.66 to 
32.0) of bay-rum, Cologne-water, or the rectified spirit 
of wine. Lotions containing tar, salicylic acid, carbolic 
acid, and boric acid (often in saturated solution) meet 
the indications of many cases. 

For the purpose of stimulating or otherwise dressing 
mucous patches and indolent ulcers, solutions of the 
nitrate of silver, five grains to a drachm to the ounce 
(0.388-4.0 to 32.0), or crayons of the solid salt may be used ; 
or even the strong caustic solutions, ¢.g., of the hydrate 
of potassium twenty to sixty grains to the ounce (1.83-4.0 
to 32.0), or of nitric acid. Solutions of corrosive sub- 
limate in tincture of benzoin, or of myrrh, one to two 
grains to the ounce (.066-.033 to 32.0) ; benzol, creasote, 
and solutions of the permanganate of potassium and re- 
sorcin, one to five per cent., are also useful in many 
cases ; the first two for destructive effects, the last as 
antiseptic dressings. 

The principles on which should be based the local 
treatment of the syphilodermata are those recognized in 
all similar non-specific affections of the skin. Of chief 
importance is the treatment of the disease itself, whether 
by internal medication, inunction, fumigation, or hypo- 
dermatic injection. To this, in most cases, may be added 
the local treatment with marked advantage. The scalp, 
hands, and feet may be often shampooed, and subse- 
quently dressed with a salve or lotion. Pustules are to 
be opened, crusts removed, and small or large ulcerated 
surfaces cleansed, cauterized or stimulated, and antisep- 
tically dressed. Soap and water are as imperatively re- 
quired for the syphilitic as for the non-syphilitic skin. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Frequent applications of water as hot as can be tolerated 
are often required for the relief of pain, and the sur- 
geon’s knife is needed for opening softened gummata. 
In extensive syphilitic ulcerations an exceedingly valua- 
ble resource is the use of the continuous hot-water bath as 
employed in Vienna, the patient, if his ulcers can be in 
this way immersed in the water, remaining in it for 
hours, the bath being kept as hot as is grateful to the 
surface of the immersed skin. The bath is left only on 
occasions requiring evacuation of: the contents of the 
bladder or of the rectum, or in order to secure sleep. 
Lastly, the mercurial, rubber, lead, and other surgical 
plasters, borated cotton, antiseptic wool (medicated with 
the mercuric iodide), prepared oakum, fuller’s-earth, 
and the other articles needed to make the dressings of 
modern surgery, are never more useful than in the 
management of multiple or extensive syphilitic ulcers. 

AFFECTIONS OF THE HAtR, HAIR-FOLLICLES, AND 
Harry REGIONS OF THE SkIN.—A common manifesta- 
tion of syphilis is a loss of hair, in excess of the physio- 
logical defluvium capillitii, resulting in alopecia. This 
may be an early or late symptom, rapidly or slowly oc- 
curring, scarcely perceptible or greatly deforming, and 
transitory or resulting in permanent baldness. 

The earliest form of alopecia may occur without local 
subjective or objective sensations, the symptoms being 
often limited to the loss of hair. It may again be ac- 
companied by macular, pustular, papular, ulcerative, or 
crusted lesions of the regions affected. It may appear 
as early as the date of the first syphiloderm, and, indeed, 
may be the first significant feature of general syphilis. 
In other cases it is conspicuous only after the third or 
later month of infection. It may affect any hairy region 
of the body, but is more commonly noticed on the scalp, 
beard, mustache, eyebrows, and lashes. Upon the scalp, 
it is probably much more common of occurrence than 
of observation, since it is often first recognized in men 
only after the hair is cut short. 

The hair may appear to be merely thinned in syph- 
ilitic alopecia, when the pilary loss is actually conformed 
to type. The close-shaven head of the syphilitic, af- 
fected with the early form of alopecia, presents almost 
always the same appearance» The scalp is then seen to 
be covered with irregularly circular areas of baldness, 
- symmetrically arranged as regards the two halves of the 
body, these areas varying in, size from a split-pea to a 
silver dollar. There is asymmetry, however, in the 
disposition of individual patches. The scalp thus af- 
fected may be apparently sound, or dry and lustreless, 
or, as described above, the seat of a syphilitic exanthem. 
When the hair is long, as in women, the striking dis- 
figurement visible on the shaven scalp is scarcely appar- 
ent ; in men whose hair has been cut moderately short 
the effect is that of a characteristic patchy irregularity, 
in which it is clear that the temple and occiput are as 
much affected as the vertex. The eyebrows, eyelashes, 
and mustache may be merely thinned, or suffer a loss 
in patches. The shaven beard may present an appear- 
ance in nowise distinguishable from the condition of 
the same region when affected with alopecia areata. 

The late forms of syphilitic alopecia are always due to 
destructive lesions of the cutaneous region covered with 
hairs; and the alopecia is hence usually the less important 
feature of the disease. Thus deep pustular, gummatous, 
ulcerative, and other like changes in the scalp are usu- 
ally followed by an asymmetrical loss of hair, often 
limited to a single patch, where, after cicatrization, the 
resulting alopecia is remediless. 

The early form of alopecia is unquestionably chiefly 
due to defective nutrition of the hairs in the hair-foll- 
cles, and, as alopecia areata is probably due to the same 
immediate cause (the remote cause being essentially dif- 
ferent), it follows that the shaven scalp presents almost 
the same appearance in two selected cases of the two 
diseases. The bulbs of the fallen hairs are seen under 
the microscope to be distorted and misshapen in early 
syphilitic alopecia, and the hairs themselves are usually 
dry and lustreless. The pathology of the late forms of 
alopecia in syphilis is that of the syphilitic process to be 


Syphilis. 
Syphilis, 


studied in the tissues generally. Usually a degenerating 
gummatous infiltration eventually encroaches upon and 
destroys the hair-follicle. Syphilitic alopecia is to be 
distinguished from all physiological losses of hair by its 
sudden occurrence in persons of the age in which syphilis 
is most commonly encountered, its asymmetry, and its in- 
volvement of the temples and occiput equally with the ver- 
tex. A history of infection can usually be obtained, and 
other symptoms can often be discovered. Seborrheea capi- 
tis, or alopecia furfuracea, is distinguished by its fatty or 
dry scales, and its failure to remove the hairs in distinct 
areas. The patches of alopecia areata strongly resemble 
those of early syphilitic baldness in the shaven head ; 
the loss, however, in the former disease is more sudden, 
and recovery is marked by the appearance of whitish or 
grayish downy hairs, which is not the case in restora- 
tion after syphilitic alopecia. The internal treatment is 
largely that of the secondary symptoms of the disease. 
The local treatment should consist of daily shampooings 
with hot water and the Sarg fluid soap ; or, where mere 
stimulation is required, by the aid of the tincture of green 
soap flavored with lavender. After such shampooing the 
scalp may be anointed with scented lanoline or vaseline, 
or with an oleaginous lotion made by adding two drachms 
each of the oil of sweet almonds and glycerine to an 
ounce each of the spirit of rosemary and alcohol, and 
two ounces of Cologne-water. 

AFFECTIONS OF THE Narus, MATRIX AND BED OF THE 
NaAILs, AND ADJACENT Parts.—The term onychia is ap- 
plied to the changes which are first apparent in the nail ; 
and paronychia to those which only secondarily affect 
the nail and primarily the matrix, nail-bed, or cutaneous 
folds by which the nail-substance is surrounded. It is 
probable that the distinction is purely artificial, both forms 
being preceded by alterations of tissue exterior to the 
nail-substance proper. ‘These appendages of the skin are 
frequently affected in syphilis, both during the secondary 
and during the tertiary stages, and the resulting lesions 
may be transitory or persistent, and mild or grave in char- 
acter. The course of these changes is usually chronic. 

In the most frequent form of onychia (onyzis craquelée 
—dry or friable form) a portion or the whole of one or 
several of the nails may become dry, lustreless, grayish 
yellow in color, friable, rugous, irregularly thickened, 
traversed by furrows in one or more directions, or sin- 
gularly disfigured by numerous minute pockets, from 
which the crumbling nail-substance has fallen or been 
removed by washing and scrubbing. The nails are usu- 
ally tilted up at the free border and separated from their 
beds. Careful examination will often reveal a ridge of 
thickened epidermis at the sides or attached border of 
the nail, which may be normal in appearance or dull 
purplish in color and scaling ; or, on pressure, a few drops 
of thin, ill-conditioned pus may escape from beneath 
it. This form is said to be more common in women. 
Under treatment these phenomena may disappear ; and 
the distorted nail be pushed forward and replaced by a 
healthy new one. In other cases one or several of the 
nails are insidiously loosened from bed and matrix, and 
are shed without the occurrence of any appreciable 
change in the surrounding parts, precisely as the hairs 
fall in many cases of syphilitic alopecia. Sometimes, 
even when attached at its border, the nail is seen to be 
completely separated over its entire area from the bed be- 
neath. When the nail, on the other hand, is affected 
with an onychauxe, it may increase to three or four 
times its normal bulk, a condition described by some 
writers as hypertrophic onychia. 

Paronychia may affect the whole or a part of the nail, 
and be dry or ulcerative in type. In the former case a 
dull-purplish ridge of cutaneous tissue, in the vicinity of 
the nail-fold and including it, becomes indolently thick- 
ened, scaling, and fissured. Superficial ulceration may 
follow, with purulent or hemorrhagic secretion and crust- 
formation, the ulcer spreading slightly beneath the nail 
at one point, the substance of that organ having already 
exhibited the changes due to impaired innervation. The 
characteristic feature of this complication is a finger with 
its distal phalanx having a bulbous appearance, its par- 


719 


Syphilis. 
Syphilis. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


tially altered, dirty-looking nail tilted upward or to one 
side, and a dry, scaling, or indolently granulating sur- 
face exhibited in the exposed part of the bed. 

Ulcerative paronychia is characterized by a shallow or 
deep ulceration extending at the central or lateral parts 
of the nail-fold, matrix, or bed, bathed with a sanguino- 
lent, thin, or ill-conditioned pus. It may begin with the 
dry lesions described above, or with the development of 
marginally seated papules or pustules. The nail may, as 
a result, be in lateral deviation from the axis of the phal- 
anx, or partially or wholly loosened from its attach- 
ments. In this state it may present any of the changes 
seen in syphilitic onychia. The nail-bed, when thus ex- 
posed, is usually tumid, covered with a thin, puriform 
secretion, granulating, or the seat of an irregular, firm, 
and whitish, epithelial investment. Thin layers of new 
nail-substance speedily form over this surface if proper 
treatment be instituted ; and, even in the cases where a 
distorted nail at first covers the bulbous phalanx and its 
purplish, tumid nail-fold, the restoration is eventually 
complete. In some cases the ulcer first forms beneath a 
crust under the free edge of the nail, and thence, when 
not properly managed, spreads irregularly over the ma- 
trix, the nail becoming loose and undergoing the changes 
already described. Care should be taken in the diagno- 
sis of such cases to exclude trichophytosis unguium 
(where the parasite is recognizable under the micro- 
scope) ; eczema and psoriasis (in which there is no his- 
tory of syphilis and none of its other symptoms) ; digital 
chancres (in which the nails are not chiefly involved) ; 
and ordinary forms of paronychia (which commonly spare 
the nail-bed and matrix). 

The treatment is largely internal; locally the white 
precipitate salve [one scruple to the ounce (1.30 to 32.0)] 
may be applied on rags. Ulcers may be dressed with 
pencillings of the nitrate of silver, followed with iodo- 
form or iodol in powder. 

AFFECTIONS OF THE Eyres.—The bones composing the 
orbit may be involved in osteitis or periosteitis, with de- 
generative results in the form of caries or necrosis. In 
this way may be lighted up an intraorbital cellulitis re- 
sulting in abscess. Nodes also occur within the orbit, 
and may be followed by serious consequences when pro- 
ductive of pressure-effects. The lachrymal passages also 
may be involved in obscure catarrhal changes, associated 
with pharyngeal lesions. Mucous and subcutaneous tis- 
sue, periosteum, and bone may be eventually implicated, 
with the result of producing lachrymation, epiphora, ab- 
scess, and eventually fistule. The treatment is by divi- 
sion of the canaliculi and dilatation of the canal by 
probes. The parts may then be treated with weak in- 
jections of the nitrate of silver, or, what is fully as 
valuable, two to five per cent. solutions of resorcine. 
When the canal is pervious to the probe, the trouble is 
usually due to changes in. the periosteum of the nasal 
process of the superior maxillary bone. The frequent 
application of water, as hot as can be borne, to the af- 
fected parts, if required in connection with the applica- 
tion of fomentations, will often give relief in these cases 
when energetic constitutional measures are adopted. 
Bumstead and Taylor report syphilitic changes in the 
lachrymal gland sufficient to produce a species of ptosis, 
and also gummata of the caruncles. 

The eyelids may be severely and extensively involved 
in syphilis. ‘They may be the seat of papules, pustules, 
ulcers, and resulting cicatrices dragging the lids into ec- 
tropion. Syphilitic ulcerations attack the canthi and 
free edges of the lids, encroaching also upon the mucous 
surfaces.. The author has seen both upper lids symmet- 
rically involved in ragged ulcerations of the edge resem- 
bling the work of a punch. Degenerating gummata of 
these regions often leave disfiguring cicatrices. The 
palpebral conjunctiva is often the seat of mucous patches. 
Subcutaneous indolent nodules, the size of a hemp-seed 
to that of a pea, occasionally form in the lid, which may 
obstinately persist when treated. The tarsus is reported 
also by several observers to have been involved in a 
tarsitis syphilitica, which is at first productive of tume- 
faction of the lids, and later, of changes in the cartilage 


720 


itself. The fascia and tendons of the ocular muscles are 
also liable to syphilitic changes, which may result in 
thickening, in abscess, or in fistula. All lesions of the 
eyelids, of secondary and .tertiary type, are to be distin- 
guished from chancres, of the lid, accidents not of very 
rare occurrence in the large cities. In these cases there ~ 
is great tumefaction, brawny, empurpled thickening (of 
the inner canthus usually, the part most apt to be rubbed 
by the finger that transports the infective secretion), and 
a specific induration of the pre-auricular or submaxillary 
gland—far more commonly the former. 

The conjunctiva may be the seat of mucous patches, 
circumscribed macules, papules, tubercles, and gummata. 
These are, however, rare. The ocular /conjunctiva is 
spared most of the lesions of syphilis, save when it be- 
comes engorged with blood as a consequence of iritis. 

The cornea, when participating in syphilitic changes, 
is usually recognized in the victim of inherited disease. 
There is found, first, slight pericorneal vascularization, 
in the diffuse form, with one or several centrally situated 
or marginal opalescent points showing in the cornea. 
These increase till the whole or a great part of the cor- 
nea is involved, producing thus a characteristic opacity 
limited to the field of the keratitis.| With the keratitis of 
inherited syphilis are often seen the alterations in the 
color, size, and shape of the permanent incisor teeth, first 
ably described by Mr. Jonathan Hutchinson. This ob- 
server regards the permanent upper central incisors as 
the test-teeth. These are usually \vertically and trans- 
versely shortened and thinned, with a crescentic notch 
at the free border, its convexity regarding the root of the 
tooth. This notching, most conspicuous in childhood, 
becomes partially obliterated by attrition in later life. 
The teeth are also often convergent, occasionally separ- 
ated ; in other cases ‘*pegged,” and again discolored in 
shades of a dull brown. 

The punctate form of keratitis is seen both in ac- 
quired and late inherited syphilis. Intracorneal puncta, 
the size of a pin-head, are then visible, careful observa- 
tion of which reveals the lack of lustre or grayish shade 
of color of corneal opacities in general. 

The sclera may be involved (1) in an episcleritis begin- 
ning with pericorneal hypereemic macule of a dull- 
reddish hue, with few if any subjective sensations. A 
circumscribed portion of the sclera may then appear 
thickened, and in some cases radii of engorged conjunc- 
tival vessels mdicate an extension of the hyperemia to 
the overlying membrane. In extreme cases the cornea, 
sclera, iris, and lens are involved in a common inflamma- 
tory process ; cases which the writer believes originate 
for the most part in aniritis. (2) An interstitial, or paren- 
chymatous, scleritis may present the features of an in- 
flammation of the organ, or of a gummatous deposit, or 
of infiltration within its substance, which, following the 
rule in similar involvement of other organs, may undergo 
resolution, or degenerate into an ulcer with irregular 
edges, and softish, grayish floor. When the cornea also 
is implicated, one sees a characteristic conical area of 
corneal opacity, its base resting upon the involved sclera, 
its apex projected forward to the centre of the cornea. 

Lritis,—More than one-half of all cases of iritis are of 
syphilitic origin, the proportion ranging between sixty 
and eighty per cent. of allcases. It is not only a common 
complication of the disease, but, as regards the loss of 
vision, one of the most disastrous. The symptoms of 
specific and non-specific inflammation of the iris are, 
taken per se, indistinguishable. Three forms are to be 
recognized : Simple plastic, serous, and parenchymatous. 
The two first named belong to the secondary period of 
the disease ; the last is due to a gummatous infiltration 
of the organ. The disease is commonly unilateral in 
situation at the outset; but in fifty per cent. of all cases 
ultimately attacks the other eye. It occurs most fre- 
quently at the average age of the syphilitic subject, that 
is, in early adult life ; and is much more frequent in men, 
by reason of the greater exposure of the eyes of the male 
to the accidents incidental to the trades and occupations 
of life. Simple plastic iritis is the condition in which 
there is, first, hyperemia and a plastic exudate. from 


, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


some portion of the iris, with proliferation of the connec- 
tive-tissue elements. It may be so slight in its symptoms 
as to escape detection, and be then accompanied by mild 
photophobia and vascular injection. In other cases the 
symptoms are marked and distressing. There is dis- 
tinctly pericorneal vascularization, sometimes subcon- 
junctival edema. The large, mobile, tortuous, brick-red 
conjunctival vessels contrast strongly with the straighter 
radii of delicate pinkish underlying vessels visible in the 
_ sclerotic zone and limited largely to it. Both planes of 
injection aid in giving a distinctly reddish color to the 
eye, which is evidently in a state of inflammation. The 
affected iris is peculiarly dull-hued, its color, as com- 
pared with its unaltered fellow, being changed in various 
shades according to the color natural to the organ in 
health. It is sluggish to the light, and often its structure 
is indistinguishable to the eye of the careful observer, 
because covered with a delicate stratum of the ‘plastic 
exudate. The latter may extend also over the anterior 
capsule and give the pupil a cloudy appearance. The 
aqueous humor may also become turbid. In conse- 
quence of these changes the free border of the iris is often 
agglutinated, in various degrees, at one or several points, 
to the anterior face of the capsule of the lens, so that 
when its muscles contract the pupillary outline becomes 
irregular, being changed from the figure of a circle to 
that of an interrupted curve, or to semilunar, trefoil, 
figure-of-eight, or scallop shapes. 

Serous iritis is characterized by the exudation of a se- 
rous fluid, with hypersecretion of a cloudy aqueous hu- 
mor, which precipitates a deposit in the form of a delicate, 
opaque, punctate, or diffuse film on the posterior face 
of the cornea, the anterior face of the lens, and the mem- 
brane of Descemet. There is increased intra-ocular ten- 
sion, the pupil is immobile and dilated, and the iris is 
changed in hue. There is less injection of the sclerotic 
zone than in the plastic form of iritis. Glaucoma may 
eventually result, from participation of the ciliary body 
and choroid in the process. 

Parenchymatous, gummatous, or suppurative iritis af- 
fects the stroma of the organ, whose cellular and vascu- 
lar elements then proliferate, causing a regular or irreg- 
ular increase in its dimensions. The attachments which 
form between the lens and iris are firm and unyielding. 
Tubercles, nodules, or ‘‘condylomata” (gummata), be- 
come visible as light- or dark-colored, circumscribed ele- 
vations on the surface of the iris, marginal or not in situa- 
tion, sometimes vascularized as they persist, and attesting 
the unicity of the syphilitic process in all tissues of the 
body. Pus may form in the anterior chamber, especially 
in cachectic subjects. 

The diagnosis of these disorders is not difficult, since 
their association with a syphiloderm, often papular, and 
the history of the case, usually corroborate the suspicion 
aroused by the lachrymation, pain, photophobia, and cir- 
cumcorneal vascularization. The treatment is by the 
administration of mercury and the iodide of potassium 
internally, pushed until the system is controlled by these 
drugs ; and by the instillation into the eye of the sulphate 
of atropine in solution (grs. ij. ad f %j. [0.183-32]). In 
exceptional cases vesication over the temple may be em- 
ployed with advantage, or a leech or two affixed near 
the ear. Opium hypodermatically, or cocaine locally, 
may be required to relieve pain. The oleate of mercury 
and morphine also may be applied by inunction over the 
brow, even where the mydriatic is employed. The eyes 
should be disused and protected against light (by a dark- 
ened chamber or shaded glasses). Paracentesis of the 
cornea and iridectomy may be required in severe cases 
at the hands of the ophthalmic surgeon. 

A form of iritis has been observed in the first half-year 
of life of infants, mostly of the female sex, affected with 
inherited syphilis. It is both unilateral and bilateral, 
and accompanied by few of the marked subjective symp- 
toms of the disease experienced by adults, but is far more 
liable to result in pupillary occlusion. 

The lens is affected in syphilis chiefly by extension to 
it of inflammation of the delicate organs with which it 
sustains anatomical relations, Cyclitis, or inflammation 


Vou. VI.—46 


Syphilis. 
Syphilis. 


of the ciliary body, is for the most part similarly excited 
by an iritis or choroiditis of the same eye. Very rarely, 
indeed, a gummatous exudation occurs primarily in its 
substance, and then commonly the iris is secondarily in- 
volved, with characteristic symptoms. 

Choroiditis and Retinitis.—Plastic, serous, and paren- 
chymatous inflammations of the retina and choroid are 
described by authors, the distinction between which forms, 
as also between inflammations of the two organs, is diffi- 
cult to establish. The objective symptoms of these dis- 
orders, as recognized by the aid of the ophthalmoscope, 
may be described as increased vascularity, ecchymosis, 
opacity, oedema, and appearance in the fundus of the eye 
of whitish or yellowish spots. Often the pigment of the 
choroid atrophies, permitting in one or more places a 
view of the sclera through its tissue. Blackish areole may 
surround these irregularly bordered macules. In other 
cases the choroid presents the appearance of maceration ; 
or again, circumscribed nodules (gummata) project above 
the generallevel. Whenthere are distinct retinal‘thanges, 
the point of entrance of the optic nerve is usually pinkish 
or reddish in shade, cedematous, and surrounded by dis- 
tended and conspicuous vessels; or hidden from view 
by plastic deposits upon its surface, or by a fog in the 
vitreous humor. 

The optic nerve, when affected with syphilis, is usually 
involved after extension to it of a retinitis or choroiditis. 
It is said also to be very rarely primarily infiltrated with 
a gummatous product. The same is true of the vitreous, 
which is usually implicated only after syphilitic changes 
in its investing membranes. 

Paralysis of the nerves of the eye is as nearly pathogno- 
monic of syphilis as is iritis, from fifty to sixty per cent. 
of all cases occurring in syphilitic subjects. Many of 
these are early phenomena of cerebral syphilis, and hence 
amblyopia, failure of co-ordination of the ocular move- 
ments, and visual disturbances of every kind shpuld be 
closely investigated at all times when occurring in the 
victim of syphilis. Paralysis of the third pair of cerebral 
nerves, the oculo-motorius, is characterized by ptosis of 
the upper lid, external strabismus, and inability to move 
the globe upward, downward, or inward. Accommoda- 
tion is wholly or partially lost, and the pupil is dilated. 
Paralysis of the sixth pair, the abducens, is, on the other 
hand, characterized by internal strabismus, amblyopia on 
the outer side of the vertical axis of the eye, and inabil- 
ity to move the globe outward. Paralysis of the fourth 
pair, the patheticus, is characterized by amblyopia for all 
objects lying below the equator of the globe of the eye, 
and an effort on the part of the patient to correct the 
visual impressions of objects below that equator by the 
inclination of the head. 

These paralyses may occur singly or in combination ; 
and, with or without them, may be recognized monocu- 
lar mydriasis, which, albeit occasionally associated with 
grave cerebral syphilis, the author has seen persist for a 
year without impairment of co-ordination or other ocular 
symptom. Unquestionably these paralyses may be due 
at times to gummatous and other syphilitic changes in 
the membranes, periosteum, and bones within the cranial 
vault. Convergent strabismus is readily distinguished 
from paralysis of the sixth pair by the relief of the squint 
in the former case when the sound eye is covered. The 
treatment of these paralyses by the usual method of 
managing constitutional syphilisis, for the most.part, en- 
couraging. , Tenotomy may be occasionally required. 

The Eye in Inherited Syphilis.—In congenital disease 
the lids, conjunctive, cornea, iris, choroid, retina, and 
optic nerve, may, one or all, be affected with specific in- 
flammatory changes, or, more commonly, by gummatous 
deposits resulting in degeneration and ulceration. Grave 
ocular troubles in early life, especially if coexisting with 
persistent alterations of the subcutaneous structures, peri- 
osteum, or bone, should generally awaken the suspicion 
of syphilitic disease. 

AFFECTIONS OF THE EAR IN SypuILis.—The external 
ear may exhibit the lesions of secondary syphilis. Mu- 
cous patches, erosions, ulcerations, and the pathological 
secretions furnished by them, are occasionally sources of 


721 


Syphilis. 
Syphilis. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


I 


annoyance in the external auditory canal. The underly- 
ing submucous tissue, cartilages, and bones may become 
also the seat of gummata capable of resolution under 
treatment ; and, on the other hand, of degeneration with 
the production of ulcers. Nodes also form, which are at 
times of such size as to block up the lumen of the canal 
and interfere with audition. The middle ear is, more fre- 
quently than the external canal, implicated in syphilis, 
because of its anatomical relations with the nares and 
fauces. But little is known of these complications. Un- 
doubtedly mucous patches, with erosive and ulcerative 
sequele, occasionally form upon the mucous lining of the 
Eustachian tube or lining membrane of the middle ear. 
There is usually considerable pain in the latter event ; 
the drum membrane loses its polish ; its surface may be- 
come the seat of vascularized deposits ; or it may be per- 
forated ; as a result the ossicles may be loosened or lost, 
and the mastoid process or other osseous tissue in the 
neighborhood become carious. Presumably also, nodes 
may spring, in rare cases, from the bony tissue beneath 
the investments of all parts of the middle ear; and un- 
doubtedly, if recognized in life, these would explain 
many obscure cases of deafness. The changes in the in- 
ternal ear due to syphilis are so obscure as to furnish no 
basis for study. 

Under the heading ‘‘Sudden Deafness Produced by 
Syphilis,” Bumstead and Taylor describe a condition in 
which, after manifest hypereemia of the drums, both ears 
are affected suddenly with an extreme degree of deafness 
accompanied by vertigo, and without obvious changes in 
any special part of the organ of hearing. In these in- 
stances the cochlea and labyrinth have been supposed to 
be the seat of disease; yet other cases have been ex- 
plained by disarrangement of the ossicles. Deafness 
may, however, be due to syphilitic involvement of the 
brain; and, in this relation, is more common than is gen- 
erally supposed. (See also Syphilis of the Ear, in the 
Appendix.) . 

AURAL AFFECTIONS OF HEREDITARY SYPHILIS.—Se- 
vere, and often remediless, loss of hearing, usually involv- 
ing both ears, may occur in the subjects of syphilis in 
the second decade of life. According to Hutchinson, the 
result depends upon changes either in the auditory nerve 
or in the deeper parts of the organ of hearing, more par- 
ticularly the labyrinth. The loss of hearing may be com- 
plete and result in deaf-mutism. 

AFFECTIONS OF THE REspPrrATORY TRACT. The Nose. 
—The lining membrane of the nares may be the seat of 
macules, papules, erosions, mucous patches, and ulcera- 
tions, with catarrhal symptoms, the discharge from the 
nares becoming serous, purulent, or hemorrhagic. In- 
spissated masses of these secretions smeared with an 
offensive discharge are at times expelled. Gummata 
form in the same region, whose degeneration leads to 
ulcerative changes in cartilage, periosteum, and bone. 
This order of sequence may be reversed, the gummatous 
infiltration first occurring in the osseous structure. The 
septum, floor, Eustachian tube, pharynx, roof of the 
mouth, antrum, and even the cerebral meninges, may be 
attacked by extension of the disease from one point to 
another. When the bridge of the nose is in this way 
undermined, a characteristic and highly disfiguring flat- 
tening occurs, which is rarely seen in any other dis- 
order save syphilis, traumatism excepted. Cartilaginous 
destruction is productive of flattening of the tip of the 
nose. The practically remediless nature of these deform- 
ities renders the treatment of all nasal disorders in syph- 
ilis a matter of the highest consequence. When the 
antrum of, Highmore is affected there is a peculiar tume- 
faction, unaccompanied by coloration or change in the 
skin, of one side of the face, whose treatment may re- 
quire removal of a tooth, penetration of the floor of the 
antrum, and the wearing of an obturator for a time. 
When the Eustachian tube is involved, the drum mem- 
brane may be perforated and a purulent otitis media be- 
come apparent. Many of these changes, whether vegeta- 
tive, erosive, or ulcerative in type, are accompanied by 
fetid ozeena, nasal phonation, and partial or total loss of 
the olfactory sense. 


722 


Sometimes osseous fragments, vary- - 


ing in size froma hemp-seed to a finger-nail, are discharged 
from the nares, the detritus of the carious process as it af- 
fects the nasal, turbinated, or other bones. Eburnation and 
thickening of the bones 77 s¢tu may also result. The in- 
ternal treatment of these cases is by mercury, iodide of po- 
tassium, the mineral acids, and ferruginous tonics. Lo- 
cally the treatment may be successfully conducted by the 
aid of mercurial fumigation, but the use of a cleansing 
douche, followed by lotions containing the bichloride of 
mercury, resorcin, iodized phenol, potassium chlorate, or 
boric acid, may be regarded to-day as preferable. 

The Laryna.—The vocal cords, arytenoid and glosso- 
epiglottic folds, and all parts of the mucous, submucous, 
cartilaginous, and osseous tissue of the larynx, may be- 
come the seat of syphilitic changes. Diffuse circum- 
scribed erythema, mucous patches, papules, ‘‘ condylom- ° 
ata,” vegetations, erosions, and gummata may be fol- 
lowed by superficial or deep ulcerations, circumscribed or 
extensive infiltrations, and cicatrices whose contraction 
may induce grave and dangerous laryngeal stenosis. 
Pain, cough, changes in the volume or pitch of the 
voice, dyspnoea and dysphagia, are not at first noticeable. 
The supervention of oedema may gradually or rapidly 
usher ina serious condition. Later, when stenosis of the 
larynx (the more frequent of the ultimate results) is 
induced by cicatricial contraction, or (more rarely) by 
vegetations, false membranes, gummata, or nodes, the 
voice may be reduced to a whisper or there may be com- 
plete aphonia, dysphagia to a slight extent, or dyspnea 
evento a grade demanding tracheotomy for the preserva- 
tion of life. The mucous membrane of the larynx is 
affected also with a chronic form of infiltration which re- 
sults in a characteristic induration of the important sub- 
mucous tissues of the larynx, distinguishable from cedema 
by its firmness and density. The deeper ulcerations of 
this organ resulting from degenerating gummata, circum- 
scribed or diffuse in extent, commonly spread from simi- 
lar lesions in the pharynx, resulting ultimately in de- 
struction of the epiglottis, leaving often in such cases a 
single wide and ragged laryngo-pharyngeal chasm ;. or 
involving the cords, aryteno-epiglottic ligaments, and 
deeper structures. When the cartilage is involved, crep- 
itation is said to be perceptible after the occurrence of 
perichondritis ; and sequestra have been removed when 
caries or necrosis has attacked the ossified cartilage. 
Syphilitic aphonia, obscure as to its immediate cause, as 
well as paralyses whether of one or both sides, are not to 
be confounded with syphilitic aphasia. Tuberculosis can 
now be satisfactorily differentiated from these affections 
by the modern methods of recognizing the bacillus of 
that disorder, as wellas by the other signs of phthisis and 
the absence of a history of syphilis and its concomitant 
symptoms. 

The trachea may become the seat of lesions similar to 
those recognized in the larynx ; but the absence here of 
the delicate mechanism required for phonation explains 
why they are rarer, less conspicuous, and less complicated. 
The larynx, trachea, and bronchi are usually simultane- 
ously or successively involved, the trachea alone very 
rarely. All the lesions of mucous surfaces in syphilis, 
all the vegetations, infiltrations, and degenerations, may 
here be noted, including extra-tracheal abscess from per- 
foration. Stenosis from cicatricial contraction may here 
also induce fatal results. The internal treatment of 
laryngeal and tracheal syphilis is that of the disease in 
general. Locally, the parts may be sponged with solu- 
tions of boric acid, benzoin tincture, eucalyptol, or dusted 
with iodoform, or tannin in fine powder, reduced if de- 
sired. The galvano-cautery is best employed in the surgi- 
cal management of membranoid occlusions, which are, it 
should be remembered, quite uninfluenced by large doses 
of the potassic iodide. The last-named drug is indeed, in 
some cases, credited with producing a form of laryngeal 
edema. Dilatation’with bougies has not won for itself 
much favor in the management of these cases. The use 
of tobacco, both by smoking and chewing, is to be inter- 
dicted in all cases. 

The bronchi, it can scarcely be questioned, may be- 
come the seat of the syphilitic changes described in con. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Syphilis. 
Syphilis, 


nection with the larynx and trachea. Few cases, how- 
ever, have been carefully studied, though stenosis follow- 
ing ulceration has been recognized post mortem. 

The lungs may be the seat of a syphilitic infiltration 
affecting usually one side of the chest only, and then the 
upper, middle, or lower lobe.. The pulmonary tissue be- 
comes so dense in these cases as to be impermeable to the 
air; and yellowish points are visible here and there in 
the relatively small patch of consolidation, due to the 
irritation of the parenchyma by the sclerotic nodule. 

These sclerosed portions of the lung by their contrac- 
tion induce either stenosis or ectasia of the normal canals 
and chambers in the vicinage. Under the microscope 
the sclerosis is seen to be made up of bundles of firm 
-connective tissue, between which appear stellate, fusi- 
‘form, and roundish cells, with a granular detritus. The 
vessels of the part are first engorged with blood, and 
later choked with the stasis of their contents. | 

Pulmonary gummata, or circumscribed syphilomata, of 
the lung rarely form at the apices of these organs, but are 
found in all other parts. They are grayish, semi-solid 
masses, varying from the size of a pea to that of an egg, set 
in the pulmonary parenchyma, surrounded always by an 
opalescent, fibrous, basket-like capsule, and as they grow 
older often exhibit one or more yellowish points in their 
mass where caseation has begun. Softening in these pro- 
gresses from centre to periphery, and the contents may 
find exit by the portal of a neighboring bronchus with a 
secreting cavity left behind; or resorption may occur 
with the result of leaving a fibrous mass in the lung tis- 
sue, having a cheesy centre. These conditions may be 
found in one and the same lung, gummata forming in 
cavities left by others that have degenerated, fibrous se- 
quele of resorption, and contracting cicatrices. Often 
the pleura and bronchi are either involved in the same 
process or exhibit the irritating effects of the pulmonary 
neoplasms. Microscopically, the centre of these gum- 
mata is found to be made up of granular connective tis- 
sue, in process of degeneration, and highly refractive 
granules. The fibrous tissue is concentrically wrapped 
about them, the cellular elements nearest the core having 
often undergone in part fatty metamorphosis. Still more 
externally lie irregular masses representing a small-celled 
infiltration, which in places blocks up the alveoli. The 
symptoms of these lung-changes of syphilis are largely 
those of non-specific inflammatory disorders, viz., bron- 
chial catarrh with expectoration of muco-pus; diminu- 
tion of sonority in percussion ; limitation of the respira- 
_ tory area in affected parts of the lung; dry and moist 
rales ; prolonged expiration ; and dyspneea, The author 
has published a report of a case of severe hemorrhage in 
a patient affected with syphilitic pulmonary sclerosis, 
with complete recovery after appropriate therapy. . In 
the event of degenerating gummata of the lung, the symp- 
toms are those of pulmonary caverns, whatever be the 
cause, hollow gurgling rales, pectoriloquy, raucous voice, 
etc. The diagnosis is established by the history of syphi- 
lis and any concomitant symptoms present; by the rela- 
tive immunity of the pulmonary apex; by the smaller 
number and larger size of gummata, as contrasted with 
miliary tubercles ; and by the absence of the bacilli of tu- 
berculosis, of the signs of hydatid cysts, and of neoplasms 
of other diseases. The treatment is that of syphilis in 
general, with such remedies as are specially indicated by 
the pulmonary symptoms present. 

AFFECTIONS OF THE DIGESTIVE TrRAcT. The Mouth. 
—As the lining membrane of the mouth is more often 
exposed to the eye of the practitioner than any other 
mucous surface in the body, the symptoms it exhibits in 
the victim of syphilis may be regarded as representative 
of mucous lesions in general. They are all properly in 
alignment with the cutaneous lesions, the modifying in- 
fluences being chiefly heat, moisture, and motion; the 
latter incidental to the performance of the important 
functions of the mucous cavities. Thus the buccal cay- 
ity is often the seat of diffuse or circumscribed erythema, 
in dull red shades, faucial or palatal in situation, with 
defined or irregular outlines, accompanied by infiltration, 
cedema, and often by erosions. These may be multiple, 


pea-sized patches, or a single sheet of diffuse blush. 
The former, after maceration, may, by either a vege- 
tative or a degenerative process, form papules, mucous 
patches, or ulcers. In malignant cases a dull-red ery- 
thema often precedes the gangrenous crateriform ulcer 
which opens, almost as at a stroke, the oral and nasal 
cavities by a communicating chasm. 

Mucous Patcnes (Mucous tubercles, plaques mu- 
queuses, moist papules, etc.).—The larger number of these 
lesions appear in the mouth and about the anus, though 
they are to be seen near all the mucous outlets of the 
body. They are far more common and more severe in 
the mouth of men than of women, on account of the to- 
bacco habits of the former. They are early and late le- 
sions of syphilis, and are represented in the symptoms of 
relatively few diseases not syphilitic. They consist of 
roundish, ovalish, or irregularly shaped disks, or longer, 
narrow, indefinitely outlined bands of a delicate rosy 
hue; grayish or opalescent in color; often granular and 
elevated about a millimetre above the general level of the 
surface where they appear. Many of them look as if 
covered with a delicate pellicle. When of a pinkish or 
reddish shade, they represent merely a stage of hyper- 
zenia of the membrane; when opalescent, as if pencilled 
by the silver crayon, a stage of maceration of the previ- 
ously infiltrated epidermis; when granular, a stage of 
attempted repair, the loosened pellicle having been re- 
moved by friction or otherwise, and the surface beneath 
forming a new epithelial envelope. They may form 
upon a chancre when undergoing its so-called ‘‘ trans- 
formation 77 situ,” already described. When located in 
quasi-mucous situations, viz., those portions of the skin 
in the vicinity of the mucous outlets subjected to fric- 
tion and kept moist and warm (inner faces of the thighs, 
inside of the toes, etc.), they may vegetate and produce 
the condyloma, a lesion frequently seen about the anus 
and genital region, more particularly in syphilitic women 
of filthy habits. These are usually circumscribed, mul- 
tiple, roundish, or irregularly shaped, wart-like eleva- 
tions, smeared with a whitish mucus, highly contagi- 
ous, and of especially disgusting odor when seated about 
the ano-genital orifices. In the same situation they are 
remarkable for the production of a sensation of itching, 
rarely awakened by other syphilitic lesions. Occasion- 
ally they are dry. They are, as a matter of fact, merely 
papular lesions, flattened by apposition of the surfaces 
between which they are developed, or vegetating as the 
clefts in these same surfaces permit of such a growth, 
secreting because moist and macerated, and itching be- 
cause irritated by the same agencies. When exposed, as 
about the bearded lips and nares, they are dryer, and 
browner, or duller red in hue. They occur in and about 
all the mucous outlets, and affect all mucous surfaces, 
with a marked predilection for the neighborhood of the 
muco-cutaneous borders. They are exceedingly common 
in both infantile and inherited syphilis. They may be- 
come cracked, eroded, and superficially or very deeply 
ulcerated. Their excessive proliferation produces enor- 
mous masses of secreting, wart-like, softish growths, de- 
scribed by authors as frambesioid condylomatous syph- 
ilodermata. 

The mucous patches of the mouth are less elevated and 
more opalescent than others, and appear upon the inside 
of the lips and cheeks, gums, uvula, palate, tonsils, and 
pharynx. They should never be confounded with the 
transitory, minute, usually distinctly circular, aphthous 
ulcerations to be seen in healthy adults after a fit of in- 
digestion ; nor with the persistent, much firmer, leathery 
disks, or striated or ribbon-like streaks, described as pso- 
riasis lingue, leukoplakia buccalis, etc., which, as is now 
well known, may be the earliest epitheliomatous trans- 
formation of a mucous membrane; nor, lastly, with the 
so-called ‘‘ smokers’ patches” (plaques des fumeurs, etc.), 
which in many cases, it can scarcely be questioned, rep- 
resent buccal lesions in a veteran of syphilis. 

The tongue may display a wide variety in the lesions 
of syphilis. In the order of gravity may be named: Mul- 
tiple, macular lesions, the size of a pin-head, abundantly 
spread over its upper surface; mucous patches in all 


723 


Syphilis. 
Syphilis. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


forms, particularly over the edges and tip, often forming 
where the organ is rasped by the rough edge of a carious 
molar tooth; flat, circular papules, the size of a bean 
and larger, elevated a millimetre or two above the gen- 
eral level ; circumscribed and diffuse, superficial or deep 
(parenchymatous) scleroses, usually developed upon the 
upper surface of the organ and near its mesian line, 
characterized by irregular increase of bulk and almost 
cartilaginous density, which may result in resorption 
and atrophy or ulceration ; and, lastly, superficial or pa- 
renchymatous gummata, submucous or muscular in site, 
occasionally single, often multiple, which also may dis- 
appear by resorption or degenerate by ulceration. One 
of the remarkable features of disintegrating syphilitic, as 
distinguished from other neoplasms, of the tongue is the 
relatively slight damage apparent after completion of re- 
pair. The author lately examined a patient’s tongue two 
years after closure of a crater, the size of a pigeon’s-egg, 
left by a deep gumma, with the result of finding merel 

an irregular band-like scar to indicate the site of the le- 
sion. These all are to be distinguished from epitheli- 
omata, Which are more voluminous, more hemorrhagic, 
less deeply excavated, more irregular in mass, and more 
painful; as also from colloid lingual tumors (so-called 
‘‘hygroma” of English authors), with the appearance of 
vesicles on the upper surface and enormous asymmetrical 
increase in the bulk of the organ in childhood; and, 
lastly, from tuberculosis of the organ, rare of occur- 
rence, to be recognized only by its histological characters. 

The maailiary bones may undergo necrosis as a result 
of syphilis. The most common site of the accident is the 
central part of the dome of the hard palate. There is 
first a dull-red erythematous swelling of the membrane 
and submucous tissue, which in severe cases may seem 
to melt away like wet paper, leaving a conical perfora- 
tion through which communication is opened between 
the oral and nasal cavities; in other cases an abscess 
forms and bursts, after which the bone is laid bare and 
exfoliates in larger or smaller masses from time to time. 
Necrosis of the alveolar processes usually occurs in the 
upper jaw. Gummata of the soft palate often form insid- 
iously ; are circumscribed or diffuse ; at first firm, later 
softish, tumors, varying from the size of a pea to that of 
a small nut, or in patches of thickening. Absorption or 
ulceration may result, and the latter often rapidly, in 
consequence of the lax and unsupported tissues involved ; 
the process in grave cases opens (by destruction in whole 
or in part, of the uvula, pillars of the fauces, and velum) 
a wide chasm between the fauces and the posterior nares. 
Interference with the Eustachian tube often produces 
temporary deafness. The voice is disagreeably nasal, 
deglutition is often difficult in the erect posture (patients 
with extensive tissue-loss will often assume singular pos- 
tures, by which they can even succeed in swallowing 
liquids without the passage of the latter into the nose), 
and the pain in general is quite disproportionate to the 
severity of the damage. Marvellous are the reparative 
results when, as is usually the case under sound manage- 
ment, repair ensues. The remaining fragments of the 
velum palati contract adhesions to the posterior pharyn- 
geal wall, the chasm contracts, and the expert can trace 
the picture of the mischief that has occurred when in- 
specting only the narrow and distorted chink left after 
contracture is complete. 

Fournier only has reported a case of syphilitic in- 
volvement of the sublingual gland. 

The pharynx may become the seat of macules, papules, 
mucous patches, gummata, and ulcers, which in many 
cases are formidable. The latter may spread from the 
posterior nares and extend downward into the cesopha- 
gus, or backward, so as to produce destructive effects 
upon the periosteum of the vertebre and the structures 
they protect. Occasionally, patients long neglected or 
badly treated exhibit gigantic caverns, including what 


were once the nasal, buccal, and pharyngeal cavities, — 


the whole lined with a granulating or secreting, and ul- 
cerated membrane. Even in those extreme cases where 
one is disposed to wonder even at the prolongation of 
life, repair ensues and emphasizes the striking, almost 


124 


pathognomonic, distinction between the damages inflicted 
by syphilis and all other destructive diseases, 

The esophagus is said to be very rarely the seat of 
syphilitic lesions which, after ulceration, may produce 
stricture, either spasmodic or organic, resulting in serious 
danger to life. 

The treatment of all these lesions is practically the 
same. Internally, mercury and the iodide of potassium 
are essential, the latter often in the largest permissible 
doses, tosave important organs. Care of the patient’s nu- 
trition is in most cases imperative. Locally, the nitrate 
of silver, sulphate of copper, chlorate of potash, tannin, 
resorcin, acid nitrate of mercury, nitric acid, and tinct- 
ure of iodine, may be employed in strength varying ac- 
cording to the requirements of each case—the first-named 
in solid stick or solution of a strength of from five to sixty 
grains to the ounce (0.33-4. to 32.0). By spraying; pen- 
cilling, dusting, washing, and gargling, these prepara- 
tions may be used, with the greatest advantage, a num- 
ber of times throughout the course of the day. The 
following are excellent formule for gargles : 


Be. 3) otass, chlorata ig: ene ce 5 4. 
Mel. despum., \ 
Myrrh.:tinct epee \.a8 £Zss. 16, 
Ag. dest... :Jce- ic eee eae etn 

M. §8.—Gargle. Use diluted as required. 

By Potass: chlorats.72-- eee hee ei 4, 
Infus. lini. . /20\\2oo9 See Nett OF FOO, 

[Bumstead and Taylor. | ‘ 

i. Acid. carbolicl) {22 eo me AP 4, 
Glycerin, 
Spts..Vin, rectil jee ae aa f %.ij. 8. 
lodin. tinct 2.76 jake ae ee ESS 88 eee, 
Ag.,.dest, <.. 0° oe ee adr t 3:}: 32. 


M. Five to fifteen drops in a third of a tumbler of 
water for gargle or lotion. 


The tooth-brush, in all cases, is to be regularly em- 
ployed twice daily ; if the patient is unaccustomed to its 
use the mouth should be well cleansed and the gums rub- 
bed with a bit of soft muslin on the finger, dipped in wa- 
ter to which a few drops of the tincture of myrrh and cin- 
chona has been added. Tobacco is to be, in every form, 
absolutely interdicted ; and all very hot and very cold, 
and irritating articles of diet are to be excluded (e.g., hot 
coffee, ice cream, vinegar, spirits, spices, etc.). 

The stomach and intestinal canal may become the seat 
of syphilitic lesions of the type seen upon the other mu- 
cous surfaces. Huet, Cornil, Klebs, and others report 
gummata of this part of the digestive tract; Leudet, 
Virchow, and Fauvel describe diffuse infiltrations of por- 
tions of the tube ; Engel, Fioupe, Cullerier, and others, 
perforating ulcers (probably due to gummata) as well as 
scleroses resulting in contracture, even productive of suf- 
ficient irritation to light up a peritonitis near a stricture 
of the colon. It should not be forgotten that a long list 
of functional disorders of the alimentary canal might be 
enumerated as of occurrence in the syphilitic subject, 
which are often due to the toxic influence of the disease 
(cachexia, etc.) ; to the effect of certain of the medica- 
ments ingested or externally applied for its relief ; and to 
improper alimentation or hygiene. 

The rectum may become the seat of a series of impor- 
tant changes due to syphilis. Women are more liable to 
be thus affected than men in the proportion of eight to 
one, a preponderance which has been referred to the an- 
atomical differences between the sexes ; to the physiolog- 
ical fluxes of women ; previous pregnancies ; and to un- 
natural or excessive coitus. Chancroids, occurring as 
they do frequently about the anus of women, may result 
in induration of the submucous tissues, accompanied by 
purulent and sanguinolent discharges, constipation, or 
looseness of the bowels, and painful defecation. This 
condition is to be carefully distinguished from syphilitic 
stricture of the rectum. 

The syphilitic affections of the rectum may, perhaps, 
include the category of syphilitic lesions of mucous sur- 
faces in general. The most important, however, are 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


those characterized by ulceration or gummatous changes. 
The former may extend from without inward, from the 
perianal region to an inch or more within the sphincter ; 
or may begin by one or several points of ulceration in the 
latter situation. The so-called ‘‘ano-rectal syphiloma ” 
is a cylindriform, gummatous, non-ulcerated infiltration 
of the entire circumference of the ano-rectal walls, capa- 
ble of producing stricture by transformation into fibrous 
tissue. It is, however, an error to suppose that stricture 
of the rectum not due to chancroids, but syphilitic in 
character, always conforms in type to the syphiloma. 
The author has at present under his care a middle-aged 
woman, whose husband and two children are victims of 
severe syphilis, and whose left lower extremity is exten- 
sively seamed with perfectly typical syphilitic cicatrices. 
There are in this case four abscesses in the nates, com- 
municating by fistulous sinuses with the bowel and va- 
gina, the syphilitic stricture of the rectum being repre- 
sented by a sharply defined, thin, annular coarctation of 
the rectal wall, with a submucous gummatous infiltration 
strictly limited to the ring of the coarctation. It is evi- 
dent that only in exceptional cases, probably during the 
period before contracture has set in, can internal medica- 
tion accomplish practical results in these cases. Dilata- 
tion, or division of the stricture by the knife or galvano- 
cautery, is usually required, with free opening of all 
. abscesses and sinuses, and observance of strictest antisep- 
tic precautions with bichloride dressing. The future is, 
however, rarely promising for these cases, many women 
who are the victims of the disorder having their health 
profoundly impaired by previous suffering and disease. 

The diver, like the intestinal canal, may suffer during 
the period of syphilis by functional disorders, which may 
depend upon slight structural changes participating in 
the process which results in the cutaneous exanthem. 
The icterus probably originating in this way, which may 
somewhat precede or accompany the first syphiloderm, 
has already been described. It may be accompanied by 
hepatic congestion and by symptoms of malaise, hebe- 
tude, cephalalgia, and even slight pyrexia. The tertiary 
forms of syphilitic involvement of the liver are well 
marked. General, more commonly partial, interstitial 
hepatitis, affecting chiefly the capsular and ligamentous 
attachments of the organ, produces a distortion of the 
gland by contracture of fibrous bundles which, springing 
from these attachments, penetrate the hepatic parenchyma 
and divide it into uneven lobulations and irregular mass- 
es separated by furrows. ‘There is at first increase, and 
~ later diminution, in the bulk of the organ, with the usual 
symptoms of cirrhosis. Hepatic gummata are of more 
frequent occurrence, and in ‘‘ galloping” cases may be 
seen within six months after infection. They are usually 
grouped in clusters of from six to a dozen lesions, vary- 
ing in size from a large pin-head to asmall nut. Cen- 
trally they contain roundish cells and granules in a deli- 
cate connective-tissue reticulum, surrounded by a fibrous 
envelope, and embedded in dense hepatic tissue. The 
symptoms in mild cases are probably scarcely sufficient 
to indicate the nature of the affection. In others, dis- 
turbance of the alimentary canal (icterus, constipation, 
dysentery); pain in various degrees, limited to the he- 
patic region or radiating from it; and, very rarely, mor- 
bid changes perceptible on palpation of the enlarged, or 
previously enlarged and subsequently shrunken, organ, 
may first point to the precise nature of the trouble. 

Gummata of the liver are to be distinguished from hy- 
datid cysts ; carcinoma (of advanced years) ; hepatic ab- 
scess (in persons who have been long resident in tropical 
countries) ; tubercles (usually softer, more cheesy, more 
purulent in the centre); and the rare forms of sarcoma 

of the liver. The prognosis of hepatic syphilis is usually 
not grave. 

Amyloid degeneration of the liver may be the result of 
syphilis as of other diseases. There is increase in the 
bulk of the waxy-looking organ, the hepatic cells becom- 
ing enlarged after involvement of the swollen hepatic 
capillaries. Often there are coincident amyloid changes 
in the heart and spleen. The symptoms of hepatic gum- 
mata are as obscure in many cases as in syphilitic cir- 


Syphilis. 
Syphilis. 


rhosis, There may be ascites, hemorrhage from the 
portal vein, and dyspnea. The treatment is largely that 
of syphilis in general. 

The spleen often enlarges in those early periods of 
syphilis when the lymphatic glands tumefy. Commonly 
the enlargement subsides as the disease progresses or is 
modified by treatment. Syphilomata of the spleen (gum- 
mata) are rarely observed, but have been recognized in 
both circumscribed and diffuse forms. Splenic gummata 
are yellowish, softish nodules, from the size of a pin-head 
to that of a small nut, set in a dense splenic tissue of un- 
usual dryness. In diffuse forms, the organ appears to be 
in part hypertrophied and dark brown in color. Later, 
islets of grayish sclerosed tissue become apparent in this 
mass, whose involution leaves cicatriform depressions. 
There is reason to believe that rarely a perisplenitis may 
be lighted up by these changes, leading to the formation 
of whitish patches of almost cartilaginous density. The 
clinical symptoms of syphilis of the spleen are obscure. 

The pancreas is said to be occasionally the seat of 
changes which have been. supposed to represent the cir- 
cumscribed and diffuse syphilomata recognized in the 
liver and spleen. 

AFFECTIONS OF THE CIRCULATORY ORGANS.—Myocar- 
ditis, recognized chiefly in post-mortem examinations, 
may be a late complication of syphilis, which affects men 
more often than women in the proportion of six to one. 
Softish, yellowish gummata, from the size of a nut to 
that of an egg, as well as circumscribed and diffuse scle- 
rosis, have been recognized in the ventricular walls and 
auricles of both sides. Plastic or fibrous metamorphosis 
of the muscular tissue about any of these lesions may oc- 
cur. Whitish diffuse infiltrations, firm, or of the consist- 
ence of a sarcoma, with round-celled infiltrations and 
vegetations, may affect the endocardium or muscular tis- 
sue; and the same changes in the pericardium may result 
in partial or total obliteration of its sac. These com- 
monly originate in sub-endocardial or sub-pericardial 
gummata. Wagner, Lancereaux, and a few others have 
reported gummata limited to these serous membranes. 
The symptoms excited by these changes are dyspnea, 
palpitations, cyanosis, precordial distress, and angina pec- 
toris. The prognosis is naturally described as grave, since 
all the identified instances of this affection were recog- 
nized in the bodies of the dead. It is reasonable, how- 
ever, to suppose that syphilis here, as elsewhere, exhibits 
its usual amenability to treatment in the case of patients 
with symptoms not diagnosticated in life. 

Arteries and Veins.—The femoral, jugular, saphena, 
and other veins have been’reported affected with a phle- 
bitis due usually to the pressure exercised by a gumma- 
tous tumor in the vicinity. A sclerous phlebitis, in which 
the intima was first attacked, has also been recognized 
post mortem. 

The capillaries and arteries also may be primarily or 
secondarily involved. In the latter case it is commonly 
the result of compressive or destructive effects exerted by 
syphilitic processes in adjacent organs. Syphilitic endar- 
teritis, however, is much more common; and recent in- 
vestigators, including Virchow, Heubner, and others, 
have revealed its pathology with sufficient clearness. 
These lesions are more commonly observed in the smaller 
cerebral arteries, but the carotids and other vessels are 
occasionally involved. The definite limitation of the dis- 
ease to a single patch is declared by the rapid appearance 
of whitish, opaque nodules, the size of a millet-seed, 
composed of small, roundish, or spindle-shaped cells, 
which may be agglomerated into a firm, fibrous mass, 
from the size of a pea to that of a nut, obliterating the 
lumen of the invaded artery by thickening of all its in- 
vesting coats, and producing eventually either rupture or 
an atrophic or cicatriform relic of its existence. This in- 
farction is remarkable for the indirect results it produces, 
including cephalalgic, aphasic, paretic, paraplegic, and 
even comatose, symptoms. 

THE GENITO-URINARY ORGANS.—Secondary and ter- 
tiary, as well as primary, symptoms of syphilis are dis- 
closed in the genito-urinary tract of patients of both 
Sexes. 


725 


Syphilis. 
Syphilis. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


The penis may become, in one part or another, the seat 
of circumscribed tertiary syphilitic infiltrations, as well 
as of gummata. 

Lesions of this nature may be subcutaneous, or there 
may be nut-sized masses deeply lodged in the substance 
of the corpora cavernosa, or in the submucous tissue of 
the urethra. Some of the lesions discovered post mortem, 
and described as ‘‘chancres of the deep urethra,” are 
really tertiary ulcers resulting from broken-down gum- 
mata of the prostatic or membranous urethra. Jullien 
figures a cavern of the cutaneous surface of the penis 
originating in this way in one of Langlebert’s patients. 
Bumstead and Taylor describe tubercles of syphilitic ori- 
gin near the furrow at the base of the glans. 

Any part of the testicles may be affected with syphilis. 

The epididymis, when involved, may display either an 
early or late form of syphilitic epididymitis. 

The early form, first described by Dron, in 1863, may 
be observed at any time between the third and thirtieth 
months after infection. 'The’disorder bears no relation 
to gonorrheeal epididymitis. The globus major, or head, 
of the organ, much more rarely the globus minor, is at- 
tacked and either insidiously or acutely affected, produc- 
ing a roundish or squarish, circumscribed tumor, from 
the size of a bean to that of a small nut, which has been 
compared to a ‘‘monkey-nut screwed to the testicle.” 
One or both organs may be involved, successively or si- 
multaneously, and the globus minor may be attacked later. 
It is amenable to treatment, and commonly disappears 
without unfortunate sequele. 

The late form is often connected with gummatous 
changes in the testis proper, but very rarely arises inde- 
pendently of the latter. Here also the globus major is 
more often attacked; and resolution, as is the case with 
tertiary deposits in the testis proper, may be followed by 
atrophic changes. 

Syphilitic orchitis, sarcocele, or albuginitis, may be a 
late secondary or tertiary symptom of syphilis, involving 
one or both organs simultaneously or in succession. In 
these cases, the body of the testicle is involved, often 
without the production of pain, in a smooth, uniform, 
and firm swelling, which may be due in part to enlarge- 
ment of the testicle, and in part to a moderate grade of 
hydrocele concealing the irregularities perceptible later 
in the body of the organ. In other cases, this body can 
be recognized by palpation as the seat of one or several 
masses, from the size of a pea to that of a small nut, which 
may be at first isolated and circumscribed, but later be- 
come fused into a solid, resisting mass having the general 
shape of the testicle, but often three or four times larger. 
Under energetic treatment, resolution of these masses is 
accomplished ; but obliteration of the vasa deferentia and 
atrophy, or fatty, fibrous, cartilaginous, amylaceous, even 
osseous metamorphosis of the parenchymatous tissue of 
the gland, may follow the absorption of the neoplasm. 
In this way the testicle may be, after completion of this 
cycle of changes, represented by merely a bean-sized 
mass of fibrous tissue. Suppuration and ulceration of 
the tunics almost never result, though a few authors 
have reported a resulting ‘‘ fungus of the testicle.” 

Pathologically studied, the glands are found to be the 
seat of vascularization and proliferation of connective 
tissue, resulting in the production of fibrous trabecule 
traversing the organ in various directions, but always at- 
tached to its thickened investments, resulting by contract- 
ure in compression and atrophy of the secreting cells of 
the tubules. In other cases, true, grayish or yellowish 
gummata are found in the testis, single or multiple, dif- 
fuse or circumscribed, from the size of a pin-head to that 
of a pigeon’s egg, environed by fibrous capsular coats. 
These commonly disappear by absorption; even in the 
rare cases of disintegration and the formation of ‘‘ fun- 
gus of the testis,” recovery ensues under proper treat- 
ment. 

All syphilitic lesions of the epididymis and testis are to 
be distinguished from the gonorrhceal, the cancerous, the 
sarcomatous, and the tubercular. The blennorrhagic af- 
fections of the epididymis are acute in type, painful, at- 
tack the tail of the organ by preference, and are usually 


726 


preceded by an unequivocal history of urethritis and dis- 
charge. The neoplasms of cancer and sarcoma in the 
testicle are usually accompanied by inguinal adenopathy, 
severe pain, systemic cachexia, extensive damage to the 
parts affected, and proneness to disintegration. 'Tuber- 
culosis is far more common in young men virgin of all 
venereal antecedents, usually with tuberculosis of the 
prostate gland and marked dysuria. Almost invariably 
the bacillus tuberculosis may be recognized in the secre- 
tion obtained by ‘‘ milking” the prostate. The treatment 
internally is by the potassic iodide and mercury. Lo- 
cally, suspension is to be recommended ; hot fomentations 
for relief of pain when such exists ; and applications of 
salves containing lead, mercury, belladonna, or, opium. 
The oleate of mercury and morphine, mercurial plaster, 
white precipitate salve, or the compound iodine ointment, 
may be applied. Strapping, as employed for relief of 
gonorrheeal epididymitis, may be practised with advan- 
tage in some cases. ‘The prognosis is not unfavorable as 
regards the health of the patient; but, after double 
syphilitic orchitis, the patient on have complete asperm- 
atism. The prostate gland, vasa deferentia, common ejac- 
ulatory ducts, and vesicule seminales are all probably the 
seat at times of syphilitic changes, the characters of 


\ 


which are not known. \ 

In women the labium majus, usually one, occasionally 
both, may be the seat of gummatous changes due to 
syphilis. These may be late and \unique manifestations 
of the disease. Often nothing can\be gathered in cases 
of this sort as to the history of syphilis, a not uncom- 
mon experience in the infected of that sex. The organ 
is found, when examined, to be wholly or in part the 
seat of a dense, smooth or irregularly lobulated, verti- 
cally disposed tumor, very closely resembling in size 
and external appearance the scrotum which contains a 
testicle affected with syphilitic orchitis. It is usually an 
exceedingly indolent affection, lasting for years, rarely 
occurring at the outset till three or four years have 
elapsed since infection. It is often diagnosticated as 
‘‘elephantiasis”” of the labium. Disintegration of the 
mass by ulceration is rare. 

The syphiloma of the vagina is similar to the lesion de- 
scribed above in the date of its occurrence, its exceedingly 
indolent career, and its existence for months without a 
single coincident symptom of syphilis to substantiate the 
diagnosis. Many of these cases have been recorded, 
treated, described, and éven illustrated as ‘‘ lupus of the 
vagina,” which disorder is even rarer than this exceed- 
ingly rare manifestation of syphilis. When recognized, 
the vagina is converted into a thickened cylinder of 
tissue infiltrated with gummatous material, which greatly 
restricts the distensibility of the vaginal walls. In some 
of these cases the finger can with great difficulty be in- 
troduced into a channel through which viable infants 
have been ushered into the world. Irregular projections 
of the inextensible vaginal membrane, club-shaped, 
knobbed, granular, eroded or ulcerated, represent points 
where the larger submucous gummata are undergoing 
extreme development or ulcerating. These lesions break 
down more frequently and more disastrously than is true 
of the gummatous metamorphoses of the labia. Occa- 
sionally the ostium vagine is converted into a vast 
gummatous ulcer, invading the vestibulum and even the 
urethra. In one very severe case, the author has seen 
the rectum participate in the change. 

The neck and body of the wterus exhibit more rarely 
and to a much less marked degree similar changes ; in- 
duration, tumefaction, erosion, and ulceration of the 
mucous lining are reported by authors. 

The Fallopian Tubes and Ovaries.—Lancereaux and 
Lecorché, respectively, have reported instances of diffuse 
and gummiatous changes in the ovaries. In the case re- 
ported by the first-named author, there’ were two egg- 
sized tumors with long diameters parallel with the broad 
ligament. Bouchard and Lepine, quoted by Jullien, de- 
scribe a single case of syphilitic salpingitis. 

The kidneys undergo changes both in early and late 
syphilis. The phosphates and chlorides may be un- 
changed in the urine ; urea may be quantitatively in ex- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


cess, and albumen occur in quantities as great as in 
Bright’s disease. Fifteen years ago, the author had un- 
der observation a case of severe albuminuria following 
syphilitic changes in the kidney of a man who is_ to-day 
living and well. Ten years ago, the author had under 
observation a severe case of anasarca following marked 
albuminuria, the patient, a young man, losing for five 
days ten pounds by weight daily in the Turkish bath. 
When recovery was complete, the patient was examined, 
and two years ago found free from disease. Similar ob- 
servations have been made by most experts. Glycosuria 
has appeared and disappeared under precisely similar 
circumstances in syphilitic subjects. By some authors, 
these several conditions are claimed to be the results 
simply of the cachexia which may affect syphilitic as 


well as noh-syphilitic patients, producing thus the amy- - 


loid, waxy, and other metamorphoses recognized in 
other cases. Without denying the possibility of such 
accidents, the author calls special attention to the strik- 
ing fact that some of these cases bear the special imprint 
of syphilis in this, that after the exhibition of alarming 
symptoms, a complete, rapid, and permanent recovery 
may ensue after energetic treatment by mercury and, 
more often, by the iodide of potassium. 

Syphilitic sclerosis and gummata of the kidney are 
late lesions of syphilis, and of rare occurrence, the last 
named being decidedly the rarer of the two accidents. 
In the diffuse form of syphilitic nephritis, there is usu- 
ally a cycle of vascularization and tumefaction of the 
cortical portion, followed by interstitial proliferation, 
attachment of capsule to cortex, and formation of ir- 
regular, small or large nodules and projections from the 
surface whose exterior gross appearances suggest the 
similar lobulations of the syphilitic testicle. In some 
places these undergo lardaceous, amyloid, and other de- 
generative changes resulting in cicatrices. Precisely as 
the seminiferous tubules of the testicle are choked and 
eventually reduced to atrophy, are the glomeruli and 
uriniferous tubules of the kidney compressed, their chan- 
nels obliterated, and their functions arrested. Here and 
there, on section, yellowish points or streaks of fatty met- 
amorphosis are visible upon a granular surface ; or the 
totality of the organ may be changed to a dead whitish 
color. 

Gummata of the kidney are developed in both the cor- 
tical and pyramidal portions. They are single or multi- 
ple, grayish or whitish, definitely circumscribed masses, 
from the size of a pin-head to that of a pigeon’s egg, with 
~ a whitish or reddened and vascular, fibrous envelope like 
acapsule. The centre is firm or cheesy, according to the 
age of the gumma; and the body of the lesion is made up 
of elements derived by proliferation from the connective 
tissue of the renal stroma. The subjects of these several 
complications of syphilis may suffer from vague pains, 
changes in the eye, peritoneum, pleura, and nervous cen- 
tres, as well as ascites, anasarca, lumbar pain, hematuria, 
and albuminuria. ‘The prognosis is decidedly less grave 
than in non-specific renal affections of similar type. 

THe Nervous System.—Affections of the nervous 
system may be early or late symptoms of syphilis, and 
are commonly the results of morbid changes in contigu- 
ous structures, such as bone, vessel, or investing mem- 
brane. They are much more common in men, chiefly 
because of the greater tax levied upon that sex in the 
demand for physical and mental strain constantly made 
in business. 

The literature of nervous syphilis, most of which has 
been contributed during the last decade, has been both 
voluminous and valuable. In the following paragraphs 
it will be possible merely to trace the outlines of the im- 
portant advances which have been made in this special 
field. The clinical pictures presented may be briefly 
named as follows: 

Headache, insomnia, and irregular performance of 
. functions of many of the organs of the body (eye, ear, 
heart, muscle, liver), dependent upon nervous disturb- 
ance, are not infrequent in the early periods of syphilis. 
The headache of this stage of the disease is often persist- 
ent and obstinate. It may be frontal, temporal, or oc- 


Syphilis. 
Syphilis. 


cipital in situation, and of the moderate grade from 
which few infected subjects are wholly exempt, or se- 
vere, with intense nocturnal exacerbation, eliciting groans 
from the sufferer. This distressing complication of the 
disease may endure for only a few days, or last for weeks 
or months, proving eventually a mere precursory symp- 
tom of cerebral syphilis. Jullien, with certain others of 
the French school, lays stress upon the return or exag- 
geration, at this time, of the nervous symptoms displayed 
previous to infection by the subjects of hysteria, alcohol- 
ism, other cerebral affections, and epilepsy. Mild ner- 
vous manifestations are recorded by observers in this con- 
nection, including aneesthesia, analgesia, circumscribed 
hyperidrosis, and hypertrichosis, and cutaneous sensa- 
tions of coolness, heat, formication, and tingling. Many 
of these features are such thatthe pathological changes 
on which they depend are necessarily unknown, or can 
be estimated only by reasoning from analogy. The sup- 
posed cerebral syphilis séne materda has for its basis only 
the non-recognition of structural changes where autop- 
sies were made after the exhibition of well-marked ner- 
vous symptoms. In such cases, the possibility that the 
actual physical basis of the morbid phenomena was sim- 
ply not discovered cannot be properly ignored. 

When a patient is actually affected with cerebral syph- 
zlis, the unmistakable features of the accident often fol- 
low, as indicated above, the milder symptoms. The 
headache, which was at first simply annoying or toler- 
able, sets in with paroxysms of distress which make the 
patient dread the hours of the night as a period of tort- 
ure. Constant or intermittent grinding, boring, or ham- 
mering sensations are referred to the whole or any one of 
the regions of the head described above. The patient 
will grow eloquent in declaring that the head feels as-if 
it were screwed in a vice, riveted with iron bands, ham- 
mered upon an anvil, etc. Under treatment even this 
condition may yield in a few days, or, defying all skill (a 
rare complication), go on to the extreme conditions de- 
scribed later. At times definitely circumscribed regions 
of tenderness may be appreciated by both patient and 
physician, the latter by the pain evoked in percussion of 
the cranial vault. Insomnia, vertigo, intellectual hebe- 
tude, apathy, melancholia, and other morbid mental 
states, photophobia, and marked cachexia, are the usual 
concomitants of this state. When the disorder progresses 
uninterruptedly to full evolution, the patient becomes 
weaker, takes to the bed day and night, may exhibit 
some mild ataxic or paretic symptoms, usually goes into 
delirium, and presents the picture of one affected with 
utterly hopeless cerebral disease. Yet here, as so often 
in the history of this singular malady, he is really far 
from such a hopeless state, and thus furnishes the diag- 
nostician with a clue to the syphilitic origin of the dis- 
ease. Such a patient, properly treated, may rise from 
his bed, regain his flesh, return to his occupation, and 
live out his natural days, so far as regards the disorder 
under consideration. 

Many odd features may be presented in the course of 
this complication. There are patients thus affected who 
present singular hallucinations ; yet others suffer from 
vague terrors, dreading self-destruction or attacks from 
enemies. 

Chorea, or at least choreic symptoms, may be recog- 
nized in some patients of this class. Spasmodic con- 
tractions may affect one or a group of muscles, either be- 
fore or after the occurrence of paralytic symptoms, or 
independently of the latter. There may be slight, se- 
vere, transitory, remittent, or constant contractions of 
muscles of the head or extremities. One of the author’s 
patients had a persistent, rhythmical swaying of the 
head from side to side, which lasted during the hours 
of wakefulness for a fortnight. 

Aphasia, partial or complete, continuous or intermit- 
tent, may be the sole symptom of nervous syphilis, or 
occur before or after some of its grave complications. 
Often it is of sudden onset—one of the author’s patients, 
for example, presenting himself at a bank in order to se- 
cure a foreign draft, and finding it on the instant impos- 
sible to make himself understood. 


127 


Syphilis. 
Syphilis. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, 


Paralysis, sensory or motor, partial or complete, usually 
succeeds a prodromal stage in which the patient has com- 
plained of obstinately persistent headache or some other 
premonitory symptom of cerebral disorder. The paraly- 
ses of the motor muscles of the eye belonging to this 
group of disorders have been already described. In a 
similar way the nerves of special sense, not only those of 
vision and hearing, but of olfaction and gustation, are 
totally or partially deprived of sensitiveness to external 
impressions. 

Hemiplegia, occurring suddenly in a patient under 
fifty years of age, is, in the great majority of all cases, 
of syphilitic origin. It may be of early or late, sudden 
or gradual occurrence, and constitute a mere paresis of a 
group of muscles on one side, or much more rarely, a 
complete motor paralysis of one half of the body. It is 
usually preceded by cephalalgia, vertigo, lassitude, and 
neuralgia, with anesthesia or tingling of the parts about 
to be affected, or mild choreic, rarely convulsive, seiz- 
ures. Usually, after well-marked prodromal symptoms 
have been exhibited for some days or weeks, the patient 
awakes from sleep to find himself more or less unable to 
move one or both limbs of one side ; or the attack comes 
on in the hours of the day, the patient falling to the 
ground in a state of partial unconsciousness. The leg 
only is most commonly affected ; at times it is followed 
by involvement of the arm. Rarely the arm alone is af- 
fected. The bladder and rectum may participate in the 
resulting symptoms by loss of power to expel their con- 
tents. Alternate paralysis of the facial muscles is occa- 
sionally noted, ¢.g., the right leg and the left side of the 
face. There may be dilatation of the pupil of the eye on 
the sound or affected side, with or without ptosis and in- 
volvement of the oculo-motorius. With these symptoms 
are occasionally associated total impotence, which may 
even survive the paralytic symptoms in the extremities, 
muscular tremors, and contractures. Sensory disturb- 
ances are few ; rarely there is complete sensorimotor loss. 
The affection is commonly attributed to an obliterating 
endarteritis. The prognosis in most cases is favorable. 

Epilepsy is simulated in syphilis, under the influence 
of which epileptiform seizures occur. They are far rarer 
than hemiplegic complications. With or without pre- 
monitory sensations comparable to those experienced in 
the aura, both the grand mal and petit mal are represented 
in syphilitic seizures. There is, in the first case, the usual 
precursory severe cephalalgia, followed by distressing 
sensations in the extremities or about the heart, or sin- 
gular creeping sensations of chilliness. Jullien insists that 
during these attacks the patient, even if unable to speak 
or to move, never wholly loses consciousness and never 
utters the cry, an important diagnostic distinction. The 
patient may fall as if shot, and exhibit tonic, followed 
by clonic, convulsions during a portion of the time, but 
rarely throughout the whole period occupied by a seiz- 
ure. These convulsive movements do not notably affect 
all of the muscles of the body. The patient may foam at 
the mouth and bite the tongue or lips, though often, with 
marked convulsive seizures, these symptoms are absent. 
The intervals between these crises may be but a few 
hours, or days, or several weeks. They tend to multiply 
with each recurrence, and may result in dementia. 

The petit mal, or mild form, is betrayed in tremors, 
spasms of the muscles, for example, of a single limb, or 
of the neck, or of one shoulder ; dyspneea, dysphagia, or 
vertigo. Other patients experience sudden loss of mem- 
ory, or imperception of environment, confusion of idea- 
tion, and incoherence of speech. 

Paraplegia is, in more than fifty per cent. of all cases 
occurring in male patients under forty years of age, of 
syphilitic origin. Over ninety per cent. of cases of syph- 
ilitic paraplegia occur in males. There may be prece- 
dent cephalalgia of extreme violence, rachialgia, neural- 
gia, convulsive seizures of the muscles of the lower 
extremities, and hyperesthesia or anesthesia of the cu- 
taneous surface. The paraplegia may be partial or com- 
plete, and sudden or gradual as to occurrence, but, as 
Althaus indicates, is unaccompanied by loss of conscious- 
ness, the patient often ‘‘ assisting” at the invasion. It is 


728 


apt to terminate in complete loss of power of both lower 
extremities, with and without sensory disturbances, par- 
tial paralysis of rectum and bladder, and complete impo- 
tence, lasting often for years. One side of the body may 


- be involved after the other ; or the same side may be again 


affected after an interval of months has elapsed. Paraly- 
sis of cranial nerves, mental hebetude, mydriasis, and 
other signs of syphilis of the nervous system may be 
present, but are often absent ; and when the paraplegia 
is complete this may be the sole objective symptom of 
the infective disease. 

The occurrence of locomotor ataxia in syphilis is both 
asserted and denied by observers, The author’s experi- 
ence is in accord with that of Messrs. Bumstead and 


‘Taylor, who are unable to recognize in the syphilitic 


affections of the cord, the well-defined sclerosis of the 
posterior columns which is characteristic of progressive 
spinal ataxia. The clinical symptoms of syphilitic 
changes in the cord may, for a brief time, simulate those 
of locomotor ataxia, but the results—not merely in well- 
treated, but in unrecognized and therefore wholly un- 
treated cases of syphilis—are widely separated /from the 
remediless sequel of the non-specific disease. / 
Fournier, Erb, and Althaus have advanced strong rea- 
sons in favor of the syphilitic origin of tabesy which have 


- been offset by the statistical facts cited by Oppenheim 


and others. ‘The classical features of theast-named dis- 
ease are not only not exhibited by the syphilitic patient, 
but specific treatment, as even Fournier admits, has not 
succeeded in procuring relief for the ataxic ‘‘ syphilitic ” 
patient. Pathologically, it is known that syphilis rarely 
selects a definitely limited portion of the cord for its 
manifestations, but involves here and there a patch in 
the columns, near which can commonly be recognized 
altered vessels or investing membranes where the morbid 
process originated. 

Symptoms resembling those of general paralysis of the 
insane (délire de grandeurs, etc.) have been recognized in- 
a very few syphilitic patients (Dreer), but with relation 
to syphilis they may be relegated to much the same posi- 
tion as those observed in locomotor ataxia. There isa 
suggestive doubt as to whether the few patients affected 
with general paralysis, who have, at some remote period 
in the past, admitted the occurrence of ‘‘a chancre,” 
really had syphilis, and as a result of this last-named dis- 
ease the progressive symptoms of general paralysis. 

Jullien aptly calls attention to the striking fact that 
the syphilitic patient supposed to have general paralysis 
is really ill (cachectic, anemic, or adynamic), while the 
‘“‘real fool,” on the contrary, exhibiting moral decrepi- 
tude, stupid facial expression, and perturbed cerebration, 
appears to be otherwise in good physical health. The 
former, moreover, is apt to display one or more of the 
syphilitic paralyses following a characteristic vertigo, 
hemicrania, or a cephalalgia, or some one of the ocular or 
aural complications of syphilis, in brief, at capriciously 
selected points where nervous symptoms are displayed. 
This also is associated with a milder exaltation of ideas, 
and a more rapid evolution of symptoms. : 

Other symptoms of nervous syphilis are exhibited in 
gastro-intestinal derangements (vomiting, etc.); func- 
tional disturbances of the kidneys and bladder ; and dis- 
orders of other viscera. 

Coma, preceded by cephalalgia, anesthesia, mental 
hebetude, or aphasic symptoms, may occur during sleep, 
or result from sudden diurnal accidents. The patient is 
usually found lying listless, or apparently asleep, pallid, 
expressionless, and not suffering pain. He may be 
roused to take food or drink, to thrust out the tongue, 
or even momentarily to recognize a friend or answer a 
question. ‘The pupils are usually small, insensitive to the 
light, and covered by the lids. The globes are shrunken 
in the orbits. Sensibility and reflex excitability are either 
wholly preserved, impaired, or lost. The pulse and res- 
piration are retarded in frequency ; the temperature is | 
subnormal ; the excretions are passed unconsciously. 
__The pathology of these several complications of syph- 
ilis is explained chiefly in post-mortem examinations. 

The cranial and other bones, when involved in an oste 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Syphilis. 
Syphilis. 


itis or periosteitis (diffuse, circumscribed, gummatous), 
may produce nodes capable of explaining etiologically 
several of the groups of symptoms described above by 
pressure effects, including inflammation and even de- 
struction of the parts invaded. Nodes of the internal 
tables of the cranial vault or of the vertebrae may thus 
be responsible for mental, paretic, paralytic, convulsive, 
neuralgic, and ataxic symptoms of the most varied char- 
acter. The author is inclined to believe, after observa- 
tion of typical cases, that well-defined cranial nodes in 
the outer table also of the skull are, as the result of sym- 
pathetic influences, capable of producing many of the 
milder symptoms of nervous syphilis. 

The meninges of the brain (dura mater, arachnoid, pia 
mater) are subject to the same involvement. They may 
be changed by pressure of a node, and be agglutinated to it ; 
or may be separately involved in diffuse or circumscribed, 
single or multiple thickenings, due to proliferation and 
vascularization of the tissues (pachymeningitis). The le- 
sions may be symmetrical or asymmetrical, and involve 
the brain more often than the cord. These changes are 
capable in various degrees of producing cephalalgia ; and 
at times a distinct area of meningeal surface may be re- 
cognized as the seat of the severe headache of syphilis, 
with intense nocturnal exacerbation, by pressure or per- 
cussion with the finger over a limited region of the skull 
—a manceuvre which decidedly increases the pain. 

The brain and medulla are always involved as a se- 
quence of changes either in the bones, meninges, or ves- 
sels in anatomical relation with those organs. The soft- 
ening which results may be either of the red or white 
forms of ramollissement recognized in non-syphilitic 
cerebral disease. Gummata of the brain are recognized 
as single, or usually multiple, occasionally exceedingly 
numerous, circumscribed or diffuse, superficial or deep 
tumors, from the size of a millet-seed to that of a small 
egg. They most often exist as superficial lesions in di- 
rect association with gummatous changes in the menin- 
ges. They have a well-defined yellowish or whitish 
cheesy centre, with a firm, sclerotic, peripheral mass set 
in vascularized and greatly softened nervous tissue. Evi- 
dences of simple inflammation in the brain-substance, 
excited by the irritating presence of the neoplasm, are 
usually to be recognized, and are described by Jullien as 
distinctive marks of a cerebral syphiloma, inasmuch as 
the brain-substance tolerates with greater ease the softer 
nodules of tuberculosis. The deep-set lesions are much 
rarer, but are recognized, for example, in the substance 
—of one ventricle, in the optic thalamus; the corpus stria- 
tum, or the white substance of the cord. 

The arterial changes, responsible for so many of the 
nervous complications of syphilis, are of frequent occur- 
rence, and may be primary or’consecutive in order—that 
is, they may be the original and immediate cause of cere- 
bral disease, or the sequence of changes induced by a 
neighboring gumma or pachymeningitis. Heubner, 
Greenfield, Hutchinson, Dowse, Dreschfeld, and others, 
have chiefly contributed to the present knowledge of this 
interesting subject. The small arteries are most often at- 
tacked, symmetrically at times as regards the two halves 
of the brain, in distinctly limited areas, where whitish 
points or nodules become visible to the naked eye. 
Longitudinal section of vessels thus implicated reveals an 
obliteration wholly or in part of the lumen of the vascu- 
lar tube, due to thickening of the inner coat ; the middle, 
clearly defined, being scarcely affected (endarteritis ob- 
literans). The adventitia is doubled or trebled in vol- 
ume, its cells under the microscope being exhibited as 
long, parallel, fusiform elements. The obliteration of the 
lumen, however, is chiefly due to a cellular proliferation 
between the endothelial lining of the vessel and the fe- 
nestrated membrane, resembling a granuloma in appear- 
ance. Externally and internally are flattened or fusiform 
cells, arranged more or less regularly in parallel lines, be- 
tween which are more irregularly and loosely packed 
larger cells, mingled with minute fibres of elastic tissue 
and the vasa vasorum. ‘The endothelium is then finally 
separated from the membrana fenestrata, and projects 
into the lumen of the vessel as a vegetation, occasionally 


forming a second fenestrated membrane on the sides of 
the vessel-wall. In this way complete stenosis of the tube 
is eventually produced—an accident rare in atheroma, 
in which the cellular proliferation is more indolent, more 
generalized, more disposed to terminate by calcification, 
and never results in complete obliteration. These acci- 
dents are often the causes of the severe headache, vertigo, 
chorea, epilepsy, and other of the nervous phenomena 
noted above. 

It is by the production of thrombosis or cerebral ischee- 
mia that the arterial stenosis operates to induce the de- 
rangement. 

A syphilitic periarteritis is described by a few authors 
(Charcot, Rabot, Bumstead and Taylor), in which cir- 
cumscribed, lenticular, whitish masses of irregular shape 
result from an endarteritis affecting the external coats of 
the vessel, with proliferation also of the media and inter- 
nal coat. The internal elastic tissue is reported intact, 
with round-celled infiltration of the muscular layer, and 
multiplication and dilatation of the vasa vasorum. 

The cerebro-spinal nerves may suffer compression by 
an osseous or meningeal lesion of syphilis sufficient to 
produce a series of symptoms ranging from formication, 
hyperesthesia, and moderate numbness, to complete anes- 
thesia, analgesia (rare), or paralysis. The derangements 
of vision induced by syphilitic changes in the optic nerves 
supplying the muscles that move the globe of the eye 
have been already considered. In a similar way, the ol- 
factory, sympathetic, and other nerves may be implicated. 
Petrow, in the cases examined by him where the sympa- 
thetic nervous trunks were involved, recognized a pig- 
mentation of the cellular protoplasm, attributed to the 
deposit of heematine in the nervous cells. The endothe- 
lial elements were proliferating and surrounded by polyg- 
onal nucleated cells, some undergoing colloid metamor- 
phosis, These nervous elements were compressed by an 
hyperplastic connective-tissue growth, undergoing later 
sclerosis, and eventually starving the nervous elements 
into atrophy. The membranous envelope of the latter, 
after undergoing hypertrophy, may be the seat of fatty 
metamorphosis. 

The treatment of the nervous complications of syphilis 
is that of the disease in general. The credit of employ- 
ing large and progressively larger doses of the iodide of 
potassium in all serious emergencies, with brilliant re- 
sults, is largely due to American practitioners. The best 
and simplest way of attaining the end.is to administer 
drop doses of a saturated aqueous solution of the potassic 
iodide in milk every four hours, beginning with a rela- 
tively small dose, five to ten drops (0.83-0.66), and push- 
ing on by increasing one drop each dose until the end in 
view is reached. By this means the author has, in excep- 
tional cases, given one ounce and a half (48.00) of the 
iodide in twenty-four hours, with happy effect ; and still 
larger doses have been reached by others. The rule 
should be to stop the increase at once on the super- 
vention of any toxic effects or marked symptoms of 
physical protest against the large dose; to then hold ata 
given point, or to reduce the dose to a point of complete 
toleration, and to recognize the fact that after the extreme 
point of toleration has been fully reached, perhaps slightly 
surpassed, and for a moderate length of time held, further 
medication of this sort, in the absence of the definite and 
brilliant results usually attained by its adoption, is use- 
less, and in cases harmful. It should not be forgotten, 
also, that in the absence of such desired results, mercury 
in full doses (e.g., calomel one-tenth of a grain (0.0066), 
every hour or two in any serious emergency) may prove 
of inestimable value. 

The prognosis in syphilis of the nervous system, even 
in the face of apparently desperate peril, is far more fa- 
vorable than in the case of nervous symptoms of similar 
import occurring in those who are not the victims of that 
disease. 

MuscLEs, TENDONS, AND ARTICULATIONS.—Muscular 
contracture is described by a number of authors as a 
syphilitic accident occurring slowly or rapidly, and pro- 
ducing fixed flexion or extension of any movable part to 
which the tendon of the muscle is attached, the latter, on 


729 


Syphilis. 
Syphilis. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, 


palpation, being recognized asa rigid and inflexible cord. 
The joints are not in such cases involved. One or sev- 
eral muscles may be attacked, the biceps being that most 
commonly affected, the forearm being then flexed at an 
acute angle upon the arm. The involved muscle may 
and may not be then the seat of pain and tenderness. A 
tetaniform involvement of a much larger number of 
muscles is described also by writers as of occurrence in 
syphilis. : 

In the diffuse form of myositis occurring in syphilis, 
there is diffuse swelling of the whole or a part of a mus- 
cle, some redness and cedema of the overlying skin, 
and pain when the muscular fibres contract. Gummata 
of the muscles are small, at first firm, later softish, usu- 
ally globular masses, from the size of a nut to that of an 
egg, of insidious development, and often, when in pro- 
cess of disintegration, attached to the skin and undergo- 
ing the cycle of changes already described in connection 
with the ulcer resulting from subcutaneous gummata. 
It is believed that the sheaths of the muscle-bundles are 
first involved in these changes. They undergo, in some 
instances, osseous and cartilaginous metamorphoses in- 
stead of disintegrating. 

The tendons, tendinous sheaths, and aponeuroses may 
become in syphilis the seat of flattish, triangular, cir- 
cumscribed, and usually painless tumors, due to effusion 
in the serous sacs ; or to projecting gummata which may 
break down and ulcerate, leaving a cicatrix whose con- 
traction may subsequently interfere with the function of 
the muscle to which such a tendon or aponeurosis is at- 
tached. Diffuse gummatous thickenings also affect the 
fasciz and aponeuroses, more particularly those of the 
lower extremities. 

The burse are not rarely affected in tertiary syphilis, 
more particularly those of the patella and of the tibial 
tuberosity in women. They begin as single, painless or 
slightly painful, firm, elastic, or softish gummata, from 
the size of a nut to that of an egg, which are apt to in- 
volve the skin eventually, and to be obstinate under treat- 
ment. The author has now in hospital a woman, twenty- 
five years of age, with the ligament of the left patella 
fully exposed at the bottom of an ulcer, as large as the 
palm of the hand, and involving all the neighboring parts, 
which began as a gummatous bursitis. 

Syphilitic rheumatism (arthralgia, pseudo-rheumatism) 
may be an acute, more often a subacute, polyarthritis 
with tender and painful points about the articulations, 
preceded often for days by arthritic pains, as distin- 
guished from simple rheumatism. This complication is 
remarkable for the failure of acuity in the symptoms, the 
relative painlessness of the affected joints, the absence of 
articular swellings (arthritis sine materia), and the noctur- 
nal exacerbation of the pain. Hydrarthrosis, most com- 
monly symmetrical and of the knee-joints, though also 
mono-articular, is both an early and a late symptom of 
syphilis, and is chiefly remarkable for the extent to which 
the joints may be distended with synovial fluid, and be 
yet sufficiently free from pain to permit of performance 
of their function. It often recurs and disappears for sey- 
eral weeks at a time. The so-called ‘‘ syphilitic white 
swelling” is due to fibrous thickenings and subsynovial, 
gummatous infiltrations in and about the joint. In the 
author’s experience, these synovial effusions have occurred 
only in the subjects of cachexia, or young male patients 
of fragile constitution. 

The fingers and toes may be the seat of primary, sec- 
ondary, and tertiary syphilitic lesions, and in both ac- 
quired and inherited syphilis. To Dr. R. W. Taylor’s 
exhaustive researches we are greatly indebted for a 
knowledge of this interesting subject, to which merely a 
brief reference can be made in these pages. 

The affection is more common in hereditary than in 
atquired disease. In the former the disease may begin 
in the subcutaneous connective and fibrous articular tis- 
sues, or primarily in the osseous and periosteal tissues, 
and consecutively invade the other structures named. 
The digit affected, either in one or more phalanges, en- 
larges insidiously, becomes dense, painful, inflexible, 
with attached overlying and purplish-red skin. Some- 


730 


times an articular hydrarthrosis can be detected ; again, 
one or more of the symptoms resulting from gummatous 
infiltration. These gummatous deposits are circumscribed 
or diffuse, and not prone to ulcerative degeneration. 
Specific dactylitie osteo-myelitis, periosteitis, or osteo- 
periosteitis, may be a slow, rapid, or relapsing accident, 
producing in full evolution a balloon- or acorn-shaped, 
globular, or pyriform swelling, involving one or several 
phalanges of asingle digit, usually the proximal, and more 
often those of the fingers than of the toes, As sequele, 
may be enumerated inflammatory changes with abscesses 
discharging a caseous matter, crepitation from roughness 
of the articular faces of the cartilages, the formation of 
sinuses, hydrarthrosis, and osseous atrophy after resorp- 
tion of the gummatous deposit, leaving the shaft of the 
phalanx more slender and fragile than before. In other 
yet more marked cases, two conspicuous instances of 
which were lately exhibited at the author’s clinic, the 
phalanx is reduced by shrinkage till the finger is short- 
ened one-third or one-fourth of its length. The result- 
ing deformity is conspicuous, and almost peculiar to the 
special disease under consideration. 

Cartilages and bones are attacked in both early and 
late forms of the disease. The most common form of 
bone disease is an osteo-periosteitis characterized by in- 
flammatory phenomena, vascularization, and exudation, 
diffuse or circumscribed, of the area of contact of the 
osseous and periosteal surfaces. The/result is declared 
in the formation of well-defined, rarely poorly circum- 
scribed nodosities in various degrees sensitive, and usually 
the seat of a characteristic pain, intensely, often intoler- 
ably, aggravated at night after retiring to bed. Absorp- 
tion may result or, much more rarely, degeneration and 
exfoliation of a thin lamella of bone. In other cases an 
exostosis results from a plastic effusion between the peri- 
osteum and bone, usually circumscribed and _flattish, 
globoid, annular, sessile, or pedunculated, which may 
undergo eburnation and exhibit compact or cancellated 
tissue in its structure. When the bone has been infil- 
trated with a gummatous material which degenerates, it 
is usually the epiphysis which is the seat of the disorder, 
though the medulla (osteo-myelitis) and bony substance, 
or even periosteum and bone, may be involved. Ulcera- 
tion may then leave a roundish cavity, from the size of 
a pea to thatof a nut, possibly communicating with the 
medullary canal, filled with a bright-yellowish pulp ; the 
faces of the cartilages become the seat of salient granula- 
tions and depressions (scars ?), the size of millet-seeds., 
At times the diaphysis of the bone is first attacked and 
the epiphysis secondarily. Often the synovial membrane 
remains intact. 

The ‘‘dry caries” or ‘‘inflammatory atrophy” of 
Virchow is a change beginning with vascularization, but 
unaccompanied by suppuration or ulceration, in which 
the osseous substance is found wanting in stellate or 
foveolated pits which may enlarge in the line of furrows 
representing the Haversian canals. These parts are sur- 
rounded by hyperostosis. Bumstead and Taylor look 
upon these and similar depressions in the osseous sub- 
stances, when osteoid growth has ceased centrally and is 
actively progressing at the periphery, as syphilitic cica- 
trices of bone. The meninges, periosteum, and integu- 
ment may participate in the formation of such cicatrices, 
resulting finally in the production of a uniform, thin, 
contractured, whitish or grayish fibrous tissue, unpro- 
vided with vessels. 

The various bones of the skeleton are in different de- 
grees subject to the several changes described above. 
The vault of the cranium is particularly liable, in both 
external and internal tables, to exhibit single or multiple, 
circumscribed osseous changes, as also are the sternum, 
the clavicle, the ribs, and particularly the tibia. The sub- 
sternal and similar pains, noted so frequently as preco- 
cious phenomena in the early periods of the disease, are 
probably associated with transitory osteo-periosteal hyper- 
cemia. In the later periods the nodes that form, whether 
inflammatory or gummatous in type, are characterized by 
the same severe nocturnal exaggeration of the pain they 
excite, and by marked localized tenderness. Some of 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Syphilis. 
Syphilis. 


the consequences resulting from the pressure induced by 
intracranial nodes have been described in the paragraphs 
devoted to the phenomena of nervous syphilis. Gum- 
mata of the frontal and temporal bones, forming firm 
projecting tumors, are at times so conspicuous as to pro- 
duce marked deformity. Other bones besides those 
named, ¢.g., the radius, ulna, femur, maxillary, and, in- 
deed, any part of the skeleton, may become the seat of 
these lesions. The treatment is that of syphilis in gen- 
eral, more particularly in its tertiary stage. The re- 
markable effect of the potassic iodide upon many of 
these lesions is one of the demonstrations, which even 
the most sceptical are compelled to accept, of the signal 
efficacy of an ingested drug upon a neoplasm defying 
local therapy. The dose is to be pushed, to secure 
marked relief, to any required point precisely as indicated 
above in the management of nervous symptoms.  In- 
deed, as will be gathered from what has preceded, the 
same treatment is often urgently demanded in the same 
patient, at the same moment, for relief of grave nervous 
complications depending solely upon syphilitic osseous 
disease. Locally, the mercurial ointments, plasters, and 
oleates, with occasional use of anodynes, fill an important 
part. 

HEREDITARY SYPHILIS.—This form of the disease, the 
only one not known to originate by an initial sclerosis, 
is also termed congenital and infantile syphilis. The 
syphilis of infants, acquired by accidental or intentional 
transmission after birth, is practically that of acquired 
syphilis of adults, the differences being chiefly due to 
the tender skin of the young patient and its extreme 
liability to nutritional disorders. 

Hereditary. syphilis is the disease transmitted by inher- 
itance from one or both progenitors to a second genera- 
tion. Evidences of such transmission to the third genera- 
tion are extremely rare. The more active the disease in 
the progenitors, the greater the chances of infection of 
the offspring. 

In inherited, no less than in acquired, syphilis patholo- 
gists have recognized micro-organisms which have been 
claimed to be effective in the evolution of the disease. 
Doutrelepont, Kassowitz, Hochsinger, Kalisko, and Chat- 
zen have both detected and failed to detect streptococci 
- in the viscera of children affected with hereditary lues, 
more particularly in the skin, mucous surfaces, bones, 
and liver. In some instances the lymph-channels have 
been found choked with micro-organisms of this kind, 
which fact has suggested to Chatzen that the cachexia of 
-some patients in this category was a streptococcus-septi- 
ceemia. 

Relative Influence of the Parents in the Transmission of 
the Disease.—The father alone, when the victim of an 
active constitutional syphilis, is capable of transmitting 
the disease to his child without infection of the mother. 
It is probable that he does not possess this power before 
the disease is actively displayed in his own person by 
constitutional symptoms. It is certain that this power is 
greatly weakened while he is under the influence of mer- 
cury ; is weakened and regained during the respective 
periods of repose and activity so commonly observed in 
the disease ; and is finally extinguished by time. It re- 
mains to be admitted that the cases in which the father 
alone is thus responsible for syphilis in the second gener- 
ation are far fewer than those in which the mother alone 
is thus responsible ; and that the power of such trans- 
missibility is positively denied to the father by the fol- 
lowers of Cullerier, Oewre, and others. 

The mother alone, the father being unaffected, may 
transmit syphilis to the child, if she be the victim of an 
active constitutional disease. If conception occur later 
than the twentieth day after the appearance of the earli- 
est syphiloderm, the product of such conception is almost 
certainly doomed to destruction, abortion of the ovum 
commonly following from the third to the seventh 
month. The woman, however, profoundly syphilitic, 
may abort or miscarry in consequence of the cachectic 
state to which she is reduced by syphilis, and may thus 
throw off, as in any cachectic condition, the unaffected 
germ, Again, the child may escape entirely by the 


operation of that inscrutable law which ever and again 
protects the offspring from the vices and errors of the 
parents. Lastly, in a series of pregnancies, abortions 
may be followed by miscarriages; the latter by still- 
births at term ; then by viable infants exhibiting symp- 
toms of syphilis before the fourth month of life ; and, 
lastly, by the birth of children in whom syphilis can 
never be recognized, the power of transmission being 
weakened till it is wholly lost in the process of time. 

If the mother be affected after conception, it is prob- 
able that she cannot convey her disease to the child. 
She may abort or miscarry in consequence of the anemia 
induced by her own disease, but it is improbable that, 
either in the first or latter half of pregnancy (both peri- 
ods have been claimed as those of special danger), the 
virus can be transmitted through the utero-placental cir- 
culation. Cases have been cited in support of both views 
as to the possibility and impossibility of such transmis- 
sion, the cases cited in support of the affirmative view 
being in the main defective, by reason of failure to de- 
monstrate both perfect immunity of the father and posi- 
tive syphilis of the child. 

A healthy mother may bear a syphilitic child. On this 
point also there has been much division of authority. 
The large number of all mothers who bear syphilitic 
children are themselves unquestionably syphilitic. But 
the possibility that a syphilitic child may be infected by 
inheritance from the father alone, the mother remaining 
sound (precisely as is the case when the child is sound 
and the mother healthy), is demonstrated by numerous 
facts. Dr. Taylor, of New York, and the author have 
in this country substantiated by reported cases the facts 
set forth abroad by Kassowitz and others. The well- 
known law of Colles is urged in support of such trans- 
mission. That law formulates a well-known clinical fact, 
viz., that the mother of a syphilitic child is never in- 
fected at the breast by her offspring—the secretions of 
whose diseased mouth are infective for all healthy per- 
sons, <A few exceptions are reported to this law, so few 
and so inconclusive as to rather more fully establish its 
general applicability. It is probable that the system of 
the mother, after the bearing of such children, is so mod- 
ified as to render her incapable of receiving the disease. 
If the sound child be infected at the moment of birth 
by direct contact with recently developed, secreting, pri- 
mary, or secondary lesions existing upon any part of the 
external genitals of the mother (an accident reported in 
a few cases), the result is acquired infantile, and not in- 
herited, syphilis. 

The clinical symptoms of hereditary syphilis are first 
the death of ovum or foetus. These products of concep- 
tion are then ushered into the world either undistinguish- 
able from the dead products of pregnancies where no 
syphilis has interfered ; or macerated, the epidermis be- 
ing readily separable from the corium, which is deeply 
congested, or, for the reason first named, raised into bul- 
le, and the viscera in various ways are profoundly al- 
tered. Ina second list are to be classed stillbirths, and 
the birth of children surviving but a brief time. These 
may be apparently unaffected by disease ; or covered, in 
various degrees, with bullous lesions produced by passive 
exudation of fluids elevating the loosened epidermis from 
the corium ; or suffer from visceral changes. In a third 
category may be named children who survive for various 
periods to maturity. One-third of all are thought, how- 
ever, to perish without attaining that development. 
Many perish before the second month; those who sur- 
vive commonly exhibit the symptoms of inherited syph- 
ilis in the same period, even if no signs are apparent at 
birth. Hereditary syphilis is rarely deferred in its mani- 
festations after the fourth month. Cases reported as of 
late inherited syphilis, where the first symptoms of that 
disease were manifested at the period of puberty, for ex- 
ample, are regarded by most experts with suspicion. 

The placenta may be the seat of a diffuse or circum- 
scribed gummatous infiltration. The two may concur. 
In such cases the syphiloma is characterized as usual by 
the firm, external, fibrous, grayish-tinted layers surround- 
ing a softer, yellowish central mass. Hydramnios is 


73] 


Syphilis. 
Syphilis. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


also counted among the possible syphilitic changes of 
pregnancy. Rr: 
The skin of the victim of inherited syphilis is subject 
to many. changes resembling, for the most part, those 
recognized in the acquired form of the disease. It is 
commonly seen to be either flaccid and wrinkled, or 
tightly stretched over the bones as if deprived of its pan- 
niculus adiposus. In this way the characteristic little- 
old-man and little-old-woman appearance of the syphil- 
itic infant is produced. The skin has, moreover, a not 
less constant and characteristic sallow, yellowish, earthy 
hue. Manifestly the nutrition is profoundly impaired, 
and the child exhibits a series of symptoms, such as 


vomiting, diarrhoea, etc., which indicate that not the. 


skin alone but other organs are participating in the dis- 
ease. Asa matter of practical moment, it is well for the 
practitioner to remember that a healthy-looking, well- 
nourished child, six months and more of age, without 
pulmonary or gastro-intestinal disorder and no signs of 
disease save a suspicious-looking eruption upon the skin, 
is probably not the victim of inherited syphilis. 

The macular or erythematous rash (roseola) appears 
usually over the belly, face, neck, palms, extremities, 
and other parts, in the form of roundish or oval-shaped 
macules. from the size of a split-pea to that of the finger- 
nail, of the copper-and-reddish shade, soon refusing to 
yield under pressure, often seen as the earliest cutaneous 
symptom of the disease. The spots may enlarge by mul- 
tiplication or coalescence ; may, in cases, become elevated 
or covered with scales ; or may undergo fissure. 

Papules, mucous plaques, mucous patches (of the skin 
and mucous membranes), and condylomata lata are all 
phases of one and the same process of proliferation in 
hereditary syphilis. The most common of all is the oc- 
currence of these flattened papules or patches in the nasal 
cavity, furnishing a serous discharge which rapidly be- 
comes purulent or hemorrhagic in type, and which by 
desiccation soon blocks up with crusts the nasal passages. 
As a consequence a characteristic ‘‘snuffles” follows, 
the child abandoning the nipple to get breath, and even 
in sleep uttering a diagnostic snore. On many occasions 
physicians, hearing this suspicious respiratory sound in 
infants brought to them for relief of cutaneous ailments, 
have thus obtained a clew to the real nature of the 
malady. Specific coryzas of this sort may progress to 
ulceration or osseous necrosis. Similar roundish or 
oval-shaped patches, or (after confluence) large sheets of 
involved mucous surface, may be recognized in the 
mouth, furnishing a highly contagious secretion. In 
this way the tongue, lips, gums, and fauces may be in- 
volved, and the child may be rendered incapable of seiz- 
ing the nipple with the mouth. At the angles of the 
mouth, also, on the muco-cutaneous surface, flat papules, 
condylomata, or secreting patches may conceal the nat- 
ural outlines of the parts, be extensively crust-covered, 
or even superficially or deeply ulcerated. 

Over the general surface of the body, small or large, flat 
or, more rarely, acuminate papules, copper-colored and 
reddish in hue ; smooth or scaling, symmetrical, and gen- 
eralized or limited to a single region, may be conspicuous. 
They may coalesce, furnish a patch of infiltration, and 
even extensively ulcerate. The most frequent manifes- 
tations of this type, next to the nasal lesions accompa- 
nied by ‘‘snuffles,” are the condylomata about the anus, 
from the size of a pea to that of an egg and larger, flat- 
tened, whitish or reddish lesions, secreting, elevated, and 
distinctly circumscribed. 

Vesicles, isolated or confluent, conical or flattened, 
from the size of a pin-head to that of a split-pea, may also 
spring from macules or papules, rest upon a brownish 
and reddish base, and be filled with serum or a sero-puru- 
lent fluid. They are rare lesions. Pustules, from the 
size of a pin-head to that of a split-pea, are more often 
seen, with and without a previous or concurrent evolu- 
tion of vesicles or papules ; often as a metamorphosis of 
the latter. The skin thus affected is commonly infil- 
trated, purplish, and covered with brownish or greenish 
crusts. Beneath these may be simply excoriation or ul- 
ceration. The genital region, face, scalp, and lower ex- 


732 


= —— 


tremities may be involved; rarely the entire surface of 
the body. The scarring which results is not conspicuous. 

Bulle are grave and unfortunately common symptoms 
of inherited syphilis. They may, as indicated above, be 
conspicuous at birth, single or multiple as to number ; or 
develop later as wine-colored, circumscribed patches of 
integument ; first pea-sized, later as large as an egg, an 
orange, or a cocoa-nut, filled with serous, lactescent, or 
hemorrhagic contents. The palms and soles are fre- 
quently involved. The areola is violaceous, often infil- 
trated and raised. The brownish crusts cover ulcers 
with a foul, hemorrhagic, or diphtheritic floor. Death 
usually ensues, when the eruption is at all generalized, 
in the course of a few days. Furuncles, beginning as 
circumscribed cutaneous or subcutaneous and indolent 
nodules, from the size of a pea to that of a nut, may be 
in some cases SO numerous as to constitute a characteris- 
tic and even symmetrical eruption. They may, after a 
typical suppuration, discharge a core by sloughing, or 
break down into conical ulcers of the crateriform shape. 

Tubercles and gummata may observe almost the same 
cycle. They also begin as roundish or irregularly 
knobbed, usually subcutaneous nodules, which break 
down, furnish an irritating, semi-purulent or serous dis- 
charge, and finally result in ulcers of the typical aspect 
already described as of occurrence in the acquired forms 
of syphilis. These ulcers may also follow the less cir- 
cumscribed gummatous infiltrations of the skin and sub- 
cutaneous tissues. | 

Many of the grave cases of profound destruction of 
tissues about the face (eyes, nose, lips, jaws, etc.), illus- 
trated in the works of the best authors on the subject of 
hereditary syphilis, originated in gummata whose ulcer- 
ative processes, beginning in or beneath the skin, spread 
thence to muscles, fascia, periosteum, and bone. 

The laryna, trachea, and neighboring parts may be, in 
early inherited disease, the seat of ulcerations resultin 
in the production of stenosis, cicatrization, and bridles 
stretched between adjacent walls, so as to interfere with 
the function of the organ implicated. The late forms 
are described by Fournier as diffuse hyperplastic, cir- 
cumscribed gummatous, and sclero-gummatous—the last- 
named a combination of other forms. These may be 
serious in consequence of the results recognized in ac- 
quired disease, viz., production of (chiefly laryngeal) 
dyspnoea, glottic spasm, acute cedema, and sudden death. 
Sclerosed masses, subsequently exhibiting a central yel- 
low softening, have been recognized by Lebert and oth- 
ers in the lungs of children dead of inherited syphilis, 
which are believed to be gummata of these organs. 

The mucous lining of the alimentary canal may be the 
seat of changes similar to those observed in the exposed 
mucous surfaces of the subjects of the disease. Circum- 
scribed hyperemia and even indurated hyperplastic, as 
well as ulcerative, patches have been recognized about 
the solitary and agminated glands.. The liver may be, 
after the occurrence of specific changes in the walls of 
its vessels, hypertrophied, dense, and resisting; or the 
seat of pedunculated tumors, or of diffuse or circum- 
scribed parenchymatous gummata. These may be mili- 
ary or nut-sized, and surrounded by the usual fibro: plas- 
tic envelope. The spleen is probably always involved in 
the child affected with inherited syphilis. It may be the 
seat of a partial or general perisplenitis, capsular or sub- 
capsular in situation ; is always greatly increased in size 
and weight; and may undergo later, under treatment, 
reduction to its normal size, or, in other cases, lardaceous 
metamorphosis. The increase in size and weight which 
has been noticed in the pancreas is different, in that it 
seems to be accompanied by a sclerosis due to hypertro- 
phy of the interstitial connective tissue. 

The suprarenal capsules may be involved in a partial 
or complete peri-capsulitis ; as also in a parenchymatous 
deposit of miliary gummata. Fatty, colloid, and gelat- 
iniform degeneration may be observed as a result of 
these morbid changes in both capsule and substance 
proper. The kidney has been found enlarged and also 
containing one or many miliary, whitish or yellowish, 
circumscribed gummata, or diffuse infiltrations. The 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


° 


Syphilis. 
Syphilis, 


origin of these lesions has been traced to proliferative 
changes in the connective-tissue stroma of the organ. 
Here, too, colloid and fatty degeneration has ensued—in 
rare cases, ulcerative destruction. One or both testes 
may be involved in male patients, the disorder beginning 
with an indolent tumefaction of the testis proper (the 
epididymis being usually spared), smooth, lobulated, and 
accompanied or not by moderate hydrocele and scrotal 
engorgement. Fournier calls attention to the discovery, 
in patients exhibiting tardy symptoms of inherited dis- 
ease, of small, densely indurated testicles, either arrested 
in development or the fruit of the gummatous changes 
wrought in earlier periods of the disease. It is possible 
that the ovaries may be similarly involved (Panot). 

The hair and nazls are affected in hereditary as in ac- 
quired syphilis, chiefly after involvement of the tissues 
on which they depend for nutrition and support. In this 
way patches of alopecia become visible in the scalp. The 
nails are surrounded by a ring of purplish infiltration ; or 
papulo-pustules, degenerating into ulcers, Undermine the 
matrix and possibly finish with loss of the nail and for- 
mation of a cicatrix. The deformity of the distal phal- 
anx in these cases is strikingly characteristic, presenting 
as it does a livid club-like enlargement, often both ten- 
der and painful, bearing, usually on one side only, a 
semilunar ulcer with sero-purulent secretion, foul base, 
and distorted or displaced nail. The nail-substance in 
these cases may be friable, eroded, ‘‘ worm-eaten ” in ap- 
pearance,-frayed, or laterally ridged and furrowed. 

The changes so strikingly characteristic of inherited 
syphilis in the eye (keratitis, etc.), ear (remediless deaf- 
ness of late inherited syphilis), and teeth (Hutchinson’s 
changes), have already been described. A group of symp- 
toms less classical and constant are puriform depots in 
the thymus gland, supposed to be abscesses (Dubois) ; 
glandular abscesses due to the irritation of neighboring 
cutaneous lesions (e.g., in the neck, when associated with 
scalp or mouth disease); hemophilia, or hemorrhagic 
symptoms appreciable at birth or soon after, in the cuta- 
neous or mucous surfaces, probably due in greater meas- 
ure to the cachexia of the disease than to specific changes ; 
stenosis of veins and arteries (perhaps associated with 
gummatous changes in the vascular wall similiar to those 

occurring in the endarteritis obliterans of acquired syphi- 
lis); and fusiform swellings of the synovial sheaths over 
the metacarpal bones (Bumstead and Taylor). 

The affections of the bones in hereditary syphilis have 
been exhaustively studied in the last decade by Wegner, 
Waldeyer, Parrot, Taylor, Fournier, and others. They 
are among the most common of all the symptoms of the 
disease, being next in order to the ocular changes. All 
the phenomena long ascribed to rickets are to-day re- 
ferred to inherited syphilis. Osteochondritis usually af- 
fects the diaphyso-epiphyseal extremity of the forearm, 
leg, arm, or thigh, but all the bones may be involved in 
the newlyborn infant, and that as the sole manifestation 
of the disease, or in conjunction with skin and .other le- 
sions. A partial or complete annular swelling, smooth, 
or irregular, or ridged, is then found, of insidious or rapid 
development, encircling the extremity of the bone (distal 
extremity of ulna, sternal extremity of clavicle). There 
may be articular effusions in the contiguous joint. The 
swelling may disappear under treatment, or degenerate 
by ulceration as in gummata, resulting in loosening, sepa- 
ration, or destruction of the epiphysis or cartilage ; or ul- 
timately result in death by exhaustion, The bone may 
be shortened as a result, or invested with a thickened 
periosteum. The pathological changes may be described 
briefly as due to proliferation of the cartilage cells, with 
mamelonation of the epiphyseal surface, and calcification 
of the osteoid processes. Periosteal and perichondrial 
thickenings follow, conjointly with retarded osteogenesis 
at some points. 

Osteoperiosteitis is a later bone symptom of inherited 
syphilis, affecting predominantly the tibia, but also the 
ulna, radius, cranial, and other bones, often more than 
one bone in one subject of the disease, and then at times 
symmetrically. The hyperostosis resulting may distort 
the tibia so as to produce the so-called ‘‘sabre-blade” de- 


formity, its voluminous mass forming a curve, with an 
anterior or lateral convexity, painful, tender, and indolent 
of development; or it may result in characteristic mul- 
tiple cranial hyperostoses of the temporal and frontal re- 
gions. Allthese forms may result in necrosis, ulceration 
of bone, and formation of fistulous tracts through which 
sequestra may be removed. 

In gummatous osteomyelitis the medullary canal, after 
degeneration of a gummatous infiltration, may be the 
seat of a cheesy tissue here and there enclosing solid 
masses, surrounded by layers of newly formed bone. 

The syphilitic dactylitis of inherited resembles that 
of acquired, disease, the swellings attacking slowly or 


_rapidly, with or without pain, one or more of the proxi- 


mal phalanges, or metacarpal or metatarsal bones. In 
all these bone lesions the joints may participate second- 
arily, or the synovial membrane or fibrous capsule may 
be first to induce a hydrarthrosis or tumefaction, which 
may go on to degenerative changes involving cartilage 
and bone, or be averted at any stage by treatment. 

The nervous system, in inherited syphilis, is chiefly in- 
volved after the occurrence of structural changes in the 
meninges and other neighboring parts. Fibrous and 
gummatous thickenings and infiltrations, diffuse and cir- 
cumscribed, may implicate one or more of the meningeal 
layers, agglutinating them to each other or to the nervous 
structures they enclose. Periosteitis of the surfaces in 
contact with these membranes, intracephalic scleroses 
and gummata, and occlusions of the lumen of the cere- 
bral vessels, may here, as in acquired disease, be followed 
by a long series of nervous symptoms, dilatation of the 
pupil, facial paralysis, paraplegia, hemiplegia, epilepti- 
form seizures, hydrocephalus, idiocy, and various grades 
of failure of intellectual development and vigor. Four- 
nier, in describing the late forms of this complication, 
lays stress upon the occurrence of severe and persistent 
cephalalgias, similar to those so frequently recognized 
in acquired syphilis of the nervous system. The same 
author believes that there is an heredito-syphilitic tabes, 
and possibly also a sclerosis en plaques. The paralyses 
resulting from compression or other changes in the ner- 
vous trunk chiefly involve the ocular muscles. 

The treatment of the mother affected with syphilis, 
and pregnant or nursing a syphilitic infant, is usually in- 
dicated. Mercurial inunction of the infant by smearing 
its flannel roller with oleates and salves, is an efficient 
means of introducing the metal when it is required. Cal- 
omel, or the gray powder, may be given, one grain to 
one-twentieth of either (0.066 to 0.0033) rubbed up with 
sugar of milk, and placed upon the tongue of the infant, 
three or four times daily. The dose can be nicely ad- 
justed to the requirements of each case. The bichloride 
may be substituted in combination with syrup of licorice 
or of ginger. Ten drops may be given of a two-ounce 
(64.0) solution, containing from one-fourth to one grain 
(0.0160 to 0.66) of the sublimate to the ounce (82.0). In- 
unction is, however, far preferable for the majority of 
cases, With the administration of cod-liver oil by the 
mouth. When mercury and the iodide of potassium are 
both indicated (more particularly in the management of 
osseous lesions), the several combinations known as the 
syrup of Gibert are useful, e.7. - 


Bec EV VC rATer eC, G05. os ns a8 «ira 2 Pr 2000.00) 
POUREs JOU Meee Ma alate ace os «fh 2m books Zss. (16.0 ) 
Syr. glycyrrhiz. (vel zingiber.), 

AG Cee ee tian iss os Cd reiteln « aa Zij. (64.0 ) 

M. 


Of this solution the infant under the fourth month can 
take from five to ten drops in water, the larger dose be- 
ing gradually reached. Similarly, in all portentous cases, 
the iodide of potassium may be administered in drop- 
doses of a saturated solution to the point required to pro- 
duce any desired effect, as already described in the treat- 
ment of nervous syphilis in the acquired form. In all 
cases the diet and hygiene are highly important consid- 
erations. The heredito-syphilitic child should be at the 
breast of the mother (and at the breast of none other), if 
it can be thus properly nourished. The local manage- 


733 


Syphilis. 
Syphilis. 


ment of the mouth, the ano-genital region, and all syphi- 
lodermata is important, and to be conducted on principles 
heretofore indicated. Tonics are often useful. The prog- 
nosis is grave in all severe cases. In viable chilcren, free 
from visceral complications, much can be accomplished 
by treatment. ‘ j 

TREATMENT OF SyPuHiLis.—The chief point of impor- 
tance in syphilis is the non-medicinal management of the 
patient, without a proper knowledge of which the most 
skilful use of drugs is ineffective. ‘This introduces to the 
wide field of diet, hygiene, climate, and occupation of 
mind and body. The diet should be nutritious, and 
should exclude alcohol in all forms not specifically di- 
rected by the practitioner, with a view to securing its 
valuable tonic (not stimulating) effects. Tobacco in every 
form is best discarded, as having an injurious effect upon 
the nutrition in general, as well as upon the mucous sur- 
face of the mouth, which constitutes such a fertile field 
for the development of mucous patches. The body should 
be sponged daily with cool or tepid water, and then 
briskly scrubbed till warm, when the general surface is 
not the seat of syphilodermata forbidding such a course. 
The skin should be properly protected by woollen under- 
wear. To the immense majority of syphilitic patients 
sexual indulgence should be absolutely prohibited, the 
few exceptions being furnished by husband and wife both 
convalescent from unmistakable disease. Most patients 
are better for regular and systematic attention to their 
usual occupation, though the latter should not unduly 
tax the mental or physical powers. ‘The bowels should 
be evacuated daily. Exercise in the open air and due 
regulation of the hours of sleep should not be forgotten. 
In many cases, where the purse of the patient will per- 
mit, the recreation of travel, a sojourn at the sea-shore, 
or a change from an inhospitable to a mild climate, are 
valuable steps toward recovery. 

In a small percentage of cases the expectant or tonic 
treatment of syphilis, conducted largely by the measures 
described above, aided by the use of tonics (ferruginous, 
bitter, acid), suffices for what seems to be a cure. Indeed, 


no observer of large experience can deny that cases of ex- 


ceedingly mild and benignant syphilis are often untreated 
and exhibit no recurrence. 

The immense preponderance of cases, however, is on 
the other side of this slender border line of safety ; and 
the danger of such an expectant course, for most patients, 
is sufficiently grave almost to furnish the basis of serious 
charges of neglect and carelessness against the practi- 
tioner who habitually pursues it. 

Mercury is to-day, as for nearly four hundred years 
past, counted the most efficient of all drugs in the treat- 
ment of syphilis. It is given by the mouth in the form 
of the protiodide, biniodide, bichloride, calomel, gray 
powder, blue mass, or other combinations of the metal. 
The protiodide is deservedly popular with American phy- 
sicians, and may be given in one-fifth of a grain (centi- 
gram) granules, pellets, or disks. It is usual to begin 
with one after each meal, and to increase gradually till 
some constitutional effect is produced, such as looseness 
of the bowels, slightly increased flow of saliva, or moder- 
ate abdominal pain, after which the dose is reduced. 
Keyes suggests at this point a ‘‘ tonic” dose—one which 
can be tolerated for months at a time without inconven- 
ience, and reached by the reduction of the dose described 
above. For speedy effect, calomel is employed in doses 
of one-tenth of a grain (0.0066) every hour; and for 
slower effect, less often. It is well administered in pow- 
der rubbed up with sugar of milk. The mercurial pill 
has the advantage of being readily combined with iron, 
ase. g.'2 


Seth tl. NV CTAr eters een. c Dij. (2.66) 
Mass. Vallet (pil. ferri sub- 

CUD) un las SP CRN ETD ee. Dss. (0.66) 

PIV extrac’, 244 Sateen a gr. iv. (0.26) 


M. Ft. pil., No. xx. 


The dried ferric sulphate, quinine, ergotine, and aloes, 
may each, when indicated, be incorporated in these or 
similar pills. 


Sig.—One after meals. 


734 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


The bichloride is often best combined with iron in 
some such acid solution as: 


R. Hydrarg. bichlorid,. grs. i.-ij. (0.066-0.188) 


Weérri, tines. war. 
Acid. mur. dil... .a&3ij.-iv. (4.-16.) 
Syr. zingiber. (vel 

SAYZ#):... SP yee te: eu b 32.) 
AGUCESE Wants. ad f % vj. 192.) 


M. S8.—A. teaspoonful in a wineglassful of water after 
each meal. 


Solutions of the bichloride effected with the aid of alco- 
hol or with an equal quantity of the muriate of ammonium 
are also useful. 

The biniodide is usually administered by decomposing 
corrosive sublimate with the potassic iodide, and dissolv- 
ing the precipitate in an excess\of the same salt, ¢.g. - 


R. Hydrarg. bichlorid....... Nee 2b pd. UGG) 
Potass. iodid...... Decl oS Aaa 
AG: est... es acale oo eas sa eeell Lor 


M. §.—A teaspoonful in water after meals. 


The Gibert formula, modified variously by almost 
every author, is nearly as follows: 


R. Hydrarg. biniodid.......)... gr. j.( 0.06) 
Potass. iodid........ RO ren Se eR Gc BM, 
AAO sce See a he hen ke Hee, SS ge ea.) 

M. Filtra, deinde adde syrup, au- 

Tantccort. 7.io. see ee cise % vj. (192.) 


Combinations of mercury and the potassic iodide are 
employed chiefly in the so-called ‘‘ mixed ” treatment of 
syphilis ; in lesions that are transitional in type between 
secondary and tertiary stages ; and also in many precari- 
ous or rebellious symptoms in the earlier stages of the 
malady. Pills of the bichloride and biniodide are usually 
objectionable on account of their tendency to the produc- 
tion of irritative effects, but are in some cases given with 
great advantage. From one-sixteenth to one-fortieth of 
a grain of either (0.004 to 0.0016) may thus be administered | 
after meals. 

Mercury is of great service when applied by vapor in 
fumigation. This method is generally, in the larger cities 
of the country, relegated to the bath-houses, but by the 
aid of a chair, a blanket, and Lee’s or Maury’s lamp, it 
can be employed at the residence of any patient. From 
one to three drachms (4.-12.) of calomel, cinnabar, or the 
gray oxide, or two or more of them in combination, are 
used for the production of the vapor when placed on the 
metallic plate of the lamp. Steam is furnished by water - 
boiling in the chamber designed for that purpose, and the 
naked and sweating skin of the patient, wrapped in the 
blanket over the lamp, is thus subjected two or three 
times a week to the fumes of the mercury. 

The uncleanly, but very effective, method of introduc- 
ing mercury by inunction is popular abroad, but used in 
this country chiefly by experts, in hospitals, and at certain 
springs enjoying repute for the relief of this disorder. 
Equal parts of the twenty per cent. mercuric oleate and 
scented vaseline, or the ordinary mercurial ointment, may 
be used, one drachm (4.) or more being rubbed at night 
before retiring into different portions of the skin (select- — 
ing a new region each night), and removed by a bath in 
the morning. 

Hypodermatic injections of mercury in various forms 
are popular upon the Continent of Europe, but much less 
frequently employed in England and America. They 
are rapidly effective when used. They have been the 
subject of much favorable and adverse criticism, and 
even at this late hour are both praised and decried by 
leading syphilographers. They are subject to the disad- 
vantage of requiring a physician for the administration 
of each dose, and therefore more suited to hospital than 
to private practice. The following formule have been 
employed: Calomel, one and one-half to three grains 
(0.10 to 0.266), rabbed up with about twenty-four minims 
(1.50) of pure glycerine (Scarenzio) ; corrosive sublimate, 


4 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


four grains to the ounce (0.266 to 32.0) of distilled water ; 
fifteen minims (1.00) to be injected every two or three 
days (Lewin). These solutions have been modified by in- 
corporating with them one-tenth of a grain (0.0066) of the 
acetate or of the sulphate of morphine, to relieve pain; 
and the chloride of sodium, four parts to one of the bi- 
chloride, to render the solution less irritating. As these 
subcutaneous injections are liable to be followed by ab- 
scesses, attempts have been made in the direction of se- 
curing a soluble albuminate or peptonate of mercury, all 
of which have proved unsatisfactory. Solutions of the 
bicyanide, biniodide, nitrate, and formidate of mercury 
have also been recommended. None of these devices 
has yet rivalled in popularity the solutions of corrosive 
sublimate in distilled water. 

When mercury produces its happiest effects in syphilis, 
by any mode of administration, the symptoms diminish 
or disappear, and the patient actually gains in weight. 
This has led to conclusions respecting a so-called ‘‘ tonic” 
effect, which it is supposed by some authors to produce 
when properly administered. When improperly em- 
ployed, it is not responsible for many of the results popu- 
larly ascribed to its influence. These are chiefly syphi- 
litic symptoms of patients misinformed as to the nature 
of their disorder. The statistics collated by the physi- 
cians of the great Russian mercury mines, of disease ob- 
served among the workers in the metal, include none of 
the symptoms popularly ascribed to the influence of this 
metal in syphilitic patients—mouth patches, rheumatism, 
eruptive symptoms, etc. They are all in the direction of 
salivation, and, in grave cases, of maxillary necrosis. 
Tenderness of the gums, moderate fetor of the breath, 
slight increase in the salivary flow, noticeable indentation 
of the sides of the tongue by the teeth, and tumefaction 
of the mucous membrane—these are the first signs of a 
toxic effect which may increase, if the drug be further 
pushed, to the extreme of complete salivation, with loos- 
ening and even falling out of the teeth. In the modern 
treatment of syphilis no such effects are desired, or even 
attained. The milder of these manifestations readily 
disappear under appropriate therapy: tepid gargles of 
milk, flaxseed tea, or sweetened or demulcent water, 
containing one drachm (4.) of potassium chlorate to the 
_ pint (500.) of vehicle; a liquid and nutritious diet; ab- 
stinence from iced, alcoholic, spiced, acetous, and hot 
articles of food and drink ; suspension of the mercurial ; 
laxatives sufficient to secure complete evacuation of the 
bowels ; and often a tonic, not containing the mineral 
acids. 

Iodine and its compounds are useful in combination 
with mercury and without such union. They are more 
available in tertiary or late secondary symptoms, but 
may be often employed with the greatest advantage in 
the earliest symptoms of the disease. The articles of the 
class most used are iodine, iodoform, and the iodides of 
lithium, sodium, starch, and potassium. No one of these 
is equal in value to the iodide of potassium, or enjoys to 
the same degree the confidence of the profession. It 
may be given alone or with mercury by the mouth ; or it 
may be given by the mouth when mercury is employed 
by inunction or fumigation ; or it may be given in alter- 
nation with one or more of the courses named. * 

-It is always best administered in solution, from three 
grains to twenty (0.26 to 1.33) given in distilled water, 
milk, or any other vehicle preferred, such as cinnamon 
water, or one of the various syrups employed as vehicles 
by the druggist. The method of administering the iodide 
of potassium in largest dose, gradually reached, from one 
drachm to an ounce (4.0 to 382.00) in the twenty-four 
hours, has been fully described in the paragraphs de- 
voted to nervous syphilis. Employed with all due pre- 
cautions it furnishes one of the most brilliantly effective 
of the measures at hand in the grave emergencies of the 
disease. When its morbid effects are produced, these 
may become apparent after the exhibition of the smaller 
doses. Among them may be named severe coryza, with 
cedema of the lids, lips, and glottis; salivation ; gastro- 
intestinal distress and tenderness; and a series of cuta- 
neous eruptions. In the order of frequency the latter are 


Syphilis. 
Syphilis. 


acne-form papulo-pustules ; furuncular lesions ; purpura ; 
tubercles ; erythematous macules; bulle; and eczema- 
form patches. 

An enormous number of medicinal articles, beside 
those named, have been used in the treatment of syph- 
ilis. Some are indispensable in the management of most 
cases ; some have a doubtful effect ; many are absolutely 
worthless. In the first class may be named the ferru- 
ginous tonics ; the mineral acids (not to be given simul- 
taneously with a mercurial) ; cod-liver oil ; quinine and 
the vegetable bitters ; alcohol, judiciously administered ; 
and, in particular, the fluid extract of erythroxylon coca, 
first warmly recommended by Taylor in the management 
of syphilis, and fully endorsed by the author, who has 
employed it with advantage in many cases. In the sec- 
ond class may be named sarsaparilla (probably having 
no other than a purely ‘‘stomachic” value); the ‘‘ Mc- 
Dade formula” (equal parts of the fluid extracts of smi- 
lax, sarsaparilla, stillingia sylvatica, kappa minor, and 
phytolacca decandra, with one-half of one part of the tinct- 
ure of xanthoxylum carolinianum; and Zittman’s de- 
coction (probably efficient chiefly for the mercury it con- 
tains). In the last class may be named nitric acid, gold, 
thuya, cascara, berberis aquifolium, and the mass of 
proprietary preparations, many of which, though adver- 
tised as ‘‘ purely vegetable” compounds, depend for a 
short-lived popularity upon the mercury or iodine which 
they contain. None of the mineral springs, in this coun- 
try or abroad, which enjoy a reputation in the treatment 
of syphilis, supplies a water which can be demonstrated 
to possess a therapeutic value outside of the climatic, 
hygienic, and, indeed, medicinal effects obtained by resi- 
dence and treatment by physicians in the districts where 
such springs are found. ‘The waters of the well-known 
Hot Springs of Arkansas, in this country, have never 
yet been shown to possess any medicinal virtue ; and the 
number of svphilitic patients who annually resort thither 
and reap some advantage from such a course are, for the 
most part, those who have been treated there with mer- 
cury or the iodine compounds by their physicians. Even 
better results might have been obtained in localities more 
commended to the intelligent physician on the basis of 
sanitation. The so-called process of ‘‘ syphilization ” 
has not survived its brief period of notoriety. It was 
based upon a confusion respecting the nature of the 
syphilitic and the non-syphilitic sore, and is now not 
more than a curiosity in the literature of syphilis.. 

No limit can be set to the length of time which should 
be assigned for the treatment of the disease. The aver- 
age patient requires careful observation and treatment for 
from two to two and a half years. Many require this 
for a far longer period. Mild cases may require less. 
No guarantee of future immunity can be given any pa- 
tient on the conclusion of treatment, though probably 
seventy-five per cent. of them all have no symptoms of 
returning disease after the proper management of their 
cases by a competent physician. Two years at least 
should elapse after a mild syphilis before a patient of 
either sex should be permitted marriage with an unin- 
fected person. In any case, one year of immunity should 
certainly precede the marriage of an infected man or 
woman. Two years of immunity is required by some of 
the larger insurance companies before accepting life- 
risks of the infected. Syphilis, however, is, as a matter 
of fact, one of the most readily managed and promising 
of all diseases that affect the human race. ; As distin- 
guished from them all, its prognosis may be pronounced 
good. It may often disfigure, but it rarely destroys, its 
victims. As against the frequent fatality in pneumonia, 
variola, typhoid fever, or erysipelas, its statistics include 
an overwhelming preponderance of infected subjects in 
whose later years it figures only among those indelible 
reminiscences which teach the sternest lessons of life. 


LITERATURE. 


The literature of syphilis has accumulated to such an enormous extent 
that anything like a full bibliography, in the limits assigned to this arti- 
cle, would be impossible. Appended is a brief but selected list of titles, 
embracing a few of the older classics of syphilitic literature, a number of 
the modern standard treatises devoted to the subject, and some of the 


735 


Syphilis. 
Tar. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


more important and quite recent contributions to its several departments 
which have appeared in special and general periodicals: 


Astruc, John: A Treatise of the Venereal Disease. London, 1787. 

Althaus, J. : Medical Record, October 16, 1886 ; British Medical Journal, 
1883, p. 887 ; Lancet, December, 1883. 

Arthur, G.: New York Medical Record, December 16, 1886. 

Andronico: Giorn. Ital, d. Malatt. Vener. ed. Pelle, May, June, and 
August, 1886. 

Aubert: Lyon Médical, September 21, 1884, 

Armstrong: British Medical Journal, March 12, 1887. 

Aufrecht: Ctblt. f. Med. Wissen., No. 18, 1881. 

Buzzard, Thomas: Clinical Aspects of Syphilitic Nervous Affections, 
London, 1574. 

Butlin, H. F.: Diseases of the Tongue. Philadelphia, 1885, 

Behrend, G.: Die Hautkrankheiten. Braunschweig, 1879. 

Boerhaave, H.: De Lue Vener., 1762. 

Boeck, W.: Erfahrungen tiber Syph. Stuttgart, 1875. 

Barduzzi: Giorn, Ital. d. Malatt. Vener. e d. Pelle, p. 84, 1884. 

Bumstead, F. J. : Transactions International Medical Congress, Septem- 
ber, 1876. 

Bumstead and Taylor: Pathology and Treatment of Venereal Diseases, 
Philadelphia, 1883. 

Bulkley : New York Medical Journal, 1874. 

Barthélemy: Arch. gén. de Méd., May, 1884. 

Besnier, E.: Art. Spleen, Dict. Encyc. des Sc. Méd., 1874. 

Bassereau: Orig. dela Syph. Paris, 1873. 

Baumler: Ziemssen’s Cyclopeedia, vol. iii. New York, 1881. 

Brown, Lennox: British Medical Journal, 1881. 

Birsch-Hirschfeld : Arch. d. Heilkunde, February, 1875. 

Barlow: Transactions Pathological Society, London, 1875. 

Bronson : New York Medical Record, September 21, 1886; Art. Chancre, 
Reference Handbook of the Medical Sciences, Vol. Il. New York, 1886. 

Cornil, V.: Syphilis (Simes and White), Philadelphia, 1882; Lecons sur 
la Syph. Paris, 1879. 

Cooper, A.: Syph. and Pseudo-Syph. London, 1884, 

Carmichael, R.: Venereal Diseases, etc. London, 1825. 

Cohen: Diseases of the Throat. Philadelphia, 1879. 

Després, A.: Traité Théorique et Prat. dela Syph. Paris, 1873. 

Dujardin-Beaumetz: Note sur un Cas de Syph. Ulcer. Rapide. 
1879. 

Durkee, Silas: Treatise on Gonorrheea and Syphilis. Philadelphia, 1877. 

Dowse: Brain and its Diseases. London, 1879. 

Duplay : Prog. Méd., Paris, November 30, 1876. 

Dreschfeld: Rev. des Sci. Méd., 1883, C. xxi. 

Déjerine: Annal. de Derm., 1884. 

Diday et Doyon: Annal. de Derm., 1884, p. 152. 

Dron: Arch. gén, de Méd. Paris, 1863. 

De Paul: Bulletin Société Anatomique de Paris, 1852. 

Elsberg: American Journal of Syphilis and Dermatology, January, 
1874. 

Edson : New York Medical Record, March 26, 1887. 

Foote, J.: Observations upon New Opinions of John Hunter, London, 
1786. 

Finger, E.: Wien. Med. Arch., Nos. 28-34, 1884; Die Syph. und die 
Vener. Krankheiten, Wien, 1886. 

Ferrasi: La Sifilide Eredit. Pisa, 1877. 

Fracastoro, G.: La Sifilide. Parma, 1829. 

Furgusson ; Medical News, January, 1885. 

Fraenkel: Arch. f. Gyneek. Berlin, 1873. 

Fournier, 8,: Syphilis and Marriage, New York, 1881 ; La Syph. Hérédit., 
Tardive, Paris, 1875: Gazette Hebd. de Méd., Paris, 1886; Glossites 


Paris, 


Tertiaires, Paris, 1877; Ann. de Derm. et de Syph., 1874 (see transla- _ 


tion of paper on Tertiary Degen. Subling. Gland, made by the author, 
American Practitioner, 1874); Syph. de Cerveau. Paris, 1877; Annal. 
de Derm., 1885, p. 296 ; Nour. et Nourissons Syph., Union Méd., Nos. 
74-101, 1877. 

Guntz, J. H.: Die Chromwasser Behandlung der Syph. Leipzig, 1883; 
ene? f. Derm. u. Syph., 1876; Annales de Derm. et de Syph, t. iii., 

Prete et Walther: Art. Testicules, Nouveau Dictionnaire de Méd., 

§83. 

Gradle: American Journal of the Medical Sciences, p. 652, June 11, 1887. 

Gangolphe: London Medical Record, April, 1886. 

Goodwillie: New York Medical Journal, 1886. 

Hill, B. : Syphilis and Local Contagious Disorders. Philadelphia, 1869. 

Hutchinson, J.: British Medical Journal, November 12, 1887; Clin. 
Mem. on Certain Diseases of the Eye and Ear, Consequent on Inher- 
ited Syphilitic Disease. London, 1863; Ophthalmic Hospital Rep., 
vol. i., p. 227; Medical Journal and Gazette. London, 1875; Medical 
Press and Circular, April 30, 1884; Syphilis, London, 188%, 

Hutinel: Rev. Mens, de Méd. et de Chir., February, 1878. 

Hyde: American Journal of the Medical Sciences, January, 1874; Chi- 
cago Medical Journal, July, 1872: Archives of Dermatology, April, 
1878; Art. Syphilis, Supplement to Ziemssen’s Cyclopedia. New York, 
1881; Revision of Mr. Henry Lee’s Art. on Syphilis in Holmes’ System 
of Surgery. American Edition. Philadelphia, 1881. 

Jackson, H.: Hereditary Syphilis. London, 1878; Journal of Mental 
Science, January, 1875. 

Jullien, L.: Traité Prat. des Maladies Vénér., Paris, 1886. 

Keyes: American Journal of the Medical Sciences, January, 1876; Trans 
actions of the International Medical Congress, September, 1876; Vene- 
real Diseases. New York, 1880. 

Kobner: Arch. f. Path. Anat. Berlin, 1872. 

Kelsey, C. B.: New York Medical Record, December 4, 1886, 

Kassowitz: Die Vererb. der Syph., Vienna, 1876. 

Knapp: New York Medical Journal, p. 435, 1880. 

Koebner: Val. Therap. de Merc. Ann. Derm., 1885. 

Kaposi: Before the Fifth German Congress for Internal Medicine. Wies- 
baden, April 14-17, 1886. 

Lee, H.: Annal. Derm., p, 319, 1885; Lectures on Syphilis, etc. 
delphia, 1875, 

Lancereaux, E.: Traité Hist. et Prat. dela Syph. Paris, 1873. 


736 


Phila- 


ef E.: Vorlesung. tiber Path. und Therap. der Syph. Wiesbaden, 

886. 

Lesser, E.: Lehrbuch der Haut- und Geschlechtskrankheiten, 
1885. 

Leistikow: Charité Annal., vii., 1882. 

Lewin, George: Treatment of Syphilis with Subcutaneous Sublimate In- 
jections. Philadelphia, 1872; Berlin Klin, Woch., 1883. 

Lebert: Traité @’Anat. Path. Paris, 1878. 

Lacombe: Etude sur les Accidents Hépat. Paris, 1874. 

Morrow, P. A.: Venereal Memoranda. New York, 1885; New York 
Medical Record, March 5 and October 15, 1887; Drug Eruptions. New 
York, 1887. : 

Mackenzie: Medical News, May 17, 1884. 

Ne R. B.: Maryland Medical Journal, January 1, 1883, and May 
5, 1883. , 

Milner: British Medical Journal, February 26, 1887, 

McDonnell, Robert: Selections from the Works of Abraham Colles, Lon- 
don, 1881. ; 

Mireur, H.: La Syph, et la Prostit.. etc. Paris, 1875. 

Mansurrow, N.: Die Tertiare Syph. Gehirn., Geisteskrankheiten, und 
Deren Behandlung. Wien, 1877. 

Mauriac, C.: Lecons sur les Malad.\Vénér., Jour. de Méd., July, 1886; 
Mémoir sur les Affect. Syph. Préecoces. Paris, 1872. 

Marchiafava : Revista Clinica, No. 10} 1885. 

Madier-Champvermeil: Syph. Palm. et\Plant. Paris, 1874. 

Neumann: Ann. de Derm., p. 374, 1885, 

Nettleship: Syphilis of the Eye, etc. London, 1881. 

Neisser: Ziemssen’s Handbook, Heft i. eipzig, 1883, 

Owen: British Medical Journal, March 29, 1887. 

O'Reilly, J.: New York Medical Gazette, January 3, 1854, 

Otis, F. N.: Practical Clinical Lessons on Syphilis and the Genito-urinary 
Diseases. New York, 18883; New York\ Medical Monthly, May and 
June, 1886. 

Piffard and Fox: Cutaneous and Venereal Memoranda, New York, 1877, 

Peabody, G. L.: New York Medical Record, July 17, 1886. - 

Peiser, L.: Die Leber Syph. Leipzig, 1886, 

Pasteur: Lancet, January 1, 1887. san 

Porter, W. H.: New York Medical Record, March 12, 1887. 

Parrot: Arch. de Phys. Norm. et Path. Paris, 1872. . 

Pellizari: Ann. de Derm., p. 587, 1885. | 

Rollet. J.: Traité des Maladies Vénériennes. Paris, 1866; Wien. Med. 
Presse, 47, 1875; Anc. Foyers de Syph. Paris, 1877, 

Siréday : London Medical Record, 1885. 

Sexton, S.: American Journal of the Medical Sciences, July, 1879. 

Semon, F.: Pathological Society’s Transactions, v., xxxi. 

Seguin : New York Medical Journal, June 28, 1884. 

Sturgis: Chicago Medical Journal and Examiner, June, 1876; Boston 
Medical and Surgical Journal, June 3, 1880; Students’ Manual of Ve- 
nereal Diseases. New York, 1880. 

Sée, G.: Mal. Spéc. des Poum. Paris, 1884. 

Taylor, R. W.: Syphilitic Lesions of the Osseous System, etc. New 
York, 1875; Journal of Cutaneous and Venereal Diseases, October 1, 
1883; American Journal of Syphilis and Dermatology, January, 1871. 

Vidal, A.: Treatise on Venereal Diseases. New York, 1865; Bull. Gén. 
de Thérap., November 30, 1888. 

Van Harlingen: American Journal of the Medical Sciences, April 1880. 

Van Buren and Keyes: Genito-urinary Diseases with Syphilis. New 
York, 1874. 

Verneuil: Cliniq. la Pitié, 1887. 

Videlet: Syph. Inf. Paris, 1874. 

Wegner: Arch. f. Path. Anat. Berlin, 1870. 

Warner: British Medical Journal, April 30, 1887. 

Wecker and Landolt: Tr. Compl. d’Ophth., 1884. 

Zeissl, H.: Lehrbuch der Syph., etc. Stuttgart, 1875; Viertl. f. Derm. 
u. Syph., Heft ii. Wien, 1876. 

Zeine: Ctblt. f. Klin, Med., January 16, 1885. 


James Nevins Hyde. 


Leipzig, 


SZCZAWNICA, though little known in other coun- 
tries, is one of the most frequented and popular spas in 
Austrian Poland. It is situated in a pleasant hill-coun- 
try, lying at an elevation variously estimated at from 
1,100 to 1,700 feet above the sea. The climate is mild 
and agreeable. There are six mineral springs here, with 
a temperature of from 48° to 52° F., of which the Mag- 
dalenenquelle is the richest in mineral ingredients. The 
following is the analysis of this spring, as given by Kisch 
in Eulenberg’s ‘‘ Real-Encyclopadie.” One litre of water 
contains : 


Grammes, 
Sodium Picarbonater: seen sone Lie ween eee ects mec 8.447 
Sodium chicride BS Wee oc tire chia ae ene ee ae 4,615 
Sodium)sualphate! t..4 22 arenes tee eee ean ete 0.022 
Magnesitim (bicarbonate s,s gees ee eiclee oaeeneeete 0.786 
Oalcium) ‘bicarbonate oN. et dee eh cies cement eien 0.874 
Ferrous bicarbonate: (24 lees lene neneboenen ie ae 0.010 
Potassinmichlorides. snes oeeee eee abies 0.091 
Sodium: iodides (58.0 7 en es ates ee 0.0016 
Sodium: bromides ic. setts sateen hee canes 0.0085 
Orgatiic matters;ete. ti O20 ae dee see ca ee i eee 0.2949 
Motel asker sorts are sated ety ost athe sate ES 15.1500 
- Cub. ctm. 
Pree Carbonic: acid. a teccsnee ounitese « aeeeae anes 711.5 


The waters are given internally and in the form of 
baths, and milk and whey are also extensively em. 
ployed. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Szezawnica enjoys a high reputation in the treatment 
of subacute and chronic catarrhs of the respiratory pas- 
sages, chronic pneumonia, pleurisy, incipient phthisis, 
and catarrhal gastritis. It is also frequented to some ex- 
tent by those suffering from the so-called scrofulous af- 
fections of the joints, glands, and skin. The accommo- 
dations for visitors are said to be good, and obtainable at 
a moderate price. Tai: 


TAMARIND (Tamarindus, U. 8. Ph., Br. Ph.; Pulpa 
Tamarindorum Cruda, Ph. G.; Tamarinier, Codex Med.). 
The preserved pulp of the fruit of Tamarindus Indica 
Linn. ; Order, Leguminose Cesalpiniew. The tamarind 
is a large, handsome, widely spreading, locust-like tree, 
with rough, dark-gray bark, and rather small, cassia-like, 
abruptly pinnate leaves of from eight to sixteen pairs 
of oblong-blunt, oblique leaflets. Flowers, in axillary or 
terminal racemes of eight or ten each. Calyx irregular, 


Fra. 3749.—Tamarindus Indica ; flowering branch with fruit. (Baillon. ) 


of four lobes, the upper larger than the others, and col- 
ored. Petals three, the upper one smallest, yellow, veined 
with red. Stamens three, united below. Ovary one, 
curved upward, one-celled, many ovuled. The fruit is a 
flattened, curved, solid ‘‘ pod,” from three to six or more 
inches long; smooth, yellowish-brown externally, with 
a brittle shell, and a firm acid pulp surrounding the 
seeds. The pulp contains a skeleton of fibrous bundles 
running lengthwise over the seeds. The tamarind-tree 
grows now in all tropical countries, and is, besides, ex- 
tensively cultivated. It came originally from the Old 
World, presumably from Africa, but is equally abundant 
in India, Australia, and the West Indies. The earliest 
knowledge of tamarinds appears to,come from India. 
They were introduced into Europe during the middle 
ages. 

CoLLECTION.— When the fruits are ripe, the outer shell 
(epicarp) becomes brittle, and is broken between the fin- 
gers and removed. The stringy pulp is then packed in 
kegs and covered with boiling syrup. In this way the 
West Indian tamarinds, which comprise most of those 


Vou, VI.—47 


Syphilis. 
Tar. 


that reach our market, are prepared. In the East, sugar 
is often used instead of syrup, or they may be packed 
dry, without any sweetening, in a hard, semisolid mass. 
The seeds are always included. 

Preserved tamarinds, as they reach us, are in a moist, 
reddish-brown, pulpy, stringy mass, with numerous 
flattish-quadrangular, smooth seeds, and a little thick, 
dark syrup. They have a pleasantly sourish-sweet taste. 
Mixed with water they make a pleasant acid drink, which 
was formerly used in fevers and other forms of sickness. 
They are very little employed at present. 

Composition.—Cttric acid, eight or nine per cent., is 
the most important substance. One and a half per cent. 
of tartaric acid, a little malic acid, and, say, three per 
cent. of potassium bitartrate, are adjuvants to the former, 
and add to the acidity of the fruit. Gum, jelly, and ordi- 
nary vegetable matters, and in our preserved tamarinds 
the sugar that is added, complete the list of ingredients. 

Usres.—Tamarinds are rather an agreeable luxury than 
medicine, and in some countries are consumed extensively 
as a preserve. Here they are used to make a refreshing 
acid drink, or as an adjuvant to some laxative compound. 
The Confection of Senna (Confectio Senne, U. 8. Ph.) 
contains ten per cent. of them. Dose of tamarinds in- 
definite. 

ALLIED PLANTS.—This is the only plant in the Genus. 
For the Order see SENNA. 

ALLIED Druaes. — Lemons, 
Prunes, and other fruits. 


Barberries, Sumach, 
W. P. Bolles. 


TANSY (Zanacetum, U. 8. Ph.; Tanasie, Codex Med.),. 
Tanacetum Vulgare Linn. (Chrysanthemum Tanacetum 
Karsch), Order, Composite, is a well-known garden plant 
and weed, introduced from Europe and thoroughly nat- 
uralized. It has a characteristic, rather agreeable and re- 
freshing odor, and a very bitter taste. It contains about 
one per cent. of a peculiar essential oil of a greenish-yel- 
low color, bitter, burning taste, and sp. gr. 0.92, an amor- 
phous hygroscopic, bitter substance, tanacetin, soluble 
in alcohol and water but not in ether, and malic (tanace- 
tic) acid. Tansy and its oil belong to the more poison- 
ous group of aromatics (camphor, cedar, juniper, turpen- 
tine, etc.), producing in large doses vomiting, convulsions, 
coma, etc., and death. Half anounce, and even adrachm, 
of the oil have proved fatal. It is rather frequently 
taken by women for menstrual irregularities and to pro- 
duce abortion, which latter, however, it seldom accom- 
plishes. It may be given for same purposes as camphor 
and turpentine, but has little practical value. 

ALLIED PLANTS, ETC.—See CHAMOMILE. 

W. P. Bolles, 


TAPIOCA (Zapioka, Codex Med.). The starch of Mani- 
hot Utilissima Pohl. (Jatropha Manihot Willd.), Order, 
Huphorbiacee, the cassava or manioc plant of the West 
Indies, a native of Brazil, but cultivated as a food-plant in 
many parts of tropical America. It is a perennial, grow- 
ing several feet high, with three-, five-, or seven-lobed, pal- 
mate leaves, and very large tuberous roots. These latter, 
which are the edible part, are loaded with starch. When 
fresh, some varieties, ‘‘ bitter cassava,” contain a bitter, 
poisonous juice (prussic acid) which is dissipated by 
washing, expression, drying, cooking, etc. The pulp, 
ground fine, pressed and dried, and then pulverized, forms 
cassava meal, which is made into cakes and eaten ; the 
starch washed and dried over a fire, stirred so as to 
agglutinate into irregular, partly cooked lumps, is the 
tapioca of commerce. The uncooked starch, like arrow- 
root in appearance, sometimes called ‘‘ Brazilian arrow- 
root,” occasionally reaches us. 

Tapioca is simply an amylaceous food and has no me- 
dicinal properties. For the starches in general and a 
picture of Tapioca-granules, see STARCH. 

W. P. Bolles. 


TAR. Tar is a well-known product of destructive dis- 
tillation of the wood of coniferous trees. It is a pecul- 
iarly sticky, semisolid body, nearly black in color, and 
of a characteristic empyreumatic odor and taste. It is 


737 


Tar. 
Taste. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


of acid reaction and very complex composition. By dis- 
tillation it separates into three portions: one, the acid 
fluid known as pyroligneous acid ; One, an empyreumatic 
oil, called oz/ of tar ; and the third, the familiar substance 
pitch. Pyroligneous acid contains as its main ingredient 
acetic acid; the oil of tar is made up of a considerable 
number of bodies—hydrocarbons—including benzene, to- 
luené, xylene, naphthalene, pyrene, chrysene, retene, and 
paraffins ; phenols, including phenol (carbolic acid), ere- 
sol, guaiacol, creasol, phlorol, methylcresol, and pyrocate- 
chin, besides resins and other substances. Pitch consists 
essentially of the resinous ingredients of the wood. Tar 
dissolves in alcohol, ether, fixed and volatile oils, and in 
solutions of potassa or of soda. Water dissolves a small 
proportion only of the constituents of tar. 

Tar partakes of the general medicinal properties of the 
aromatic hydrocarbons and phenols. It is inhibitory of 
bacterial growth, is locally mildly irritant and healing, 
and of a tendency to repress catarrh, and, taken inter- 
nally, may possibly exert a feeble anti-catarrhal influerice 
through transportation by the blood to the affected spot. 
Tar has been used locally as an application in skin-dis- 
ease ; and, internally, for the relief of catarrhs and uri- 
nary affections. It is very much less used now than 
formerly, its strong odor and taste being objectionable 
features. Tar is officinal in the United States Pharma- 
copeia under the title Piz Liquida, Tar. For internal 
administration an officinal syrwp of tar is convenient. 
For the making of this syrup a portion of tar is first 
washed with cold water, to remove the irritating acid in- 
gredients, and is then treated with boiling distilled water. 
To the resulting solution, filtered, sugar is then added. 
This syrup may be administered in teaspoonful doses or 
more. A tar ointment is also an officinal preparation 
of the United States Pharmacopceia, consisting of equal 
parts of tar and suet, mutually incorporated into a homo- 
geneous mixture by effecting the mixing with the suet 
liquefied by gentle heat. This ointment furnishes a con- 
venient means of making local applications of tar to the 
skin in cases of skin-disease. Edward Curtis. 


TARASP, called also Tarasp-Schuls and Tarasp-Nairs, 
is an Alpine health-resort of growing popularity, lying 
in the Valley of the Inn, in the Lower Engadine, Canton 
Grisons (Graubiindten), Switzerland. It lies at an eleva- 
tion of about 4,000 feet above the level of the sea, and the 
climate is consequently cool, though not so cold as might 
be expected from the elevation, as the place is well pro- 
tected against the north winds. There are several min- 
eral springs here, of which the best known is the Lucius- 


quelle. The following is the analysis of this water, 
according to Huseman. Lach litre contains: 
Grammes. 
Bocdiemybromide eens — fee oe cee eee 0.0212 
OMIM OAIMS Se Liaise aie ete sean RE eee 0.0008 
Bogitimychi@ride (ick cae Gort esi kOe 0 on eee dae 3.6740 
Hithianyehloriderwes wwe red yoked wee ee aa eas 0.0630 
Potassiuimisniphate te satin cs sco cick oan 0.38797 
Sodinmersulptiatemere ct ehiekk lacscuc eee nee 2.1004 
SOdimM DOravene eistec ta ee ettnre hack ea Aeiecite Meee 0.1722 
Bodininwnitrater (ere. wee nbs. Ne gt eee ey eee 0.0008 
DOCU DicaLVOnalemacep scams manta ciecede cea oem 4.8788 
Marnesium bicarbonate i. 22. sens cece dele anee 0.9797 
AmMmoniumebicarbouate ys LCase Ae ess on Ee 0.0661 
Calcium bicarbonate tice elas s inne: she cans aero aon 
Strontium picarbonater ate ee oe eee ee eee 0.0007 
Manganese ‘bicarbonate waevc. coeue sss clee loan uehe 0.0008 
Merrousbicarbonabelene meets ee eae ko eee 0.0215 
EHOSphOrIC AiG cea Ae oe eres desis Go rast ieemee 0.0004 
MUICIGACIG ere tee hac CR Nee cance icuue oe nahh 0.0090 
Clay ee. Wo aes are Mee Ra ICR Ae reacted 0.0002 . 
TLOUCL sc6be 3 Wien trad test Cee reat CR choke Sev chor emiola 14,7585 


There is a large amount of free carbonic-acid gas. 


A second spring, the Emeritaquelle, is very similar to 
this in composition, but is less highly charged with car- 
bonic acid. 

The Ursus- and the Badequelle are also similar, but 
weaker in mineral constituents. These waters, used in- 
ternally and in baths, are recommended in the treatment 
of catarrhal troubles of the digestive organs, hepatic dis- 
orders, gall-stones, obesity, and all congestive affections 
of the abdominal organs. * 


738 


The Bonifacius-, Carola-, and Wyquelle are the cha- 
lybeate springs at Tarasp, the former containing about 
double the proportion of ferrous carbonate that is found 
in the Luciusquelle. They all contain a large amount of 
free carbonic-acid gas. These waters are used in the 
treatment of anemia, debility, nervous disorders, and 
other conditions, in which a chalybeate tonic is indicated. 

The season extends from the middle of June to the 
middle of September. The accommodations for guests 
are said to be good. TPL 


TARTARIC ACID. Tartaric acid, H2C.H,Og, takes its 
name from the substance which is its commercial source, 
namely, the material tartar that forms as an incrustation 
on the inside of wine-casks. ‘Tartar is substantially an 
impure acid potassic tartrate, which salt by decomposi- 
tion furnishes free tartaric acid. The acid is officinal in 
the U. 8. Pharmacopeceia under the title Actdum Tartar- 
tcum, Tartaric Acid, and is described as ‘‘ nearly or en- 
tirely colorless, transparent, monoclinic prisms, perma- 
nent in the air, odorless, having a purely acid taste and an 
acid reaction. Soluble in 0.7 part of water, and in 2.5 
parts of boiling alcohol at 15° C. (59° F.); in 0.5 part of 
boiling water and in 0.2 part of boiling alcohol ; also sol- 
uble in 86 parts of absolute alcohol, in 23 parts of ether, 
and in 250 parts of absolute ether, and nearly insoluble 
in chloroform, benzol and benzin. When heated for 
two hours at 100° C. (212° F.), the crystals do not lose 
more than a trace in weight. On ignition, they should 
not leave more than 0.05 per cent. of ash” (U. 8. Ph.). 
Tartaric acid is most often met with in the shops in the 
form of a white powder, tending more or less to cake 
into lumps. 

Tartaric acid is a pleasantly flavored, sour, so-called 
organic acid, and in considerable quantity in strong solu- 
tion is sufficiently irritating to cause dangerous and even 
fatal irritant poisoning. Several cases of death by tar- 
taric-acid poisoning are on record, and in one of these 
half an ounce of the acid was the fatal dose. Tartaric 
acid being cheaper than citric, is often used as a substi- 
tute for that acid in the making of artificial lemonade. 
A six per cent. aqueous solution of tartaric acid may be 
regarded as the equivalent, in acid strength, of good 
lemon-juice, and a tablespoonful of such a solution may 
be used, like lemon-juice, by dilution with sweetened 
water for the making of an acid draught. A drop or 
two of essential oil of lemon, triturated with the dry acid 
before solution, improves the flavor of the draught. 
Tartaric acid is the acid used in the officinal formule of 
the U. S. Pharmacopeceia for the making of effervescent 
preparations. Hdward Curtis. 


TASTE, THE SENSE OF. The chief organ of the 
sense of taste is the mucous membrane of the dorsum of 
the tongue, although, to a less extent, that covering the 
soft palate, the uvula, and the velum palati is capable of 
receiving gustatory impressions. 

The special nerves presiding over the sense of taste are 
the glosso-pharyngeus for the posterior third, and a 
branch of the chorda tympani for the anterior two-thirds 
of the tongue. The nerves of common ard tactile sen- 
sation are the glosso-pharyngeal for the posterior, and 
the lingual branch of the fifth for the anterior two- 
thirds. : 

However, this point is far from being definitely set- 
tled, some physiologists claiming that the lingual branch 
of the trigeminus, instead of the chorda tympani, is the 
gustatory nerve; others, that the only nerve of taste in 
the tongue is the glosso-pharyngeus, with which the spe- 
cific nerves of gustation in the anterior two-thirds, after 
a circuitous route, ultimately unite. 

The weight of evidence, both pathological and experi- 
mental, seems to be on the side of those who consider 
the chorda tympani and the glosso-pharyngeus as special 
nerves. 

That the fibres of the chorda tympani terminate in 
the mucous membrane of the tongue is unquestionably a 
fact, since, as Vulpian has proved, degenerated nerve- 
fibres are found in this region after cutting that nerve. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Tar. 
Taste, 


eee 


The dorsum of the tongue is covered with stratified 
epithelium and beset with a number of papille of various 
forms and sizes, richly endowed with vessels and nerves. 
These papillae are known as the filiform, fungiform, and 
cireumvallate papille. 

The filiform papille are principally found in the an- 
terior two-thirds of the tongue. They are slender ex- 
crescences of the mucous membrane, slightly recurved 
and beset with epithelia, somewhat after the fashion of 
inverted ears of wheat. In the feline tribe these epithelia 
undergo cornification, which enables the animals to use 
the tongue as a rasp for the separation 
of the flesh from the bone. : 

Probably they are not concerned in . 
taste, but simply serve the purpose of 
common sensation, 

The fungiform papille, from one 
hundred and fifty to two hundred in 
number, are round, knob-like expan- 
sions of mucous membrane, set on short, 
thick pedicles. They consist of a num- 
ber of single papille and are distributed 
all over the tongue. 

The circumvallate papille, numbering yg. 3750.—Isolated 
about nine or ten in man, are arranged  Cover-cells, from 
in a V-shaped manner at the base of the a Leave of 
tongue. They are elevations of the Grol see y's 
lingual mucous membrane, bearing on 
their flattened top numerous stunted papillee, and are sur- 
rounded by a rim, a narrow deep fossa intervening. 

Between the epithelia covering the slopes of the cir- 
cumvallate papille and those of the inside of the circular 
ridge, occasionally also on the fungiform papille, pe- 
culiarly shaped flask-like bodies are met with, the taste- 
goblets, or taste-buds, so called from their forms. There 
are many reasons for looking upon these as being the 
terminal apparatus of the nerves of taste, notwithstand- 
ing that they have also been found on the posterior sur- 
face of the epiglottis, which certainly is not concerned 
in-gustation. ‘They are more numerous on the slope of 
the papilla than on that of the rim, and sit with a broad, 
rounded extremity on the limiting membrane. They 
consist of two kinds of cells—the outer, which are fusi- 
form and joined together after the fashion of the leaves 
of a bud, and the inner, about four or five in number, 
which are long, slender cells, terminating at both ends 
in long protoplasmic rods, and containing in their centre 
_a large, shining nucleus. They project slightly through 
an opening of the investing cells, the gustatory pore. 

Although their connection with nerve-filaments has 


Fia. 3751,—a, Isolated taste-cells, from the lateral organs of the rabbit; 
b, a taste-cell and two cover-cells, isolated in a connected condition, 
from the same source. >< 600. (From Stricker.) 


never been clearly made out, it is highly probable that 
they are analogous to the similarly shaped cells con- 
cerned in olfaction, to the rods and cones of the retina, 
etc. ’ 

At the bottom of the fossa open a number of convo- 
luted tubular glands, secreting a serous fluid during gus- 
tation. The object of this secretion seems to be partly 
to dissolve the sapid substances, partly to wash them 
away after having been tasted, and thus prepare the ter- 
minals for fresh gustatory impressions, 

The glosso-pharyngeal nerve-fibres serving common 
tactile sensation terminate after the fashion of the nerves 


of the epithelial layers of the cornea and skin; 7.e., they 
end by minute knobs in the cement substance of the 
epithelia. This manner of nerve termination obtains 
also in the anterior two-thirds of the tongue, where no 
special tasting orgahs are found, and where the nerve- 
fibres of special sensation terminate, like those of common 
sensation, between the epithelial cells. 

Unlike the olfactory sensations, which cannot be classi- 
fied, the various kinds of taste are generally divided into 


Fie, 3752.—Longitudinal Section of a Taste-bud. yp, Gustatory pore; s, 
taste-cell ; 7, supporting cell; m, migratory cell, containing fat gran- 
ules; é, epithelial cells; 7, afferent nerve. (From Ranvier.) 


salt, sweet, sour, and bitter. These qualities of taste 
correspond in general to certain chemical groups; thus 
the salt taste is peculiar to the neutral soluble salts of the 
alkalies; the sweet, to the polf-atomic alcohols (glyce- 
rine, grape-sugar, etc.), which have, as a rule, a sweet 
ee the sour to the acids; and the bitter to the alka- 
oids. 

There are an infinite variety and an unlimited number 
of shades of these four fundamental tastes, but the nicer 
distinctions, in what is generally called the taste of dif- 
ferent substances, are made out by olfaction rather than 


ay 


Les ; 
eH 
eS ey 


YEE 


SSeS 


Diy 
BiG 
~ es 


Se 


ot 


yr 4h for ANAL Wie Se: 
Beye y ales GH } Mi pas ; eA id 
bY, WD PA 9A ACS Be } fai aa 
hie) 


ROI: Ake 
EN TG, 


AM Lepr ai?” 


wh Zoomarch: of ig WL 


Fic. 3753.—Longitudinal Section of Papille Foliate of the Rabit. p, 
Central vascular tuft ; v’ transverse section of the central vein of the 
papilla; p’, nervous tuft or papilla; g, taste-bud; n, », sections of 
afferent nerves; @, serous gland. (From Ranvier.) 


by gustation. Every substance which has a taste has 
also a flavor. . 

The dorsal surface of the tongue does not perceive all 
the fundamental tastes equally well in all its parts. The 
sweet is best tasted with the tip, the sour at the edges, 
the bitter on the posterior third of the tongue. A cat 
whose glosso-pharyngeal nerves have been cut is said to 
drink without reluctance milk containg quinine. 


739 


Taste. 
Teeth. 


Water and alcohol are tasted equally in every part of 
the dorsal mucous membrane ; possibly these fluids give 
rise only to general sensations, and are not perceived by 
the special nerves. 

The intensity of taste depends on the area to which the 
sapid substance is applied, on the degree of concentration, 
and on the temperature. The taste is best perceived of 
substances registering about 95° F. The interval between 
the application and the perception of the several sapid 
substances differs considerably ; salt is tasted the most 
quickly. 

In the same manner as colors become more dull when 
gazed at intently, and as odorous substances (perfumes or 
flowers, for instance) when smelled too long are no longer 
perceived, or may even give rise to disagreeable sensa- 
tions, so the same food, especially when very savory, 
tasted continually, will exhaust the gustatory apparatus, 
and become insipid, or even distasteful. 

It is not exclusively the sapid substances that give rise 
to gustatory sensations ; a smart tap on the tongue with 
a small instrument (a lead-pencil or piece of whalebone, 
for instance) will produce a taste which is not, however, 
very definite, and is differently classified by different in- 
dividuals. A fine current of air striking the tongue gives 
the impression of salt ; the continuous electrical current, 
that of an alkali. The interrupted current does not pro- 
duce any particular taste. I have found, however, that 
there are many individual variations in this matter. 
Thus, some persons distinguish between a bitter, metal- 
lic taste at the anode, and an acid one at the cathode. 

The senses of touch and of temperature, which are very 
acute in the tongue, especially at the tip and on the edges, 
enable that organ to execute the many delicate and com- 
plicated movements which form part of its functions. 

Hallucinations of taste are, like those of smell, of not 
unfrequent occurrence in the nervous and insane. The 
ideas of poisoning in the latter are probably always as- 
sociated with such hallucinations. They depend on irri- 
tation and perverted function of the psychogenic centre, 
which lies in close proximity to the olfactory centre. 

L. Bremer. 


TATE EPSOM SPRING. Location and Post-office, 
Tate Spring, Grainger County, Tenn. 

AccEess.—To Morristown by the East Tennessee, Vir- 
ginia & Georgia Railroad, thence by carriage, ten miles, 
to the spring. 

ANALYSIS.—One pint contains : 


Grains. 

Carbonate ofdime,).dc 2! beau eo ee eee 2.695 
Chiorideyofi sodium nc. 26 e- seecaeae nee 5.033 
Chioridevof ironeys Male 2 cde see ee ce 0.365 
Chioride.ciimanganese’, ». 2. Sogo Cree 0.086 
Sulphate or poteassitim ©...) ic, een ana ee ee 0.192 
Sulphate Gl sod & eee. Jot ae cee eies emer te 1.062 
SU MABiOl MA PNERIIM es Ey. pee eee ee 8.996 
SULPHALEIOn TIME wee te ciek ene cing oe en 20.082 
Ehosphaterotsiime: chrks tee cae seo cn ee 0.142 
Lopide OMsSOdIUMI Te neem as sce cel aan Rene ae traces 
SILICA ha ere eek oer ne eee ea eee es cee eee ee 0.387 
UNELIIC GCIOUASE AP Been eenier rota sy. oe nl ame cued eae 0.002 
TOLLE TR tioetE ete a hre Ne cs ce he eke hs ae oee 33 .992 


THERAPEUTIC PROPERTIES.—This is a very valuable 
calcic water, containing sufficient carbonic acid gas to 
render it very agreeable to the eye and to the taste. It 
is used with success as an alterative. 

The spring is located in Beau Station Valley, at the 
southern base of Clinch Mountain, in the northeastern 
portion of Tennessee, at an altitude of 1,400 feet. The 
fact that it is situated amid the Cumberland and Alle- 
ghany Mountains insures grand scenery and pure air. 
The surrounding country affords fine hunting and fish- 
ing. ‘The hotel and cottages are surrounded by a well- 
shaded lawn. Gai Bai 


TATTOOING OF THE CORNEA. It has long been 
known that living animal tissues could be permanently 
colored by introducing into their substance finely pow- 
dered material, non-irritating in its character, that was 
itself insoluble or was capable of entering into insoluble 
composition with the tissues themselves. 


740 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Apart from purposes of savage decoration and the 
marking of criminals and prisoners for identification, 
this knowledge has not been particularly useful to the 
human race until a very recent date, when De Wecker, of 
Paris, gave it its recognized place among the expedients 
of ophthalmic surgery for the covering up of deformi- 
ties, and occasionally for the improvement of the optical 
condition of the eye. 

It was De Wecker’s original intention merely to con- 
ceal or to render inconspicuous the unsightly scars, leuco- 
mata cornee, that, when left on the cornea, as the result 
of injury or ulceration, are especially noticeable on ac- 
count of their brilliant white appearance in the place 
where the darker coloring of the pupil and iris is gen- 
erally seen, and where it often remains in sufficient 
amount to heighten by contrast the effects of the injury. 

Several successful operations of this sort having been 
done, it was noticed that in some there was an improve- 
ment in vision as well asin personal appearance. This 
improvement, it was. supposed, was caused in part by 
the narrowing of available pupillary area, and in part by 
the cutting off of that portion of the light which passed 
into the eye through the bright but irregular scar, thus 
having in some measure the optical effect of a stenopaic 
slit. 

From these facts De Wecker was led to prophesy for 
tattooing a more brilliant future than it has since realized, 
and to think that it might come to be a supplementary 


operation to those cataract-extractions in which an iri- 


dectomy had produced a pupil too large for the best opti- 
cal effects. The operation is seldom undertaken, how- 
ever, except for cosmetic effect, and when done for that 
purpose it occasionally gives very gratifying results. 

The substance most frequently used is India ink. 
That of the best quality should be selected. It is com-. 
posed of fine lampblack united with a small amount of 
glue, so that the particles will be held in suspension by 
the water, which is ordinarily used as amenstruum. Mr. 
Charles Bell Taylor, of London, in order to obtain the 
deepest coloring, employed a mixture of India ink, fine 
lampblack, and nitrate of silver, and used sepia or ultra- 
marine when the color of the iris made it desirable. 

De Wecker operated with a lance-shaped knife having 
a groove on one side to hold the ink, which was made 
into a thick solution by the addition of water. From 
five to ten punctures were made at one time by push- 
ing the knife obliquely into the superficial layers of 
the opaque cornea. These punctures were made as 
near together as possible, and it was sometimes neces- 
sary to repeat the operation five or six times before 
the desired result could be obtained. Later, mul- 
tiple punctures were made by the use of seven needles 
held together in one bundle. There is not so much 
advantage in the use of the bundle of needles as would 
at first appear. It takes, of course, seven times the 
impact to penetrate the tissues with seven needles as 
with one, and thus more violence is done, while the 
punctures are more likely to,be made in a perpendicular 
direction than when a single instrument is used. Prob- 
ably as good an instrument as any for practical use is a 
fine steel writing pen, the point of which has been sharp- 
ened on an Arkansas stone. 

To perform the operation the eye should be held open 
with a speculum and steadied with fixation forceps. 
Some absorbent, like cotton or sponge, should be held in 
contact with the lid or the periphery of the globe to 
drain away the tears as they are formed, so that they 


‘shall not wash away the coloring matter as fast as it is 


applied. It has been found best to work from above 
downward, so that the overflow of pigment shall not 
obscure the work as it progresses. The effect of the 
operation is probably increased by rubbing the pigment 
over the corneal surface with the end of the finger, so 
that it shall be well packed into the punctures made by 
the instrument. When the operation is complete the 
eye should be allowed to dry for a few minutes before 
the speculum is removed and the tattooed surface ex- 
posed to the action of the tears and lids. 

The reaction after this operation is usually very slight, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Taste. 
Teeth. 


and the improvement in the appearance is often remark- 
able ; still, it is necessary to remember that many eyes in 
which the cosmetic effects of tattooing would be desir- 
able are such as will not admit of any unnecessary dis- 
turbance, however slight ; and where synechie exist that 
have proved themselves to be a source of continued dis- 
turbance, or where an irido-cyclitis, a glaucoma, or other 
destructive process has been going on, this operation is 
hardly advisable. W. S. Dennett. 


TAYUYA. The root of Dermophylla pendulina, a Bra- 
zilian drug introduced a few years ago as a remedy in 
syphilis, scrofula, etc., has not taken any hold in prac- 
tice in this country, and is probably without value, at 
least for the purposes named. It appears to be emetic and 
cathartic, having properties similar to bryony and 
other drastic cucurditacew. From three to six drops of 


a ten per cent. tincture is said to be the dose. 
W. P. Bolles. 


TEETH. Dentat Anatomy. — The 
teeth are commonly divided into two sets, 
according to the period of their eruption. 
The teeth which erupt first are variously 
designated as the deciduous, the temporary, 
the milk, or the primary teeth. The teeth 
erupting subsequently to the first set are 
called the permanent or secondary teeth. 
In addition to these there are supernume- 
rary teeth, which usually occur in connec- 
tion with the permanent, but may, in rare 
instances, be found with the temporary 
teeth ; and there are so-called third denti- 
tions, the genuineness of which, though 
fairly well established, is not without question. 

' The permanent teeth are thirty-two in number, sixteen 
being placed in the upper, and sixteen in the lower, jaw. 
In each jaw there are four incisors (two central and two 
lateral), two canines, four bicuspids, and six molars. 

A formula to express the number of the various teeth 
in each jaw is written as follows: I 4, C 3, Bic. 4, molars 
Baa Be: 

The teeth of the upper jaw are symmetrically arranged 
along the alveolar margin of the superior maxillary 
bones. When viewed from below, their crowns are found 
to describe a parabolic curve. This curve, however, va- 


Fia. 3754.—The Permanent Teeth, natural size, showing their method 
of arrangement and articulation. (Carabelli.) 


ries according to nationality, heredity, and accidental 
circumstances. The teeth of the lower jaw are arranged 
along the alveolar margin of the inferior maxillary bone, 
and their crowns describe a curve similar to that found 
in the upper jaw. This curve, however, is more pointed 
in front and more divergent behind. Speaking roughly, 


) Stenger 


the masticating surfaces of the teeth of each jaw le in a 
single plane, no crown projecting in a marked way be- 
yond its neighbor. The teeth, also, when normally ar- 
ranged, show no gap in the row, each tooth thus by its 
position giving and receiving support. In both these re- 
spects human teeth contrast strongly with those of the 
lower animals. In these itis common to find that certain 
teeth, as the canines in. the carnivora, present a marked 
elongation, and also that between the teeth there occur 
intervals which allow of their interlocking. 


Fiq. 3755.—The Permanent Teeth, natural size, showing the curves in 
the alignment of the crowns, (Carabelli.) 


The curve on which the upper teeth of the permanent 
set are arranged is normally somewhat larger than that 
of the lower teeth. In consequence, the anterior supe- 
rior teeth overlap the anterior inferior teeth, as do also to 
a slight extent the superior bicuspids and first and sec- 
ond molars the corresponding lower teeth. The wisdom 
teeth, however, meet practically edge to edge. It is to 
be further noted that the superior teeth are not situated 
directly opposite corresponding inferior teeth. The su- 
perior centrals are opposite the inferior centrals and a 
portion of the inferior laterals ; the superior laterals are 
opposite a part of the inferior laterals and a part of the 
inferior canines ; the superior canine occludes between 
the inferior canine and the first inferior bicuspid ; the 
first superior bicuspid occludes between the first 
and the second inferior bicuspids; the second 
superior bicuspid occludes between the second 
inferior bicuspid and the first molar ; the first su- 
perior molar occludes with the first and the ante- 
rior portion of the second inferior molar; the 
second superior molar occludes with the second 
and the anterior part of the third inferior molar ; 
the third superior molar occludes with the third 
inferior molar, and is the only tooth in the upper 
jaw having a single antagonist. While it has 
been stated that the masticating surfaces of the 
teeth of the upper and lower jaws are on a single 
plane, yet slight deviations from this rule are to 
be noticed. If we follow the lower edge of the 
upper teeth from a superior central around to the wis- 
dom, we shall find that the line ascends gently from 
the central to the interval between the first and second 
bicuspids, then descends till past the first molar, when it 
ascends slightly to the end of the row. On the lower 
jaw the anterior teeth are slightly elevated above the pos- 
terior, and between the canine and the wisdom tooth a 
slight concavity is to be observed. 

In its description a tooth is to be divided into a crown, 
a root or fang, and a neck. The crown ofa tooth is that 
part which normally appears beyond the margin of the 


741 


Teeth. 
Teeth. 


gum. The root or fang is that part which is normally 
embedded in the alveolus of the maxillary bone. The 
neck is a more or less constricted belt lying at the margin 
of the gum where the crown joins the root. The sur- 
faces of the crowns are thus designated. Those surfaces 
lying adjacent to the lips are called labial surfaces, those 
lying adjacent to the buccinator muscle are called buccal 
surfaces. Those surfaces on the inner side of the teeth 
lying adjacent to the tongue are called lingual surfaces. 
In the case of the upper bicuspids and molars, however, 
such surfaces are more commonly called palatal surfaces, 
from their relation to the hard palate. The grinding 
surface of the bicuspids and molars is called the coronal 
surface. The surfaces between adjoining teeth are 
called approximal surfaces, and are divided into two 
classes—mesial and distal. The mesial approximal sur- 
face of a given tooth is that surface which, were the row 
of teeth in a straight line, would face toward a line drawn 
between the central incisors. The distal approximal 
surface is the corresponding surface at the opposite side 
of the tooth. These names are, as arule, applied to the 
crowns of the teeth, though they are, with the exception 
of the term coronal, used also in connection with the 
roots. 

Description of Individual Teeth.—The upper central in- 
cisor, so called from its chisel-shaped cutting edge, is 
the most noticeable tooth in the front of the mouth; its 
crown is wedge-shaped, and is bounded by four surfaces, 
which are, in a general way, 
triangular. The anterior tri- 
angular surface has for its base 
the cutting edge of the tooth, 
its apex lying at the margin of 
the gum, The anterior surface 
is convex from side to side, and 
also from above downward. The 
posterior surface is opposite the 
anterior, and, like it, is of triangu- 
lar shape; the base of the posterior 
triangle unites with the base of the 
anterior triangle at the cutting edge of 
the tooth, while their apices are sepa- 
rated by the antero-posterior thickness 
of the root. The posterior surface is con- 
cave from above downward, and slightly 
concave or flat from side to side. A promi- 
nence can be noticed in the posterior plate 
near the gum, which is often accompanied by 
a pit situated at its lower base. Slight ridges 
run from the lower corners of the tooth posteri- 
orly, and unite with this prominence at the mar- 
ginof the gum. ‘The cutting edge formed by the 


Fia. 8756.—The Permanent Teeth, Natural Size, Internal View. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


crown, the two remaining surfaces correspond to the 
lateral and posterior plates of the crown. The root is 
much narrower posteriorly than anteriorly, and is thus. 
able to adjust itself to the curve of the dental arch. The 
pulp cavity of the superior central is simple in form, and 
follows the external contour of the tooth ; it is largest at 
the neck of the tooth, broad, but very shallow in the 
crown, and at the apex of the root is reduced to a thread. 
The neck of this tooth is situated high up anteriorly and 
posteriorly, but at the sides dips downward, forming a 
notch in the lateral plates. 

The superior lateral incisor is situated at the distal side 
of the central incisor, and resembles that tooth in its gen- 
eral outlines, though it is much smaller in every dimen- 
sion. The anterior surface of the crown is narrow and 
somewhat longer for its width than that of the central 
incisor ; it is convex in both directions. The posterior 
surface of the crown is concave in its vertical measure- 
ment, and flat or slightly concave from side to side. A 
prominence can be noticed in the posterior plate at the 


(Carabelli.) 


union of the anterior and posterior plates has three well- | margin of the gum, similar to that described as existing 


marked tubercles, which, however, are to be seen only in 
the newly erupted tooth, the friction of mastication soon 
wearing them away. In connection with the three tuber- 
cles on the cutting edge are necessarily two depressions, 
from which, in many cases, start shallow vertical grooves 
along the anterior surface of the crown. ‘The lateral 
surfaces of the crown are triangular, the bases of the tri- 
angles being toward the gum and the apices at the cut- 
ting edge. The lateral surfaces always show a departure 
from a perfect triangular form, in having a notch in the 
base line caused by the encroachment of the cementum 
of the root upon the enamel of the crown. 

The lateral surface toward the median line is convex 
from above downward ; and slightly convex or flat from 
side to side. Its union with the anterior and posterior 
plates at the cutting edge forms the lower mesial angle 
of the crown, which is slightly acute. The distal lateral 
plate resembles in contour the mesial plate, except that 
it is more convex from side to side. It helpsto form the 
distal angle of the cutting edge, which is obtuse and de- 
cidedly more rounded in contour than the mesial angle. 
The root of the upper central incisor is, roughly speak- 
ing, conical. Three distinct surfaces may, however, be 
described, one anterior and two lateral, which give to 
the root a triangular configuration. The anterior surface 
corresponds in position with the anterior plate of the 


742 


on the central incisor. This prominence is more marked 
than in the central, and indicates the development of a 
our which attains its full proportions in the bicuspid 
teeth. 

The lateral surfaces of this tooth are convex, the 
mesial less so than the distal. The crown upon its cut- 
ting edge is marked, in the freshly erupted tooth, by three 
tubercles, asin the centralincisor. Between the tubercles 
are two depressions, with which slight vertical grooves in 
the crown are connected. ‘The inner angle of the crown 
at the cutting edge is slightly acute, while the distal 
angle is obtuse, the corner of the tooth being rounded 
off to a greater extent than the similar angle of the cen- 
tral. The root of the superior lateral is irregularly con- 
icalin shape. It is decidedly more flattened at the side 
than is the root of the central; itis broadest in front, and 
is bevelled slightly toward the posterior surface. The 
pulp-cavity is simple, following the outline of the tooth. 

The superior canine is so called because it corresponds 
to the most prominent and characteristic tooth in the 
dog. It is also named the cuspid from having a cusp or 
point at the cutting edge. Popularly it is called the eye- 
tooth, from its location with reference to the eye. The 
canine, situated by the side of the lateral, is important in 
forming the contour of the face, while from its size and 
strength it is especially fitted for service in mastication. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


The crown differs in a marked way from that of the inci- 
sors. Instead of its cutting edge being chisel-shaped it is 
pointed, and thus fitted to pierce rather than cleave. It 
is easy to trace the development of the crown of the 
canine from that of the freshly erupted central incisor. 
As stated above, the newly erupted central has three 
tubercles on its cutting edge. 
If the median tubercle is decid- 
edly enlarged, while the later- 
al tubercles are nearly obliter- 
ated, and if, at the same time, 
the eminence described on the 
posterior plate of the central 
incisor be exaggerated, we have 
substantially the true form of 
the crown of a canine tooth. 
The anterior surface of the 
crown is convex, as are also 
the lateral surfaces. The pos- 
terior surface is concave from 
above downward, and flat or 
slightly convex from side to 
side. The prominence at its 
upper margin is marked, and 
is connected with the point of 
the cutting edge by a slight 
ridge. This prominence is also 
connected by similar ridges 
with the mesial and distal an- 
gles of the crown. The dis- 
tance from the cusp to the me- 
sial angle is less than from the 
cusp to the distal angle. By 
this means a right canine can 
be distinguished from a left. 
The root of the upper canine is 
longer than that of any other 
tooth, and gives rise toa marked 
ridge in the maxillary bone, as- 
sociated with a marked depres- 
sion called the canine fossa. 
The root, though more or less 
conical, is flattened laterally 
and bevelled away from front 
to back. This bevelling is 
necessitated by the position 
which a canine holds, at a de- 
cided curve in the dental arch. 
Slight longitudinal grooves are 
found at the sides of the root, 
which indicate a transition to 
a bifurcated or multiple root. 
The pulp-cavity is simple in 
shape and follows the exterior 
contour. 

In passing from the canine 
to the bicuspid, the shape of 
the tooth is decidedly changed. 
According to comparative anat- 
omists there are, in the typi- 
cal dental formula, four bicus- 
pids on each side of both jaws ; 
and the sharp transition in the 
human species from the canine 
to the bicuspid is explained by 
inferring that the first two bi- 
cuspids are absent, and that 
those present are really the 
third and fourth, which are 
therefore somewhat removed 
in shape from the canine tooth. 

The first upper bicuspid, also 
called the first premolar, has a 
crown which is rectangular in 
shape, having a long dimension from within outward and 
being narrow from front to back. The crown is sur- 
mounted by two cusps, hence the name bicuspid; one 
cusp is external and one is internal. The external cusp 
is longer and broader than the internal; its outer surface 


tact, (Carabelli.) 


Teeth. 
Teeth. 


is convex and is continuous with the external plate of 
the crown. Its coronal surface is convex from side to 
side, and likewise from above downward. The line from 
the apex of the cusp to the mesial side of the crown is 
shorter than the line from the apex to the distal side. 
The internal cusp is similar in shape to the external, and 


Fic. 3757.The Permanent Teeth, Natural Size, showing the Labial and Buccal Surfaces. The middle 
row of teeth represents freshly erupted incisors and canines, with the tubercles on their cutting edges in- 


is connected with it by an anterior ridge which unites the 
bases of the external and internal cusps along the mesial 
edge of the crown, and by a posterior ridge which unites 
the bases along the distal edge of the crown. Between 
the two cusps is a valley into which the sides of the cusps 


743 


Teeth. 
Teeth. 


slope. The mesial and distal sides of the crown are con- 
vex, especially near the grinding surface, where promi- 
nences are developed for contact with adjoining teeth. 
The neck of this bicuspid is much constricted from its 
mesial to its distal side. The root is quite long, and is 


Fie. 8758.—The Permanent Teeth, Natural Size, Side View. (Carabelli.) 


much flattened on its mesial and distal sides, displaying 
deep vertical grooves ; in fact, it is often bifurcated near 
the extremity. The pulp-chamber is quite narrow from 
before backward, and is prolonged in the direction of 
each cusp; in the root it is usually compound, being 


744 : 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


divided into two compartments by the longitudinal con- 
striction of the root. 

The second upper bicuspid, situated behind the first, 
resembles it in shape. It may be distinguished from it, 
however, by its root, which is less flattened, thicker from 


Fie. 8759.—The Permanent Teeth, Natural Size, a Section through the 
Pulp-cavity, showing its Size and Shape. (Carabelli.) 


the mesial to the distal surface, and does not tend to bifur- 
cation near the apex. Its pulp-cavity is usually single. 
The first upper molar, situated behind the second bi- 
cuspid, is the most bulky tooth in the mouth ; from its 
size it plays an important part in giving fulness and ex- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


pression to the side of the face. Its crown is cuboidal 
in shape, and bears upon its grinding surface four cusps, 
which are situated at the corners of the cube—two ex- 
ternally and two internally. The external cusps are of 
about equal size, and are divided by a fissure which 
starts at the grinding surface and is prolonged vertically 
up the buccal side of the crown. From the anterior 
external cusp to the anterior internal cusp there exists a 
ridge which borders the mesial surface of the crown, and 
antagonizes with a similar ridge on the distal surface of 
the second bicuspid. The anterior internal cusp is the 
largest of the four ; it is connected with the anterior ex- 
ternal cusp by the ridge just described, and with the 
posterior external cusp by another, called the oblique 
ridge. The posterior internal cusp is separated from the 
anterior internal cusp by the oblique ridge and its valley ; 
and is joined to the posterior external cusp by a ridge 
which bounds the distal edge of the crown, The roots 
of the first molar are three in number—two external or 
buccal, and one internal or palatine. The palatine root 
is the largest of the three, and underlies the two internal 
cusps. It diverges from the crown at a slight angle 
toward the palate ; it is conical in shape, but has in many 
cases a vertical groove on its palatine side, which hints 
at a division into two roots. ‘The two external roots un- 
derlie the anterior and posterior external cusps respec- 
tively ; they are broader upon the external surface than 
upon the internal, and diverge lightly outward from the 
crown, and also from each other. The anterior buccal 
root is larger in every dimension than the posterior. The 
pulp-cavity is complex, occupying the three roots and 
extending into the four cusps of the crown. 

The second upper molar, situated behind the first, is 
similar to itin shape. It is, however, somewhat smaller 
in all dimensions. 

The third upper molar, or wisdom tooth, is situated 
behind the second molar. In some cases, where a roomy 
jaw exists, it resembles closely the second molar in shape. 
As a rule, however, it is imperfectly developed. Its 
crown is much smaller than that of the second molar, 
and has three cusps instead of four, two external and 
one internal. Its root, formed by the confluence of three 
roots, is through most of its length single, but at the tip 
usually separates into three. The direction of the root 
is backward and outward. The pulp-cavity is small, and 
in the root tends to a threefold division. __ 

The teeth of the lower jaw, though they in general 
resemble the corresponding teeth of the upper jaw, 
present many differences. The lower central. incisor is 
~ much smaller than the upper central incisor ; its crown is 
chisel-shaped, being convex in front, and flat or slightly 
concave behind. The angles formed by the cutting edge 
and the body of the crown are both acute, and substantially 
equal, thus differing from the upper central, whose distal 
angle is obtuse. The root is long and tapering, flattened 
on the sides, and slightly bevelled toward the posterior 
surface. Shallow vertical grooves may be seen upon the 
anterior face of the crown, similar to those described in 
the upper centrals. When newly erupted, both lower 
central incisors possess upon their .cutting edges three 
tubercles and two intervening depressions, but these are 
soon lost through wear. 

The lower lateral incisor is placed on the distal side of 
the central incisor; it resembles that tooth in shape, but 
is larger. It will thus be seen that the relative size of 
the inferior lateral and central incisor is the reverse of 
that of the superior lateral and central incisor. 

The lower canine tooth follows the shape of the upper 
canine ; its crown is, however, not so pointed as that of the 
upper canine, and its root is more slender. The cusp of 
the crown is directed somewhat inward, and is thus able 
to shut inside the teeth of the upper jaw. 

The first lower bicuspid resembles in shape the upper 
bicuspids ; its crown is, however, smaller, especially in 
the labio-lingual dimension. Of its two cusps, the outer 
is the larger, and is directed slightly inward; the inner 
cusp is often quite small, and only slightly larger than the 
rudimentary second cusp of the canine. The root is 
more conical than are the roots of the upper bicuspids, 


Teeth. 
Teeth. 


and, though somewhat flattened on the mesial and distal 
sides, does not tend toward a bifurcation. 

The second lower bicuspid is situated behind the first. 
Its crown resembles that of the first, but is somewhat 
larger. The internal cusp is often divided by a slight 


notch into two cusps, thus indicating a development 


toward the multicuspid teeth which follow. The root 
is conical, but flattened on the mesial and distal sides; 
the pulp-cavity is single. 

The lower first molar, situated behind the second bi- 
cuspid, is the largest tooth in the lower jaw. Its crown 
is quadrilateral in shape, and is surmounted by five cusps, 
three external and two internal. Of the five cusps the 
external posterior cusp is much the smallest, being often- 
times of rudimentary size. The two internal cusps are 
larger than the external cusps. . A valley at whose bot- 
tom is a fissure separates the external from the internal 
cusps, and a lesser valley separates each cusp from its 
neighbor. As a rule, a well-defined crucial figure is 
formed by the fissures in the crown of this tooth. The 
longer fissure extends from the mesial to the distal side, 
and the shorter fissure from the buccal to the lingual 
side, of the tooth. Where the small buccal cusp is pres- 
ent the long fissure bifurcates at the centre of the crown, 
one branch passing between the second and third buccal 
cusps, and the main branch directly backward, between 
the posterior buccal and the posterior lingual cusp. 
The roots of the first molar, two in number, are situated, 
one beneath the anterior, and the other beneath the pos- 
terior, part of the crown. The two roots, starting from 
the under side of the crown, diverge from each other at 
an acute angle, while at the same time they both curve 
gently backward. The anterior root is much broader 
than the posterior; it is decidedly flattened from front 
to back, and has a vertical median groove along its an- 
terior and posterior surfaces. Jn some cases this root is 
bifurcated along the line of these grooves, and two dis- 
tinct roots take the place of the single one which exists 
normally. The posterior root is conical in shape, though 
more or less flattened from before backward. It does not 
tend to subdivision. The pulp-cavity is complex, the 
anterior root containing two very small root-canals, the 
posterior root, one single and ample canal. 

The second lower molar is situated behind the first, 
and resembles it in its outlines, though of smaller dimen- 
sions. The crown often drops the small posterior buc- 
cal cusp and limits itself to four cusps, one on each cor- 
ner of the crown, and separated by a crucial depression. 
The roots are smaller than those of the 
first molar, but have the same configura- 
tion and curve. 

The third lower molar, where plenty of 
room exists for its development, resembles 
the second molar in shape. As a rule, J 
however, it is cramped for room, and be- ggQattow, 
comes dwarfed. Its cusps are diminished F 
to three, two buccal and one lingual. Its 


Fie. 3760.—A 


Lower Third 
two roots are small, and to a large extent Molar, with 
confluent. Their backward curveis much  hook-shaped 
more decided than is that of the first two Ean) (Cara- 


lower molars, and so great is it in man 
cases that the root resembles a hook, and is thus locked 
into the alveolus of the jaw. 

The temporary teeth are twenty in number. In each 
jaw there are four incisors, two canines, and four molars. 
The dental formula is I 4, C %, molars + = 20. 

This formula differs from that of the permanent teeth 
by the entire absence of bicuspids, and by the loss of 
four molars. The temporary teeth can best be described 
by comparing them with the permanent teeth, which they 
closely resemble. 

The incisors and canines of the upper and under jaws 
are very much smaller than the corresponding teeth in 
the permanent set, and the root of the upper central in- 
cisors is somewhat curved on the mesial side where the 
corresponding root in the permanent teeth is practically 
straight. 

The first upper molar is situated behind the canine, and 
in appearance is a compromise between a bicuspid and a 


745 


Teeth. 
Teeth. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


molar. 


Fia. 8761.—The Temporary Teeth, Natural Size, showing their Arrange- 
ment in the Maxillary Bones, and Relations to one Another. (Carabelli.) 


cusps—two external and one internal. The 
roots are three in number, resembling in shape 
and position those of the permanent molars. 
They are, however, more divergent, thus pro- 
viding room for the first bicuspid, whose crown 
is situated directly beneath the temporary tooth, 
and within the grasp of its roots. 

The second upper molar is a much larger 
tooth than the first, and resembles so closely 
the first permanent molar that it might be mis- 
taken for it. Its roots are more divergent, how- 
ever, in order to embrace the crown of the 
second bicuspid, to.which it gives way in the 
permanent dentition. 

The first molar in the lower jaw is situated 
behind the canine, and resembles in shape a 
permanent molar of the lower jaw. Its crown 
is surmounted by four cusps—two external and 
two internal. It has two roots, one anterior 


and one posterior, between which is developed the crown 


of the first inferior bicuspid. 


The second lower molar is larger than the first, and a 


Its crown resembles in general shape that of an 
upper molar, but is quite small, and bears only three 


Fie. 376 


3.— An 
Upper Tempo- 
rary Molar, 
with a Bicus- 
pid within the 
grasp of 
Roots, (Wedl.) 


little smaller than a permanent lower molar, which it 
closely resembles. 
ternal and two internal. 
terior and one posterior, which embrace the developing 


Its crown has five cusps—three ex- 
There are two roots, one an- 


crown of the second lower bicuspid. It is 
characteristic of the temporary teeth that 
the foramen at the apex of the roots is 
larger, that the necks of the teeth are more 
constricted, and the color whiter and more 
delicate than in the permanent teeth; also, 
that the six anterior upper teeth do not 
overlap the corresponding lower teeth to 
such an extent as in the permanent set. 
Microscopic ANATOMY OF THE TEETH. 
—A longitudinal section through a tooth 
will reveal four distinct structures—the 
enamel, the cement, the dentine, and the 
pulp. The pulp is a soft mass of connec- 
tive tissue richly supplied with blood-ves- 


its 


sels and nerves, and located in the centre of the tooth. 
It fills the pulp-cavity. The pulp-cavity starts at the 


apex of the root or roots, as the case may be, as a thread- 


Fie. 8764.—The Temporary Teeth, Natural Size; a Section through the Pulp-cavity 


shows its Size and Shape. 


(Carabelli. ) 


like canal, and gradually enlarges till it reaches the 


crown, where it attains its greatest size; throughout its 


Fia. 8762,—The Temporary Teeth, Natural Size, showing the External and Internal 


Surfaces, (Carabelli.) 


746 


whole course it imitates in shape the external contour of 


the tooth. Anartery and nerve, and sometimes 
more than one of each, enter the apical foramen 
of each root of a tooth, and, branching freely, 
distribute themselves to all parts of the pulp, 
being especially abundant about its periphery. 
A venous system returns the blood through the 
apical foramen into the general circulation. It 
is a matter of dispute whether a lymphatic system 
is present or not ; most observers consider that it 
is not. Around the periphery of the pulp, and 
distinct from the connective-tissue cells forming 
its body, there exists a layer of cells called the 
odontoblastic layer, or the membrana eboris. In 
shape these cells are large in comparison with 
the connective-tissue cells ; they are of colum- 
nar form, and have several processes. By these 
processes they are united to the terminal fila- 
ments of the nerve of the pulp, joined to one 
another, and connected with the dentinal fibrils. 

Immediately surrounding the pulp comes the 
dentine, which is the most abundant tissue of 
the tooth. It is hard and dense in structure, 
of a yellowish-white color and silky lustre. On 
analysis it is found to contain animal matter, 
twenty-eight per cent.; earthy matter, seventy- 
two per cent. Its various components are thus 
given by Von Bibra: 


Organic matters) 5, Ose5 ik le recs beets 28.01 
Phosphate and fluoride of calcium ........... 66.72 
Carbonate of Calcitim.... 10. veeee sees eiie st a eoeoe 
Phosphate of magnesium.......:........+-s- 1.18 
Other ‘saltgisie, Rie cots. cease Coe eee eee 43 

Otel Ae te athelen he Oe ee mTOR Seo eS 100.00 


Morphologically considered, it is composed of 
a structureless matrix permeated by countless 


° 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


tubules, each tubule possessing a lining membrane and a 
central fibril. The tubules start from the pulp-cavity, 
where they have a diameter of about soa of an inch, and 
radiate toward the periphery of the dentine, beecming 
smaller and more numerous as they advance. While 
the direction taken by the tubules in different parts of the 
tooth varies greatly, yet contiguous tubules are essentially 
parallel. ‘Two or three undulatory curves are to be no- 
ticed in the length of a tubule, and the name primary cur- 
vature has been attached to them. Numerous spiral turns 
occurring in the course of the undulatory curves have 
been named the secondary curvatures. The tubules give 
off frequent branches throughout their entire length. 
Some of these branches are important, extending to the 
outer layers of the dentine parallel to the main channel. 
Other branches serve merely to connect one tubule with 
another, and still others are blind processes. At the outer 
layer of the dentine the tubules become diminished in size, 
and very numerous. Some of the tubules can be seen 
entering the granular layer of the dentine, while others 
either terminate blindly or anastomose with neighboring 
tubules. The ‘‘ granular layer of Purkinje” consists of 
numerous irregular cavities filled with cells having nu- 
clei, and forming a layer about the peripheral portion of 
the dentine, being especially well developed where the 
dentine is covered by the cement of the root. The cavi- 
ties of this layer communicate with each other, and, in 
some cases, with the canaliculi of the cement, besides be- 
ing connected with the tubules of the dentine. The 
tubules of the dentine have been shown to possess a 
lining membrane, and to this the name dentinal sheath has 
been applied. This structure resists the action of reagents 
which destroy the matrix in which the tubules are em- 
bedded, and is supposed to consist of elastic tissue, 
though its composition is not surely determined. The 
dentinal fibril which occupies the centre of the tubule is 
a soft homogeneous substance, having a nerve-like func- 
tion, but lacking true nerve-structure. 

The fibril is connected at one end with an odontoblas- 
tic cell in the periphery of the pulp, and the other end 
enters, in many cases at least, the granular layer of the 
dentine, coming into contact with the soft tissue there 
contained. Through the dentinal fibril communication 
is maintained with the nerves of the pulp, and sensation 
is supplied to all parts of the dentine. In longitudinal 
section of that part of the dentine which lies in the 
crown of the tooth are to be seen lines which are called 
the ‘‘ incremental lines of Salter.” They run, in general, 
parallel to the external contour of the crown, and mark 
stages in the development of the dentine, being not un- 
like the circular rings of wood-fibre, and are due to the 
presence of interglobular spaces. That the dentine is 
developed by stages is made apparent by treating it with 
hot caustic potash. By this reagent the dentine becomes 
separated into layers, which cross the tubuli at right 
angles, and are concentric about the pulp. In the crown 
of the tooth, between one layer of dentine and another, 
there occur imperfectly calcified spots where the dentine 
assumes a globular form, and where irregular interglob- 
ular spaces are found. Series of interglobular spaces 
give rise to the ‘‘ incremental lines of Salter.” 

The dentine is surrounded in the crown by the enamel, 
and in the root by the cementum. 

The cementum, or crusta petrosa, is the outer covering 
of the root. It is thinnest at the neck of the tooth, where 
it meets and slightly overlaps the enamel, and grows 
gradually thicker toward the apex, about which point it 
is most abundant and its structure is most perfectly de- 
veloped. Cement has essentially bone-structure ; it pos- 
sesses lacune and canaliculi, but has normally no Haver- 
sian canals. The lacunz and canaliculi’are wanting or 
rare in that part of the cement near the neck of the tooth, 
but about the apex of the root they are numerous and well 
developed. The lacune lie in parallel planes encircling the 
pulp-cavity, their canaliculi anastomose freely with each 
other, and in some cases they connect with the granular 
layer of the dentine, thus establishing a communication 
between the lacune of the cement and the pulp of the tooth 
through the granular layer and tubuli of the dentine. 


Fie. 3765.—A Microscopic Section of a Canine Tooth, 


The 


It is especially marked between the cement and dentine, and practically absent 


The interglobular spaces are represented in the coronal portion of the dentine just removed from the junction of the dentine and enamel. 


The dark stripes indicate places where the enamel-rods cross each 
C indicates the cement, with its lacunze 


The undulatory curves of the tubules are called the primary curvatures, 


B is the dentine, with its tubules radiating from the pulp-cavity. 


showing, A, the enamel, with its enamel-rods running from the dentine to the outer surface, 
The granular layer is indicated by the dotted line about the periphery. 


of Retzius,” 


The fine parallel lines are the ‘*‘ brown lines 
secondary curvatures are not visible at this enlargement. 


between the enamel and dentine. 


and canaliculi, 


other. 


TAT 


Teeth. 
Teeth. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Se 


—————— 


Fie. 3766.—Cross-section of an Upper Bicuspid Tooth. A, A, the root-canals; B, the granular layer of the dentine; C, the cementum, showing 
occasional lacunz ; D, the dentine. 


Immediately surrounding the cementum of the root ex- 
ists the peridental membrane, which is identical with the 
periosteum which lines the bone forming the socket of 
the tooth. The peridental membrane serves a triple 
function. It nourishes the bone of the socket and the 
cement of the root, besides forming a bond of union be- 
tween the root and its socket. The peridental membrane, 
like all periosteum, is composed of connective tissue richly 
supplied with blood-vessels. The arterial supply comes 
from capillaries of the gum about the neck of the tooth, 
from the deep substance of the bony socket, and from a 
peace of the artery entering the apical foramen of the 
tooth. 

The enamel forms the outer covering of the crown; it 
is the hardest structure in the body. It resembles den- 
tine in its chemical constituents, but has a much greater 
proportion of inorganic material. The following analy- 
sis is given by Von Bibra: 


Phosphate and fluoride of calcium .................- 89.82 
Carbonate-of calcite See, ee eee 4.37 
Phosphate of mapnesiom Jo. 05200. eee ee 1.384 
Other salts 528. oot is ere cas eee ie cme 0.88 
Carttiage ii. io ea ats ere en eae a) ane 3.389 
BUD 55 arereip aval Sie,'s leh a Bieter Sars pane eiaie io Wn Rte oe MIE BR eee 0.20 
otal Saxe cemeteries ec tht ee ee ae 100.00 


The proportion of organic and inorganic matter is as 
follows : Poh 


Organic. oF ne ioe ie ae 3.5 
Inorganic: 214 {ai Dee ae ie Oh oe Aer De, He 96.5 
gia) rN Oia ti ei as URC Ry ACM a a Da 100.00 


Morphologically considered, enamel is composed of 
rod-like, hexagonal prisms, arranged side by side, one 
end of the prism resting on the outer layer of the den- 
tine and the other forming the free surface of the crown 
of the tooth. Each prism extends, as a rule, through 
the entire thickness of the enamel. There are some, 
however, which extend only from the centre of the 
enamel to its free surface, thus preventing gaps which 
would otherwise occur, the outer surface of the enamel 
being of greater extent than the inner. In diameter the 
enamel prisms measure ¢g9 to za Of an inch. Each 
prism, when isolated, has slight varicosities and presents a 
striped appearance similar to muscular fibre. The prisms 


148 


run, in general, parallel to each other, and in a wavy 
course ; their inner ends are implanted in slight hexagon- 
al depressions in the 
= surface of the den- 
1 “tines andutheirpouter 
—— -7 ends are received in- 
to similar depressions 
in the under side of 
the cuticle of the 
enamel when the 
nN cuticle is present. A 
BCU OG vertical section of the 
AA eC enamel shows that it 
: is thickest in the 
crown, especially in 
the region of the 
cusps, and becomes 
thinnest at the neck 
of the tooth, where it 
is overlapped by the > 
cement of the root. 
The enamel - prisms 
are seen to leave the 
outer surface of the 
dentine at right an- 
gles, and radiate to- 
ward the ~ external 
surface of the tooth. 
The general yellow- 
ish-white color of the 
enamel is varied by 
dark bands extending 
vertically from the 
dentine to the free 
surface of the enam- 
el, caused by the 


heabhgee ; crossing of bundles 
Fia. ioe oe of Dentine and Ce- gf enamel - prisms 
ment. The figure 1 represents the cement . . NS 
with its lacunz and canaliculi ; the figure Certain delicate lines 
2 represents the granular layer of the den- running lon gitudi- 
tine. It is to be noticed that the lacune nally through the 
communicate with the cells of the granular bst f th e 
layer. The figure 3 represents the tubuli supstance oO © ee 
of the dentine, showing their diminution amel are also to be 
in size as they go toward the cement, also noticed. These are 
their frequent anastomoses and their con- called the ‘‘ brown 


nection, in some cases, with the cells of ; 
the granular layer. (Quain.) lines of Retzius,” but 


i) 
iI 


ty { 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Teeth. 
Teeth, 


it is not known to what they are due. Also between en- 
amel rods, usually near the surface of the dentine, are 
found irregular cavities due to an imperfect calcification 
of the enamel. On cross-section the enamel has the ap- 
pearance of a mosaic pavement, each prism showing its 
hexagonal shape. The small amount of organic material 
which exists in enamel is deposited mainly between the 
prisms, forming a cement which binds them together. 
oe cement is more abundant in young than in adult 
teeth. 

The cuticle of the enamel, or Nasmyth’s membrane, is 
to be found in a freshly erupted tooth. It consists of a 
delicate epithelial covering which encloses the enamel ; it 


A shows 
the varicosities and striations of the prisms. B is a cross- 
section of enamel, showing the hexagonal shape of the prisms, 
and their tessellated appearance, (Quain.) 


Fia. 3768.—Enamel-prisms magnified 350 diameters. 


J 


is, however, so delicate that in the slightest use it is worn 
away. It receives in hexagonal depressions on its under 
side the outer ends of the enamel prisms. 

TIME OF ERUPTION OF THE TEETH.—The first den- 
tition. begins about the seventh month, and is completed 
about the twenty-fourth month. The second dentition 
begins about the sixth year, and is completed about the 
twenty-first. Considerable variation exists in the time at 
which individual teeth erupt, and no date can be absolute- 
ly fixed for the appearance of a given tooth. It is possi- 
ble, however, to state the time when the eruption of a 
tooth is normally to be expected, and the following tables 
are appended : 

: Temporary Teeth. 


The central incisor erupts at the............... %th month. 

The lateral incisor erupts at the.............. 9th month. 

TPhevirsh molar erupts at they o.caysnisn sce cee 12th month. 

The canine erupts at the. ..........cccescee> 18th month, 

The second molar erupts at the............... 24th month, 
Permanent Teeth. 

Thenitst molar erupts at thes ise sis ble. «eects 6th year 


The central incisor erupts at the............... ‘th year, 


The lateral incisor erupts at the’................ 8th year, 
The first bicuspid erupts at the ............c.cces 9th year 
The second bicuspid erupts at the........... _..- 10th year. 
The canine erupts at the ......... ce sciele atioie 11th year. 
The second molar erupts at the... ........... .. 12th year 
The third molar erupts at the.............. 17th-21st year. 


As a rule, in both the first and second dentitions the 
lower teeth erupt before corresponding teeth in the upper 
aw. 
PHYSIOLOGY OF THE TEETH.— Under this head we nat- 
-urally consider the purposes for which teeth exist, and 
how they perform their several functions. The subject 
may be divided into three heads : 

(1) The function of the teeth in facial expression. (2) 
The function of the teeth in mastication. (8) The func- 
tion of the teeth in articulation. 

The importance of the teeth in facial expression be- 
comes apparent when we consider the effect of their ab- 
sence, as shown in aged people. In such the lower part 
of the face has lost the round and graceful lines of early 
years ; the chin is pointed, and approximates the end of 
the nose ; the lips are retracted and flabby, and a charac- 
teristic hollow extends along the cheek. When present, 
each tooth aids in sustaining the proper proportions of the 


face. The upper front teeth, by being slightly in advance 
of the lower, produce that slight projection of the upper 
lip beyond the lower, found in normally shaped features. 
The bicuspids and molars, by their apposition, fix the re- 
lation of the lower to the upper jaw, and by their bulk 
give fulness to the cheeks. The bony alveolus, also, in 
which the teeth are embedded, has an important relation 
to facial expression, for when a tooth has been lost, its 
bony support, being no longer needed, is absorbed, and 
thus the features are still further deprived of support. 

The function of the teeth in mastication is the most obvi- 
ous and important. Standing as they do at the entrance 
to the digestive tract, it is their duty to seize upon food, 
sever its connection with its surroundings, and commi- 
nute it so that it can be acted upon readily by the various 
digestive fluids. The act of seizing and cutting is per- 
formed by the six anterior teeth, whose edges, by the 
protrusion of the lower jaw, are brought opposite to each 
other. When once a morsel of food has been detached 
by the anterior teeth, it is passed backward by the tongue 
and cheeks, to be operated upon by the bicuspids and mo- 
lars. ‘The bicuspids are fitted both to cut and to grind. 
They cut by the outer cusps of opposing teeth meeting 
and passing each other like the blades of a pair of scis- 
sors. They crush by a lateral motion, the crowns of the 
lower bicuspids moving across those of the upper. The 
function of the molar teeth is to 
crush and grind, for which pur- 
pose they are fitted by their broad 
crowns. ‘They crush by means 
of an up-and-down movement, 
and grind by a lateral movement. 

The function of the teeth in 
articulation is best understood by 
a brief survey of the mechanism d 
of speech. This mechanism in- 
cludes the vocal cords, and a re- 
sonant cavity above the cords, 
formed by the pharynx and the 
oral and nasal cavities. This re- 
sonant cavity reinforces and mod- Fy¢g, 3769.—The first profile 
ifies sounds made by the vocal _ represents the features un- 
cords. Articulation is concerned eee. Be loss of teeth. 
with sounds of two kinds—vow- agjentulous condition: He 
els and consonants. The vowels which the lips fall in and 
are musical notes formed by the the chin becomes pointed 
vocal cords, and given quality or ®n@, inclined toward the 
timbre by the size and shape of 
the air-column in the resonant cavities above. The con- 
sonants are sounds produced by the same mechanism, but 
due to irregular vibrations, and hence are noises. The 
oral cavity, being able to change its size and shape in 
numberless ways, is the most important agent in sound 
modification. 

To produce articulate sounds the column of air must be 
obstructed and forced into channels of definite size and 
shape. The column of air is obstructed in three ways : 
first, by applying the back of the tongue to the palate ; 
second, by applying the tip of the tongue to the posterior 
surfaces of the anterior teeth ; and third, by a closure of 
the lips. It is forced into definite channels by pressing 
the tongue against different parts of the roof of the mouth, 
and against the inner surface of the upper teeth. 

To produce the sound T, the tip of the tongue is 
placed against the posterior surface of the upper incisors, 
while the sides of the tongue touch the bicuspids and 
molars on both sides. With the tongue in this position 
a column of air is held under pressure and suddenly re- 
leased through the front part of the mouth with an ex- 
plosive sound. D is made in a similar way. F and V 
are made by bringing the lower lip against the under side 
of the upper incisors, the tongue meanwhile touching 
the inner surfaces of the upper second and third molars. 
A column of air is then forced out between the upper 
incisors and the lower lip. The letter S is sounded by 
nearly shutting the teeth and forcing the air between 
them, the tongue meanwhile being placed against the up- 
per bicuspids and molars, and thereby narrowing the oral 
cavity to a slight channel along the roof of the mouth. 


749 


Xe 


Teeth. 
Teeth. 


To pronounce Sh, the teeth are closed and the tongue is 
placed against the upper bicuspids and molars, leaving a 
narrow channel along the roof of the mouth. Along 
this channel a blast of air is forced which escapes between 
the front teeth with a hissing noise. | 

The agency of the teeth in the formation of the con- 
sonants is recognized by grammarians in their separation 
of the consonants into labials, palatals, and dentals. A1- 
though the teeth are important for perfect articulation, 
yet when lost they are to a great degree compensated for 
by an increased activity of the lips, cheek, and tongue. 
These parts so adapt themselves to the diminutive alveo- 
lar ridge which remains that fair articulation is still 
possible. What most seriously interferes with articula- 
tion is the loss of one or two of the front teeth while the 
others remain. In such a case the adjoining structures 
exercise their compensatory function with difficulty, and 
sounds depending for their formation upon the presence 
of the front teeth are not easily made. The loss of the 
back teeth is compensated for by the drawing in of the 
cheek and the bulging outward of the tongue. By this 
means it is possible to carry a column of air to the front 
of the mouth and prevent its escaping at the sides. 

As a minor function of the teeth may be mentioned 
their tactile sense, by which, together with the muscular 
sense located in the muscles of mastication, the degree 
of hardness of bodies is perceived. This tactile sense of 
a tooth is dependent on the sensitive peridental mem- 
brane, which perceives and records the impact of the 
tooth against every substance. 

PATHOLOGY OF THE TEETH.—Pathology in the Number 
of Dentitions and their Time.—While two is the normal 
number of dentitions, much can be heard and read of a 
third dentition, the authority for which, however, rests, 
as a rule, with unscientific observers, and is of very little 
value. It is a fact of common observation with dentists 
that individuals know very little accurately of what is 
going on in their own mouth, and consequently often 
make positive but inaccurate statements with regard to 
their teeth. The statements of parents, also, with regard 
to the condition of their children’s teeth, are very unre- 
liable ; they fail to distinguish temporary from perma- 
nent teeth, supernumerary from normal teeth, and a nor- 
mal from an abnormal number. The teeth are sometimes 
so irregular that a double row exists at some parts of the 
arch, and the phenomenon is explained as due to a third 
set of teeth. The late eruption of certain teeth, notably 
the wisdom, which may be delayed till middle or ad- 
vanced life, often gives rise to a reported case of third 
dentition, a few teeth being represented as a whole set. 
The matter is so clearly stated by Salter that I cannot 
do better than quote from the ‘‘ Dental Pathology ” (Wm. 
Wood & Co., 1875, p. 32), as follows: ‘‘ There is no re- 
corded instance of the occurrence of a third set of teeth 
in the writings of any modern observer of scientific re- 
pute ; but the authorities of earlier date who have asserted 
the fact are so respectable that it is difficult altogether to 
discard from one’s mind the idea that the circumstance 
has occurred in some shape.” Later authorities than 
Salter, while in the main holding his view, yet strengthen 
somewhat the probability of the occurrence of a third 
dentition by cases which have been under fairly good ob- 
servation. The conclusion -to be drawn is, that a third 
dentition probably has occurred in rare instances, but 
that the vast majority of reported cases are spurious, the 
error having been caused by the presence of supernu- 
merary teeth, irregular and crowded teeth, or by teeth 
which have been delayed in their eruption till late in 
life. 

While the existence of an extra dentition remains in 
doubt, the entire absence of one or both of the normal 
dentitions is an established fact; such cases, however, 
are decidedly rare, especially those in which neither den- 
tition has occurred. There is usually associated with 
this condition a failure in the growth of hair throughout 
the body. ‘The condition of the alveolar ridge in such 
cases is similar to that which ensues on the extraction of 
the permanent teeth. Artificial substitutes, however, 
are not always necessary, inasmuch as the gum, in such 


750 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


cases, is very tough, and capable of performing with re- 
markable facility the duties of mastication. 

Pathology in the Time of Dentition.—The deciduous 
teeth are sometimes erupted at birth. An interesting 
statement of cases of this kind is given in the ‘‘ American 
System of Dentistry,” vol. ili., p. 423: ‘* Pliny the 
Younger has handed down to us several instances of pre- 
natal dentition, the most conspicuous of which was that of 
a Roman consul, Marcus Curius, who, on account of be- 
ing born with a full 
set of teeth was 
surnamed Dentatus. 
Zoroaster, the Per- 
sian legislator, is 
also said to have had 
a complete set of 
teeth at birth. Louis 
XIV. of France, 
and his Secretary of 
State, Cardinal Ma- 
zarin, were each 
born with two teeth. 
Richard III. of Eng- 
land, and Mirabeau, 
Fra. 8770.—Illustrates the Impaction of both &Te both said to have 

Lower Canines. It occurred ina person of had congenital teeth. 

advanced age, and the impacted teeth were F{aller collected a 

not visible abovethe gum. The canines are list of nineteen cases 


kept from eruption by the neighboring bi- ~* : 
cuspids and lateral incisors. (Wedl.) of teeth at birth, and 
very many more 


have been recorded by others.” When deciduous teeth 
are delayed in their eruption it is commonly due to rick- 
ets. A delay in the eruption of the permanent teeth is 
also frequently noticed. An important cause for this de- 
lay is the prolonged retention of the deciduous teeth, an 
obstacle being thus present which prevents the permanent 
teeth from taking their place. Cases are on record of de- 
ciduous teeth persisting till middle or old age. It often 
happens, however, that a permanent tdoth is kept from 
eruption because its place has been taken by another per- 
manent tooth which had an earlier start, and which has 
occupied all the available room. This is especially lia- 
ble to happen with the superior canines, on account of 


. their coming to the surface after the lateral and the first 


bicuspid have taken their place in the arch. If, as often 
happens, the temporary canine has been prematurely ex- 
tracted, allowing the adjoining 
teeth to close in the gap, or if the 
arch is unusually narrow, or the 
teeth unusually large—and some- 4 
times the two latter conditions g§:% 
exist together—then if 
the canine is likely 
to be crowded out 
beyond the arch or 
to be imprisoned in 
the alveolus. The ca- 
nine may be perma- 
neatly imprisoned, 
or until the extrac- 
tion of a bicuspid or 
lateral incisor offers 
it a chance to erupt. | i 

The wisdom teeth INGE 
are always very lia- . 
ble to detention with- F1¢. 3771.—Illustrates the Impaction of a 
in the jaw, and their Right Superior Lateral (a), which lies in 


g the superior maxillary bone at right angles 
eruption may _ be _ to its normal position, (Wedl.) 


either prevented or 

long delayed. This happens from causes similar to those 
just described with regard to the canine. The modern 
civilized jaw seems to be made too short to contain a full 
complement of developed teeth, and, as the wisdom teeth 
come last, they, though of stunted size, are frequently 
unable to enter the arch. Imprisoned or partly erupted 
wisdom teeth, especially of the lower jaw, may cause 
very serious symptoms, both local and reflex. The local 
symptoms consist of pain and swelling in the vicinity of 
the tooth ; the reflex symptoms of neuralgias about the 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


head, and a tonic contraction of the muscles which close 
the jaw. Insomecasesan abscess may be formed which, 
if lacking prompt exit, may open by fistula on the out- 
side of the face, at the angle of the jaw, or in the neck, 
or even as low down as the subclavicular region. Im- 
prisoned canine and incisor teeth are sometimes found 
far from their normal position. Cases are cited where 
the crown of the superior canine has penetrated the nasal 
cavity and the antrum ; they have also been located in 
the palatine portion of the superior maxillary bone. 
Lower canines have been found with their long axes 
parallel to the body of the jaw, at or near the tips of the 
roots of the inferior lateral and bicuspids. The superior 
lateral may be delayed 
in its eruption, or im- 
prisoned for want of 


may in consequence take 
_abnormal positions simi- 
lar to those taken by the 
superior canine. 
Pathology in the Num- 
ber of Teeth in a given 
Dentition. —In connec- 


Fre. 38772.—A Conical Supernumerary ,;; * 
Tooth located between the Superior tion with both the first 
and second dentitions 


(Carabelli, ) 
we find, at times, both 
an excess and also a deficiency of teeth. Teeth in excess 
of the normal are called supernumerary teeth. Such may 
be coincident in time of eruption with the teeth in whose 
neighborhood they appear, or they may precede or follow. 
Supernumerary teeth are divided into two main classes 
—teeth whose form differs from that of normal teeth (con- 
ical teeth), and teeth whose form resembles that of nor- 
mal teeth. Supernumerary teeth are not common in con- 
nection with the first dentition ; when they occur they are 
found more frequently in the lower jaw, and belong in 
shape to the second class, inasmuch as they resemble the 
teeth with which they are associated. The duplicate 
tooth is usually a lower incisor, and it takes its place reg- 
ularly in the arch, being erupted at about the same time 
.as its companion incisor. Supernumerary teeth are more 
frequently found in con- 
nection with the second 
dentition, and are usually 
located in the upper jaw. 
They as a rule make 
their appearance just af- 
ter the adjoining 
tooth is erupted. 
Conical supernu- 
merary teeth are 
the most common 
kind. They have 
the same structure as 
normal teeth, butin shape 
resemble a diminutive 
cuspid. Their crown, 
however, has not the an- 
gular outline belonging 
to that tooth, but is cone- 
shaped, as their name 
implies. The root is 
round and __ tapering. 
These teeth occur most 
frequently in connection 
with the superior inci- 
sors. One may be located belli.) 
between the two cen- 
trals in the arch, or between the central and the lateral. 
They may be placed without the arch, on either its labial 
or palatal side. Conical teeth are not commonly found 
adjoining the molars, bicuspids, or cuspids, though they 
may exceptionally be found in all these localities. If 
found outside the arch, conical teeth are of no value, 
and should be extracted ; if found in the arch, it often 
becomes a question whether their presence or absence 
produces the greater deformity. Supernumerary teeth 
which resemble normal teeth are generally found among 


Central Incisors. 


Teeth. 
Teeth. 


room in the arch, and. 


Fie. 37'74,—A Case of Projecting Upper Front Teeth. (Cara- 


the upper incisors and regularly placed in the arch ; they 
do not necessarily produce deformity, and by the unpro- 
fessional eye would not be noticed. A supernumerary 
superior lateral is most commonly found; next in fre- 
quency comes the superior central, while duplicates of the 
superior molars, bicuspids, and canines are rare. Carl 
Wedl, in his ‘‘ Pathology of the Teeth,” gives a drawing 
of the superior and inferior maxille of a negro, in which 
appear four molars on each side of both the upper and 
under jaw, beside an extra bicuspid in the lower jaw, 
making five supernumerary teeth in all; the molars are 
all in the dental arch, but the bicuspid is situated at 
the inner side of its neighboring bicuspid. <A third kind 
of supernumer- _ a 

ary tooth, some- ie 
times described, 
is called the 
cubic-crowned 
tooth ; it resem- 
bles in shape the 
lower bicuspid, 
and occurs in the 
anterior part of 
the mouth _be- 
hind the superior Fre. 3773.—Shows two Cubic-crowned Supernu- 
incisors. merary Teeth, occurring behind the Upper Cen- 

Pathology in tral Incisors. (Salter.) 
the Arrangement of the Teeth.—A pathological arrange- 
ment or irregularity may affect groups of teeth or indi- 
vidual teeth. Among the irregularities which affect 
groups of teeth are cases in which the anterior teeth of 
the upper jaw project so far in advance of the corre- 
sponding teeth of the under jaw that a considerable space 
exists between the anterior surface of the lower teeth and 
the posterior surface of the upper teeth. This arrange- 
ment is in many cases hereditary, but may be induced 
by thumb-sucking in infancy. Infants addicted to this 
habit place the thumb between the front teeth and pry 
the upper teeth forward, using the under as a fulcrum. 
The force exerted is very slight, but, being continued 
for perhaps several hours during the day, is sufficient to 
move the imperfectly calcified bony alveolus. 

An irregularity 
the reverse of the 
above, and of fre- 
quent occurrence, 
is produced when 
the anterior teeth 
of the under jaw 
are placed in ad- 

vance of those of the 
upper jaw, leaving an 
interval between their 

posterior surfaces and 
the anterior surfaces of 
the superior teeth. To 

this condition the name 
underhung jaw has been 
given. It is usually heredi- 
tary, and results either from 
an overdeveloped under jaw or 
from an underdeveloped upper 
jaw, the under jaw being normal. 

This irregularity, as well as the 
one first described, is very unfavor- 

able to facial expression. The for- 
mer causes an excessive protrusion of 
the upper lip beyond the under, and the 
latter a protrusion of the under lip be- 
yond the upper. <A third irregularity is produced when 
the superior anterior teeth, instead of slightly overlapping 
the inferior anterior teeth, meet them edge to edge. ‘This 
arrangement causes no marked facial blemish, but is det- 
rimental to the teeth, which become worn away by edge 
to edge contact, and thereby shortened. 

‘The six anterior teeth of both jaws are sometimes 
tilted forward to a marked degree. This irregularity is 
commonly caused by the loss of molar and bicuspid teeth, 
which allows the whole force of occlusion to come upon 


751 


Teeth. 
Teeth, 


the anterior teeth. This irregularity causes the upper 
and under lips to protrude. 

On the other hand, the six anterior teeth of both jaws 
may be inverted, and a corresponding falling in of the 
lips occur. 

A V-shaped jaw is often seen ; this irregularity is con- 
fined to the upper jaw, whose alveolar arch, instead of 


Pa 


| 


Fie. 8775.—An Underhung Jaw, the Lower Front Teeth in advance of 
the corresponding Upper Ones. (Carabelli.) 


being in the form of a parabola, becomes so contracted in 
front that it resembles in shape the letter V. In such a 
jaw the room for the tongue is much diminished, and a 
thick and somewhat indistinct articulation may result. 

There are cases in which the back teeth are of undue 
length and prop the mouth open so wide that the anterior 
teeth do not meet. Such an arrangement is likely to 
keep the lips from closing, except as the result of con- 
scious effort. 

The dental arch may be asymmetrical. Such a condi- 
tion may be congenital, or produced by tongue-sucking in 
infancy. In this habit the tongue is crowded against the 
alveolus bordering the upper molars and bicuspids, a 
constant repetition of force in this direction unevenly 
spreading and thus distorting the dental arch. 

The ‘‘ flat mouth,” so called, is produced when the six 
anterior teeth of both jaws are arranged in nearly a 
straight line instead of in a curve. When so 
placed they join the bicuspids ata right angle, or 
nearly so, and give a characteristic flatness to 
the expression about the mouth. 

These various irregularities are, as a rule, con- 
fined to the permanent set. An underhung jaw 
has, however, been noticed in the temporary set, 
followed by the same in the permanent. 

Irregularities of individual teeth are to be ex- 
plained by several causes, of which the most im- 
portant is the occurrence of a small-sized jaw 
associated with large-sized teeth, a small-sized 
jaw being inherited from one parent and large 
teeth from the other. ; 

The premature extraction of the temporary 
teeth is responsible for many cases of irregular- 
ity. The place of each temporary tooth is taken 
normally by a tooth of the permanent set, and, 
unless the temporary tooth remains in situ till 
the permanent is ready to be erupted, there is danger 
that the place which the permanent tooth should occupy 
will be encroached upon by an adjoining tooth. 

The too long retention of the temporary teeth may 
produce irregularity. In this case the temporary teeth 
become an obstacle to the descending permanent teeth, 
and may deflect them from their course, forcing them to 
appear inside or outside the dental arch; or, as not in- 


752 


Fia. 3776.—A Case in which the Front Teeth meet Hdge to Edge. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


frequently happens, keeping them imprisoned within the 
maxillary bones. 

Irregularities of individual teeth of the temporary set 
are rare. There may bea slight twisting or lapping .of 
the incisors, but no great deformity has been observed. 
Most important irregularities occur in the permanent set; 
the superior central incisors may stand inside the dental 

arch, so that the inferior centrals close in front of 

them. Their crowns may be rotated either toward the 
median line or away from it, or may overlap each 
other. In the lower jaw the central in- 
cisors, owing to the frequent crowding 
of the lower anterior teeth, are often 
twisted or overlapped. The superior 
laterals are more frequently irregular 
than are the centrals. The most common 
irregularity consists in the crown of the 
lateral overlapping that of the central. The 
laterals may be placed within the dental arch 
and held in that position by the interlocking 
of the lower teeth. Sometimes it happens that 
they are prevented from eruption by the canines, 
which have, by premature eruption, occupied 
their space. The inferior laterals are liable to ir- 
regularities similar to those described in connection 
with the inferior centrals; such irregularities pro- 
duce, as a rule, no marked deformity, and are not 
usually of sufficient importance to be regulated. The 
superior canines are more often irregular than any other 
tooth in the mouth. The reason for this is not difficult 
to find, and has already been partly explained. Erupt- 
ing, as they do, subsequent to the lateral and first bicus- 
pid, it often happens that the space necessary for their 
regular appearance in the dental arch has been en- 
croached upon by the adjoining teeth. In consequence 
the canines must either take a position on the outside of 
the arch or within. Sometimes the canine takes a posi- 
tion alongside the central incisor ; when this is the case, 
the displaced lateral is usually within the arch. A ro- 
tated canine is not uncommon ; the rotation being toward 
the median line or away from it. The lower canines are 
seldom irregular. The upper first bicuspid also usually 
finds its normal place, on account of the period of its 
eruption and the fact that its crown is smaller than that 
of the first temporary molar which it supplants. : 


(Carabelli.) 


The second upper bicuspid is much more frequently 
out of place than is the first. Though its crown takes 
up much less room than that of the second deciduous 
molar, which it replaces, still the teeth adjoining it, 
namely, the first bicuspid and first molar, being in 
position some time before the second bicuspid is ready 
to erupt, may encroach upon the space which should 
have been reserved for that tooth. Such a condition 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Tecth. 
Teeth. 


usually results from the too early extraction of the 


second deciduous molar. 


As a result of such extrac- 


tion the neighboring teeth move together, and sufficient 


Fig. 3777.—Protrusion of the Anterior Teeth, caused by loss of Bicuspids 


and Molars. 


(Carabelli, ) 


room is not left for the free eruption of the second bi- 
cuspid, and that tooth, in consequence, finding its way in 
the direction of least resistance, is compelled to appear 
within or without the dental arch, as the case may be. 
The lower bicuspids are subject to irregularities similar 


ANN 


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Fie. 8778.—A V-shaped Upper Jaw, from Kingsley’s ‘‘ Oral Deformities.” 
(By permission.) 


to those of the upper bicuspids, although they occur less 
frequently. The first and second molars are rarely ir- 
regular in either jaw; each in turn being developed be- 
hind teeth already in place, there is nothing to crowd 


— - —s 


irregularity of the upper wisdom tooth is the turning of 
its crown outward or backward. 

Pathology in Stze and Shape of the Teeth.—As a rule, 
the size of the teeth is in harmony with the proportions 
of the body. Giants have teeth which would be abnor- 
mally large if found in a person of ordinary size. The 
teeth of males are larger than those of females. When 
teeth are of unusual size, but proportioned to the size 
of the individual, they are 
normal for that individual. 
There occur cases, however, 
in which certain teeth are 
entirely out of proportion 
to the alveolar arch. Such 
teeth may be too large or 
too small. Upper central 
incisors, in rare instances, be-— 
come a monstrosity in the exces- 

Sive size of their crowns; the roots 
in such cases are not developed in 
similar proportion. 
The superior canines sometimes possess 
abnormally long roots, whose length may 
not be suspected till an attempt is made to ex- 
tract them. Their extraction, on this account, 
is very difficult, or, perhaps, impossible. The mo- 
lar teeth are sometimes abnormally developed, the 
crowns and roots alike being of unusual size. .An ab- 
normal diminution in the size of the teeth is not com- 
monly found, except in the case of the upper wisdom 


on) “ CH 
if ) 
hey 
if y 


) 
! 
i 


2 Aw Dire 
{ ee Ay Ml i 


Ws = 
Nt 


oy 
\\s ” : 


Fra. 3750.—A case in which the superior canines have not room to erupt 
regularly in the arch, and are forced to appear within the arch. (Salter.) 


teeth, which are often quite small, no larger than a 
conical supernumerary tooth. Teeth which are patho- 
logical in shape are frequently observed. Their unusual 
shape may be due to a consti- 
tutional disturbance, occur- 
ring during their formative 
period, or it may be due toa 
freak of nature—a cause un- 
known. Of the irregular 
shapes produced by a constitu- 
tional disturbance is to be no- 
ticed a pitting of 2 

the enamel of the 
six anterior teeth, 
and sometimes of 
the molars in either 


them from their normal position. 


The third molar, on 


the contrary, has scanty room 
for eruption, and in conse- 
quence presents frequent ir- 
regularity. The lower third 
molar is often found with its 
crown presenting toward the 
posterior surface of the crown 
of the second molar. Some- 
times it is tipped forward so 
far that the force of occlusion 
and mastication is borne upon 
its distal surface. This is the 
most usual form of irregular- 
ity, but the tooth may assume 


Fie. 3779.—Is a case in which 
the superior canine has not 
room to erupt regularly in the 
arch, and is forced to appear 


outside of the arch. (Salter.) 


almost any position, even with the crown pointing back- 
ward toward the ramus of the jaw. The most frequent 


Vou. VI.—48 


Fic. 3781.—The Right Upper 
Canine, First and Second Bi- 
cuspids, and First Molar. The 
first molar and first bicuspid 
have moved together, probably 
on account of the premature 
extraction of the second tem- 
porary molar. The second bi- 
cuspid is thus prevented from 
erupting regularly, and must 
force its way outside the arch. 
In some cases further eruption 
would cease, and the tooth 
would remain in the position 
represented, (Carabelli.) 


a single crown. Sometimes the pits are stained 
a yellowish or yellowish-brown color. 


jaw. The pits may 
penetrate the entire 
surface of the en- 
amel, or only a 
part of it. They 
may be irregular- 
ly disposed, or, as 
usually occurs, ij 
may be arranged Fra. 3782,— 
in horizontal rows, Representsa 
of whichtheremay SyPener 


; nine with 
be two or three in an unusual- 


ly long root. 
(Carabelli. ) 


This 


irregular development is caused by some severe infantile 
disease occurring during the period in which the enamel 


753 


Teeth. 
Teeth. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


of these teeth is being calcified, the process of calcifica- 
tion being thus interrupted. The administration of mer- 
cury in the early years of childhood has also been con- 


Fria. 3783.—A Pitting of the Enamel of the Six Anterior Teeth, due to infantile disease arresting the pro- 
(Carabelli.) 


cess of calcification of the enamel. 


sidered by some to account for this irregularly formed 
enamel, but such a view is not now generally accepted. 
Another malformation due to a constitutional disturb- 
ance is that produced by inherited syphilis. The ef- 
fects of this disease upon the teeth are most notably 
seen in the upper central incisors of the permanent set. 
The crowns of these teeth are stunted in size, are some- 
what irregularly placed, and their cutting 
edges are narrower in width than are the 


cutting edges is imperfectly developed and 
soon crumbles away, leaving crescentic 
notches. The upper laterals and canines, as 
well as the lower centrals, laterals, and ca- 
nines may be affected in a similar but less 
marked way. The first molars are usually 
fs imperfectly developed, and from a loss of 

Fie. 3784.— enamel the corners of the teeth are rounded 
peg off, giving to the crowns a domelike ap- 
Khe ot Phe pearance. As the characteristics of teeth 
enamel, due affected by inherited syphilis were first de- 
to arrested scribed by Jonathan Hutchinson, it is com- 
(Gumball) mon to call such teeth Hutchinsonian teeth. 
They are also called notched teeth, from the 

notch which may be found in the cutting edge of the six 
anterior teeth. This notch, however, is obliterated by 
wear, and thus in time becomes lost as a diagnostic sign. 
The term peg teeth in this connection is commonly used, 
and refers to the peglike appearance of the crowns of the 
anterior teeth. The peg shape does not become oblit- 


aig 


erated by wear, and always remains a diagnostic sign. 


HHO 
| i Din 


" i 


Wi of 


} mn , 


’ Fre. 8785. 


Fie. 3786. 


Fias. 3785 and 3786 illustrate the effects of hereditary syphilis on the 
superior incisors of a boy and a girl, aged twelve and fourteen years, re- 
spectively. These cases came under the observation of Henry W. 
Williams, M.D., and are copied by permission, from his ‘‘ Diagnosis 
and Treatment of the Diseases of the Eye.” 


While inherited syphilis does not always leave its mark 
upon the teeth, yet when the appearances described are 
present they are considered to be positive evidence of 
this disease. The temporary teeth are said, by good au- 
thority, to be sometimes affected by hereditary syphilis, 


754 


necks of the teeth. The enamel on their’ 


and to become notched and peg-shaped after the manner 
of the permanent teeth. 

Pathological shapes to be ascribed to a freak of nature 
are not commonly met with; still, 
alarge number of such cases have 
been reporced, and drawings made 
to illustrate them. As one of the 
more frequent ir- 
regularities may be 
mentioned the fusion 
of adjacent teeth. 
There are two kinds 
of fusion; in one 
the union is accom- 
plished by the ce- 
ment of one root 
becoming increased \ 
and uniting itself to pie 37387. A 
the cement of an- Case of Fu- 
other root. In such mioe gutniade 
cases each tooth has P'S" Fateral 
a separate pulp-cav-  Incisors. 
ity and independent 
nourishment, the union being 
merely upon the outside and not 
affecting the individuality of 
either tooth. The other kind of 
fusion consists in the union of 
the dentine as well as the cement, and a fusion of the 
pulp-cavities into a single irregularly shaped space. 
Such teeth have a common and in- 
terdependent life. 

Fusion of this kind may be con- 
fined to the roots or include the 
crown as well, in which casea union 
occurs between the enamel of the 
two teeth. Fused teeth may be 
: found in the temporary or in the 

‘ permanent set, and any teeth may 
eee ee ihe Senorioc Gon, be so affected. Generally the fu- 
tral and Lateral Incisors. Sion is confined to two teeth. It is 

Anterior and posterior sometimes unsuspected when in- 

hone volving only the roots, and the at- 
tempt to extract either of the fused teeth may result in its 
companion also being dislodged, or in a failure to extract 
either. The first form of fusion probably 
takes place after the formation of the teeth, 
the latter while the teeth are in a develop- 
mental stage. ‘ 

There are irregular shapes not due to fu- 
sion, and which come under the head of 
miscellaneous forms. ‘The incisors some- 
times have their crown developed at right 
or obtuse angles with their roots, or have 
more than one root. ‘The canines may 
have a twisted root, or one with a sharp 
bend occurring at the middle or upper end 
of its length. The bicuspids may have two 
or even three roots. In consequence of the 
tendency of the roots of the bicuspids to bifurcate, this 
occasional development of two distinct roots 
is to be expected. ‘The upper and lower mo- 
lars may have as many as five roots, or all 
their roots may be fused into one. 

Pathology of the Component Tissues of the 
Teeth.—Of these tissues the pulp is most sub- 
ject to pathological changes. Normally this 
delicate and sensitive organ is well guarded 
by rigid walls, which not only protect it 
against external force, but also against the 
~ extreme thermal changes to which the oral 
Fi. 5790.—A cavity is exposed. So long, then, as the pulp 

or Central remains thus protected, it is not subject to 

Incisor hav- pathological changes; morbid processes do 

ae a ue not originate in its tissue. It is true that 

vot.» there are writers who describe affections of 
the pulp independent of outside influences, 

but the genuineness of such cases has not been well es- 
tablished. In general the pulp is subject to pathological 


ie 


Fre. 3789.—A 
Right Superior 
Central Incisor 
whose root is 
developed at 
right angles to 
the crown, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Teeth. 
Teeth. 


changes similar to those found in the soft tissue in other 
parts of the body ; such peculiarities as are found are due 
to the existence of the pulp within a bony encasement. 
It must be borne in mind that the pulp is very vascular 
and very sentient; that the vessels and nerves are sup- 
ported by a parenchyma of connective tis- 
sues, and that the whole organ is contained 
in an unyielding cavity whose only entrance 
and exit is a small foramen, whose calibre 
may not be larger than a bristle. Through 
this foramen the blood enters, and is in due 
time returned—a delicate piece of machinery 
capable of easily performing its duties when 
in natural adjustment, but impaired or de- 
stroyed when affected by force from without. 
Any agency which interferes with the pro- 
tection which nature has thrown around the 
pulp is calculated to set up morbid changes F1¢. 3791.—A 
in its structure and interfere with its func. "ish Supe- 


: rior Canine 
tion. The most potent and frequent agency with an ab- 
to be named is caries. When once this dis- is Sapa 

. * a e€ ena 
ease has located itself upon a tooth it usually Gr ine Root. 


progresses, unless checked by appropriate 
mechanical means, till a considerable portion of the en- 
amel and dentine are destroyed and the pulp laid bare. 
Long, however, before the pulp is reached, it has been 
subjected to conditions unfavorable to its healthy activity, 
and the chances are that when exposed by caries it is al- 
ready in a pathological condition. 

An agency in producing disturbances of the pulp, less 
important than caries, is the natural wearing away of the 
substance of the teeth in the process of mastication. 
Such wear is usually without serious effect 
upon the pulp up to, the period of middle 
life. Subsequent to that time, however, it 
may so deprive the pulp of its natural cov- 
ering as to induce pathological changes. 

A. third outside agency, and one less fre- 
quently met with than the other two, is 
mechanical violence, in the form of a blow 
or fall, of such a nature as to sever the 
union between the pulp and its blood- and 

nerve-supply. Under such circumstances 
Fre. 3792.—A the pulp, as a rule, dies. There are, how- 

Superior Bi- ever, cases reported in which a sound tooth 

eric deal ae having been pushed out of its socket has 

long Roots. been replaced, and the pulp has apparently 

remained in a healthy condition. Such 

~cases lend support to a supposition that a reunion is pos- 

sible between the pulp and its blood- and nerve-supply ; 
but this point has not yet been satisfactorily settled. 

One of the simplest and commonest pathological affec- 
tions of the pulp is congestion. A pulp examined in 
this condition shows increased redness, due to an in- 
creased flow of blood to the part and dilatation of the 
vessels. This condition is brought about through the 
vaso-motor system, which responds to an irritation of 
the dentinal fibrils, which are in connection 
with the nerves of the pulp, and so with the 
general nervous system. Inasmuch as the 
normal pulp fills its cavity, an increased 
supply of blood must compress the tissue in 
the neighborhood of the vessels. The nerves 
share this compression, and hence the severe 
pain which is the usual accompaniment of a 
congested pulp. Caries of the tooth is the 
most common cause of congestion of the Fi. 3793, —A 
pulp. Through it a cavity in the direction Oe awith 
of the pulp is produced which allows hot and © Three Roots. 
cold drinks, food, and cold air to approach 
so near the pulp that they irritate it. Salt and sweet sub- 
stances, also, if allowed to enter the cavity produced by 
the caries will act upon the dentinal fibrils and irritate the 
pulp. A congested pulp is hypersensitive, giving pain 
upon the slightest occasion. A draught of cold water, 
the effect of which upon a normal pulp might be but a 
momentary twinge, would cause a congested pulp to ache 
violently. This ache is one of the more common kinds 
of toothache ; it is violent, intermittent, throbbing. It is 


very likely to be worse at night when the body is in a re- 
cumbent position. Congestion of the pulp does not neces- 
sarily result in a permanent pathological condition, pro- 
vided the environment of the pulp can be so improved as 
to become normal, or nearly so. The normal environment 
may be restored by filling the cavity produced by caries, 
the pulp being thus removed from the near approach of 
heat or cold and irritating substances. The filling 
material should be a poor conductor of heat and cold, re- 
sembling in this respect, as far as possible, enamel and 
dentine. Gutta-percha or oxyphosphate cement have 
proved the best substances with which to protect a con- 
gested pulp. Itfrequently happens that the pulp becomes 
congested in a tooth which contains a large metallic fill- 
ing. The metal filling, being a good conductor of heat 
and cold, conveys injurious shocks deep into the dentine 
and unfavorably affects the pulp. Such 
a condition may be remedied by substitut- 
ing a non-metallic filling for a metallic 
one. 

While a congested pulp may recover 

its normal condition, it frequently passes 
into a state of inflammation which may be 
either acute or chronic. In acute inflam- 
mation there succeeds to the active hyper- -: 
emia of congestion a stasis of blood in the F16. 3794.—A Mo- 
inflamed portion; the vessels become di- Maryse Hee 
lated more than before, and often assume ; : 
a tortuous course. The leucocytes can be seen leaving 
the capillaries and invading the surrounding tissue. If 
the inflammation is purulent, pus cells and broken-down 
tissues become abundant. The affection may be local, 
confined to a small point which has been exposed by ca- 
ries, or it may be general, involving the entire pulp. The 
organ is swollen, as in congestion, and pain results from 
pressure upon the nerve-fibres. If the inflammation is 
very violent, it is likely to destroy the life of the pulp in 
a short time, through pressure upon the blood-vessels at 
the foramen. The symptoms attending an inflammation 
of the pulp are similar to those of a congested pulp, but 
more severe. The pain is violent, throbbing, paroxys- 
mal, and is commonly known as a ‘‘ jumping toothache.” 
The tooth is extremely sensitive to heat and cold, to 
sweet and salt substances, and to pressure within the cav- 
ity of decay. 

Such an acute inflammation may subside or pass into a 
chronic inflammation, the symptoms of which resemble 
those of the acute, but are of a less severe grade. The 
cause of inflammation of the pulp is caries, which, as a 
rule, has penetrated to the pulp cavity and laid bare a 
minute portion of that organ, exposing it to the irritation 
of foreign bodies, thermal changes, and the secretions 
of the oral cavity. When suppurative in- 
flammation occurs, the probable agency of 
bacteria is of interest, as it is well known 
that many varieties of these organisms ex- 
ist in the mouth. Their approach to the 
pulp is made easy through the carious cav- 
ity, which lays bare the pulp, and the con- 
ditions seem favorable for their peculiar 
activity. Dr. H. C. Ernst says, in his 

Ss: ‘Consideration of the Bacteria of Surgical 
Fre. 8795.—A Diseases” (p. 4): ‘‘ The point being deter- 
volar ctearg Mined that there is at least a very strong 
fused into one. probability that no suppuration occurs 
without the presence of bacteria, the 

study of the organism concerned in these processes be- 
comes at once of great interest.” Dr. Black, in the 
«American System of Dentistry,” while admitting the 


z 


‘probability that micro-organisms are influential in sup- 


purative inflammations of the pulp, says that in the cases 
which he has examined he has as yet failed to discover 
their presence. The course pursued by an inflammatory 
affection of the pulp depends largely on the extent to 
which its surface has been exposed through caries. That 
there is always such an exposure in case of inflammation 
of the pulp cannot be affirmed, but that it does exist in the 
large majority of cases is attested by experience. If 
this exposure is small and allows no relief to the swollen 


7d5 


Teeth. 
Teeth, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


condition of the organ, and no sufficient outlet to prod- 
ucts of inflammation, then an acute inflammation is 
likely rapidly to destroy the pulp, and transmit an in- 
flammatory process along the root canals to the periden- 
tal membrane. If, however, the pulp has been freely 
exposed before an inflammation has been started up, then 
the inflamed pulp has a way of relief to its enlarged sub- 
stance, and an exit for the products of inflammation. 
Such cases are more likely to assume a chronic form, in- 
asmuch as the life of the pulp is not immediately threat- 
ened. It is a matter of some chance, in the case of a 
pulp exposed by caries, just how soon an inflammatory 
affection will be started up, though no pulp when once 
exposed can long escape. If the cavity which exposes 
the pulp is hidden away in the back of the mouth, or 
protected by adjoining teeth, so that the pulp of the 
tooth is, in a measure, protected from alternations of 
temperature and severe contact with food, then the in- 
flammatory affection may be delayed, and, when it does 
come, decay may have so opened the pulp cavity as to 
greatly modify the severity of the inflammation. On the 
other hand, when caries attacks the crown of the first 
molar and lays bare the pulp, it is immediately subject 
to severe irritation in the process of mastication, and 
trouble begins at once. Inflammatory affections of the 
pulp do not tend to recovery, but generally end in death 
of the pulp. This result may be, however, somewhat 
delayed by appropriate treatment. The exposed pulp 
may be capped over with non-irritating, non-conducting 
material, and thus shielded. It is sometimes possible to 
prolong the life of the pulp several years, provided the 
treatment is not long delayed after the beginning of the 
inflammatory affection. After having been thus treated 
the pulp may give no further sensation of pain ; it does 
not, however, often regain its normal condition when it 
has once passed through the inflammatory process. 

To alleviate the pain of a congested or inflamed pulp 
it isimportant, first, to determine which tooth is giving 
trouble. The testimony of patients cannot be relied 
upon to settle this point. They can usually indicate cor- 
rectly the side upon which the affected tooth is located, 
but will often point to a perfectly sound tooth as the 
cause of their pain. A thorough examination should be 
made, by the aid of the mouth-mirror and a fine explor- 
ing point, of all suspected teeth. If a tooth is found with 
a carious cavity of any considerable size, especially if 
the cavity is sensitive to the touch of an instrument, it is 
fair to infer that such a tooth is the one giving pain. 
The diagnosis can be confirmed by the application of a 
little cold water to the cavity of decay. Where a con- 
gested or inflamed pulp exists, this application will cause 
an exacerbation of the pain. 

Having located the tooth which is the seat of the diffi- 
culty, its carious cavity should be washed out with a 
syringeful of warm water, in order to remove irritating 
particles of food. The next step is to make an applica- 
tion to the exposed pulp, or, if the pulp is not exposed, 
to the dentine in the neighborhood of the pulp, which 
will allay the pain. 

A simple and efficacious remedy is the oil of cloves. 
More powerful remedies are: Carbolic acid, ninety-five 
per cent.; creasote; a mixture of equal parts of oil of 
cloves and chloroform ; a mixture of equal parts of oil 
of cloves and creasote. 

One drop of any of these remedies is usually sufficient 
for a single application, The medicine should be applied 
to the cavity on a pledget of cotton. Care should be 
taken not to press the cotton too tightly into the cavity, as 
it might thus become a mechanical irritant to an exposed 
pulp. In the use of concentrated carbolic acid, care 
should be taken to prevent its spreading to the adjoining 
gum and mucous membrane of the lips and cheek. 

It is very important, in treating toothache, to know 
whether the pulp in the affected tooth is alive or dead: 
If alive, it will respond to thermal changes and be sensi- 
tive to exploration in the carious cavity, and should be 
treated as just described. If the pulp is dead the tooth 
is usually sore to percussion, and unaffected by applica- 
tions of cold, though heat will usually be painful. 


756 


It is not sensitive to the exploration of an instrument 
in the cavity of decay. The carious cavity of such a 
tooth should not be plugged with any dressing, but 
should be opened freely to give vent to the decompos- 
ing pulp in the manner described in the section on affec- 
tions of the peridental membrane. : 

Closely allied to inflammation of the pulp is abscess of 
the pulp. This affection, clinically, cannot always be dis- 
tinguished from the preceding. Upon microscopic ex- 
amination, however, it is possible to make out true ab- 
scess cavities. ‘These may be deeply situatedin the body 
of the pulp, or near its surface. 

The microscopical examination of a diseased pulp is 
conducted in the following manner: An aching tooth, 
which is presumably in a pathological condition, is ex- 
tracted and at once dropped into Miller's fluid ; here it 
is to remain for several weeks till the pulp has become 
somewhat hard. Then the tooth, after having been 
wrapped in a cloth, is to be put between the jaws of a 
vise, and carefully cracked open, and the pulp removed 
from its cavity. The pulp is again subjected to Miller’s 
fluid, and then to gum arabic, which permeates its sub- 


Fia. 8796.—Initial Points of Calcification occurring in the Pulp. 


stance and forms a stiff coating outside. The whole 
mass is then mounted in paraffine, and is in condition to 
be cut with a microtome. In this way the relation be- 
tween clinical symptoms of the pulp and pathological 
changes in that organ can be accurately traced. 

Among the more advanced pathological changes in the 
pulp may be mentioned gangrene. ‘This, as in other 
parts of the body, may be moist or dry. Gangrene fol-. 
lows upon the sudden cutting off of the circulation from 
the pulp, as a result of acute inflammations, or violence 
to the tooth of such a kind as to sever the artery at the 
apical foramen. A gangrenous pulp is of a grayish-green 
color, of slight consistency, and fetid odor. In such a 
pulp the normal structural elements become undistin- 
guishable. In dry gangrene the pulp contracts to a very 
small compass, and the part of the pulp cavity thus left 
vacant is occupied by a gas of decomposition. Gangre- 
nous pulps, unless the pulp cavity is freely opened, pro- 
duce severe inflammation of the peridental membrane. 

Another group of pathological changes embraces the 
various forms of calcification to which the pulp is sub- 
ject. Among such may be mentioned the nodular form. 
In this variety small nodules of calcareous matter are 
sprinkled through the substance of the pulp, giving to it . 
a gritty feel. The calcareous matter is similar in chem- 
ical composition to dentine, but does not have its charac- 
teristic structure. The calcareous nodules are located 
between the component parts of the pulp, and are not 
formed at their expense. This condition seems to be 
compatible with a healthy activity of the pulp, and ap- 
parently does not lead to serious consequences. _ Its eti- 
ology has not been explained. Another form of calcifi- 
cation exists, in which the new-formation takes the place 
of the normal tissue of the pulp and is formed at its ex- 
pense. ‘The calcareous points are found scattered here 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Teeth. - 
Teeth. 


and there through the pulp, usually in the coronal por- 
tion. These points become confluent till an aggregation is 
formed ranging in size from a grain of sand up to a mass 
sufficient to fill the entire pulp cavity, coronal and radi- 
cal portion as well. This form of calcification appar- 
ently does not take place when the tooth is in a normal 
condition, but seems to be induced either by the wearing 
down of the crowns of the teeth or by caries. In both 
cases the dentinal fibrils are subject to irritation, and this 
irritation determines the deposition of lime salts in the 
substance of the pulp. When once such a deposition be- 
gins, it tends to increase till the pulp is changed from a 
highly sensitive living organism to one practically life- 
less, without nerves or vessels, and without the system 
of tubules which exists in the dentine. During the course 
of calcification quite severe pain may arise, evidently due 
to the pressure of the calcareous masses upon the nerve- 
filaments. 

A pathological change similar to that occurring in cal- 
cification of the pulp is that which takes place in the for- 
mation of secondary dentine. This formation is found 
on the periphery of the pulp at a place adjacent to a ca- 
rious cavity, and is deposited by the odontoblastic layer 
of the pulp, which is the formative agent in normal den- 
tine. Secondary dentine is evidently a means taken by 


a 


Mee 


i 
ha hie 


_ Fa, 8797.—A Section across the Neck of a Molar, showing a Growth of 
Secondary Dentine in the Pulp-cavity. 


nature for the protection of the pulp against the injurious 
influences incident to advancing caries. Secondary den- 
tine is similar in structure to normal dentine, containing, 
like it, tubules and fibrils. Its formation is, however, 
somewhat less regular, and in case the secondary dentine 
extends far toward the interior of the pulp, it loses its 
supply of dentinal tubes and becomes less like dentine, 
and more like a calcified pulp. While the formation of 
secondary dentine in the neighborhood of decay undoubt- 
edly tends for atime to prolong the life of the pulp, ex- 
perience seems to show that secondary dentine, when 
once deposited, tends to increase to such proportions as in 
the end to destroy the life of the pulp. 

The process just described is to be distinguished from 
that deposition of dentine which takes place by degrees 
during the whole life of the tooth. This deposit is very 
slow in formation, and takes place uniformly around the 
inner side of the whole pulp-cavity. By this physiologi- 
cal deposition of dentine the pulp-cavities in the teeth of 
old people are reduced to very small proportions. This 
seems to indicate that the pulp is useful and necessary 
inversely to the age of the tooth. 

There remains to be mentioned a pathological change 
which increases the size of the pulp. Such an increase 
can occur only in case the pulp has been exposed. Let 
such a pulp be subjected to the irritation of foreign sub- 


stances, and likewise to that of the sharp edges of a ca- 
rious cavity, and it will sometimes proliferate and fill the 
cavity. 

Why the pulp does not become inflamed and destroyed 
under such circumstances cannot be explained. This 
process has usually been noticed in the case of young 
teeth. The growth may assume 
the size of a pea, or be larger. It 
is of fleshy consistency, and is or- 
ganically united to the pulp by a 
narrow pedicle, hence it is called 
polypus of the pulp. In micro- 
scopic examination it is found to 
consist of numerous round and 
spindle-shaped cells, interspersed 
with fibrous tissue, and an epithe- 
lial covering has been described 
by some writers. Its blood-vessels 
pursue a tortuous and irregular 
course, unlike those in the pulp. 
No nerves have been found in this 
tumor, yet it is slightly sensitive 
to touch, resembling the gum in 
this respect. Sometimes a muco- 
purulent discharge issues from its 
periphery. A polypus protects the 
pulp against external violence. It 
is extremely tenacious of life, and 
will grow again if cut off. 

A growth similar to a polypus 
takes place in some cases of fract- 
ured teeth. The pulp having been 
exposed, proliferates through the 
openings caused by the fracture 
and forms a tumor outside the pulp- 
cavity. This tumor, morphologi- 
cally, resembles a true polypus of 
the pulp; it has, however, a nerve- 
supply, and is quite sensitive to the 
touch, thus differing from a poly- 
pus. Salter has named this growth a “‘ sensitive sprout- 
ing of the pulp.” . 

Under pathology of the dentine the most important pro- 
cess to consider is caries. This process affects the enamel 
and cementum as well as the dentine, but has more to do 
with the dentine than with the other tissues. In the first 
place, it may be said that caries of the teeth does not re- 
semble caries of bone. The term caries as applied to the 
teeth is a misnomer, given at a time when the true nat- 
ure of the process was not understood. However, the 
term has become so generally used that it cannot now be 
easily dropped. The pathological change which occurs 
in caries is a decalcification and disintegration of the 
several tissues of the teeth. The latter condition follows 
very quickly upon the former, on account of the large 
proportion of earthy constituents existing in the parts at- 
tacked. Caries may affect any of the teeth of either den- 
tition, but it affects certain teeth more fre- 
™. quently than others. Magitot has tabulated 
ten thousand cases of caries occurring in the 
permanent teeth, and his tables show that the 
tooth most liable to caries is the first lower 
molar, after which follow in succession the first 
upper molar, the second lower molar, first up- 
ii |) per bicuspid, second upper bicuspid, upper 
4 j ff lateral, second upper molar, upper central, 

w second, lower bicuspid, upper canine, first 
Fie. 3799.— ]ower bicuspid, upper wisdom, lower wisdom, 

oor as lower canine, lower central, and lateral. Ca- 

occupying ries not only shows a preference for certain 
the Cavity teeth rather than for others, but it also shows 

Pe eae: a preference for certain parts of individual 

’ teeth rather than for other parts. Those sur- 
faces of the teeth which are smooth and kept clean by 
the motions of the tongue, lips, and cheeks, are not at- 
tacked by caries; while surfaces presenting an uneven 
contour, abounding in pits and fissures, are its favorite 
seat. Hence, we find it located in the crowns of the 
molars and bicuspids, in the pits on the lingual surfaces 


757 


Fra. 8798. — An Incisor 
Tooth affected with Ca- 
ries, a, A deposition of 
secondary dentine about 
the cavity of decay. 


Teeth. 
Teeth. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


of the six superior front teeth, and on all approximal 
surfaces which, though not uneven, are not cleansed 
by the motions of the mouth. The buccal and labial 
surfaces of the teeth, just at the margin of the gum, are 
likewise often the seat of caries. Caries manifests its 
presence by a change of color in the tissues attacked. 
This change may be merely from translucency to opacity, 
or to a variety of colors ranging from yellow to brown, 
and even black; sometimes a gray or bluish-gray is seen. 
As a rule, the slower the progress of the disease the 
deeper the color of the affected parts, and conversely, the 
more rapid its progress the lighter the color of the af- 
fected parts. Caries usually attacks the enamel first, 
though it may begin with the cementum. It starts in a 
small pit or fissure, where soon the enamel is found to 
have lost its peculiarly hard and dense surface. Instead 
of resisting the most highly tempered steel instruments, 
as does normal enamel, it crumbles away under slight 
force. Thus a small opening is made through the enamel 
tothe dentine. This opening may be as large as the head 
of a pin, or it may be very minute. During this process the 
enamel has become decalcified and disintegrated. Some 
authorities say that the centre of the enamel prisms are 
first affected, and others that the interprismatic substance 
is first destroyed, in consequence of which the prisms 
separate and fall to pieces. When once caries has per- 
forated the enamel it no longer confines itself to a narrow 
area, but spreads out laterally between the enamel and 
dentine. The degree of lateral extension varies greatly, 
but seems to be somewhat dependent on the structure of 
the dentine. Ifthe dentine is well calcified, and with 
few interglobular spaces, the lateral extension is not so 
great as when the dentine is imperfectly calcified and 
abounding in interglobular spaces. The carious process 
in its lateral extension seems to follow the anastomoses 
of the dentinal tubules, which are very abundant at the 
junction of the dentine and enamel. After having af- 


fected a certain area on the periphery of the dentine, 
caries penetrates its substance, following the tubules 
Inasmuch as the tubules converge 


toward the pulp. 


Fie. 8800,—Microscopic Section through a Carious Cavity occurring in 
a Molar Tooth. A, the initial opening through the enamel; B, the 
cone-shaped area of decay—the affected tissue being discolored and 
somewhat softened, but not disintegrated; C, a minute pit in the en- 
amel where caries has just started; D, the enamel; E, the dentine; 
F, the pulp-cavity. 


from the periphery of the dentine toward the pulp-cav- 
ity, the progress of caries is marked by a cone-shaped 
area, the large end of the cone being in the periphery 
of the dentine, and the small end pointing toward 


758 


the pulp. Caries tends to penetrate the pulp-cavity, and 
rarely fails, unless checked by mechanical means. When 
once the pulp-cavity has been penetrated, the pulp is ex- 
posed to the degenerative changes already described, and, 


Fi1a@. 8801.—Microscopie Section through a Molar Tooth affected with 
Caries. The darkly shaded portions represent a brown discoloration. 


as a rule, dies and disintegrates. The carious process 
then invades the pulp-cavity, meanwhile spreading later- 
ally through the dentine from the area originally attacked, 
and disintegrating the enamel from the under side. By 
degrees the crown of the tooth becomes so hollowed out 
by the continuous softening and disintegration of the 
dentine that the shell of enamel left becomes unable to 
withstand the force of mastication, and consequently is 
broken away. Nor does caries stop with the destruction 
of the crown, it continues its work in the root, enlarging 
the root-canal at the expense of the surrounding root- 
substance until the root becomes a mere shell, and is final- 
ly entirely disintegrated. The carious process in the 
root is not so rapid as in the crown, and roots may 
withstand its action for years. 

The microscopic examination of the carious 
process shows the change in color of the affected 
parts which has been described, and the disinte- 
H) Q gration of the enamel rods. The tubules of the 
G dentine appear enlarged in calibre; and their 
size increases as the process advances. ‘The inter- 
tubular substance diminishes with the enlarge- 
ment of the tubules, and finally disappears with 
the confluence of adjacent tubules. Micro-organ- 
isms are found in great numbers within the tubules. 

In the cement, the carious process is similar to 
that found in the dentine. The lacune and ca- 
naliculi are enlarged at the expense of the sur- 
rounding tissue, which softens and breaks down 
as the process advances. 

Micro-organisms are present as in carious den- 
tine, 

A chemical change to be especially noted in 
connection with all the tissues affected by caries 
is the acid reaction which is invariably present. 

Etiology of Caries.—There are certain predis- 
posing causes upon which all are agreed ; of such 
may be mentioned a faulty calcification of the en- 
amel, which leaves the dentine exposed ; a faulty calcifi- 
cation of the dentine, which leaves it less able to resist 
degenerative changes ; a crowded condition of the teeth, 
on account of which it is difficult to keep the spaces be- 
tween the teeth clean. 

With regard to the exciting or immediate causes of 
caries, there has been great diversity of opinion. Of the 
ancient pathologists, some ascribed caries to a disturb- 
ance in the ‘‘ humors of the body.” Others regarded it 
as due to the ravages of worms which infested the oral 
cavity. 

When we come to observers of scientific repute, we 
find that the older ones held to a vital or inflammatory 
theory. According to them, the disease began from 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


within, by an inflammatory process of the dentine or 
pulp, the process in dentine resembling caries of bone ; 
hence the term caries was applied to it also. 

The vital theory of caries has been effectually dis- 
proved by the fact that when natural teeth have been 
mounted upon artificial plates, and thus worn in the 
mouth, they have been subject to caries precisely resem- 
bling the caries of the teeth normally situated in the jaw. 

By others, caries was considered to be a sort of gan- 
grene, due to a disturbance in the nutrition of the den- 
tine. 

When, however, the secretions of the mouth came to 
be studied with reference to their possible agency in pro- 
ducing caries, and when they were found to be at times 
acid, and when, also, the acid fermentations occurring in 
the mouth came to be studied in this connection, there 
was developed what is called the acid theory of caries. 
According to this theory, caries originates from without 
and not from within, as those holding the vital theory 
claimed. The active agency in producing it is acids, which 
are always present in the mouth, due either to acid secre- 
tions or acid fermentations. These acids are to a large 
extent, it is true, neutralized by the alkalinity of the 
normal mixed saliva; but in some places, as in the 
crowns of molars and in the spaces between the teeth, 
the acid secretions are so protected from the neutralizing 
influence of the saliva that they are able to retain their 
reaction and attack the enamel, decomposing the phos- 
phate of lime and other mineral constituents, of which it 
is largely composed. Having penetrated the enamel, the 
acids act in a similar manner upon the dentine. Accord- 
ing to this theory the tissues of the tooth are affected by 
chemical decomposition, as if there were no vital element 
whatever concerned. To substantiate this view many 
experiments were made, by subjecting extracted teeth to 
the influence of a weak acid solution imitating conditions 
found in the mouth. Teeth thus treated underwent a 
softening and decalcification similar to that found in the 
mouth in the case of caries. The point was thus well 
established that caries consisted in the decalcification and 
disintegration of the mineral constituents of the teeth by 
an acid. 

While some have held a vital theory to account for ca- 
ries, and others an acid theory, still others again have 
taken middle ground and held a chemico-vital theory. 

The discovery of the presence of micro-organisms in the 
tubules of dentine affected by caries was an important 
step in advancing our knowledge of the process. The 
_ name of leptothrix buccalis was given to these organisms 
when first discovered. Though their true agency in caries 
was not at once understood, they were considered to play 
an important réle. During the last few years, however, 
extensive investigations have been made to determine 
more accurately the nature of the micro-organisms found 
in the mouth, and their relation to the process of caries. 
The most valuable of these investigations have been con- 
ducted by Dr. W. D. Miller, of Berlin. His method has 
been to infect sterilized culture media of various kinds 
with neutral saliva or with neutral carious dentine, and he 
has found, invariably, that, when the culture medium con- 
tains sugar, an acid is produced. By successive cultures 
he has isolated the organisms which produce the acid. Of 
the organisms he writes as follows: ‘‘ We have, then, in 
carious dentine, two distinct fungi—one always, the other 
often, present ; the former surely, the latter probably, pro- 
ducing lactic acid from sugar” (‘‘ American System of 
Dentistry,” vol. i., p. 803). Perfectly sound dentine, sub- 
jected to a pure culture of the fungi just mentioned in a 
medium containing sugar, underwent, in course of time, 
typical caries. According to Dr. Miller—and his theory 
is now quite generally accepted—the history of caries is 
as follows: It starts wherever, from the contour of indi- 
vidual teeth or from the relation of one tooth to another, 
a collection of food is possible. In every such collection 
are multitudes of micro-organisms which are capable of 
thriving in the presence of sugar, and of decomposing 
this substance and forming lactic acid. This acid decal- 
cifies the enamel and forms a small pit which, being con- 
stantly filled with food, offers a favorable nidus for the 


Teeth. 
Teeth. 


continued growth of the same organisms. When the 
enamel has been penetrated, the organisms begin to mul- 
tiply in the tubules of the dentine, and there continue 
the decomposition of sugar absorbed from the mouth. 
The resulting lactic acid enlarges the tubules by the de- 
composition of the mineral constituents of the dentine. 
According to this theory, the secretions of the mouth 
have very little todo with the production of caries. Itis 
possible that at one time the secretions of the mouth may 
be more unfavorable to the life of micro-organisms than 
at another, since it is well known that, at 
certain times and in certain individuals, 
caries progresses very rapidly. 

A condition resembling caries, and yet 
essentially differing from it, is erosion. 
Erosion is commonly found on the labial 
surface of the six anterior teeth, either at 
the margin of the gum, or between it and 
the cutting edge. It also sometimes af- 
fects the bicuspids and molars. Erosion py¢. 3g92,—Noau- 
produces shallow cavities, which involve lar Hypertrophy 
the enamel and penetrate to the dentine, of Cement in the 
These cavities are larger at their external CoS,o09 Baba 
opening than in their deeper parts, and 
are smooth, hard, and polished throughout. They pre- 
sent neither the characteristic softening nor undermining 
growth which are found in caries. The cavities do not 
rapidly enlarge, but may become of such size as to 
threaten the life of the pulp. Caries is sometimes super- 
added to erosion, thus modifying the course of the de- 
structive process. The etiology of erosion is obscure; 
but it is usually assigned, in lieu of a more probable 
cause, to the effect of acid mucus. 

Pathological Changes in the Cement.—The most common 
pathological change of the cement is an hypertrophy, 

which is due to an irritation of the peri- 
dental membrane. This membrane, lying 
between the cement of the root and the 
bony alveolus, is at once the formative 
membrane of the cement of the tooth and 
of the adjacent bone of the alveolus. 
When, however, the cement of the root 
has been completed, the activity of the 
peridental membrane, so far as its cement- 
aval 4c Hypebend: forming function is concerned, normally 
phy of the Ce- ceases. It does not resume this function 
ment about the unless subjected to irritation, in which 
nO an Tn case it may deposit additional cement 
upon the root in various ways. The de- 
posit may be diffuse, covering the entire root, though 
most abundant at the apex. It may be nodular, the no- 
dules being found at any point on the root, and being of 
various sizes; or it may consist of a club-shaped enlarge- 
ment at the end of the root. 

The added cement is similar in structure to the pri- 
mary cement, the union between the two deposits being, 
as a rule, not noticeable. In certain cases, however, 
blood-vessels penetrate this secondary deposit of cement, 
a condition not found in the primary deposit. Hyper- 
trophy of the cement has never been ob- voter: 
served in the case of the temporary teeth, fas 
and affects the permanent teeth during 
adult life. The teeth most commonly in- 
volved are the upper bicuspids and molars, 
though the others are not exempt. Hyper- 
trophies of the cement are called hyper- 
cementoses, osteomata, and exostoses. Of 
the causes which produce an irritation of 
the peridental membrane, and consequent Fie. 88C4.—Hy- 
hypertrophy of the cement, perhaps the Pertrophy of 
most frequent is caries with its sequel,  abouttheend 
viz., inflammation and death of the pulp, ofthe Root of 
with extension of the inflammation to the #Bieuspia 

. : ooth. 
peridental membrane. Another cause is 
the undue pressure which teeth are sometimes subjected 
to in the process of occlusion and mastication. This 
arises when many of the teeth have been lost and the few 
remaining ones are compelled to bear all the strain of 
service. In such cases the peridental membrane is over- 


Fre. 3808, — Gen- 


759 


Teeth. 
Teeth. 


worked, literally crowded to the wall, and in consequence 
may become irritated. The same effect may be produced 
by the insertion of fillings which project from the crown 
of a tooth so far as to concentrate the force of occlusion 
on the filled tooth. While hypertrophy of the cement is 
commonly due to irritation from undue force, there are 
cases in which teeth having no antagonists are found to 
have hypertrophied cement. The symptoms which may 
arise from an hypertrophy of the cement are caused by 
the pressure of the new-growth upon the nerves of the 
peridental membrane and upon the nerves of the pulp at 
the apical foramen. Many cases of hypertrophy exist 
which occasion no symptoms, the condition becoming 
known only after extraction. In old people it is usual to 
find the cement somewhat thickened, and this change can 
almost be called physiological, so constantly does it oc- 
cur. Doubtless the process is so gradual that the sur- 
rounding tissues accommodate themselves to the enlarged 
root, and their nerves are subjected to no irritation. In 
other cases pain is an important and persistent symptom. 


The pain may be localized and accompanied by a soreness © 


in the socket, or it may be diffused throughout the jaw or 
reflected to adjoining parts of the head. Severe neural- 
gias of the head, face, and neck have been found to owe 
their origin to the hypertrophy of the cement of a tooth. 
The tooth may appear to be perfectly sound, in which 
case it is exceedingly difficult to locate the source of the 
pain. When, however, neuralgias exist in connection 
with teeth which, though not carious, are the seat of pain 
or are sore in the socket, it is fair to suspect either an hy- 
pertrophy of the cement or a calcification in the pulp. 
Not only does an enlarged cement cause severe neuralgic 
pains about the head and face, but cases of epilepsy and 
insanity have been reported as due to the same cause. A 
case from Tomes’ ‘‘ Dental Surgery” is in point. “A 
lad, a farm-laborer from Windsor, was admitted into the 
Middlesex Hospital for epilepsy. The usual remedies 
were tried for six weeks without effect. His mouth was 
then examined and the molar teeth of the lower jaw 
found to be much decayed, the fangs of some alone re- 
maining. Although he did not complain of pain in the 
teeth or in the jaw, the decayed teeth were removed, and 
the fangs of each were found to be enlarged and bulbous 
from exostosis. During the eighteen months that suc- 
ceeded the removal of the diseased teeth, he had not suf- 
fered from a single fit, though for many weeks previous 
to the operation he had had two or three per day.” 

A second pathological change of the cement is absorp- 
tion. This is often found in connection with hyper- 
trophy, and occurs at scattered points and produces de- 
pressions in the surface of the cement. In cases of long- 
continued inflammation about the apex of the root, the 
cement is likely to be in part absorbed, giving a rough 
outline to the apex. 

Pathology of the Peridental Membrane.—Disease of the 
peridental membrane may be due to a constitutional dis- 
turbance, or to pathological affections of the pulp, or may 
be dependent upon, or associated with, calcareous deposits 
upon the root of the tooth. Of the constitutional affec- 
tions which react upon the peridental membrane, Tomes 
enumerates rheumatism, syphilis, and the exhibition of 
mercury. 

Inflammation of the peridental membrane from rheu- 
matism is independent of caries, and may involve one or 
more teeth. The inflammation is distributed over the 
entire membrane, causing a loosening of the tooth and a 
soreness in the socket. Its course is subacute or chronic, 
does not tend to abscess, and is amenable to constitu- 
tional treatment. 

Inflammation of the peridental membrane from syph- 
ilis is chronic. Pus may be discharged around the neck 
of the tooth, which becomes sore in the socket and loose. 
If the disease is unchecked the teeth may fall out of their 
own accord, owing to a complete destruction of the peri- 
dental membrane. Associated with this process there 
often occurs a necrosis of the surrounding bone. 

Inflammation from the administration of mercury, 
whether in the treatment of syphilis or not, is associated 
with ptyalism, and is of a subacute or chronic character. 


760 


‘way of the apical foramen. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


The teeth become loosened and sore in their sockets, and, 
if the drug is long continued, a discharge of pus around 
the neck of the teeth and final loss of the teeth may re- 
sult, 

The effect of phosphorus upon the peridental mem- 
brane, though not belonging strictly under constitutional 
affections, is of great interest. Persons subjected to the 
fumes of phosphorus, as are those who work in match 
factories, often have necrosis of the maxillary bones. 
This necrosis starts with an inflammation of the peri- 
dental membrane, which is very sensitive to the irri- 
tating fumes of phosphorus. As a result of inflamma- 
tion the membrane is destroyed, and the bony alveolus 
being thus cut off in large degree from its source of 


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Fria. 38805.—The Relation between the 
Membrane, and its Bony Socket. 1, The enamel; 2, the dentine; 3, 
the cement; 4, the peridental membrane, which is also the periosteum 
of the socket ; 5, the bony socket. 


nourishment, necrosis is invited. It has been found that 
this disease mainly affects operatives in whose mouth are 
carious teeth, or who have had teeth extracted while 
pursuing their occupation. The phosphorus fumes enter 
a carious cavity and reach the peridental membrane by 
If, however, the teeth are 
sound and the gums healthy, phosphorus has little if any 
destructive effect in the mouth. | 
Pathological affections of the peridental membrane 
consequent upon disease of the pulp are of frequent oc- 
currence. When the pulp has become severely inflamed 
it is common to find, in addition to the symptoms attend- 
ant upon simple inflammation of the pulp, a soreness of 
the tooth in the socket. If the tooth is then percussed 
with a steel instrument the patient will flinch. This is 
an indication that the inflammation has proceeded up the 
root-canal and extended to the peridental membrane situ- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


ated around the apex of the root. Symptoms pointing 
to inflammation around the root do not always appear 
during the inflammatory stage of 
the pulp; they more commonly 
follow its death and putrefaction. 
When this has occurred, irritat- 
ing products of decomposition, 
both gaseous and liquid, pass 
up through the canal and set 
up acute inflammation in the 
membrane at the apex of the a 
root. In the light of our 4 
knowledge of the agency 
of micro-organisms in in- 
flammatory processes, 
we must consider that 
the germs, which were 
active in producing 
inflammation of the 
pulp, are also active 
in the consequent 
inflammation of 
the peridental 
membrane. This 
membrane being 
of connective 
tissue, and 
richly supplied 
with blood-ves- 
sels, iS an ex- 
cellent field for 
inflammatory 
action, and be- 
ing closely con- 
fined between 
unyielding 
walls, and hav- 
ing an abun- 
dant nerve-sup- 
ply, is capable 
of producing 


Rea nie: 


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symptoms - 
the severest 
character. When an inflammatory process has started 


at the apex of the root, the tissues become swelled and 
engorged with blood, the condition extending from the 
apex toward the neck of the tooth. In consequence of 
the swelling of the membrane, the tooth is pushed slightly 
~ from its socket and becomes loose. The clinical symp- 
toms are ushered in by a dull, continuous pain, which is 
not occasioned by changes of temperature, as is often the 
case with inflammation of the pulp. The tooth upon 
pressure feels sore in the socket, yet, during the first 
: stages of the inflammation a 
grinding of the affected tooth 
against its antagonists gives 
some relief. The inflammatory 
process sometimes stops at this 
point, but very often goes on to 
the formation of an alveolar ab- 
scess. 

Alveolar abscess forms about 
the tip of the root. As pus col- 
lects, the neighboring bony tis- 
sue is absorbed, and a cavity is 
Fra. 3807,—Absorption of Bone, formed varying in size accord- 

produced by an Alveolar Ab- ing to the severity of the in- 

See aE ee tap of the Root flammation, Like abscesses in 

x ‘other parts of the body, it seeks 
an outlet at the point of least resistance. There are sev- 
eral ways in which the pus may make its escape. It may 
penetrate the bony alveolus in a line which is, roughly 
speaking, at a right angle to the root of the affected 
tooth, and thus make its escape into the mouth, or, in some 
cases, upon the face. Or it may pass down the length of 
the root, either between the peridental membrane and 
the cement, or between the peridental membrane and the 
bony socket, in both cases discharging about the neck of 
the tooth. When an alveolar abscess occurs in connec- 


F1a. 8806.—Phosphor-necrosis of the Lower Jaw. 


Teeth. 
Teeth, 


tion with the six anterior teeth and bicuspids of the up- 
per jaw, it usually discharges on the labial surface of the 
alveolus, at a point about opposite 
the tip of the root of the affected. 
tooth. In rare instances an abscess 
connected with these teeth may 
discharge on ,the outside of the 
front part of the face or into the 
nasal cavity, and in the case of 
the bicuspids, into the antrum 
Highmorii. An abscess occur- 
ring in connection with the 
upper molars most common- 
ly discharges on the buccal 
surface of the alveolus, 
4 about opposite the tips of 
“the roots affected. It 
may, however, . dis- 
charge in the neighbor- 
hood of the hard palate, 
when proceeding from 
the palatal root. Be- 
sides these usual 
points of discharge, 
the abscess may 
open into the an- 
trum or upon the 
outside of the 
face, near the 
union of the ma- 
lar and supe- 
rior maxillary 
bone. Abscess- 
es formed 
about the lower 
anterior teeth 
usually open on 
the labial side 
of the alveo- 
lus, within the 
mouth. They 
may, however, 
open on the out- 
side of the face, below the horizontal portion of the jaw. 
Abscesses in connection with the lower bicuspids usually 
open on the buccal side of the alveolus, though they 
may discharge on the face, along the body of. the jaw. 
Abscesses connected with the lower molar teeth usually 
find exit upon the buccal 
side of the alveolus, but | 
sometimes on the outside 
of the face, adjoining the 
inferior maxillary bone. 
Cases are reported in 
which the abscess has 
opened in the neck, and 
even as low down as the 
infraclavicular region. 
Alveolar abscesses usu- 
ally assume a _ chronic 
condition, and keep up 
a discharge of pus from 
their fistulous opening as 
long as the root in con- 
nection with which they 
have been formed re- 
mains in the mouth, or 
until the pulp-canal of 
the root has been prop- 
erly cleaned and filled. 
The opening of an alve- 
olar abscess upon the face 
or neck has oftentimes 
been mistaken for the dis- 
charge from necrosed bone. A. case coming under the 
observation of the writer, while in charge of the Dental 
Infirmary of the Harvard Dental School, will illustrate 
the point. A farmer, from the western part of Massa- 
chusetts, came to the Massachusetts General Hospital to 


761 


Fie. 8808.—A Vertical Section through a 
Lower Incisor and surrounding Parts, 
illustrating two ways in which an Al- 
veolar Abscess may find vent. The 
first, and more common, way, is by 
the fistula opening at c; the second, 
and less common, way, is by the fistula 
opening at c’, a, the tongue; b, the 
lower lip; d, the abscess cavity; é, 
the inferior maxillary bone. 


Teeth. 
Teeth. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


be treated fora fistula opening at the symphysis of the 
lower jaw. The fistula discharged more or less, and was 
thought to be due to necrosis of the lower jaw. ‘The con- 
dition had existed for about two years, and had been 
treated by injecting the fistula with various medicaments, 
At the hospital they declined to operate till his teeth had 
been examined. Such an examination showed a lower 
incisor which, though not carious, was believed to contain 
a dead pulp and to be the origin of the fistula. The tooth 
was extracted at the Dental Infirmary, and the patient ad- 
vised to return home and report in a month’s time. In 
due time the patient reported that the fistula had com- 
pletely healed. While not all cases of fistula about the 
face are due to dental abscess, yet the teeth should always 
be examined when such a case presents itself. 

The clinical symptoms attendant upon alveolar abscess 
are well marked and of peculiar severity. Since alveolar 
abscess starts with simple inflammation of the peridental 
membrane, the first symptoms are the same as those de- 
scribed under that affection. As the condition advances, 
however, the pain becomes more intense, the tooth is far- 
ther protruded from its socket, and is exquisitely sensi- 
tive, the touch of a finger often being sufficient to produce 
great agony. Sometimes the formation of pus is marked 
by a chill and rise of temperature. This formative stage 
may last from twenty-four to forty-eight hours ; mean- 
while the pus has been working its way through the sur- 
rounding bone into the soft parts. When this has oc- 
curred the face in the neighborhood of the affected tooth 
becomes swollen, and there isa marked remission of pain. 
The mucous membrane of the gum about an alveolar ab- 
scess is much congested and swollen, besides being sore 
to the touch. 

As peridental inflammation and alveolar abscess are 
very common causes of toothache, it is necessary to 
distinguish between the toothache so caused and that 
due to irritation of the pulp. Toothache from irritation 
of the pulp is started by the pressure of food against the 
pulp, by a sudden variation of temperature, or by sweet 
or salt substances. The pain is violent, but intermittent, 
and no soreness of the tooth in the socket, as a rule, exists. 
Toothache from inflammation of the peridental mem- 


brane or alveolar abscess is started by the death and de-- 


composition of the pulp. The pain is continuous; it is 
increased by the application of heat, diminished by the 
application of cold. The tooth is sore in the socket, and 
if the crown is tapped with an instrument the patient 
will flinch. The tooth is protruded from the socket, the 
gums are inflamed, and the face swollen. 

The treatment of peridental inflammation or alveolar 
abscess is, first, to remove the cause of the irritation. If 
the tooth is without value to the individual it should be 
extracted. This is the quickest way out of the difficulty. 
If, however, it is desirable to preserve the tooth, its pulp- 
cavity should be at once opened and cleansed from all de- 
composing material. Ifthisis donein the first stage of the 
difficulty it is usually sufficient, and, the source of irrita- 
tion being removed, the inflammation subsides. Ifthe case 
be one of alveolar abscess the cleansing of the pulp-cavity 
is of advantage, not only in removing the source of irri- 
tation, but also in giving a vent to the forming abscess 
through the root-canal. In many cases, however, the 
abscess will open through the alveolus in spite of treat- 
ment. Such an opening can sometimes be hastened by 
incising with the lance over the affected root. Whether 
pus can be reached with the lance or not, the incising of 
the gum gives relief by diminishing the congestion of 
the part. The use of leeches upon the gum is an old 
and often effective remedy. The tincture of iodine 
painted upon the gum is of common use; also the appli- 
cation of capsicum plasters, slippery-elm poultices, and 
roasted raisins. A poultice should never be applied to 
the outside of the face, on account of the danger of caus- 
ing the abscess to discharge externally and Jeave a scar 
upon the face which is a permanent disfiguration. 

Pathological Affections of the Peridental Membrane de- 
pendent upon, or associated with, Calcareous Deposits on 
the Teeth.—Calcareous deposits are of two classes: those 
originating from the saliva, and called salivary tartar or 


762 


salivary calculus, and those originating apparently from 
a serous exudation from the peridental membrane, and 
called serumal calculus. The salivary tartar or calculus is 
composed mainly of phosphate of calcium, which is con- 
tained in the saliva and is precipitated upon the teeth. 
It is found in greatest abundance on the buccal sides of 
the upper first molars, near the opening of the parotid 
gland, and on the lingual side of the lower anterior teeth, 
near the opening of the submaxillary and sublingual 
glands. Salivary calculus is first deposited at the neck 
of a tooth, and, if not removed, spreads both toward the 
cutting edge and in the opposite direction up the root. 
In its progress along the root it presses away the gum 
from the neck of the tooth and separates the peridental 
membrane from its attachment to the cement. If al- 
lowed to rest in contact with the peridental membrane, 
it destroys its life, and also that of the adjacent bony alve- 
olus, thus largely diminishing the natural support of the 
tooth. In this way the teeth affected become loosened, 
and may be entirely dislodged. Salivary calculus, though, 
as a rule, limited to the regions described, may in much 
neglected mouths cover the entire lingual side of the 
lower teeth and the buccal sides of the upper teeth. 
The treatment of this deposit consists in its removal, 
after which the peridental membrane quickly resumes 
its normal character, except such portions as have been 
destroyed, and the gum closes around the neck of the 
tooth. 

The second form of calcareous deposit, called the serum- 


- al, has nothing to do with the saliva, nor is it limited to 


certain localities in the mouth. It is supposed to be due 
to a deposition from serum exuded from the gingival 
margin of the gum and peridental membrane; this de- 
position taking place in consequence of irritation. It 
may affect any of the teeth, and is located at the margin 
of the gum, often hidden from sight. In color it varies 
from yellow to brown, and even black. It often encircles 
the root of the tooth, but may be deposited in patches. 
It increases slowly, but is destructive to the peridental 
membrane, which becomes separated from the root. The 
alveolar bony processes about the neck of the tooth are 
in time absorbed, and the natural support of the tooth is 
diminished. 
In connection with this deposit there may be a flow 
of pus, due to irritation of the peridental membrane. To 
this condition the name pyorrhcea alveolaris has been 
given. While salivary calculus causes the loosening and 
falling out of the lower front teeth, the serumal deposit 
may effect the loosening and falling out of any of the 
teeth, and is the most common cause of that result. 
There remains to be described an affection of the peri- 
dental membrane which is very destructive to that tissue. 
It is usually associated with a deposit of serumal cal- 
culus, and may be very similar to the affection just de- 
scribed. The calcareous deposits are, however, more 
likely to be in patches, and to advance more rapidly to 
the apex of the root. By this means pockets are formed 
along the side of the root, due to a separation of the peri- 
dental membrane from the cement of the root. In the 
first form of serumal deposit the peridental membrane 
is separated from the tooth around the entire circumfer- 
ence of the root, and from its neck as far up as the de- 
posit reaches; the tips of the root, meanwhile, being 
firmly attached to the peridental membrane until the 
tooth falls out. In the second form, however, the root 
may be separated from its peridental membrane on one 
side up to its apex, and in other parts firmly attached. 
At the apex the root is often entirely separated from its 
surrounding membrane, though at its neck there may be 
a fairly good union. Whether the deposit of calculus is 
due to the inflammation of the peridental membrane, or 
the inflammation is due to the deposit of calculus, is not 
decided. This form of calculus is associated with a flow 
of pus and rapid destruction of the peridental mem- 
brane. This membrane having been destroyed, the tooth 
loses its hold in the socket, and in time dropsout. There 
is some reason to suppose that this disease is due to a 
special micro-organism, and that it is infectious. On 
this account it has been called infectious pericementitis. ‘ 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


The term pyorrhcea alveolaris is commonly applied to 


this as to the preceding condition. 


The treatment of 


both kinds of serumal calculus with associated inflam- 
mation of the peridental membrane is to remove the de- 
posits of calculus and to keep them removed. To this 
must be added thorough cleanliness of the teeth, and a 


washing out of all pockets 
around the necks of the teeth 
produced by the separation 
of the root from its mem- 
brane. The use of antiseptic 
fluids in such pockets is a 
desirable and effective treat- 
ment, especially in that form 
of deposit last described. 
In people of middle or ad- 
vanced life calcareous de- 
posits are more destructive 
to the teeth than is caries. 
The pathological condi- 
tion commonly described by 
the term a ‘‘ dead tooth” is 
one which needs explana- 
tion. When the pulp of a 
tooth dies the tooth is often 
called a dead tooth. The 
term thus applied is incor- 
rect and misleading. When 
the pulp dies it is true that 
the main source of nourish- 
ment for the tooth has been 
cut off ; but, while the peri- 
dental membrane is alive 
and healthy the tooth still 
receives nourishment from 
it. That this membrane can 
nourish the dentine is evi- 
dent from a reference to the 
plates on dental anatomy, 
where the dentinal tubules 
are shown to connect with 
the granular layer of the 
dentine, and the granular 
layer to be in connection 
with the canaliculi of the 
cement. The cement is 
nourished by its periosteum, 
which is the peridental mem- 
brane. A pulpless’ tooth is 
not necessarily, nor is it usu- 
ally, a dead tooth. If its 
peridental membrane is in a 
healthy condition, and its 
root-canals thoroughly 
cleaned and filled, it 
may be as comfort- 
able and as useful 
an organ as a tooth 
having a pulp. 
When, however, 
both the pulp and 
peridental 


jects. 


EXTRACTION OF THE 
TEETH. — The extraction of 
the teeth may be called for by 
various conditions, of which 


the more common are: 


membrane — the 
two sources from which a 
tooth gets its nourishment— 
have been destroyed, then the 
tooth is dead, and is a foreign 
body which nature quickly re- 


Fria. 3809.*—Forceps No. 13. 
Incisor, Upper. Also made 
with straight handles. 


1. A crowded condition of the teeth which threatens 
or has caused irregularity. Teeth may be placed en- 


tirely outside or inside of the dental arch. 
tion of such teeth is often advisable. 


The extrac- 
It may, however, 


* The forceps are numbered according to the catalogue of the 8. S. 
White Dental Manufacturing Co., published in August, 1887. 


Teeth. 
Teeth. 


be laid down as a rule that the superior canines and cen- 
tral incisors should not be extracted to correct irregu- 
larity ; nor should the inferior canines, except in rare 


instances, 
superior canines make their 
appearance through the 
gum there is no room for 
them between the superior 
lateral incisors and first bi- 
cuspids. As the canines de- 
scend they in consequence 
take a position outside of the 
arch and are a deformity. 
They are not on this 
account, however, 
to be removed, be- 
cause by their posi- 
tion and size they 
give character to 
the expression of 
the face. <A bicus- he 
pid, or sometimes a first mo- 
lar, should be extracted in- 
stead, and thus room gained 
for the canine. In many. 
such cases, however, there 
is no need for extraction, in- 
asmuch as the enlargement 
of the dental arch, either by 
nature or by mechanical ap- 
pliances, will furnish the re- 
quired room. 

2. The existence of a few 
teeth in the mouth which 
interfere with the adjust- 
ment of an artificial plate. 
This is a very common cause 
for extraction, inasmuch asa 
more satisfactory plate can, 
as a rule, be made for a 
mouth having no teeth than 
for one having a few scat- 
tered teeth. 

3. The existence of pain 
due to: 

a. Congestion or inflam- 
mation of the tooth-pulp. 

6. Inflammation of the 
peridental membrane. 

c. Alveolar abscess. 


| 
ui 
tine 


More teeth are extracted - 


to relieve pain than for any 
other cause. Where teeth, 
however, by treatment can 
be relieved of pain and made 
useful organs, they should 
not be extracted. 

4. The existence of dis- 
eased conditions of the tis- 
sues in the neighborhood of 
the teeth. 

An inflammation of the 
antrum is sometimes best 
treated by extracting an up- 
per first molar or second 
bicuspid and making an 
opening through the end of 
the root-socket into the an- 
trum. By this process the 
antrum can be thoroughly 
cleansed and good drainage 
established. There are tu- 
mors of the jaw, and cases 
of caries or necrosis of the 
maxillary bones, which ne- 
cessitate a removal of teeth. 


For example, it often happens that when the 


veolar, Bayonet Shape. 


5. The persistence of the temporary teeth when the 
permanent teeth are about to erupt. 
It may be laid down as a rule that the temporary teeth 


763 


Teeth. 
Teeth. 


should not be removed until the permanent teeth are 
ready to take their place. When this condition exists 
the roots of the temporary teeth have been for the most 
part absorbed, and the crowns have become loose. While 
the above rule should be adhered to as far as possible, 
yet there are cases in which severe inflammation con- 
nected with the temporary teeth requires their premature 
extraction. 


LS 


LI p= 


Uy, 


= 7 —— = 
‘e —- <- 
= \ 


= 


eee, 
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he, Nae, 

Nee 


Fic, 5811.—Forceps No. 18. Molar, 


Upper. Right Side. Upper. 


The Process of Hxtraction.—The process may be di- 
vided into three stages : . 

1. Seizing the tooth with the forceps. 

2. Loosening its connection with its surroundings. 

3. Removing the tooth from its socket. 


764 


Fia, 3812.—Forceps No. 18, Molar, 
Left Side. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


The process of extraction and the instruments em- 
ployed vary greatly with the different teeth in the mouth. 
A knowledge of the number, shape, and size of the roots 
of the teeth is necessary to insure success in their re- 


Fig, 3813.—Forceps No. 10. Dentes Sapientize, Upper. 
Hither side. Also made with straight handles. 


moval, To extract the teeth of the upper jaw, the pa- 
tient should be placed with the head thrown well back, 
and the operator should stand at the patient’s right side. 
With the left hand the lips and cheeks should be re- 
tracted and the upper jaw firmly grasped. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


The upper central incisors are extracted with forceps 
No. 13. Its beaks are made to adapt themselves to the 
nearly conical neck of this tooth. This forceps should 
be applied with one beak at the labial surface ot the 
neck of the tooth, and the other at the lingual surface. 
The beaks of the forceps should be carried well up be- 
tween the margin of the gum and the root of the tooth. 
When the 
tooth has 
been thus 
grasped, it 
should be 
gently but 
firmly rotat- 
ed, in order 
to loosen it 
from its 
socket, A 
forward- 
and -back 
motion may with advantage be 
combined with the rotatory 
motion. When the tooth is 
felt to have been loosened, it 
should be removed by a steady 
pull in the direction of its 
long axis. 

The superior lateral incisors 
are extracted in a manner 
similar to that of the central 
incisors, and with the same 
forceps. Inasmuch as their 
roots are somewhat com- 
pressed laterally, the rotary 
motion is not so important as 
with the central incisors. 

The superior canines are 
quite difficult to extract, ow- 
ing to their very long roots. 
The upper incisor forceps 
are usually employed for the 
canines. The tooth should 
be grasped as high up on the 
root as possible. 'To loosen 
the tooth from its socket the 
rotary motion must be com- 
bined with the forward-and- 
back motion. When loose, a 
straight pull in the line of its 

long axis is necessary for its 

removal. It 
must be borne 
in mind that the 
root of the ca- 
nine is decidedly 
flattened on its 
sides, and there- 
fore offers con- 
siderable resistance to rotation. 

The upper bicuspids may be ex- 
tracted with the upper incisor for- 


PS 
OES, 5 
¢ CL EO y m4 x & < on NT 107 


extracted with the alveolar bayo- 
net-shaped forceps, No. 32. The 
upper bicuspids should be grasped 
well up on the root, and loosened 
by a side-to-side motion. Their 
roots being long and slender, great 

Incisor, Lower, Hawk- care is required to prevent their 

pu fracture. If the first upper bicus- 
pid has a bifurcated root, it is often impossible to re- 
move the tooth without breaking off the tip of one of the 
roots. 

The first and second upper molars are extracted by for- 
ceps No. 18; one pair being suited for the right side 
and the other for the left. It will be noticed that the 
inner beak of each forceps is fashioned with a single con- 
cavity, it is thus fitted to embrace the inner buccal root 
of the first or second upper molar. The outer beak is 


Fra. 8814,—Forceps No. 9. 


ceps ; or they may be conveniently | 


Teeth. 
Teeth. 


divided by a longitudinal ridge into two concavities, 
while the tip of the beak is pointed in the middle. It is 
so made in order to embrace the two buccal roots of the 
first and second upper molars, and to conform to the 
depression between these roots. These forceps should 
be grasped in the palm of the hand, the thumb being 
brought into position between the angle formed by the 
two han- 
dles and 
the joint. 
The third 
and fourth 
fingers 
should be 
closed over 
the curve 
of the left 
handle. 
Owing to the divergence of 
the three roots of the upper 
first and second molars, con- 
siderable loosening is neces- 
sary before they can be ex- 
tracted. This is effected by 
a side-to-side motion; as the 
outer alveolar plate is thinner 
than the inner, the main force 
should be applied in an out- 
ward direction. When the 
tooth is thoroughly loose in 
its socket, it can be removed 
by a downward and outward 
motion. 

The upper wisdom tooth is 
extracted by forceps No. 10. 
This forceps can also be used 
as a universal upper molar 
forceps. Upper wisdom teeth 
are not usually difficult to ex- 
tract, as their roots are com- 
monly fused together. In or- 
der to loosen them they should 
be turned firmly outward. 
By this movement their at- 
tachment to the socket can be 
readily broken up, and the 
tooth removed. 

In case the crowns of the 
upper teeth are badly decayed 
or entirely lost, the alveolar 
or root-forceps should be used, 
No. 32. (Fig. 3810.) With this 
instrument any root of the up- 
per jaw can be extracted ; the 
rules for the ex- 
traction of roots 
being substanti- 
ally the same as 
those for teeth 
with crowns, 
It is necessary, 
however, to 
carry the blades farther up 
into the alveolus than when 
the crown is present. Great 
care should be taken not to 
crush the root by too firm a 
grasp. With the first and 
second upper molars it often 
happens that the three roots 
must be extracted separately. 

In extracting the inferior 
teeth the patient should be situated much lower down 
than for extracting the superior teeth. The operator 
should stand at the patient’s right side; oftentimes well 
to the back. The lower jaw should be grasped by the 
left hand, and supported from beneath by the palm and 
last three fingers, while the thumb and forefinger are 
placed within the mouth to retract the lips and tongue 


765 


Fira. 3815.—Forceps No. 14. In- 
cisor, Canine, or Bicuspid, 
Lower. For either side. 


“ 


Teeth. 
Teeth. 


from the tooth to be operated on. The lower incisors 
are conveniently extracted by forceps No. 9. This may 
also be used for the right lower canine, and right lower 
bicuspids. The iower incisors, owing to the lateral com- 
pression of their roots, cannot be rotated in the process 
of loosening them. This must be accomplished by a 
forward - and - 
=] back move- 

ment. 

The lower 
canines, OW- 
ing to their 
very -long 
roots, are of- 
ten quite diffi- 
cult to extract. 
They are to be 
loosened by a 
forward - and - 
back movement, to which a 
slight rotary motion may be 
added. When loose, they are 
removed by being pulled 
straight up from the socket. 
Forceps No. 9 are adapted to 
the right lower canine, and 
forceps No. 14 to the left 
lower canine. 

The lower bicuspids may 
be extracted by forceps No. 
14, though the right lower bi- 
cuspids can be well managed 
by forceps No. 9. These 
teeth should be grasped well 
down upon the root, and loos- 
ened by an in-and-out motion. 
.The alveolar plate being 
much thinner on the outer 
than on the inner side, it will 
yield more readily outwards. 
When loosened, the lower bi- 
cuspids are removed by being 
pulled straight up from the 
socket. 

The lower molars are ex- 
tracted by forceps No. 15; 
this instrument can be used 
on either side. Its beaks, as 
will be seen, are divided by a 
median ridge, and are termi- 
nated by a pointed tip; it is 
thus able to embrace the two 
roots of the lower molars, 
and to engage 
the depression 
between them. 
To extract the 
lower first and ~° 
second molar 
teeth, they 
should berocked 
from within outward till loose, 
using more force when turning 
them outward than in the oppo- 
site direction. When loose, they 
may be removed by an upward- 
and-outward pull. The lower 
third molar often gives great dif- 
ficulty in extraction, owing to 
the curve of its roots, which hook 
backward toward the ramus of 
the jaw. The forceps No. 15 
may be used for this tooth. It must be loosened by a 
side-to-side rocking. Owing to the backward curve of 
its roots it cannot be lifted from its socket by a force ex- 
erted directly upward. In many cases forceps No. 98 is 
the best instrument with which to dislodge a lower wis- 
dom tooth. It is applicable when the second molar is 
present. The blades of the forceps are closed between 


Fia. 3816,--Forceps No. 15. 
Molar, Lower. Hither 
side. 


766 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the second and third molars; by depressing the handles 
the third molar can be pried out of its socket, the second 
molar being used as a fulcrum. Care should be taken 
with this instrument that it does not slip and injure the 
back part of the mouth, and that the dislodged tooth does 
not fall into the pharynx. Injury to the second molar 
should likewise be guard- 
ed against, since this tooth 
might be loosened or dis- 
lodged in the extraction 
of the third molar. 
Forceps No. 16 (‘‘ the: 
cow-horn”’) can be used 
with advantage on the 
first and second lower 
molars, The beaks are 
shaped so as to follow 
down between the anterior and 
posterior roots, and by their clos- 
ure to pry the tooth upward from 
-itssocket. To extract the roots of 
the lower jaw, forceps No. 52 have 
been designed. The extraction 
of lower roots is conducted after 
the same manner as the extraction 
of lower teeth with crowns, care 
being taken to apply the forceps as 
low down on the root as possible. 

The instruments described 
make a good working set, al- 
though others might be added to 
suit individual peculiarities. If it 
were desirable to extract teeth 
with the fewest number of for- 
ceps, this result could be accom- 
plished with Nos. 10, 15, 32, 52. 

Elevators are often useful ; they 
are straight and curved levers, 
with which a tooth is pried out 
of its socket, a neighboring tooth 
being used as a fulcrum. 

The extraction of the tempo- 
rary teeth is performed after the 
same manner as that of the per- 
manent teeth. The operation is, 
however, much simpler, especial- 
ly if performed at a time when 
the teeth are about to be shed by 
nature. Inthe premature extrac- 
tion of the temporary molars 
there is always the possibility of 
bringing away the crown of the 
developing bicuspid, which is lo- 
cated between the roots of the 
molar tooth. Diminutive forceps 
are made for the temporary teeth, 
but temporary teeth can be read- 
ily extracted by the root-forceps 
made for the permanent teeth. 

ACCIDENTS OF EXTRACTION.— 
In the extraction of the teeth cer- 
tain accidents may occur; they 
may be unavoidable or due to un- 
skilfulness or carelessness. The 
following are the more common : 

Fracture of the Tooth.—This of- 
ten happens, and is due usually 

to an excess of force, or to misdi- 
AWA rected force, or to an insufficient 
+ grip upon the tooth. Cases occur, 
however, where fracture of the 
tooth is unavoidable ; this is espe- 
cially the case when the roots are 
misshapen and locked into the jawbone. When the tips 
of roots are, as the result of fracture, left in the maxil- 
lary bones, .it is not always wise to remove them. Nature 
will usually expel them in due time. 
Fracture of the Alveolus.—This occurs, to a limited ex- 
tent, in every tooth extraction, and produces, as a rule, 


hii 
A 


i 


Fie. 381%.—Forceps No. 98. 
Dentes Sapientiz, Lower. 
Hither side. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Teeth. 
Teeth, 


no troublesome symptoms. By unskilfulness, however, 
a large portion of the alveolus surrounding a tooth may 
be crushed or fractured, and necrosis sometimes en- 
sues. 

Fracture of the Jaw may result from tooth-extraction. 
The fracture may be in the upper jaw, or in the body of 
the lower jaw. It may 
or may not imply fault 
on the part of the op- 
erator. 

Dislocation of the 
Lower Jaw.—This usu- 
ally happens with peo- 
ple whose jaws are 
loosely hung, and are 
in the habit of slipping 
out of the socket. If 
this tendency is known 
to exist, it is well to 
apply a roller bandage 
over the head and un- 
der the jaw before op- 
erating. 

Removal of the Wrong 
Tooth.—This accident 
happens, as a rule, only 
to inexperienced or 
careless operators, 

Removal of Two or 
more Teeth instead of 
One.—This may hap- 
pen from an _ hyper- 
trophy of the cement 
uniting adjoining roots 
belowthe gum. Itmay 
happen when the tooth 
to be extracted is over- 
lapped by an adjoining 
tooth. It may happen 
also by the slipping of 
an extracting instru- 
ment, whereby a loose 
tooth is knocked out. 

Laceration of the Mu- 
cous Membrane of the 
Gum.—This occurs to 
a limited extent in 
every extraction, but, 
through carelessness or 
unskilfulness, may be 
very extensive. 

Falling of the Tooth 
nto the 
Qsophagus 
or Air-pas- 
8sages.—A 
tooth will 
sometimes 
escapefrom 
the grasp of 
the forceps 
and be swallowed. From 
this accident no serious re- 
sults are to be expected. 
Cases are now and then re- 
ported where a tooth falls 
| into the larynx. This con- 
uly stitutes the most serious 
Fa. 3818.—Forceps No. 16. Molar, accident that can attend ex- 
Lower. Hither side. Cow-horn. traction. Suchatooth may 
be coughed up from the 
larynx, or it may enter the bronchial tubes, causing symp- 
toms which are always serious and often fatal. 

The inferior dental nerve has been crushed in the ex- 
traction of the lower wisdom teeth. In such cases a loss 
of sensation has occurred in the lower part of the face. 
Usually this passes away, though it may be permanent. 
In attempting to extract the roots of the upper bicuspids 
and molars they have been pushed into the antrum. 


When this happens the opening into the antrum should 
be enlarged and the roots removed. 

Hemorrhage afier Hatraction.—This is usually moder- 
ate in amount and of short duration. Such cases require 
no treatment. There are cases, however, where the 
hemorrhage is so prolonged as to produce alarming symp- 
toms, and in 
rare instan- 
ces death has 
resulted. 
Great care 
should be 
taken in deal- 
ing with peo- 
ple having 
the hemor 
rhagic di- 
athesis. To 
control hemorrhage after ex- 
traction the most successful 
method is to apply pressure to 
the bleeding parts. The bleed- 
ing usually takes place from the 
socket of the extracted tooth. 
The socket should be packed 
with cotton, lint, sponge, or any 
soft unirritating material. Af- 
ter packing the socket a com- 
press of soft material, covering 
the socket and _ surrounding 
parts should be superadded. 
Upon this compress a gentle 
pressure should be maintained, 
either by the fingers or by the 
opposing jaw. An effective 
method of applying pressure 
after the socket has once been 
plugged is to soften a piece of 
gutta-percha in hot water and 
mould it to the affected region. 
Enough gutta-percha should be 
used so that the opposing teeth 
or alveolus can be embedded in 
it by the closing of the jaws. 
Let the jaws be closed and a 
roller bandage passed over the 
head and under the chin, and 
firm and constant pressure is se- 
cured upon the bleeding area. 

In severe cases care should be 
taken to keep the head upright 
and the extremities artificially 
warmed. 

Of the various 
styptics tannin is 
the most valuable. 
The powder may 
be applied to the 
socket on a pled- 
get of cotton. The 
iron styptics are not to be 
recommended. ‘Tomes says: 
‘* In dental cases I have never 
seen it (perchloride of iron) 
succeed in cases which had 
resisted other and less objec- 
tionable styptics” (Dental Sur- 
gery, p. 632). Tomes relies 
largely on the use of the ma- 
tico leaf, softened in warm 
water and introduced into the 
socket as a plug, this plug being, if necessary, supple- 
mented by a compress of cotton or lint. Very severe 
cases of hemorrhage have been controlled by the use of 
the actual cautery. If this be used it should not touch 
the parts, but be held just near enough to bake them. 
If the cautery touches the tissues a fresh laceration is 
made by its removal. 

In desperate cases of hemorrhage internal remedies are 


767 


Fig. 3819.—Forceps No. 52. Al- 
veolar, Lower. Hither side. 


Teeth. 
Tendon Reflex. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


usually resorted to. They consist of tannic acid, gallic 
acid, and ergot. 

General Considerations.—Haste in extracting should 
be avoided ; the hand should never move faster than the 
eye can follow. The tooth should be under complete ob- 
servation from the time it is grasped by the forceps till 
it is out of the mouth. The head of the patient should 
be firmly fixed, and under the control of the left hand or 
arm. 

While considerable force is necessary to extract a 
tooth, the force should be so guarded and moderated as 
not to endanger surrounding parts. No jerks or sudden 
pulls are allowable. 

The forceps should never grasp the crowns of teeth 
alone, as the crown will usually break off, leaving the 
root undisturbed, but should engage the tooth at its neck, 
or a little higher up if possible. 

In extracting roots the beaks of the forceps should fol- 
low down between the root and its alveolus till a firm 
hold is obtained. 

The cutting through of gum and alveolus with a root- 
forceps is not a desirable procedure, but is allowable in 
certain cases. 

An excellent substitute for a dental chair is a rocking- 
chair with medium high back, a pillow thrown over the 
back forming a good head-rest. 

William Henry Potter. 


TENDON REFLEX. The tendon reflexes, properly 
speaking, include only certain muscular phenomena 
which are produced by the sudden stretching of tendons, 
as by a sharp blow or series of blows, under certain spe- 
cial conditions. Under the name of ‘‘ deep reflexes,” 
however, we find included with the so-called tendon re- 
flexes proper a number of similar phenomena, which are 
produced by sharp blows or taps on the fascie, the liga- 
ments, or the bones. As these phenomena are, so far as 
known, in nearly all respects similar to those produced 
by striking the tendons, all general statements made here 
may be considered to refer to them also. 

When a sharp blow is struck upon the ligamentum pa- 
telle in a healthy person, if the muscles be in a proper 
state of tension, it is immediately followed by a sudden 
rapid contraction of the quadriceps extensor femoris, 
causing the leg to be extended sharply upon the thigh, 
though only momentarily, as, the contraction ceasing, it 
immediately resumes its previous position. This is a 
typical ‘‘ tendon reflex,” which term is used to denote the 
sudden, rapid contraction produced in a muscle by a 
sharp blow delivered upon its tendon. Asa general rule, 
in the normal physical condition, only the muscle whose 
tendon is directly irritated contracts, but in certain hy- 
persensitive states this contraction may involve the neigh- 
boring muscles, and even be transmitted mechanically to 
the corresponding ones on the opposite side of the body. 
Under ordinary circumstances the ‘‘reflex”” consists only 
in a single contraction of the muscle excited, but under 
certain abnormal conditions the stimulation may be fol- 
lowed by a series of contractions, constituting what is 
known asaclonus. The most common form of this is 
the ankle clonus (foot phenomenon), caused by the rapidly 
alternating contraction and relaxation of the calf mus- 
cles ; and this will be considered more in detail later. 


In healthy individuals only three ‘‘ tendon reflexes” are ° 


found present with considerable constancy, the patellar 
reflex, that of the Achilles tendon, and the triceps reflex ; 
though the presence of certain other reflexes (radial, ul- 
nar, etc.) is not infrequent and cannot be considered ab- 
normal, Of these the ‘‘ patellar reflex” is so invariably 
present in health that its absence, except in old age, is 
always to be considered as a significant symptom; the 
triceps reflex and that of the Achilles tendon are very fre- 
quently present, but their absence in an otherwise healthy 
person cannot be held to have any special importance. 
The patellar reflex is so far the most important of the 
‘‘tendon reflexes,” both from its value in diagnosis and 
because of the numerous experiments and investigations 
which have been made in regard to it, that it may prop- 
erly be considered as the type of the tendon reflexes. ~ 


768 


For this reason we will first describe it thoroughly, 
and will afterward pass on to the other ‘‘ tendon re- 
flexes,” and point out any special peculiarities or differ- 
ences which may be found in them. 

PATELLAR REFLEX.—Synonyms: Patellar tendon re- 
flex, Patellar tendon phenomenon, Knee reflex, Knee 
phenomenon, Westphal’s symptom, Knee-kick, Knee- 
jerk, Réflexe rotulien, Phénoméne du genou, Tendon re- 
flex (Erb), Kniephainomen (Westphal). 

Of these terms we prefer that of knee-jerk, as it im- 
plies no theory of cause and describes the phenomenon 
concisely, and we shall use it hereafter in this article in- 
stead of patellar reflex. 

In order to obtain the knee-jerk, all that is required 
under ordinary circumstances is that the patellar tendon 
should be in a moderate degree of tension. To accom- 
plish this most conveniently, the usual method is that 
the patient, sitting on a chair, should cross one knee over 
the other, letting the upper leg hang loosely without sup- 
port at an angle of about sixty degrees. Or the patient 
may sit on the edge of a table or a bed, or, if a child, on 
a chair, letting both legs hang down without support. 
Commonly one of these methods is the readiest, but if 
the patient be stout, or for any other reason the knees 
cannot be readily crossed, it is advisable for the observer. 
to support the limb to be tested on his arm, which is 
passed beneath it, while his hand rests on the patient’s 
other thigh. When the patient is in bed, the condition 
of the knee-jerk can either be examined while the patient 
lies upon his side with the leg flexed at the above-men- 
tioned angle on the thigh, or the thigh can be raised and 
supported, the leg being allowed to hang at the proper 
angle. In any of these cases it is well, when possible, if 
there be any question in regard to the presence of the 
knee-jerk, that one hand should be placed on the qua- 
driceps extensor cruris, so as to feel the muscular contrac- 
tion if it occur. Whatever position is adopted, it is im- 
portant, in order to obtain a good knee-jerk, that the leg 
should not be held firmly in its position by the patient, 
either voluntarily or involuntarily, but that the muscles 
should be so far as possible relaxed, and the leg permitted 
to hang loosely. After the limb has been properly placed 
and the situation of the tendon patelle determined, a 
sharp blow should be given about the middle of the ten- 
don. The tips of the fingers, or, better, the inner edge of 
the hand, or in doubtful cases a percussion-hammer, may 
be used. Ordinarily the knee-jerk is obtained without 
difficulty through the clothes, unless very thick, but in 
questionable cases the blow should be delivered on the 
bare skin. 

In this way, in the normal individual, the knee-jerk can 
usually be readily obtained. In some cases, however, 
even in otherwise’ healthy persons, a certain amount of 
difficulty is found, and in them Jendrassik’s method of 
re-enforcement isuseful. Some observers also have found © 
that the knee-jerk is obtained more easily in certain per- 
sons by striking the tendon rather toward the inner 
edge. 

Hisiory.—The attention of the medical profession was 
first called to the existence of this phenomenon and that 
of the ankle clonus, by Erb and Westphal, simultaneous- 
ly, in articles published in the Archiv fir Psychiatrie, in 
1875, and from that moment these phenomena, especially 
the knee-jerk, became the subject of numerous scientific 
researches and investigations. Naturally, at first the di- 
agnostic value of these symptoms received the most care- 
ful attention, and the importance of the absence of the 
knee-jerk in the recognition of tabes dorsalis, especially 
in the earlier stages, and of its condition as a means of 
differentiating various forms of disease of the nervous 
system, caused it at once to obtain recognition, and be- 
come the object of earnest study on the part of all the 
more advanced medical practitioners. 

Physiology.—At the same time that its high value as a 
means of diagnosis and differentiation to the practising 
physician and surgeon was being practically recognized, 
its cause and the method of its production attracted in- 
terest, and became an object of inquiry to many of the 
most skilful investigators. This question was found not 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


to be by any means so simple as it might at first sight 
appear, and, indeed, up to the present time, the exact 
mechanism of the knee-jerk is undetermined. 

From the very moment when it was first brought to 
the attention of the medical profession, the mechanism 
of this phenomenon became the subject of two contrary 
views, each supported by high authority, and with more 
or less unanswerable arguments in its favor. The dif- 
ference between the opinions in regard to its origin held 
by its two discoverers is apparent even in the terms em- 
ployed to designate the symptom. On the one hand, Erb, 
viewing it as the result of a simple: reflex process, natu- 
rally gave it the name of tendon reflex, and as other 
tendons were found to act in a similar manner, this symp- 
tom became known as the patellar tendon reflex. West- 
phal, on the other hand, doubted from the very earliest 
whether this symptom was actually due to ordinary, sim- 
ple, uncomplicated reflex action, and for this reason re- 
fused to accept the designation of tendon reflex until the 
exact nature of the-occurrence could be better known, 
calling it meanwhile by the more general name of knee- 
- phenomenon, which term has now given way, to a large 
extent, before the less cumbrous one of knee-jerk. 

Immediately on the appearance of the articles of Erb 
and Westphal, investigations were begun to settle, if pos- 
sible, the correctness of the opposing theories, and to de- 
termine the exact cause and method of production of the 
phenomenon, In the beginning the general tendency of 
medical opinion was undoubtedly in favor of the view that 
the ‘‘ patellar phenomenon ” was due to a simple reflex ; 
even Gowers, afterward a strong opponent of this theory, 
writing in 1879, says, ‘‘ the reasons for regarding it as a 
spinal reflex are strong.” That this should be-so was 
only natural, since it was in the first place, superficially, 
the most obvious and reasonable explanation, and, more- 
over, it was shown that any obstruction or defect in the 
reflex is followed by an immediate diminution or loss of 
the knee-jerk. The integrity of the reflex are ts necessary 
to the production of the knee-jerk (Tschirjuv and others). 

Its external similarity, in many respects, to the ordinary 
reflexes was immediately apparent, and induced many to 
place it in this class until reasons to the contrary should 
be shown. These arguments naturally have much 
weight, and the upholders of the simple reflex theory 
have sought to strengthen them by others, such as the 
fact of the radiation of the knee-jerk to the muscles of 
the back, and the production of a contraction of the 
quadriceps extensor in the other leg at times. 

On the other hand, Westphal and others have raised 
some very serious objections to this view, and in addi- 
tion they have advocated another theory. Their argu- 
ment is as follows: Although the fact be undisputed that 
the integrity of the reflex arc is necessary to the produc- 
tion of the knee-jerk, still it does not follow that the 
knee-jerk must in consequence be a simple reflex. On 
the contrary, that it is not so is shown by the fact that 
the latent period of the knee-jerk—that is, the time which 
elapses between the moment of the blow and that of the 
subsequent muscular contraction—is much shorter than 
that of any known reflex, and more resembles in this re- 
spect the result of direct muscular excitation. It is now 
generally admitted that the latent period of the knee-jerk 
is usually from 0.02 to 0.03 second, while that of an ordi- 
nary reflex, ¢.g., skin-reflex, is much greater, 0.12 to 0.14 
second. Eulenburg gives the average of his experiments 
in adults as 0.08226 second. In children it may rise as 
high as 0.04389 (De Watteville). In this relation Eulen- 
burg’s comparative tracings of skin-reflexes and knee- 
jerks are of much interest. 

In regard to the radiation of the knee-jerk to the mus- 
cles of the back, and to the quadriceps extensor cruris of 
the opposite leg, this has been conclusively proved, by 
the experiments of Prévost and Haller, to be due to the 
direct vibration conveyed through the bones of the pel- 
vis, inasmuch as it still exists after section of the spinal 
cord and of the posterior nerve-roots. 

The theory of those who are opposed to the simple re- 
flex view is that the knee-jerk is dependent upon the 
tonicity of the muscle. They say that under normal 


Vou, VI.—49 


Teeth. 
Wendon Reflex. 


circumstances a certain amount of tonicity in the muscle 
—a muscle tonus—always exists; that this, however, is 
destroyed by injury or destruction of the reflex arc, and 
that it is due to the loss of muscle tonus that we are un- 
able to obtain the knee-jerk in such cases. Westphal 
considers three conditions necessary for the knee phe- 
nomenon: (1) Tonicity of the muscle ; (2) tension of the 
muscle ; (3) elasticity of the ligament. If either of these 
is lessened beyond a certain point, the knee-jerk is like- 
wise lessened or abolished. 

The strongest and most valid objection to this theory 
is that. it presupposes the existence of a muscle tonus, 
Until we have some definite evidence in favor of its ex- 
istence, it seems scarcely justifiable first to assume it and 
then to base a theory upon this assumption, | 

Pathology.—The pathology of the knee-jerk may be 
briefly stated. Anything which interrupts the reflex cir- 
cuit will prevent the appearance of the knee-jerk. The 
reflex arc for the knee-jerk, beginning in the sensory 
fibres running in the anterior crural nerve, passes through 
the posterior nerve-root into the spinal cord between the 
second and third lumbar vertebra, and thence returns to 
the quadriceps extensor femoris through the motor fibres 
of the anterior crural. In 1877, Schultze and Fiirbringen 
showed that after section of the crural nerve percussion 
of the patellar tendon was unable to produce contraction 
of the extensor femoris, although this muscle responded 
to direct excitations. It is well known that section of 
the lumbar posterior nerve-roots produces the same re- 
sult. In the spinal cord, in man at least, the circuit 
probably passes through the posterior columns. At any 
rate, it is certain that the knee-jerk disappears, as a rule, 
in diseases of the posterior columns, while it is increased 
in lateral sclerosis. At the present time clinical evidence 
favors the view that it is especially disease or injury of 
the portion of the posterior columns lying on the border 
of the lateral columns that causes the abolition of the 
knee-jerk. 

Clinecal Value and Symptomatology.—The value of the 
condition of the knee-jerk as a means of diagnosis has 
been much disputed, but there is now no longer any 
question that it is of great importance when its significa- 
tion is properly understood. In certain cases, even the 
probability of the existence of certain conditions of the 
spinal cord can be determined by the character of the 
knee-jerk alone. 

The knee-jerk may be exaggerated, or it may be dimin- 
ished or absent. 

Eraggeration of the Knee-jerk.—The knee-jerk may be 
rendered more active physiologically in many ways. It 
has been shown by Jendrassik, Weir Mitchell, and others 
that when the knee-jerk coincides in time with some 
other action of the body, or even with certain sensations 
or emotions, its action is increased; it is rednforced. 
This reinforcement is produced constantly by numerous 
slight conditions, so that in the healthy normal person 
the knee-jerk is constantly varying slightly. Thus, Lom- 
bard says: ‘‘ The extent of the normal knee-jerk is con- 
tinually undergoing change. The average knee-jerk 
varies in amiount at different times of day, being as a rule 
greatest in the morning, soon after breakfast, and being 
very much less at night.” The decline during the day is 
irregular, the knee-jerk increasing after each meal. In 
this case the knee-jerk may be considered as being 
strengthened by the general’ physical condition ; but it is 
also momentarily reinforced by any simultaneous action, 
as motion of the arm, crying, laughing, speaking, or by 
the sensation of a loud sound. In certain cases this ef- 
fect is mechanical, due to tension of the muscle. Jen- 
drassik first turned this fact to a practical use by sug- 
gesting that in cases where the knee-jerk was diminished, 
or apparently absent, the patient should be told to clinch 
his hands and pull on them as strongly as possible, and 
that while he was thus engaged the knee-jerk should be 
tested. ‘This procedure acts to increase the knee-jerk in 
two ways: first, probably as actual reinforcement ; second- 
ly, by distracting the patient’s attention and preventing 
him from keeping his limb in: that condition of tension 
which hinders or prevents its movement. As a general 


769 


Tendon Reflex. 
Tendon Reflex. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


rule we may consider that the stronger the reinforcement 
is, the more marked will be the knee-jerk. 

The knee-jerk is also increased by certain bodily con- 
ditions. It is increased by chronic fatigue, and in almost 
all cases of weakness and irritability of the nervous system, 
from whatever cause. Thus, we find it exaggerated in 
nearly all cases of neurasthenia, of spinal irritation, of 
hysteria—in fact, in all forms of functional nervous dis- 
order where irritation or irritability may be presumed to 
exist. It is found increased in all cases of general weak- 
ness of the nervous system—nervousness—to a greater or 
less extent, and hence appears frequently—in fact, as a 
rule—in persons convalescent from severe disease, and in 
many cases of chronic disease, phthisis, etc. 

It is also pathologically increased in certain irritative 
or inflammatory lesions of the central nervous system. 
It is thus exaggerated in certain stages of cerebral menin- 
gitis and in spinal meningitis. But the most highly de- 
veloped pathological forms of knee-jerk (knee-clonus, 
knee-tetanus) are found principally in certain definite 
lesions of the spinal cord. In lateral sclerosis the knee- 
jerk is almost typical in its exaggeration, and, vice versa, 
when the knee-jerk is increased beyond a certain point it 
strongly suggests the presence of disease of the lateral 
columns. In no other disease does it reach the extent 
which it does in this, or is it capable of being so easily 
excited. 

Increase in the knee-jerk occurs in all cases whenever 
the access of voluntary innervation to the muscles is hin- 
dered, however slightly. 

It is especially increased in cases of transverse myelitis 
when this occurs in the dorsal or cervical regions, while 
the same affection in the lumbar region abolishes it. 

It accompanies not only central organic lesions, but 
also hysterical. It is found even with lesions of the 
pyramidal tracts which produce no perceptible paral- 
ysis. 

The knee-jerk is likewise increased by causes which 
increase the general irritability of the spinal cord. Thus, 
we find it exaggerated in tetanus and in poisoning by 
strychnia. 

It should, moreover, theoretically, be capable of in- 
crease through pathological conditions of the muscle, 
tendon, etc., but in regard to this we have as yet no 
definite knowledge. 

Diminution of the Kneejerk.—In the normal, healthy 
individual the knee-jerk is, in a certain number of cases, 
only to be obtained with care and difficulty, and is decid- 
edly below the average. This seems to be idiopathic or 
constitutional, Whether this can absolutely reach the 
point of absence without the existence of any disease or 
disturbance in the nerves or spinal cord, while the proper 
conditions exist in the muscles and tendon, seems doubt- 
ful. For practical purposes, however, we may admit the 
existence of a small number of such cases, but they are 
so rare, that the value of the absence of the knee-jerk as a 
_ diagnostic symptom is not thereby essentially lessened. 
Physiologically, the knee-jerk is diminished by conditions 
of temporary fatigue. It is sometimes difficult to obtain 
it in infants and children, and it is said to be often absent 
in old age. 

Pathologically, absence of the knee-jerk may be caused 
by anything which breaks or interrupts the current of 
the reflex arc. It may even be produced by causes 
which give rise to no appreciable organic lesion, as 
stretching of the anterior crural nerve. It is caused fre- 
quently by neuritis of the anterior crural or its branches, 
and this is probably the cause of its absence in certain 
cases after diphtheria, in diabetes, in phthisis, and after 
typhoid fever and other acute diseases. For this reason 
it is apt to be absent in multiple neuritis of whatever 
origin, whether idiopathic, syphilitic, toxic (due to alcohol, 
lead, or arsenic), or accompanying general paralysis. It 
may also, of course, be produced by injuries, especially 
section of the anterior crural. Likewise, it may be 
caused by anything which prevents the transmission of 
impulses through either the anterior or posterior nerve- 
roots (injuries, tumors, etc.). As previously stated, the 
path which the sensory impulse takes in the spinal cord 


770 


after leaving the posterior nerve-roots is not yet wholly 
settled, but it seems to be especially connected with the 
external portions of the posteriorcolumns. At any rate, 
disease or destruction of the posterior columns of the 
spinal cord in the lumbar region produces absence of the 
knee-jerk. This is one cause of its absence in tabes 
dorsalis—sclerosis of the posterior columns—a disease in 
which the absence of the knee-jerk has become a most 
important diagnostic symptom and is sometimes an 
early one. But the knee-jerk may also be abolished 
by any other cause equally affecting the posterior col- 
umns, even though it do not present the clinical picture 
of tabes. Thus, it may be absent in transverse myelitis in 
the lumbar region of the cord (always is, if the myelitis 
be complete), in certain forms of diffused myelitis, in dis- 
seminated sclerosis, and in tumors or other growths 
affecting the spinal cord. Injuries and sections of the ~ 
cord in this region, respectively, may and must abolish it. 

But the posterior columns are not the only part of the 

cord the affection of which seems to produce abolition of 

the knee-jerk. It is also absent in almost all cases of 

anterior poliomyelitis. In infantile paralysis, indeed, the 

diagnosis is always rendered doubtful until after long ex- 

amination, if the knee-jerk be present. 

Whenever the knee-jerk is totally absent for a consider- 
able period without other symptoms, it points toward 
disease of the posterior columns. 

The knee-jerk may likewise be diminished or abolished 
by cerebral influences. This is the case in opium narco- 
sis, and in all forms of coma. 

It may also be diminished or caused to disappear en- 
tirely from purely mechanical causes. The tension of 
the quadriceps extensor femoris may be rendered so great 
that it is unable to contract readily. This may occur 
from the too great flexion of the leg on the thigh, or from 
some pathological condition in the muscle. Again, the 
tendon or the muscle may be so relaxed that no reaction 
can be obtained by tapping the tendon, as occurs when 
the leg is fully extended on the thigh. Lastly, it is said 
that in cases where a mass of fat is situated directly be-- 
neath the tendon this prevents its vibration, and in such 
case no knee-jerk can be obtained (Westphal). 

ANKLE CLonus.—Next to the knee-jerk, by far the 
most important of the deep reflexes, from a diagnostic 
point of view, is that caused by the stretching of the 
Achilles tendon, and usually known as the Achilles ten- 
don reaction, or in the more advanced stage as the ankle 
clonus (foot-phenomenon of Westphal). Like the knee- 
jerk, it was first brought to the notice of the medical pro- 
fession by Westphal, and Erb, simultaneously, in 1875, 
and since then has been the object of much study. The 
Achilles tendon reaction is almost always present in the 
healthy individual, and may be developed by tapping 
the Achilles tendon sharply with the fingers or a percus- 
sion hammer while it is in a state of tension. In consists 
in a single contraction of the external muscles of the calf 
(gastrocnemius, soleus, and plantaris), and is to be care- 
fully distinguished from the ankle clonus, which is a se- 
ries of rhythmical contractions of the same muscles, and 
bears the same relation to it that the knee clonus does te 
the knee-jerk. 

The ankle clonus is produced usually by the sudden 
and forced flexion (dorsal flexion) of the foot upon the 
leg, which causes the stretching of the Achilles tendon, 
and it consists in rhythmical contractions of the calf 
muscles, which cause involuntary extension of the foot. 
In severe cases these contractions may be developed to a 
high degree, and in most cases where ankle clonus exists 
the contractions will continue so long as the tendon is kept 
tense. Asa rule, with the exception of one or two weak 
contractions, the clonus ceases immediately on the cessa- 
tion of the forced tension of the tendon, but the contrac- 
tions can be made to cease instantly by extending the 
foot and thus relaxing the tendon. Ankle clonus does 
not occur in the healthy individual under ordinary cir- 
cumstances, but it may be produced if desired. If, for 
example, anyone while sitting, the leg being at an acute 
angle with the thigh, will let the foot rest upon the ball 
of the toe, the heel being raised and unsupported, and 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Tendon Reflex. 
Tendon Reflex. 


will then voluntarily raise and lower the heel, ‘‘ imitating 
the movements made when an infant is dandled on the 
knee,” he will soon find that the movements are contin- 
ued involuntarily, and cannot be stopped without a dis- 
tinct effort. The ordinary method, however, of testing 
for ankle clonus is for the physician to grasp the foot 
firmly with one hand, while the patient’s leg is almost 
fully extended upon the thigh, and to suddenly and 
forcibly flex the foot dorsally upon the leg. Tension of 
the Achilles tendon is thus best produced. 

The contractions of the muscles in ankle clonus are, as 
before stated, rhythmical, and, according to Gowers, oc- 
cur at the rate of from six to ten per second. 

An exaggeration of the tendo Achillis reaction may 
be obtained under the same conditions as exaggeration 
of the other deep reflexes. The foot clonus may be ob- 
tained in slight chloroform narcosis, but not under ether 
or nitrous oxide. It is also present for a short time 
after certain epileptic attacks. A slight clonus also oc- 
curs at times in cases of great functional nervous irrita- 
bility, toxic or other (tobacco, alcohol), but this is usually 
temporary. Gowers believes that, when ‘‘a uniform 
clonus can be obtained by simple flexion of the foot,” 
it ‘‘is always pathological, always indicates grave nu- 
tritive changes in the spinal cord, and that there is, in 
most cases in which it can be obtained, actual degenera- 
tion in the fibres of the lateral columns.” 


The diagnostic value of the ankle clonus consists in 


the fact that it is only present when the deep reflexes are 
much exaggerated, and may be regarded usually as a 
sign of some affection or lesion of the corresponding lat- 
eral column of the spinal cord. It occurs in its most 
typical form in sclerosis of the lateral columns, and it is 
often present on the affected side in cases of cerebral 
hemiplegia, in which case we are justified in presuming 
that a secondary degeneration of these columns exists. 
It naturally occurs also in cases of transverse myelitis, 
and in tumors of the cord or its membranes where these 
columns are affected. It is even present in amyotrophic 
lateral sclerosis, where both the lateral and the posterior 
columns are involved. 

It is scarcely necessary to state that the spurious or 
voluntary foot clonus, which sometimes is found in hys- 
teria, should be carefully distinguished. This latter is 
produced by the voluntary contraction of the calf mus- 
cles as the patient pushes the foot against the physician’s 
hand, and does not, like the true clonus, begin immedi- 
ately on the forced extension of the tendon, but some sec- 
onds after. 

OrHER DEEP REFLEXES.— With the exception of the 
knee-jerk and the Achilles tendon reaction, the so-called 
deep reflexes of the upper extremity, the triceps, the ul- 
nar, and the radial, of which the last two are periosteal, 
are the only ones which occur in any large proportion of 
healthy persons, and these have no special clinical sig- 
nificance. Many other deep reflexes, however, occur 
under abnormal or pathological conditions. Under the 
same circumstances which produce exaggeration of the 
knee-jerk or of the Achilles tendon reaction, muscular 
contractions from the tension of other tendons begin to 
appear in the corresponding muscles, and various similar 
phenomena from the tapping of the periosteum or fascia 
in various parts of the body. Thus, as regards those 
produced from tendons, reactions may be obtained from 
those of the biceps, the supinator longus, the radial ex- 
tensors, the flexors of the fingers, etc., in the upper ex- 
tremities ; and from those of the adductors of the thigh, 
the gracilis, the biceps femoris, the tibialis anticus, the 
tibialis posticus, and the peroneus longus in the lower 
extremities. 

Of the periosteal reflexes the best known is the ‘‘ front 
tap,” or ‘‘tibial tap,” which terms are used to denote the 
sudden contraction of the quadriceps femoris produced 
by a gentle blow on the front of the tibia, near its middle. 
This usually exists under the same conditions as the an- 
kle clonus. The ulnar and radial reactions mentioned 
above are obtained. by tapping the lower ends of the 


ulna and radius, which causes respectively contractions | 


of the triceps and biceps. Many other periosteal reflexes 


may occur, and in some cases even moderately distant 
muscles may react (remote reflexes), as in the scapular 
and clavicular reflexes, where, on tapping the spine of the 
scapula, a contraction is caused in the deltoid, and the bi- 
ceps reacts to a blow on the sternal end of the clavicle. 
Contractions of the chest muscles may sometimes be pro- 
duced by striking the costal cartilages or the ribs, while 
blows on the transverse processes of the cervical verte- 
bra may cause contractions of the muscles of the upper 
arm, and on those of the lumbar vertebre contractions of 
the glutei and adductors of the thigh. 

When the excitability of the deep reflexes is greatly in- 
creased, we even begin to find other forms of clonus, and 
this is especially common in cases of late hemiplegic ri- 
gidity. Thus a wrist clonus may be produced by a sud- 
den and forcible hyperextension of the wrist, or a toe 
clonus may exist, caused by rhythmical contractions of 
the abductor and flexor brevis pollicis. Gowers also 
describes a lateral ankle clonus from contraction of the 
peronei, which can be produced by passive pressure of 
the foot inward. ; 

SprnaL Epruepsy.—Under this name is known a con- 
dition in which the whole lower extremity shakes en 
masse, forcibly and violently, when moved passively, or 
even when touched. This is considered to be due to an 
increase in the excitability of the Achilles tendon greater 
than that which exists in ankle clonus (Mébius), or to 
‘combined contractions due to stimulation of some of 
the superficial and deep reflexes” (Ross). It only occurs 
in cases of degeneration of the lateral columns of the 
cord, and is perhaps most frequently to be observed in 
paraplegia from Pott’s disease, or ‘in other forms of trans- 
verse myelitis. 

PARADOXICAL CONTRACTION (Westphal).—This phe- 
nomenon may be considered roughly as the opposite of 
the ordinary tendon reaction. It consists in the contrac- 
tion of a muscle caused by the passive approximation of 
its extremities. It is best known in the tibialis anticus, 
in which it may be produced in the proper cases by the 
rapid dorsal flexion of the foot. In these cases the foot 
remains, after the pressure has ceased, firmly fixed in the 
position of dorsal flexion, and may be held so many min- 
utes. Other muscles sometimes assist the tibialis, as the 
extensor communis digitorum and the extensor brevis pol- 
licis. This form of contraction has also been observed in 
the biceps femoris, and may even occur in the muscles of 
the upper extremity. It is found principally in those 
muscles of the extremities in which the ‘‘tendon’re- 
flexes” are rare and difficult to obtain, and, on the other 
hand, does not seem to occur in those, like the quadri- 
ceps femoris, in which they are ordinarily present. Para- 
doxical contraction is said to be usually associated with 
paresis of the lower extremities. It occurs when the 
deep reflexes are absent or normal, and even when they 
are somewhat exaggerated ; but it cannot occur, at least 
in the-tibialis, when an ankle clonus exists. It has not 
been observed where there is an excess of cutaneous sen- 
sibility. This phenomenon is found only in disease. It 
has been observed in cases of combined sclerosis of the 
posterior and lateral columns, in paralysis agitans (West- 
phal), and in hematomyelia (Ross). 


REFERENCES. 


Erb: Sehnenreflexe bei Menschen, etc. Arch. f. Psych., v., 792. 1875. 

Westphal: Ueber einigen Bewegungs-Erscheinungen an gelahmter Giie- 
den. Arch. f. Psych., v., 808, 1875. 

Erb: In Ziemssen’s Handbuch der speciellen Pathologie und Therapie, 
xi., 2te Hilfte, 2te Aufi., 1879. 

Gowers: Tendon Reflex Phenomena. Medico-Chirurgical Transactions, 
lxii., 1879; Lancet, 1879, i., 156, and 1581, i., 584; see also Gowers, On 
the Diagnosis of Diseases of the Spinal Cord, third edition. Philadel- 
phia, 1884. 

Waller: On Tendon Reflex. Brain, vol. x., 1880; Lancet, 1881, ii., 83. 

Senator : Ueber Sehnenreflexe und ihre Beziehung zum Muskeltonus. 
Arch, f. Anat. u. Physiol., 197, 1880. 

Westphal: Ueber eine Fehlerquelle bei Untersuchung des Kniephdno- 

Arch. f, Psych., xii., 1882; also Westphal in Arch. f. Psych., 
vii., 666. 

Eulenburg: Neurol. Obl., 1882, i., 3, Transactions of International 
Medical Congress, London, 1881, ii., 42 (Diagrams of tracings). 

De Watteville :* On Reflexes and Pseudo-reflexes. British Medical Jour- 
nal, 1882, i., 736. 

Ross: Diseases of the Nervous System, second edition. 

Jendrdssik: Beitrige zur Lehre y. Sehnenreflex. 


New York, 1883, 
Pest. med.-chir, 


771 


Tendon Reflex. 
Tendons. 


Presse, xviii., 277, 302, 1882; Deutsch, Arch. f. kl. Med., xxxiii., 177, 
1883. ; 
Pelizaeus: Ueber das Kniephinomen bei Kindern. Arch. f. Psych., xiv., 

402, 
Knapp: Observations on the Cutaneous and Deep Reflexes, 
Journal of the Medical Sciences, N. S., Ixxxix., 429, 1885. f 
Mobius: Allg. Diagnostik der Nervenkrankheiten. Leipzig, 1886. 


William N. Bullard. 


American 


TENDONS, DISEASES AND INJURIES OF. The 
tendons are not so often the seat of surgical disease as 
are their sheaths, and some consideration of the diseases 
of the latter must unavoidably be included in a descrip- 
tion of the affections of the tendons themselves. _ 

Necrosis of tendons may follow injury or inflamma- 
tory conditions of the surrounding tissues, or may be a 
part of a general necrosis. This is readily understood 
when one considers that the tendons are organs of rather 
low vitality, and that their blood-supply is easily cut off. 
This necrosis may prove very troublesome and exhaust- 
ing in an already depreciated condition of the system. 
The story of such a case, which occurred in the practice 
of Dr. E. M. Culver, of New York, may not prove unin- 
teresting: An old lady, seventy-three years of age, was 
suffering from senile gangrene involving the great toe. 
The sphacelus had come away, leaving a clean granulat- 
ing surface, but in the sole of the foot, opposite the meta- 
tarso-phalangal joint, was an abscess. Slight manipu- 
lation of this abscess caused a considerable quantity of 
fetid pus to escape through the ulcer. Incision of the 
abscess showed that the necrosis of the flexor tendon of 
the toe had been its exciting cause. The process con- 
tinued, and several abscesses were opened along the 
course of the tendon before recovery ensued. Although 
so extreme a case from this cause is not common, the 
death of tendons is not rare after contused wounds, and 
as a sequel.of suppuration in the tendon-sheaths. After 
necrosis has occurred, the tendon is seldom, if ever, re- 
formed, and the function of the part is permanently im- 
paired. The condition is not one which permits of special 
treatment for the tendons, except prompt evacuation of 
all collections of pus, and the removal of the necrotic 
tissue as fast as it separates from the seemingly sound 
parts. 

Tumors do not often involve the tendons, but they 
may do so. Carcinoma and sarcoma develop in this 
tissue only through extension by contiguity, and do not 
form there by metastasis. Occasionally small fibromata 
develop upon the tendons, and give rise to more or less 
annoyance. They are usually quite small, and do not 
often attract much attention unless they interfere with 
the proper action .of the tendon, or are painful by being 
so situated that they are subject to pressure. These 
fibromata may be felt as small, hard lumps beneath the 
skin, adherent to, and moving with, the tendons. The 
flexors of the fingers are their most usual site. They 
are, aS a rule, neither painful nor tender, nor do they in- 
crease rapidly in size, nor incline to become adherent to 
the surrounding tissues. These fibromata are said to tend 
to become sarcomata when they are of large size or rapid 
growth. This tendency should lead one to exercise cau- 
tion in refusing to operate upon a tumor that seems to be 
innocuous. Should it become necessary to treat these 
growths, they may be removed, provided antiseptic pre- 
cautions are taken, and care is observed that the tendon 
does not become adherent to the sheath at the part from 
which the tumor was removed. Gummata may form 
upon tendons, but their identification is involved in their 
history and in the recognition of concurrent lesions, as 
well as in their disappearance after antisyphilitic treat- 
ment with mercury and the iodides. For a description 
of the cystic tumors springing from the tendon-sheaths, 
see article Ganglion (Vol. III., p. 297). 

ACUTE TENOSYNOVITIS (inflammation of the sheath of 
a tendon, thecitis) may follow strains or wounds, or ma 
complicate syphilis, gonorrhea, or rheumatism. Occé- 
sionally such an attack is seen during the course of one 
of the continued fevers. The severity of the attack de- 
pends, generally speaking, upon the presence or absence 


of suppuration ; the presence of pus rendering the affec- - 


V72 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


tion much more grave. It will be found convenient to 
speak of suppurative tenosynovitis separately. 
Non-suppurating Tenosynovitis,—In the traumatic cases 
of acute non-suppurating tenosynovitis, where no wound 
has occurred, the disease may foilow prolonged or re- 
peated muscular efforts; or a single severe strain, as in 
giving a hard blow with the fist, or a strong push; or it 
may follow contusion. Dr. G. B. Phelps, of New York, 
whose experience has been large in this class of cases, in- 
forms me that he has observed that tenosynovitis most 
often attacks those who change from an accustomed to an 
unaccustomed form of hard labor, and those who have 
been idle and have just obtained work. He thinks that 
it comparatively seldom follows a single severe effort. It 
attacks most often the flexor group in the wrist ; though 
it is also seen in other localities, notably the extensors of 
the fingers at the wrist, the tendons about the ankle, and 
the long tendon of the biceps cubiti. The symptoms 
which point to tenosynovitis are pain and tenderness, with 
some swelling, along a tendon-sheath. This pain will be 
increased by active or passive motion of the tendon. The 
disability of the part is complete on account of the pain ; 
or, rather, motion in the part controlled by the tendon 
will be avoided and the part will be held in a position 
most favorable for rest. In addition to this, there may. 
often be felt a peculiar rustling feeling of crepitation, dif- 
ficult to describe, but which resembles in some degree the 
sensation produced by subcutaneous emphysema. The 


~ sensation may, perhaps, be conceived, if one has a good 


imagination, by likening it to feeling crepitant rales. 
This condition is explained by the pathological condition 
which exists. 'The changes which occur are those of all 
serous inflammations: Congestion, followed by serous, 
and subsequently fibrinous, exudation. These cases usu- 
ally do well, though occasionally recovery takes place 
with an adherent tendon. There is but little tendency 
to become chronic, and the inflammation seldom becomes - 
purulent unless by infection from an open wound. 

The duration of the disease is from a week to a month, 
depending upon the severity of the attack and the con- 
stitutional ability of the patient to recover from any in- 
flammatory disorder. Constitutional treatment is not 
usually demanded in these cases when of traumatic ori- 
gin. Opium may be needed to relieve the pain, and an 
occasional laxative may be indicated. Rest, pressure, 
and counter-irritation are the chief factors in the treat- 
ment of acute tenosynovitis. Rest is secured by splints. 
Pressure evenly applied and extending above and below 
the site of the lesion is invaluable. This is well obtained 
by the application of a ‘‘ cotton dressing,” which consists 
of a tolerably thick layer of cotton-wool firmly bandaged 
in place. The rubber (Martin’s) bandage may be used, 
if it is well borne, though an ordinary muslin roller band- 
age is commonly quite sufficient. Counter-irritation in 
the milder cases, uncomplicated by wounds, is almost 
always of use. Iodine is a common application for this 
purpose, and may be used in the form of the officinal 
tincture, or better, perhaps, in that of the ointment. 
This is perhaps as good as any of the milder counter- 
irritants. If the pain is severe the mildly astringent and 
anodyne lead and opium wash (Lotio Plumbi et Opii, U. . 
S. Ph.) will often serve a good turn, and may be applied 
hot or iced, as desired, until the pain is nearly or entirely 
relieved. Hot or cold water applications are often ad- 
vised under the same circumstances, until a more perma- 
nent dressing can be borne. Moderate passive motion 
may be used if the attack is prolonged and there seems 
to be a tendency for the tendons to form adhesions. The 
rheumatic, syphilitic, and gonorrheeal forms of tenosyno- 
vitis require treatment directed to the causal disease, in 
addition to that above described. 

Suppurative tenosynovitis usually follows wounds of 
the tendon-sheaths which have become infected ; but 
roay occur after very slight injuries in the neighborhood 
of the tendon; and, sometimes, it seems to occur after thé 
milder form without open wound. The trouble, once 
started, resembles cellulitis in its course. It may be en- 
tirely local or may involve, in a very short time, a whole 
member. The disease is characterized by very severe 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


pain of a throbbing character, by fever and occasional 
chills, and by marked prostration, in addition to the 
symptoms already noted as characterizing the milder 
type. The skin is reddened in these cases, and the local 
tenderness is more marked than in the non-suppurative 
cases. The tendency of the disease is toward destruction 
of more or less of the tissues attacked, and recovery is of- 
ten rendered incomplete by the presence of unyielding 
tendons, by unsightly scars, and by the contractions re- 
sulting. In some cases even amputation is necessary to 
save life, so virulent is the septic attack. The treatment 
is the same as that of suppurating cellulitis, viz., free 
evacuation of pus and clean after-treatment. As soon as 
the presence of suppuration in a tendon-sheath seems as- 
sured, it is necessary to freely incise the sheath and drain 
the part as much as may be necessary. ‘The tendons are 
liable to necrose in these cases, and often considerable 
deformity may result in this way. 

CALCIFICATION OF TENDONS.—Old people who have 
been subject to rheumatic attacks may have deposits of 
lime in one or more of the tendons. This occurs near 
stiffened joints in most instances. The patellar tendon, 
above or below the bone, is a frequent site for such a con- 
dition. These tendons are especially liable to rupture by 
muscular violence. It is not a condition which admits of 
active treatment. . 

CHRONIC TENOSYNOVITIS (hygroma, compound gan- 
glion) is a disease characterized by gradually increasing, 
painless swelling, more or less loss of power, and the de- 
velopment of certain small fibrinous masses in the dis- 
tended tendon-sheath. These masses are known as rice- 
bodies or melon-seed bodies. The affection may follow 
the acute form, or may be of gradual development with- 
out any apparent cause. The etiology of chronic teno- 
synovitis is rather obscure; it is often tubercular and 
sometimes syphilitic or rheumatic in origin, besides, as 
we have seen, arising from trauma through the acute 
form. It most commonly affects the flexor tendons in 
the forearm and hand, in which situation the swelling 
will be seen above and below the annular ligament, and 
divided by it intotwo portions. Pain and tenderness are 
not often marked in this as in most chronic inflammations. 
The disability is of gradual development and is not usually 
complete ; the common experience is, that prolonged effort 
weakens the part so that it incapacitates the patient for 
his usual work. The tumor is fluctuating, and the wave, 
started from either pouch of the sheath, may be felt to 
pass into and distend the other. The rice-bodies may 
sometimes be felt to interrupt the regular current of the 
distending wave as they pass through the narrower por- 
tion of the sac beneath the annular ligament. .The diag- 
nosis is not usually difficult in these cases, though, if there 
has been spontaneous or operative opening of the cyst, 
with pouting granulations and serous discharge, the ap- 
pearance may simulate that of a malignant growth or a 
carious joint. 

Left alone, the disease does not tend to recovery. There 
are reported many cases of failure to cure, of anchylosis 
from tendon adhesion, and even some of caries of the 
carpal bones, and of amputation to save life after opera- 
tion; but when the operation is performed with antisep- 
tic precautions many cases may recover quickly and per- 
manently. The cure demands. treatment by operation. 
Benefit does not often follow local measures, nor the in- 
jection of the cyst. The treatment which is usually the 
most successful is that of opening the sac above and be- 
low the annular ligament, thoroughly washing out the 
cavity, and clearing it of the rice-bodies. The surfaces 
may require to be scraped with a sharp spoon, to detach 
some of the fibrinous fungosities. The entire cavity 
should then be drained by a tube passed through both 
openings, the one in the palm and the other in the fore- 
arm. <A splint is, of course, a necessary part of the dress- 
ing. If the splint can be so arranged as to avoid its re- 
moval for the subsequent dressings, much pain is avoided 
during the first few changes. The other methods by 
which these chronic inflammations have been treated need 
hardly occupy our time. Evacuation by a cannula and 
drainage, the splitting of the whole length of the wall (in- 


Tendon Reflex. 
Tendons, 


cluding annular ligament), and setons have all been of 
use, but do not seem to offer greater advantages than the 
operation mentioned. 

DisLocaTIon may follow severe strains of the ten- 
dons. This occurs rarely in any locality, but perhaps 
most often at the ankle, where the anatomical relation 
of the tendons to the malleoli is such as to permit the 
accident. It also occurs as a complication of fractures 
and of dislocations of the bones. The symptoms are 
pain, tenderness, and disturbance of function, with, usu- 
ally, deformity. The diagnosis may be uncertain, unless 
the deformity caused by the absence of the tendon from 
its usual site can be detected. This may be obscured by 
the thickness of the overlying tissues and by swelling 
after injury. At the ankle, where the injury most often 
occurs and where the results of dislocation would seem 
most serious, the displaced tendons may easily be felt. 
The outlook is not ultimately unfavorable, as the proba- 
bility of the tendon reassuming its function in its new 
locality is considerable, even when attempts at retention 
after reduction fail. Manipulation seldom fails to reduce 
the displaced tendon, but its retention is often a matter 
of great difficulty. This may usually, however, be ac- 
complished by pads and snug bandaging, perhaps with 
an elastic bandage. The part must be immobilized for a 
considerable time, and its use prohibited until the retain- 
ing bands are strongly re-formed. Tenotomy may be 
necessary to prevent muscular action throwing the ten- 
don out before it has become solid in its bed. 

RupTuRE OF TENDOoNS.—This accident occurs with 
surprising frequency when one considers that the sudden 
violence of machinery accidents, involving great strain 
of tendons, is more apt to tear out the tendon entire than 
to rupture it. This is shown in the case of evulsed fin- 
gers, where the separation occurs between the muscle and 
tendon, and not in the body of the tendon. Sudden mus- 
cular action is usually the cause of the accident. As a 
rule, the tendons that break are the seat of some degen- 
erative lesion, and for this reason the accident is more 
common in persons past their physical prime. The ten- 
dons most often ruptured are the long tendon of the bi- 
ceps cubiti, the tendon of the quadriceps extensor cruris 
(above or below the patella), the tendo Achillis, and the 
tendon of the plantaris muscle. The occurrence of such 
an accident is denoted by a sudden snap, often both felt 
and heard by the patient, and by pain and loss of func- 
tion. A day or two later, ecchymosis under the skin may 
be present. The defect in the tendon may be felt in the 
case of a superficial tendon, like the tendo Achillis. A 
cramp-like bunching of the muscle may also be noted, 
and may be of service in confirming the diagnosis. The 
result of the injury is not usually serious, with proper 
treatment. Union takes place by the organization of the 
clot which forms, as in subcutaneous tenotomy, and after 
a time the appearance of the tendon is normal. The 
treatment after the rupture of tendons is entirely by po- 
sition and such aid as can be secured by bandaging in such 
a manner as to relax the contracted muscle. For exam- 
ple, the tendo Achillis being ruptured, the treatment 
should consist of apposition of the ends as nearly as pos- 
sible by bandaging the leg firmly from above downward, 
strong extension of the foot, and fixation in an immova- 
ble splint. 
~ WOUNDS OF THE TENDONS. —The wounds of tendons are 
of the same nature as are wounds in general. ‘They may be 
the result of an accident, or may be made by the surgeon. 
Such wounds may be classified as open or subcutaneous ; 
operative wounds falling, in most cases, in the latter class, 
The wounds may be further classified as incised, punct- 
ured, or contused ; as transverse or longitudinal ; clean 
or infected ; and complete or partial, according as the 
entire tendon or a part of it is divided. The usual con- 
dition which demands the surgeon’s attention is a trans- 
verse incised wound, more or less unclean, in which one 
or more tendons have been divided. Such wounds are 
perhaps most common in the forearm, about the wrist- 
joint, and in this location the number of tendons involved 
may be quite large. To a less degree, the tendons pass- 
ing the ankle and knee-joints are liable to be cut. Knives, 


773 


Tendons. 
Tenotomy. 


sharp tools, and glass are the usual instruments with 
which the wounds are made. After the complete di- 
vision of a tendon the symptoms are complete loss of 
function, retraction of the tendon, and more or less 
‘‘bunching” of the muscle of which the tendon is a part. 
The loss of function is not complete with partial division. 
Longitudinal and punctured wounds do not often oc- 
casion complete disability or loss of function, unless in- 
flammation in the sheath of the tendon be present. Even 
after the original wound is healed the detection of the 
cut tendon is usually easy. The divided end of the ten- 
don will be involved in the cicatrix, which will be drawn 
by the contraction of the muscle. Sometimes the defect 
may be felt in the tendon, and occasionally the contracted 
muscle may be prominent. 

A cut tendon, if left to itself, is not likely to heal with 
restoration of function, for the newly formed part may 
not entirely fill the gap between the divided ends; and, 
furthermore, adhesions are likely to take place. Inflam- 
mation may in the same way lock the part. Secondary 
operations are often of use, and if the tendon is a func- 
tionally important one, they should be attempted. Con- 
tused and infected wounds of tendons, when severe sup- 
puration occurs, are apt to be followed by sloughing of 
the tendons. Amputation of a small member is some- 
times advisable, when permanent stiffening has occurred 
on account of a tendon-wound, in order to get the part 
out of the way of a more useful member which may do 
its work. Subcutaneous injuries and uninfected open 
wounds almost always unite without loss of function, 
when the parts can be approximated and retained for a 
sufficient time to allow union. 

In the case of recent wounds, in which tendons have 
been divided, the question of their immediate suture is to 
be decided upon general surgical principles. If the wound 
is clean, or susceptible of being made surgically clean, 
it will, in most cases, be best to unite the divided ends of 
the tendon. In granulating wounds the same is usually 
true. Suppurating wounds will need preparatory treat- 
ment to render them aseptic. When the tendon is only 
partially divided the use of sutures is not commonly de- 
manded, as the divided fibres will usually unite suffi- 
ciently without operation. When a number of tendons 
are divided it is difficult to unite the distal ends to their 
respective muscles, because of the disturbed anatomical re- 
lations and the similarity of one tendon to another. This 
is especially true at the flexor side of the wrist. This 
does not seem to be essential, however, as nature seems 
to permit the muscle to serve in its new duty without de- 
struction of the co-ordinating power. Restis very essential 
to a part after these operations, and should be secured 
by a splint so arranged as not to require removal for the 
dressings. The splint should be retained until the union 
is firm—usually for from three to eight weeks. Drain- 
age, too, must be very carefully looked after, for often 
sutured tendons survive suppuration in the wound when 
the products of the inflammation are well drained away. 

‘THE SuTuRE oF Trenpons.—In suturing tendons the 
most accurate details of antisepsis should be followed, be- 
cause the least suppuration will often mean the undoing 
of all the work, plus the danger of suppurative inflam- 
mation extending in the sheath of the tendon. Complete 
general anesthesia is commonly best, as it enables the 
operator to work at his leisure, and relaxes the muscles 
of the patient. To bring the retracted tendon into view, 
the part should be relaxed as much as possible by posi- 
tion. A rubber bandage (Esmarch’s), applied from above 
downward over the muscle, may advance the tendon suf- 
ficiently to enable one to draw it into view with forceps. 
Often it. will be found advantageous to enlarge the orig- 
inal wound, both to afford space for working and to faci- 
litate the discovery of the tendon. The tendon may be 
sutured without special preparation, or the ends may pre- 
viously be freshened, as seems to be expedient. Bevel- 
ling the ends by an oblique section will increase the 
area of the apposing surfaces. If the wound is to be 
closed, absorbable sutures should be used for approxi- 
mation ; moderateiy heavy catgut will often hold long 
enough to allow union, if the action of the tendon is pre- 


7174 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


vented. If the wound is to be treated openly, silkworm- 
gut or silk may be used by preference. These sutures, 
usually two or three in number, are passed at a distance 
of about a fourth of an inch from the cut ends, and are 
to be left without tension. Great care must be used not 
to tear the stitches out by violence, or by using a needle 
large enough to split the tendon. The flat needle of Hag- 
edom is especially useful here. Sutures for relaxation 
should also be inserted at a greater distance, or the ten- 
don may be temporarily held by a hare-lip pin, or by a 
suture of silver wire passed through the skin at the up- 
per border of the wound. The relaxed position must be 
carefully maintained after the operation. 

In the case of old injuries in which tendons have been 
divided, much improvement can often be effected by care- 
ful suture of the tendon. The cut ends of the tendon 
should be carefully dissected from the sheath to which 
they have formed adhesions, and should then be fresh- 
ened before approximation by stitches. It is sometimes 
impossible to find the retracted tendon, and under these 
circumstances it has been found admissible to insert the 
distal end of the tendon into the body of one having a 
similar function. For example, the common flexor ten- 
don supplying one finger may be spliced to that control- 
ling another. This splicing is done by making a partial 
oblique division of the tendon and inserting the freshened 
end of the cut tendon in the space thus made. It has oc- 
casionally been found expedient to divide a less useful 
tendon and divert its muscle to a new function by uniting 
it to the stump of another severed tendon having a more 
important function. Ff, A. Manning. 


TENESMUS. Syn.: Fr., Tenesme; Ger., Stuhl- 
zwang ; Gr., reweouds, from relvw, to stretch. By this term 
is understood a painful straining at stool, accompanied by 
spasmodic contractions of the sphincter ani muscle. It 
occurs when the rectum contains little or no feces, but 
when the mucous lining of the bowel is in an irritable 
condition, arousing a sensation as of a-large amount of 
material in the rectum, and causing an urgent desire to 
defecate ; at the same time the irritable state of the mu- 


cous membrane covering the sphincter causes that mus- 


cle to contract violently. Usually a little mucus, often 
streaked with blood, with occasionally some fluid feecal 
matter, is extruded in the intervals of the spasmodic 
closure of the sphincter. The straining is wholly invol- 
untary, and is sometimes so severe as to cause prolapse 
of the bowel. Tenesmus is a symptom of any inflam- 
matory condition of the mucous coat of the rectum or 
sphincter. It is commonly met with in dysentery, hem- 
orrhoids, and cancerous disease of the rectum; in intus- 
susception involving the large intestine; in the rare in- 
stances of gouty inflammation of the lower bowel; in 
prolapse of the rectum, and occasionally in fistula or 
fissure of the anus. 

As tenesmus is merely a symptom, the treatment 
should, of course, be directed to the cure of the causal 
disease. But the symptom is at times so distressing, that 
it demands treatment for itself, apart from that of the 
primary affection. A considerable measure of relief may 
often be afforded by small starch enemata to which a 
little laudanum has been added. Suppositories of opium 
and belladonna are also useful. Trousseau speaks highly 
of injections of a decoction of rhatany, of the strength of 
3 j. to the pint, after each stool. Very minute doses of 
gamboge have been recommended. Occasionally, ice 
suppositories or small enemata of cold water will serve a 
useful purpose, and at other times more relief may be 
afforded by warm injections or by hot applications to the 
anus. 


TENESMUS, VESICAL. Syn. : Strangury ; Lat. 
Urine stillicidium ; Fr., Strangurie; Ger., Harnstrenge; 
Gr., orpayyoupia, This is a condition in which there is 
an almost constant, urgent desire to urinate, the act itself. 
being accompanied by more or less pain. The urine, 
which sometimes contains more or less blood, is voided 
in very small quantities, sometimes drop by drop, and its 
passage 1s attended with severe pain in the perineum, 


te 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


groins, hypogastrium, and often, in men, in the glans 
penis. The pain is lancinating in character, occurring in 
paroxysms, and is caused by the forcible spasmodic clos- 
ure of the sphincter vesice ; it may vary from aslight un- 
easiness to most excruciating torture. The desire to pass 
water is constant and imperative, yet the patient fears to 
yield to it, dreading the agony which the act causes. 
Strangury is a symptom of irritability of the neck of 
the bladder, from whatever cause, and is pathognomonic 
of no special disease. It is often the most prominent 
symptom in various bladder troubles, and is usually the 
one for the relief of which the patient seeks advice. It 
is commonly present in cystitis, tumors of the bladder, 
vesical calculus or gravel, acute inflammation or conges- 
tion of the kidneys, hypertrophy and other diseases of 
the prostate, hyperacidity or alkalinity of the urine, etc. 
It sometimes occurs, with rectal tenesmus, in dysentery 
and other inflammatory diseases of the lower bowel. It 
is also caused by the ingestion or absorption of certain 
drugs, such as cantharides and turpentine, and it is a not 
uncommon experience to meet with more or less stran- 
gury after the application of a large fly-blister to any 
part of the integument. 
When a patient presents himself, complaining of this 
symptom, it is necessary, of course, to search for the 
causal affection, and to institute the treatment proper for 
that condition. But it is often possible to greatly miti- 
gate the severity of the vesical tenesmus, even before a 
cure of the affection, to which the irritability of the neck 
of the bladder is due, has been obtained. The urine 
should be rendered as bland as possible by means of de- 
mulcent drinks and by the ingestion of large quantities 
of water, so as to increase its dilution. If it is highly 
acid the citrate or acetate of potassium, in very dilute so- 
lution, may be given frequently ; and if it is alkaline, 
benzoic acid will serve a useful purpose. The distress 
may likewise bé moderated by opium and belladonna 
suppositories, by small enemata containing laudanum, 
or, better, by morphine hypodermatically administered. 
When practicable, the continuous hot sitz-bath will be 
found usually to give the greatest measure of relief, the 
patient being instructed to pass his water in the bath. 
Minute doses of cantharides or turpentine sometimes af- 
ford considerable relief, especially in the vesical tenes- 
mus dependent upon enlarged prostate. Other drugs 
that have been recommended are gelsemium, bromide of 
potassium, aconite, veratrum viride, thymol, and various 
antiseptics and_diuretics. ~ LD EASE 


TENOTOMY. The first recorded instances of tenot- 
omy were for the cure of muscular torticollis. The 
operation was performed by Roonhuysen in 1670, and 
again by Minnius, in 1685. Thilenius is said to have di- 
vided the tendo Achillis in 1684. In all these cases the 
division of the tendon was accomplished through an 
open wound. In 1816 Delpech made the first advance 
in the direction of a subcutaneous operation. He made 
‘a longitudinal incision in the skin, parallel with the 
course of the tendon, and at a little distance from it, 
and then effected the division of the tendon by means of 
a knife introduced through the wound so made. His 
operation was for the division of the tendo Achillis, and 
six years later, in 1822, Dupuytren performed tenotomy 
of the sterno-cleido-mastoid by the same method. Sub- 
cutaneous tenotomy, as it is now understood, was first 
performed by Stromeyer in February, 1831, and it is to 
him that we are indebted for the operation as it is prac- 
tised at the present day. To Dieffenbach, also, is, due 
much credit for his earnest advocacy of the procedure. 
Dr. Little, of London, who was himself a sufferer from 
talipes, and was successfully treated by Stromeyer, intro- 
duced the operation into England. In this country te- 
notomy was first performed by Dr. David L. Rogers, of 
New York City, in 1834. Dr. Detmold, of the same 
.city, Dr. Miitter, of Philadelphia, and Dr. Richardson, 
of Kentucky, also contributed much to the general ac- 
ceptance of tenotomy by the surgeons of this country. 

The operation of tenotomy is indicated whenever con- 
tracture of a muscle exists as an impediment to the re- 


Tendons, 
Tenotomy. 


duction of deformity. It is in the treatment of club-foot, 
however, that the operation finds its most frequent appli- 
cation. It is employed also in muscular torticollis, and 
in contractures of the muscles concerned in movements 
of the hip, knee, elbow, fingers, toes, etc.; in strabismus, 
in spasmodic stricture of the anus, and as a preliminary 
to the reduction of old dislocations. It should not, how- 
ever, be employed indiscriminately, but only after a care- 
ful study of the indications in each individual case, and 
with a thorough appreciation of what it is desired to ac- 
complish by means of it. In bony anchylosis, for exam- 
ple, it is evident that tenotomy alone will be useless, 
though it may sometimes be useful as a preliminary to 
osteotomy. In the malpositions occurring during the 
active stage of joint disease from reflex muscular action, 
tenotomy will be useless, and should not be attempted. 
In paralytic deformities, also, division of the tendon of a 
healthy muscle is productive of no permanent benefit. 

The sins of commission are, however, less frequent as 
regards tenotomy than are those of omission, and it is, 
perhaps, of even greater importance to 
know when to perform the operation 
than when not to perform it. The rule 
laid down by Sayre, of ‘‘ point-press- 
ure,” as an indication for the operation 
is a good one. It is not, however, in- 
fallible in every sense, for, while it will 
be perfectly safe and necessary to op- 
erate when reflex spasm is present, yet 
the writer has met with cases that were 
benefited by tenotomy, in which he was 
unable to elicit the spasmodic reflex. It 
is possible that in these cases the muscle 
might have been elongated by persever- 
ing manipulations, for stretching had 
been tried for a short time only ; but the 
division of the tendon did no harm and 
certainly expedited matters. The fol- 
lowing is the law referred to, as given 
by Sayre in his lectures on ‘‘ Orthopedic 
Surgery, and Diseases of the Joints,” p. 
35. 

‘*Place the part contracted as nearly 
as possible in its normal position, by 
means of manual tension gradually ap- 
plied, and then carefully retain it in 
that position ; while. the parts are thus 
placed upon the stretch, make additional 
point-pressure with the end of the finger 
or thumb upon the parts thus rendered 
tense, and, if such additional pressure 
produces reflex contractions, that tendon, 
fascia, or muscle must be divided, and 
the point at which the reflex spasm is 
excited is the point where the operation 
should be performed. If, on the con- 
trary, while the parts are brought into 
their normal position by means of man- 
ual tension gradually applied, the addi- 
tional point-pressure does not produce 
reflex contractions, the deformity can be 
permanently overcome by means of con- 
stant elastic tension, and the more you cut the greater 
will be the amount of damage done. This is an impor- 
tant law for its application is univer- 
sal in deciding the question of cutting contracted tissues. 
Even when the parts can be completely restored to their 
normal position by means of manual force gradually ap- 
plied, if this additional point-pressure produces pain or 
spasm, the contractured tissue must be cut before a com- 
plete cure can be effected.” 

Tenotomy may be performed either by cutting down 
directly upon the tendon through the skin and superficial 
tissues, or by what is known as the subcutaneous method. 
The latter is practically the only one employed at the 
present day, so that the word tenotomy, unless some 
qualifying term is added, is commonly understood to 
mean the subcutaneous division of a tendon. 

The instruments employed are short, slender knives, 


7T75 


Fra. 3820. — Teno- 
tomes. 


Tenotomy. 
Wenotomy. 


called tenotomes. They may be sharp-pointed or blunt, 
and may have a straight, convex, or concave cutting edge 
(Fig. 3820). The form of tenotome used is for the most 
part a matter of individual preference or custom. For 
most operations a straight, sharp-pointed instrument will 
be all that is necessary, though it is well to be provided 
with the curved and blunt-pointed instruments, which 
may be required in special cases. That part of the han- 
dle which corresponds to the cutting edge should always 
be marked in some way, in order to prevent confusion 
during the operation, when the blade is buried out of 
sight in the tissues. The strength of the tenotome is a 
matter of considerable importance, for, though of small 
size, it is often called upon to divide very dense tissues. 

The other things necessary for the operation are two 
or three narrow strips of adhesive plaster, a couple of 
small sponges or a little absorbent cotton, thoroughly 
sterilized, and a compress made of sublimate or iodo- 
form gauze. 

The use of ether or chloroform is not advisable, ex- 
cept in the case of a very timid patient, for the operation 
is of very short duration, and it may be rendered entirely 
painless, if desired, by the previous injection of a few 
minims of a solution of cocaine. When, however, it is 
proposed to perform several subcutaneous sections in a 
young or nervous child, it may save some time and an- 
noyance to have the patient under the influence of an 
anesthetic. Chloroform is preferable to ether in the 
case of a young and healthy child. Nitrous oxide gas 
has been suggested as a specially appropriate anesthetic 
in cases of tenotomy, as it is said to cause muscular con- 
tractions. Dr. W. A. Hunt has reported, in the British 
Medical Journal, an instance in which it was necessary to 
suspend the exhibition of the gas in a case of tooth ex- 
traction, because of the severe pain excited in a sprained 
ankle by the contraction of the muscles. 

The operation of subcutaneous division of a tendon is 
a very simple one. The services of an assistant are often 
of great help, yet they are not usually absolutely neces- 
sary. ‘The patient, anesthetized or not, as the case may 
be, is placed in such a position that the tendon to be di- 
vided is readily accessible, and the limb is then manipu- 
lated so as to put the tendon on the stretch. A straight, 
sharp-pointed tenotome, previously sterilized, is now 
passed flatwise beneath the tendon and as close to it as 
possible, so as to avoid wounding any of the adjacent 
tissues. The knife is then turned with the cutting edge 
against the tendon and the latter is divided, with a rock- 
ing or sawing motion, in a direction toward the skin. It 
is necessary to use great care, when the tendon is nearly 
severed, in order to avoid cutting through the skin, and 
thus making an open wound. Some surgeons prefer to 
make the incision through the skin first, and then to in- 
troduce a blunt-pointed instrument and complete the 
operation with it. This is advisable in certain cases, 
when important vessels or nerves in the vicinity are ex- 
posed to injury from the point of the instrument. In 
some situations it will be found better to divide the ten- 
don from without inward, in order to avoid the possibil- 
ity of accidentally cutting through the skin. The opera- 
tor must be sure that he has severed all the fibres of the 
tendon, otherwise the operation will fail in accomplish- 
ing the results desired. After the tendon has been cut 
through, the knife is withdrawn on the flat, in the same 
manner in which it was introduced, the finger being 
pressed upon the part so as to prevent the admission of 
air into the wound. A small pad of sublimate gauze is 
now placed over the point of incision, and retained by a 
couple of strips of adhesive plaster. 

There are several accidents which may occur during 
or after the operation, and they should always be borne 
in mind as the best means of preventing them. These 
are, wounding an artery or vein, division of a nerve, or 
of the skin above the tendon, and inflammation and sup- 
puration at the point of division of the tendon, resulting 
in non-union of the separated extremities. Non-union 
of the divided tendon may also occur from other causes, 
and sometimes has taken place most unexpectedly, when 
all the conditions seemed most favorable. 


716 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Much has been written about the repair of tendons 
after subcutaneous division, but the limits of this article 
forbid more than a very brief description of the process. 
Immediately after the operation there is a separation of 
greater or less extent between the divided ends of the 
tendon, the space between them being occupied by the 
sheath of the tendon, into which more or less blood has 
been effused. In the case of the tendo Achillis, which 
has no true sheath, the surrounding connective tissue fills 
the space. In a few days there is a pouring out of lymph 
and corpuscles, and a new formation of embryonic tissue 
takes place around the ends of the tendon and, to a less 
extent, between them. The extremities of the tendon be- 
come bulbous and are united by a cord of newly formed 
tissue, which is thinnest at its centre, growing thicker as 
it approaches the tendon at either end. This new ma- 
terial is gradually converted into fibrous tissue, which is 
barely distinguishable from true tendon tissue. The splice 
is thicker and more nearly resembles the tendon, if no 
motion of the parts has been permitted after the opera- 
tion, and if no stretching of the new tissue has been 
done. 

It was formerly taught that the divided ends of the 
tendon should never be allowed to separate, after te- 
notomy, any farther than could be helped, the fear being 
that union would be imperilled if such separation should — 
take place. Even now it is, perhaps, the rule with most 
surgeons to approximate the ends of the tendon by re- 
taining the parts in the position of the original deformity 
for some days, until it is supposed’ that union has taken 
place. Then, by means of gradual stretching, the newly 
formed tissue is elongated and the deformity is little by 
little overcome. That the deformity may be overcome 
by this method the general experience of surgeons has 
amply proved, but the plan of immediate restoration of 
the parts is much to be preferred.* In this method the 
deformity is at once overcome as far as it may be, and 
the parts are retained in their new position until firm 
union, by means of the new material between the sepa- 
rated ends of the tendon, has taken place. This method 
has several advantages in that it gives usually a better 
result, the newly formed tendon is larger and stronger, 
and the desired result is more quickly attained and at 
the expense of much less suffering to the patient. Care 
should, of course, be taken that the deformity be not 
over-corrected, so as to convert, for instance, a talipes 
equinus into a calcaneus, as has sometimes been done, 
This is, however, a rare accident, and usually, if not al- 
ways, a preventable one. Non-union is no more liable 
to occur after immediate restoration than it is when the 
divided ends of the tendon are approximated. When 
tenotomy is performed as a preliminary to the operation 
of forcible breaking up of anchylosis, the external wound 
should be allowed to heal first, as otherwise the forcible 
stretching might readily tear the skin and convert the 
subcutaneous tenotomy into an open one. The reader 
will find a very clear statement of the arguments in favor 
of this method in a paper by Dr. Reginald H. Sayre, on’ 
‘The Immediate Restoration of Parts to the Normal Po- 
sition after Tenotomy,” read before the Orthopedic Sec- 
tion of the New York Academy of Medicine, May 21, 
1886, and published in the Alabama Medical and Surgi- 
cat Journal of the same year. 

The following are, in brief, the rules to be followed in 
making subcutaneous sections of individual tendons : 

STERNO-CLEIDO-MASTOID.—In dividing either the ster- 
nal or the clavicular portion the tenotome is to be in- 
serted beneath the tendon at a short distance above its 
insertion, and the section is to be made toward the skin. 
Care must be taken not to make the incision too high up, 
for fear of wounding the vessels in the neck. 

TRAPEZIUS.—Division of this muscle, near its origin 
from the superior curved line of the occipital bone, is 


* Scoutetten, as early as 1888, advised immediate restoration, though 
in a rather timid manner. He compared stretching of the newly formed 
tissue to the elongating of a har of softened glass, and maintained that 
increased length in such a case was obtained at the expense of thickness. 


His example does not seem to have been followed by other surgeons of 
that day. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


sometimes required. This is done by inserting the knife | 


beneath the muscle, at a short distance from the bone, 
and dividing it toward the skin. 

Bicers.—This muscle may be divided just above the 
point where the bicipital fascia is given off. The ten- 
otome should be introduced beneath the tendon, hugging 
it closely, in order to avoid the brachial artery, and the 
section is to be made toward the integument. 

EXTENSOR MUscLES OF THE THUMB.—These tendons 
may be severed where they form by their prominence the 
‘‘tabatiére.” They are to be divided from within» out- 
ward, care being taken to avoid the radial artery passing 
along the bottom of this triangle. 

EXTENSOR ComMMuNIS DiarroruM. — These tendons 
may be divided on the dorsum of the wrist or of the 
hand, by introducing the knife above them and cutting 
down upon the bone. Of course, they should not be cut 
at the points where they pass over the joints. 

FLEXORES CaRPI.—Both the radial and the ulnar flex- 
ors have their corresponding arteries to the outer side, 
and the tenotome should be passed between the tendon 
and the artery, the edge turned away from the latter, 
and the tendon divided toward the integument. 

FLEXORES DiciroruM.—These tendons seldom require 
division, and as the operation is apt to be followed by 
severe inflammatory reaction it is better to avoid their 
section, if possible. They may be severed by introduc- 
ing the knife between them and the integument and cut- 
ting down upon the bone beneath. 

TENSOR VAGINA Fermoris.—In the division of this 
muscle the knife may be introduced on either side of it, 
a short distance below its origin from the crest of the 
ilium, the section being made toward the integument. 

SarToRIvus.—The knife is passed beneath the muscle, 
from its inner side, about two inches below the anterior 
superior spinous process of the ilium, and the division is 
made in an outward direction. 

PrEcTiINEvs.—Division is best made in a direction down- 
ward and inward, in order to avoid injury to the femoral 
vessels. The tenotome should be introduced at the outer 
edge of the muscle, about an inch from its origin. 

Appuctor Loneus.—The knife is to be passed be- 
neath the muscle, at its outer edge, a short distance be- 
low the pubes, and the division is to be made toward the 
integument. 

QUADRICEPS EXTENSOR FEMoRis.—The tendon of this 
muscle can be divided a short distance above the patella, 
by an incision made from without inward. Some care 
is necessary to avoid opening the synovial sac of the 
knee-joint, which extends up under the tendon at this 
point. 

HamstTRiInG TENpDoNs.—The outer hamstring tendon 
is in close relation on its inner border with the external 
popliteal nerve. The knife should be passed between 
the tendon and the nerve, and the division made from 
within outward and toward the integument. 

The inner hamstring tendons are, in their order from 
the inner side of the knee to the median line of the pop- 
liteal space, the sartorius, gracilis, semi-membranosus, 
and semi-tendinosus. The two latter are the ones that 
most frequently require division. Either or all of these 
tendons can be divided by the knife introduced at the 
inner side, and directed outward and toward the skin. 

TenDo ACHILLIS.—The patient is placed in the prone 
position, an assistant flexing the foot strongly, so as to 
put the tendon on the stretch, and the tenotome is then 
introduced from the inner side, and close to the tendon, 
so as to avoid wounding the posterior tibial artery. The 
division is made toward the skin, care being taken that 
this is not wounded when the last fibres of the tendon 
are severed. 

TrpraLtis AnTIcus.—The knife should be inserted on 
the outer side of the tendon, just in front of the internal 
malleolus, the division being made from without inward 
and toward the skin. ; 

TrBrALis Postrcus.—The division of this tendon may 
be made in the leg or in the foot, the latter being more 
difficult, however, especially in young children. If the 

division is to be made in the leg, the child should be 


Tenotomy. 
Tenotomy. 


placed so that the foot rests on its external border. The 
tenotome is introduced a little less than an inch above 
the internal malleolus, and about midway between the 
malleolus and the border of the tendo Achillis, and the 
division is made from below upward toward the skin. If 
the incision is made too near the malleolus, there will be 
danger of wounding the internal saphenous nerve or 
vein, and if it is made too near the tendo Achillis, the 
flexor longus digitorum, the posterior tibial artery, or 
the posterior tibial nerve will be liable to be severed. In 
order to avoid these structures it has been proposed to 
divide the tendon in the foot. This may be done in a 
line drawn from the tip of the internal malleolus to the 
scaphoid bone, a short distance below and in front of the 
malleolus. ‘There would seem, however, to be no special 
advantages in this procedure, and in children it is very 
difficult to make the section in the foot. 

PERONEvUS Loneus.—The knife is to be introduced a 
short distance above the external malleolus, where the 
tendinous cord can usually be felt, and the section is 
made from behind forward and toward the skin. 

PERONEUS Brevis.—The tendon of this muscle lies 
just above and behind that of the long peroneal muscle. 
It may be divided at the same time that the section of 
the long peroneal is made. If, however, it is desired to 
sever it alone, the operation should be done in the foot. 
The tendon will be found in a line drawn from the pos- 
terior border of the external malleolus to the posterior 
extremity of the fifth metatarsal bone, from one-half to 
one inch in front of the malleolus, The peroneal ten- 
dons seldom require section, and it must be very rare in- 
deed that one is to be divided without the other. 

Fiexor Lonevus Pouuicis.—This tendon may be di- 
vided at its most prominent part on the inner border of 
the foot. Care must be observed to avoid the internal 
plantar artery which runs along the inner border of the 
tendon. 

FLExorR Loneus Dicirorum.—The tendon of this 
muscle lies just behind that of the posterior tibial. The 
two tendons are usually divided simultaneously, but they 
may, with some care, be severed separately if it be de- 
sired. In division of this tendon great care will be re- 
quired to avoid the posterior tibial vessels. These should, 
if possible, be pushed toward the tendo Achillis, and the 
knife may be introduced between the vessels (held out of 
the way by the finger) and the tendons of the posterior 
tibial and flexor longus digitorum muscles, a blunt- 
pointed instrument being used after the primary incision 
has been made through the skin; the flexor tendon is 
then carefully severed in a direction toward the integu- 
ment. Parker advises the division of the tendon of this 
muscle, together with that of the posterior tibial, in the 
sole of the foot, just below the astragalo-scaphoid articu- 
lation, at a point where they cross each other. 

These are the chief muscles that require tenotomy, ex- 
cepting those of the eye; and for a description of the 
operations in this region the reader may consult the ar- 
ticle on Strabismus in this volume of the HANDBOOK. 

APONEUROTOMY, or fasciotomy, as it has been barbar- 
ously called, is the division, usually subcutaneous, of an 
aponeurosis, generally the palmar or plantar. 

Palmar aponeurotomy, as proposed by Adams in the 
treatment of Dupuytren’s contraction, consists of mul- 
tiple subcutaneous sections of the fascia made at differ- 
ent points along the ridges caused by the contractured 
tissue. The knife, which should be small though strong, 
is to be introduced between the fascia and the skin, and 
the former divided from the surface downward. The 
sections are to be repeated at various points, until the 
bent finger can be straightened. As soon as the knife is 
withdrawn from the wound, the opening should be cov. 
ered with a piece of plaster, a wad of antiseptic gauze, 
or something of the sort, before the next incision is 
made. Some care is necessary at times to avoid wound- 
ing the sheaths of the extensor tendons, an accident that 
is liable to be followed by considerable inflammation, in 
spite of the most thorough antiseptic precautions. 

Plantar Fascia.—The division of this tissue is very 
frequently demanded in the treatment of club-foot. It 


T717 


Tenotomy. 
Teplitz-Schonau. 


may be made at any point where the structure is most 
prominent, by introducing a tenotome beneath it, in the 
usual manner, flatwise, and cutting toward the skin. 

Myortomy is the term employed to denote a subcutane- 
ous section of the belly of a muscle instead of that of its 
tendon. It is very seldom performed, tenotomy being 
usually more convenient and much simpler. The same 
precautions against the admission of air and the wound- 
ing of neighboring structures are, of course, to be ob- 
served in myotomy as in tenotomy. 

SYNDESMOTOMY, or the subcutaneous division of liga- 


ments, is employed not uncommonly in the reduction of ° 


old dislocations in cases in which these structures offer 
very obstinate resistance to the replacement of the lux- 
ated bone. Syndesmotomy is advised and practised by 
Parker in the treatment of many cases of congenital tali- 
pes. He believes that the failures after tenotomy are 
often due to the fact that the ligaments are shortened, 
and do not yield sufficiently to allow of perfect reduc- 
tion of the deformity. The subcutaneous division of lig- 
aments is performed in the same manner and with the 
same precautions as that of tendons or muscles. It is 
necessary, however, to observe special care as regards 
antisepsis, since the joint is opened, and consequently 
very severe inflammation may follow the operation when 
carelessly performed. 

The reader desiring more detailed accounts of the dif- 
ferent subjects touched upon in this article may consult 
the following works, which are but a few among the 
more important of the many published : 

Stromeyer, L.: Beitrége zur operativen Orthopaédik. Hanover, 1888. 
Littie, W. J.: Treatise on the Nature of Club-foot and Analogous Distor- 

tions. London, 1839, 

Bonnet, ‘A.: Traité des Sections tendineuses, etc. Paris, 1841. 
Diefenbach, J. F.: Ueber die Durchschneidung der Sehnen und Mus- 

keln, Berlin, 1841. 

Bigelow, H. J.: "A Manual of Orthopeedic Surgery, etc. Boston, 1845. 
we T. D.: A Lecture on Coxarthrus, or Club-foot. Philadelphia, 


Scoutetten, H.: Memoir on the Radical Cure of Club-foot. Translated by 
F. C, Stewart, M.D. Philadelphia, 1840, 


178 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Paget, J.: Lectures on Surgical Pathology. London, 1853, and later 
editions in both England and America, 

Adams, W.: A Sketch of the Principles and Practice of Subcutaneous 
Surgery. London, 1857. On the Reparative Process in: Human Ten- 
dons after Subcutaneous Division, ete, London, 1860. 


Sayre, L. A.: A Practical Manual of the Treatment of Club- foot. New 
York, 1874. 

Brodhurst, B.: Orthopeedic Surgery. London, 1876. 

Sayre, L. A.: Orthopedic Surgery and Diseases of the Joints. New 
York, 1883. 

Parker, Be Wee Congenital Club-foot, its Nature and Treatment. _Lon- 


don, 1887. 
Thomas L. Stedman. 


TEPLITZ-SCHONAU is a well-known and popular 
health-resort, lying in a pleasant and well-protected val- 
ley, in Bohemia, at an elevation of about 700 feet above 
sea-level. The climate is rather mild, but there are apt 
to be sudden changes of temperature. ‘There are eleven 
thermal springs at Teplitz, the waters of which contain. 


a rather large proportion of mineral ingredients. The fol- 
lowing is the analysis of the water. One litre contains: 
Gramme 
Potassium ‘sulphate, . 0 ..b.:s..ccteuse ces oats Stone Ore 0.017 
Sodinmeulphate v4. Ac. Aaeios peice eects erento ronan 0.079 
Sodium chloride: {2s isi. Reece ca maaion aes eee 0.066 
Sodium. carbonate, .........-. Teledu arate ie ate ie eee ete Creuse 0.403 
Magnesium carbonate........... whet ste dae oc Bie oioieetotine 0.018 
Calcium carbonate........... PO ne! Fase OR nee 0.057 
Bilicic acide Be trees ces acetate oe ee ee 0.046 
Organic matters, etc:.......... Bane tere bares Amin ee: 0:007 
Totals is cece 6 eu clade Jel PRE ee Cee CORE 0.688 


The temperature of the different springs varies be- 
tween 82° and 118° F. 

The waters are employed externally only. Other ther- 
apeutic measures in use are mud-baths and the drinking 
of imported mineral waters. 

The indications for the warm baths of Teplitz are gout 
and chronic articular and muscular rheumatism, neural- 
gia, various forms of skin disease, etc. The season ex- 
tends from May to October, but many visit Teplitz even 
during the winter months. Whee SS 8 


END OF VOLUME VI. 


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